Glenn's Urologic Surgery PDF

SE V E N T H E D I T I O N
GLEN N ’S URO LO GIC

SURGERY
Editors
Sam D. Graham, Jr., MD Thomas E. Keane, MD
Urologic Specialists of Virginia Professor and Chair
M edical Director Department of Urology
Thomas Johns H ospital M edical University of South Carolina
Richmond, Virginia Charleston, South Carolina
Consultant Editor
James F. Glenn, MD, DSc, FACS, FRCS
Associate Editors
Charles B. Brendler, MD Gerald H. Jordan, MD, FACS, FAAP
Marc Goldstein, MD, DSc (hon) Jerome P. Richie, MD
Leonard G. Gomella, MD, FACS Randall G. Rowland, MD, PhD
E. Ann Gormley, MD H. Gil Rushton, MD
Thomas W. Jarrett, MD Urs E. Studer, MD
A cquisitions Editor: Brian Brown
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Library of Congress Cataloging-in-Publication Data

Glenn’s urologic surgery / editors, Sam D. Graham Jr., Thomas E. Keane ;
consultant editor, James F. Glenn ; associate editors, Charles B. Brendler
. . . [et al.].—7th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-9141-0 (alk. paper)
1. Genitourinary organs—Surgery. I. Graham, Sam D. II. Keane, Thomas E.
III. Glenn, James F. (James Francis), 1928- IV. Title: Urologic surgery.
[DN LM : 1. Urogenital Surgical Procedures. 2. Female Urogenital
Diseases—surgery. 3. M ale Urogenital Diseases—surgery. WJ 168 G559 2010]
RD571.U75 2010
617.4'6059—dc22
2009029905
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10 9 8 7 6 5 4 3 2 1
■ CO N TEN TS
Editors xi
Contributors x iii
R em em brances x x vii
Preface x x ix
SECTIO N I ■ ADREN AL, REN AL, URETER, PELVIS 1

Jerom e P. R ichie
Chapter 1 Anatomy of the Adrenal Glands, Kidney, Ureter, and Pelvis 1
R icardo Beduschi, Unyim e O . N seyo, and Sam D . G raham , Jr.
Chapter 2 Partial N ephrectomy 6

Sam ir S. Taneja
Chapter 3 Radical N ephrectomy 14

M ichael S. Cook son and Sam S. Chang
Chapter 4 Intracaval Tumors 23

Viraj A . M aster and Fray F. M arshall
Chapter 5 Transplant N ephrectomy 32

Sanjaya Kum ar
Chapter 6 Renovascular Disease 36

John A . L ibertino and Chad W otk ow icz
Chapter 7 Anatrophic N ephrolithotomy 45

Elizabeth J. A noia, M ichael L . Paik , and M artin I. R esnick
Chapter 8 Renal and Retroperitoneal Abscesses 51

D avis P. Viprak asit and A nthony J. Schaeffer
Chapter 9 Renal Trauma 58
Jill C. Buck ley and Jack W. M cA ninch
Chapter 10 Renal Allotransplantation 65

John W. M cG illicuddy, Justin D . Ellett, and Kenneth D . Chavin
Chapter 11 Ureteral Complications Following Renal Transplantation 71

R odney J. Taylor
Chapter 12 Renal Autotransplantation 76

Venk atesh Krishnam urthi and D avid A . G oldfarb
SECTIO N II ■ BLADDER 85
Charles B. Brendler
Chapter 13 Anatomy of the Bladder 85
Clinton W. Collins and A dam P. Klausner
Chapter 14 Simple and Partial Cystectomy 92

Jonathan C. Picard and J. N athaniel H am ilton
iii
iv Conte nts
Chapter 15 Radical Cystectomy in Men 97

M oham ed A . G honheim
Chapter 16 Radical Cystectomy in Women 104

A lon Z . W eizer and Cheryl T. L ee
Chapter 17 Bladder Diverticulectomy 113

M ichael S. Cook son and Sam S. Chang
Chapter 18 Bladder Augmentation 118

A nne Pelletier Cam eron, R . D uane Cespedes, and Edw ard J. M cG uire
Chapter 19 Management of the Distal Ureter for N ephroureterectomy 125

J. Stuart W olf, Jr.
Chapter 20 Vesicovaginal Fistula 130

H elen G . Z afirak is and O . L enaine W estney
Chapter 21 Enterovesical and Rectourethral Fistulas 137

Kenneth W. A ngerm eier, A aron J. M ilbank , and Eric A . Klein
Chapter 22 Vesical Trauma and Hemorrhage 143

Kam al S. Pohar and R obert R . Bahnson
Chapter 23 Interstitial Cystitis/ Painful Bladder Syndrome 150

M ichael S. Ingber and Kenneth M . Peters
SECTIO N III ■ PRO STATE 163

R andall G . R ow land
Chapter 24 Anatomy of the Prostate 163
Sam D . G raham , Jr.
Chapter 25 Surgery for Benign Prostatic Hypertrophy 166

Brian R . M atlaga and Jam es E. L ingem an
Chapter 26 Prostatic Imaging and Biopsy 175

Frances M . M artin, W illiam T. Conner, and R andall G . R ow land
Chapter 27 Pelvic Lymphadenectomy 179

M ichelle L . R am írez, R aj S. Pruthi, Joon-H a O k , and
R alph W. deVere-W hite
Chapter 28 Open Radical Retropubic Prostatectomy 186

M isop H an and W illiam J. Catalona
Chapter 29 Radical Perineal Prostatectomy 194

Sam D . G raham , Jr., Jeffrey C. L ou, and T hom as E. Keane
Chapter 30 Brachytherapy for Localized Prostate Cancer 202

John A . Fortney, A . Jason Z auls, and D avid T. M arshall
SECTIO N IV ■ URETH RA 211

E. A nn G orm ley
Chapter 31 Anatomy of the Urethra 211
E. A nn G orm ley
Chapter 32 Female Urethral Diverticulum 214

A hm ed M . El-Z aw ahry and Eric S. R ovner
Chapter 33 Reconstruction of the Female Urethra 220

Jerry G . Blaivas and R ajveer S. Purohit
Chapter 34 Surgical Management of the Incompetent Bladder Outlet

in the Patient with a N eurogenic Bladder 228
A lienor S. G ilchrist, G ary E. L em ack , and Philippe E. Z im m ern
Conte nts v
Chapter 35 Surgery for Urethral Stricture Disease 236

Jack R . W alter and G eorge D . W ebster
Chapter 36 Surgery for Urethral Trauma Including Urethral Disruption 245
Jack W. M cA ninch and Bryan B. Voelzk e
Chapter 37 Carcinoma of the Female Urethra 252
Peter L . Steinberg and W illiam Bihrle III
Chapter 38 Carcinoma of the Male Urethra 257
Peter L . Steinberg and W illiam Bihrle III
Chapter 39 Injectable Therapies for Incontinence in Women 263
R odney A ppell
Chapter 40 Pubovaginal Fascial Slings 271
A nne Pelletier Cam eron, Christina L ew ick y-G aupp,
and Edw ard J. M cG uire
Chapter 41 Synthetic Midurethral Retropubic Slings 278
Bhavin N . Patel and G opal H . Badlani
Chapter 42 The Transobturator Approach to the Midurethral Sling 282
Paul H anissian and Jam es W hiteside
Chapter 43 Abdominal Retropubic Approaches for Female Incontinence 288
L eslie M . R ick ey
Chapter 44 The Artificial Urinary Sphincter 292
H elen Z afirak is and O . L enaine W estney
Chapter 45 The Male Sling for Postprostatectomy Incontinence:
Current Concepts and Controversies 299
Craig V. Com iter
Chapter 46 Sacral N euromodulation 305
Sarah E. M cA chran, R aym ond R . R ack ley, and Sandip Vasavada
Chapter 47 Surgical Treatment of Pelvic Organ Prolapse: Anatomy
of the Pelvic Floor 311
A riana L . Sm ith, Ja-H ong Kim , and Shlom o R az
Chapter 48 Vaginal Hysterectomy for Uterine Prolapse 318
Ja-H ong Kim , A riana L . Sm ith, and Shlom o R az
Chapter 49 Cystocele and Anterior Vaginal Prolapse 326
M elissa R . Kaufm an, H arriette M . Scarpero, and R oger R . D m ochow sk i
Chapter 50 Transvaginal Repair of Apical Prolapse 335
Katie N . Ballert and Victor W. N itti
Chapter 51 Posterior Vaginal Prolapse Repair 343
L ior L ow enstein and Elizabeth R . M ueller
Chapter 52 Abdominal Sacral Colpopexy 349
J. Christian W inters and Scott D elacroix , Jr.
SECTIO N V ■ VAS DEFEREN S, SEM IN AL VESICLE, TESTIS 355

M arc G oldstein
Chapter 53 Anatomy of the Epididymis, Vas Deferens, and Seminal Vesicle 355
H ow ard H . Kim and M arc G oldstein
Chapter 54 Seminal Vesicle and Ejaculatory Duct Surgery 361

Jay I. Sandlow
Chapter 55 Vasectomy 372

D ouglas G . Stein
vi Conte nts
Chapter 56 Vasoepididymostomy 379

Peter T. K. Chan
Chapter 57 Vasovasostomy 387

M arc G oldstein and H ow ard H . Kim
Chapter 58 Microsurgical Varicocelectomy 397

A rm and Z ini and Z iv M aiansk i
Chapter 59 Testis Biopsy and Testicular Sperm Extraction (TESE) 401

Peter N . Schlegel
Chapter 60A Epididymal Sperm Aspiration 407

Cigdem Tanrik ut and M arc G oldstein
Chapter 60B Epididymectomy 410

D avid M . N udell and L arry I. L ipshultz
Chapter 61 Ejaculation Induction Procedures: Penile Vibratory

Stimulation and Electroejaculation 412
D ana A . O hl, Susanne A . Q uallich, Jens Sønk sen, N ancy L . Brack ett,
and Charles M . Lynne
Chapter 62 Anatomy of the Testis 419

H ow ard H . Kim and M arc G oldstein
Chapter 63 Simple Orchiectomy 428

Brett S. Carver and Sherri M . D onat
Chapter 64 Inguinal Orchiectomy 433

D avid A . Sw anson
Chapter 65 Organ-Preserving Surgery in Testicular Tumors 438

A x el H eidenreich
Chapter 66 Retroperitoneal Lymphadenectomy 442

M ichael L everidge and M ichael A . S. Jew ett
Chapter 67 Torsion of the Testicle 448

Blak e W. M oore and H arry P. Koo
Chapter 68 Scrotal Trauma and Reconstruction 453

Tim othy O . D avies and G erald H . Jordan
SECTIO N VI ■ PEN IS AN D SCRO TUM 465

G erald H . Jordan
Chapter 69 Anatomy of the Penis and Scrotum 465
Sam D . G raham , Jr.
Chapter 70 Partial and Total Penectomy in the Management of

Invasive Squamous Cell Carcinoma of the Penis 467
A ntonio Puras Baez and A lex M . A costa M iranda
Chapter 71 Inguinal Lymphadenectomy for Penile Carcinoma 473

Shahin Tabatabaei and W. Scott M cD ougal
Chapter 72 Surgical Treatment of Peyronie Disease 481

Uri G ur and G erald H . Jordan
Chapter 73 Priapism 487

Trinity J. Bivalacqua and A rthur L . Burnett
Chapter 74 Penile Prosthesis Implantation 492

Culley C. Carson
Conte nts vii
Chapter 75 Penile Venous Surgery 499

A udrey C. R hee, M ark R . L icht, and R onald W. L ew is
Chapter 76 Microvascular Arterial Bypass Surgery for Erectile Dysfunction 505
Irw in G oldstein and M artin Bastuba
Chapter 77 Penile Trauma 514
D aniel I. R osenstein, A llen F. M orey, and Jack W. M cA ninch
Chapter 78 Penile Replantation 519
Uri G ur and G erald H . Jordan
Chapter 79 Varicocele: General Considerations 523
Carin V. H opps and M arc G oldstein
Chapter 80 Hydrocele and Spermatocele 528
John A . N esbitt
Chapter 81 Congenital Curvature 532
Tim othy O . D avies and Kurt A . M cCam m on
Chapter 82 Reconstruction of the Penis for Complications of
Penile Enhancement Surgery 537
G ary J. A lter
SECTIO N VII ■ URIN ARY DIVERSIO N 545

Urs E. Studer
Chapter 83 Ileal Conduit Urinary Diversion 545
M ichael C. L ee and Eric A . Klein
Chapter 84 Transverse Colonic Conduit 549
M argit Fisch, R udolf H ohenfellner, R aim und Stein, and
Joachim W. T hüroff
Chapter 85 Managing the Patient with Orthotopic Bladder Substitution 555
Urs E. Studer and N . Bhatta-D har
Chapter 86 Orthotopic Urinary Diversion Using an Ileal Low-Pressure
Reservoir with an Afferent Tubular Segment 561
Stephan Jeschk e and Urs E. Studer
Chapter 87 Ileal N eobladder 566
R ichard E. H autm ann
Chapter 88 The Padua Ileal Bladder 574
Francesco Pagano and Pierfrancesco Bassi
Chapter 89 The T-Pouch Ileal N eobladder 578

John P. Stein and D onald G . Sk inner
Chapter 90 Colonic Orthotopic Bladder Substitution 586

Joachim W. T hüroff and L udger Franzaring
Chapter 91 Continent Catheterizable Reservoir Made from Ileum 594

H assan A bol-Enein and M oham ed A . G honeim
Chapter 92 Continent Catheterizable Reservoir Made from Colon 599

H ubertus R iedm iller and Elm ar W. G erharz
Chapter 93 Ureterosigmoidostomy: Mainz Pouch II 610

M argit Fisch, R udolf H ohenfellner, Jörg Schede,
and Joachim W. T hüroff
Chapter 94 Palliative Urinary Diversion 618

Burk hard Ubrig and Stephan R oth
viii Conte nts
SECTIO N VIII ■ PEDIATRIC 623

H . G il R ushton
Chapter 95 N euroblastoma 623

W. R obert D eFoor, Jr., Pram od P. R eddy, and Curtis A . Sheldon
Chapter 96 Wilms Tumor 628

Sarah Conley and M ichael L . R itchey
Chapter 97 Renal Fusion and Ectopia 634

R oss M . D ecter
Chapter 98 Transureteroureterostomy 643

H . G il R ushton
Chapter 99 Pyeloplasty 647

Evan J. Kass and Kevin M . Feber
Chapter 100 Megaureter 649

J. Christopher A ustin and D ouglas A . Canning
Chapter 101 Prune Belly (Triad) Syndrome 654

D avid B. Joseph
Chapter 102 Childhood Rhabdomyosarcoma 662

H si-Yang W u and H ow ard M . Snyder III
Chapter 103 Vesicoureteral Reflux 665

M ark R . Z aontz
Chapter 104 Endoscopic Treatment of Vesicoureteral Reflux 676

Wolfgang H . Cerw ink a and A ndrew J. Kirsch
Chapter 105 Ureteroceles 681

R ichard N . Yu, Chester J. Koh, and D avid A . D iam ond
Chapter 106 Urachal Anomalies and Related Umbilical Disorders 684

L eslie T. M cQ uiston and A nthony A . Caldam one
Chapter 107 Vesical N eck Reconstruction 689

John C. Pope IV and John H . M ak ari
Chapter 108 Surgery for Posterior Urethral Valves 697

R osalia M isseri and Kenneth I. G lassberg
Chapter 109 Hypospadias 703
L aurence S. Bask in
Chapter 110 Complete Primary Repair for Exstrophy 711

R ichard W. G rady
Chapter 111 Bladder Exstrophy and Epispadias 722

T hom as E. N ovak and John P. G earhart
Chapter 112 Congenital Anomalies of the Scrotum 731

Sean T. Corbett and D avid R . R oth
Chapter 113 Pediatric Cryptorchidism, Hydroceles, and Hernias 735

Kenneth G . N epple and Christopher S. Cooper
Chapter 114 Laparoscopic Management of the Undescended Testicle 742

D anielle D . Sw eeney, M ichael C. O st, and Steven G . D ocim o
Chapter 115 Pediatric Laparoscopic Pyeloplasty 752

Pasquale Casale and W alid A . Farhat
Chapter 116 Pediatric Laparoscopic N ephrectomy and Partial N ephrectomy 757

G lenn M . Cannon, Jr., and R ichard S. L ee
Conte nts ix
Chapter 117 Urogenital Sinus and Cloacal Anomalies 761

Jeffrey A . L eslie and R ichard C. R ink
Chapter 118 Surgery to Correct Ambiguous Genitalia (46XX Disorder

of Sexual Development) 769
A nthony J. Casale
Chapter 119 Circumcision 778
Irene M . M cA leer and G eorge W. Kaplan
Chapter 120 Augmentation Cystoplasty in Children 783

H ans G . Pohl
Chapter 121 The Mitrofanoff Procedure in Pediatric Urinary Tract

Reconstruction 793
M ark P. Cain
SECTIO N IX ■ LAPARASCO PIC 801

L eonard G . G om ella
Chapter 122 Basic Principles of Laparoscopy: Transperitoneal, Extraperitoneal,
and Hand-Assisted Techniques 801
G aurav Bandi and L eonard G . G om ella
Chapter 123 Laparoscopic Pelvic and Retroperitoneal Lymph N ode Dissection 811
H ow ard N . W infield and W illiam J. Badger
Chapter 124 Laparoscopic N ephrectomy and Partial N ephrectomy 819

Jam es A . Brow n
Chapter 125 Laparoscopic N ephroureterectomy 830

Scott G . H ubosk y and M ichael D . Fabrizio
Chapter 126 Laparoscopic Renal Procedures: Renal Cystectomy, Biopsy,

and N ephropexy 837
Chad A . L aG range and Stephen E. Strup
Chapter 127 Laparoscopic Ablation of Small Renal Masses 842

Ilia S. Z eltser and D avid E. M cG innis
Chapter 128 Donor N ephrectomy: Laparoscopic Techniques 846

Erik P. Castle, R afael N unez, Costas D . L allas, and Paul E. A ndrew s
Chapter 129 Laparoscopic and Robotically Assisted Pyeloplasty in Adults 853

Kristofer R . W agner and T hom as W. Jarrett
Chapter 130 Laparoscopic Adrenalectomy 859

A rvin K. G eorge and L ouis R . Kavoussi
Chapter 131 Laparoscopic and Robotic Radical Prostatectomy 867

Costas D . L allas and Edouard J. Trabulsi
Chapter 132 Laparoscopic Management of Lymphoceles 879

Sean P. H edican and Stephen Y. N ak ada
Chapter 133 Laparoscopic Bladder Procedures: Radical Cystectomy,

Partial Cystectomy, Urachal Excision, Diverticulectomy 885
Sebastien Crouzet, G eorges-Pascal H aber, and Inderbir S. G ill
Chapter 134 Laparoscopic Bladder N eck Suspension 892

R ichard W. G raham
Chapter 135 Miscellaneous Laparoscopic Urologic Procedures: Calculus,

Varicocele, Ureterolysis 897
G ordon L . Fifer and R aju T hom as
x Conte nts
SECTIO N X ■ N EW FRO N TIERS 905

T hom as W. Jarrett
Chapter 136 Tissue-Engineering Strategies for Urogenital Repair 905
A nthony A tala
Chapter 137 Image-Guided Therapy: Current Practice and Future Directions 913
Peter Pinto and H al B. H ooper
Chapter 138 Robotic Surgery 919

D avid Canes and M ihir M . D esai
Chapter 139 Energy Sources in Urology 926

M oses M . Kim and R ichard E. L ink
Index 937
■ ED IT O R S
Editors E. Ann Gormley, MD

Professor of Surgery (Urology)
Sam D. Graham, Jr., MD Section of Urology
Urologic Specialists of Virginia Department of Surgery
M edical Director, Thomas Johns H ospital Dartmouth M edical School
Richmond, Virginia H anover, N ew H ampshire
Urologist
Thomas E. Keane, MD Section of Urology, Department of Surgery
Professor and Chair Dartmouth-H itchcock M edical Center
Department of Urology Lebanon, N ew H ampshire
M edical University of South Carolina Section: Urethra
Charleston, South Carolina
Thomas W. Jarrett, MD
Consultant Editor Professor and Chairman
Department of Urology
James F. Glenn, MD, DSc, FACS, FRCS† George Washington University M edical Center
Professor of Surgery Washington, DC
Department of Surgery
Division of Urology Gerald H. Jordan, MD, FACS, FAAP
University of Kentucky M edical Center Professor of Urology
Lexington, Kentucky Eastern Virginia M edical School
Director of Adult Reconstructive Surgery
Associate Editors The Devine Center for Genitourinary Reconstruction
Sentara N orfolk General H ospital
Charles B. Brendler, MD
Devine-Fiveash Urology, Ltd.
Professor and Chief N orfolk, Virginia
Section of Urology Section: Penis and Scrotum
University of Chicago H ospitals
Chicago, Illinois Jerome P. Richie, MD
Section: Ureter and Pelvis
Chief, Division of Urology
Brigham and Women’s H ospital
Marc Goldstein, MD, DSc (hon)
H arvard M edical School
M athew P. H ardy Distinguished Professor Boston, M assachusetts
Cornell Institute for Reproductive M edicine and Urology Section: Adrenal and Renal
Surgeon-in-Chief, M ale Reproductive M edicine and Surgery
N ew York-Presbyterian/Weill Cornell M edical Center Randall G. Rowland, MD, PhD
N ew York, N ew York
Professor and Chief of Surgery (Urology)
Section: Vas Deferens, Seminal Vesicle, Testis
Program Director (Urology)
University of Kentucky College of M edicine
Leonard G. Gomella, MD, FACS
Lexington, Kentucky
The Bernard W. Godwin Professor of Prostate Cancer Section: Prostate
Chairman, Department of Urology
Thomas Jefferson University
Associate Director of Clinical Affairs
Jefferson Kimmel Cancer Center
Philadelphia, Pennsylvania
Section: Laparoscopic Surgery
† Deceased
xi
xii Ed itors
H. Gil Rushton, MD Urs E. Studer, MD

Department of Urology Professor and Chairman
George Washington University Department of Urology
Chairman, Urology University H ospital Bern
Children’s N ational M edical Center Bern, Switzerland
Washington, DC Section: Urinary Diversion
Section: Pediatric
■ C O N T R I BU T O R S
Hassan Abol-Enein MD, PhD Anthony Atala, MD

Professor William H . Boyce Professor and Chair
Department of Urology Department of Urology
Faculty of M edicine, M ansoura University Director
Director Wake Forest Institute for Regenerative M edicine
Department of Urology Winston-Salem, N orth Carolina
Urology and N ephrology Center Chapter 136
M ansoura, Egypt
Chapter 91 J. Christopher Austin, MD, FAAP, FACS
Associate Professor, Pediatric Urology
Alex M. Acosta Miranda, MD University of Iowa H ospitals and Clinics
Assistant Professor Iowa City, Iowa
Department of Urology Chapter 100
University of Puerto Rico School of M edicine
Staff Urologist William J. Badger, MD
San Juan Veterans Affairs H ospital Endourology Fellow
San Juan, Puerto Rico The University of Iowa
Chapter 70 Department of Urology
Iowa City, Iowa
Gary J. Alter, MD Chapter 123
Assistant Clinical Professor
Division of Plastic Surgery Gopal H. Badlani, MD, FACS
University of California Professor, Vice Chair of Clinical Affairs
Los Angeles, California Department of Urology
Chapter 82 Wake Forest University School of M edicine
Wake Forest University/Baptist M edical Center
Paul E. Andrews, MD Winston Salem, N orth Carolina
Professor of Urology Chapter 41
M ayo Clinic
Phoenix, Arizona Robert R. Bahnson, MD, FACS
Chapter 128 The Dave Longaberger Chair in Urology
Professor and Chairman
Kenneth W. Angermeier, MD Department of Urology
Center for Genitourinary Reconstruction O hio State University
Glickman Urological and Kidney Institute Columbus, O hio
Cleveland Clinic Chapter 22
Cleveland, O hio
Chapter 21 Katie N . Ballert, MD
Assistant Professor of Urology
Elizabeth J. Anoia, MD Department of Surgery
Urology H ealth Specialists, LLC Attending Surgeon
Abington, Pennsylvania Department of Surgery, Division of Urology
Chapter 7 University of Kentucky
Lexington, Kentucky
Rodney Appell, MD † Chapter 50
Vanguard Urology
H ouston, Texas Gaurav Bandi, MD
Chapter 39 Assistant Professor
Thomas Jefferson University
Philadelphia, Pennsylvania
Chapter 122
† Deceased
xiii
xiv Contrib utors
Laurence S. Baskin, MD Jill C. Buckley, MD

Professor of Urology Assistant Professor
University of California San Francisco Department of Urology
Chief, Pediatric Urology Tufts University School of M edicine
Department of Urology Lahey Clinic M edical Center
UCSF Children’s M edical Center Burlington, M assachusetts
San Francisco, California Chapter 9
Chapter 109
Arthur L. Burnett, MD, MBA, FACS
Pierfrancesco Bassi, MD Patrick C. Walsh Professor
Chief and Chairman Department of Urology
Department of Urology Johns H opkins University
Catholic University School of M edicine Johns H opkins H ospital
Rome, Italy Baltimore, M aryland
Chapter 88 Chapter 73
Martin Bastuba, MD Mark P. Cain, MD, FAAP

M ale Fertility Specialists Professor of Urology
San Diego, California Department of Urology
Chapter 76 Indiana University
Division of Urology
Ricardo Beduschi, MD Riley H ospital for Children
Chapter 1 Indianapolis, Indiana
Chapter 121
William Bihrle, III, MD
Associate Professor, Surgery Anthony A. Caldamone, MD
Dartmouth M edical School University Urology Associates
Section Chief, Urology Providence, Rhode Island
Dartmouth-H itchcock M edical Center Chapter 106
Lebanon, N ew H ampshire
Chapters 37 and 38 Anne Pelletier Cameron, MD
Assistant Professor
Trinity J. Bivalacqua, MD, PhD Clinical Lecturer
Assistant Professor of Urology Department of Urology
The James Buchanan Brady Urological Institute University of M ichigan
Johns H opkins H ospital Ann Arbor, M ichigan
Baltimore, M aryland Chapters 18 and 40
Chapter 73
David Canes, MD
Jerry G. Blaivas, MD Lahey Institute of Urology
Clinical Professor Parkland M edical Center
Department of Urology Derry, N ew H ampshire
Weill Cornell M edical College Chapter 138
Attending
Department of Urology Douglas A. Canning, MD
N ew York Presbyterian H ospital Division of Urology,
N ew York, N ew York Children’s H ospital of Philadelphia
Chapter 33 Philadelphia, Pennsylvania
Chapter 100
N ancy L. Brackett, PhD, HCLD
Associate Professor Glenn M. Cannon Jr., MD
N eurological Surgery and Urology Fellow, Pediatric Urology
University of M iami M iller School of M edicine H arvard M edical School
M iami, Florida Department of Urology
Chapter 61 Boston, M assachusetts
Chapter 116
James A. Brown, MD
Associate Professor Brett S. Carver, MD
H ead, Section of Urologic O ncology Assistant M ember
Division of Urology Department of Surgery
M edical College of Georgia Assistant Attending
Augusta, Georgia Department of Surgery
Chapter 124 M emorial Sloan-Kettering Cancer Center
Chapter 63
Contrib utors xv
Culley C. Carson, MD Kenneth D. Chavin, MD

Rhodes Distinguished Professor Professor of Surgery, M icrobiology, and Immunology
Chief of Urology Department of Surgery
University of N orth Carolina M edical University of South Carolina
Chapel H ill, N orth Carolina Charleston, South Carolina
Anthony J. Casale, MD Clinton W. Collins, MD

Department of Urology Chief Resident, Division of Urology
University of Louisville School of M edicine Virginia Commonwealth University School of M edicine
Louisville, Kentucky Richmond, Virginia
Pasquale Casale, MD Craig V. Comiter, MD

Assistant Professor of Urology in Surgery, Associate Professor
University of Pennsylvania Department of Urology
Children’s H ospital of Philadelphia Stanford University M edical School
Philadelphia, Pennsylvania Stanford, California
Chapter 115 Associate Professor
Erik P. Castle, MD Stanford H ospital and Clinics
Associate Professor of Urology Palo Alto, California
Urologic O ncology Chapter 45
Laparoscopic and Robotic Urology
M ayo Clinic Sarah Conley, MD
Phoenix, Arizona Resident
M ayo Clinic
William J. Catalona, MD Phoenix, Arizona
N orthwestern University Chapter 96
Feinberg School of M edicine
Chicago, Illinois William T. Conner, MD
Chapter 28 Division of Urology
University of Kentucky M edical Center
Wolfgang H. Cerwinka, MD Lexington, Kentucky
Clinical Instructor Chapter 26
Emory University School of M edicine Michael S. Cookson, MD, FACS
Attending Physician
Professor
Department of Pediatric Urology
Department of Urologic Surgery
Children’s H ealthcare of Atlanta
Vanderbilt University M edical Center
Atlanta, Georgia
N ashville, Tennessee
Chapter 104
Chapters 3 and 17
R. Duane Cespedes, MD
Christopher S. Cooper, MD
Director, Female Urology
Wilford H all M edical Center Professor
Lackland AFB, Texas Department of Urology
Chapter 18 University of Iowa
Associate Dean for Student Affairs and Curriculum
Peter T. K. Chan, MD, CM, MSc, FRCS(C), FACS University of Iowa Carver College of M edicine
Associate Professor Director, Pediatric Urology
Department of Surgery Children’s H ospital of Iowa
M cGill University Iowa City, Iowa
Director of M ale Reproductive M edicine Chapter 113
M cGill University H ealth Center Sean T. Corbett, MD
M ontreal, Q uebec, Canada Assistant Professor of Urology
Chapter 56 University of Virginia H ealth System
Charlottesville, Virginia
Sam S. Chang, MD, FACS Chapter 112
Associate Professor
Department of Urologic Surgery Sebastien Crouzet, MD
Vanderbilt University Glickman Urological and Kidney Institute
Department of Urologic Surgery Cleveland Clinic
Vanderbilt University M edical Center Cleveland, O hio
N ashville, Tennessee Chapter 133
Chapters 3 and 17
xvi Contrib utors
Mihir M. Desai, MD Steven G. Docimo, MD

Director, Stevan B. Streem Center for Endourology Professor of Urology, Director Pediatric Urology
Glickman Urological and Kidney Institute Department of Urology
Cleveland Clinic University of Pittsburgh School of M edicine
Cleveland, O hio Vice President, M edical Affairs and Chief M edical O fficer
Chapter 138 Department of M edical Affairs
Children’s H ospital of Pittsburgh of UPM C
Timothy O. Davies, MD Pittsburgh, Pennsylvania
Instructor, Adult and Pediatric Reconstructive Fellow Chapter 114
Eastern Virginia M edical School Sherri M. Donat, MD, FACS
N orfolk, Virginia Associate Professor
Chapters 68 and 81 Department of Urology
Weill M edical College of Cornell University
Ross M. Decter, MD Associate Attending Surgeon
Associate Professor of Surgery Dept of Surgery/Division of Urology
Department of Surgery M emorial Sloan-Kettering Cancer Center
M ilton S. H ershey M edical Center N ew York, N ew York
Penn State College of M edicine Chapter 63
H ershey, Pennsylvania
Chapter 97 Ahmed M. El-Zawahry, MD
Resident in Urology
W. Robert DeFoor, Jr., MD, MPH
Associate Professor M edical University of South Carolina
Division of Pediatric Urology Charleston, South Carolina
Cincinnati Children's H ospital Chapter 32
Cincinnati, O hio
Chapter 95
Justin D. Ellett, PhD
Scott Delacroix, Jr., MD Student
Department of Urologic Surgery Department of M icrobiology/Immunology
O chsner Clinic Foundation Surgery, Division of Transplant
N ew O rleans, Louisiana M edical University of South Carolina
Chapter 52 Charleston, South Carolina
Chapter 10
Ralph W. deVere-White, MD
Department of Urology and Cancer Center Michael D. Fabrizio, MD, FACS
University of California at Davis Associate Professor
Sacramento, California Department of Urology
Chapter 27 Eastern Virginia M edical School
Sentara M edical Group
N ivedita Bhatta-Dhar, MD Department of Urology
Assistant Professor of Urology Sentara N orfolk General H ospital
Wayne State University School of M edicine N orfolk, Virginia
Detroit, M ichigan Chapter 125
Chapter 85
Walid A. Farhat, MD
David A. Diamond, MD Associate Professor
Professor
University of Toronto
Department of Urological Surgery
Pediatric Urologist
H arvard M edical School
Associate
H ospital for Sick Children
Toronto, O ntario
Children’s H ospital
Chapter 115
Boston, M assachusetts
Chapter 105 Kevin M. Feber, MD
Pediatric Urologist
Roger R. Dmochowski, MD William Beaumount Children’s H ospital
Professor Royal O ak, M ichigan
Department of Urologic Surgery Chapter 99
Vanderbilt University
Director, Vanderbilt Continence Center Gordon L. Fifer, MD
Department of Urologic Surgery Department of Urology
Vanderbilt M edical Center Tulane University H ealth Sciences Center
N ashville, Tennessee N ew O rleans, Louisiana
Contrib utors xvii
Margit Fisch, MD, FEBV, FEAEV David A. Goldfarb, MD

Professor of Urology Professor of Surgery
Department of Urology and Pediatric Urology Glickman Urological and Kidney Institute
Center of O perative M edicine Cleveland Clinic Lerner College of M edicine
University of H amburg Director, Center for Renal Transplantations
Director, Department of Urology and Pediatric Urology Department of Urology
UKE University Clinic Eppendorf Cleveland Clinic
H amburg, Germany Cleveland, O hio
Chapters 84 and 93 Chapter 12
John A. Fortney, MD Irwin Goldstein, MD

M edical University of South Carolina Clinical Professor
Charleston, South Carolina Department of Urology
Chapter 30 University of California, San Diego
Director
Ludgar Franzaring, MD Department of Sexual M edicine
Chapter 90 Alvarado H ospital
San Diego, California
John P. Gearhart, MD Chapter 76
Professor and Director of Pediatric Urology
Department of Urology Marc Goldstein, MD, DSc (hon)
Johns H opkins University School of M edicine
M atthew P. H ardy Distinguished Professor
Baltimore, M aryland
Cornell Institute for Reproductive M edicine and Urology
Chapter 111
Surgeon-in-Chief, M ale Reproductive
Arvin K. George, MD M edicine and Surgery
N ew York-Presbyterian/Weill Cornell M edical Center
Resident Physician
The Smith Institute of Urology
Chapters 53, 57, 60A, 62, and 79
N orth Shore-Long Island Jewish H ealth System
N ew H yde Park, N ew York
Chapter 130 Leonard G. Gomella, MD, FACS
The Bernard W. Godwin Professor of Prostate Cancer
Elmar W. Gerharz, MD Chairman, Department of Urology
Department of Urology and Pediatric Urology Thomas Jefferson University
Julius M aximilians-University M edical School Associate Director of Clinical Affairs
Würzburg, Germany Jefferson Kimmel Cancer Center
Chapter 92 Philadelphia, Pennsylvania
Chapter 122
Mohamed A. Ghoneim, MD
Professor of Urology E. Ann Gormley, MD
Department of Urology Professor of Surgery (Urology)
N ephrology Center Section of Urology
M ansoura, Egypt Department of Surgery
Chapter 91 Dartmouth M edical School
H anover, N ew H ampshire
Alienor S. Gilchrist, MD Urologist
Resident in Urology, Department of Urology Section of Urology, Department of Surgery
University of Texas Southwestern M edical Center Dartmouth-H itchcock M edical Center
Dallas, Texas Lebanon, N ew H ampshire
Inderbir S. Gill, MD, MCh Richard W. Grady, MD

Chair, Department of Urology Associate Professor of Urology
USC Institute of Urology The University of Washington School of M edicine
Keck School of M edicine Children’s H ospital and Regional M edical Center
Los Angeles, California Seattle, Washington
Kenneth I. Glassberg, MD, FAAP, FACS Richard W. Graham, MD, FACS

Director, Division of Pediatric Urology Urologic Specialists of Virginia
Morgan Stanley Children’s H ospital of New York-Presbyterian Richmond, Virginia
Professor of N eurology, Columbia University Chapter 134
College of Physicians and Surgeons
Chapter 108
xviii Contrib utors
Sam D. Graham, Jr., MD Rudolf Hohenfellner, MD

Urologic Specialists of Virginia Professor of Urology
M edical Director, Thomas Johns H ospital Department of Urology
Richmond, Virginia Emer. Director
Chapters 1, 24, 29, and 69 M ainz M edical School
M ainz, Germany
Uri Gur, MD Chapters 84 and 93
Fellow, Adult and Pediatric Reconstructive Urology
Eastern Virginia M edical School Hal B. Hooper, MD
N orfolk, Virginia Resident
Chapters 72 and 78 Department of Urology
Georgetown University H ospital
Georges-Pascal Haber, MD Washington, DC
Section of Laparoscopic and Robotic Surgery Chapter 137
Glickman Urological and Kidney Institute
Carin V. Hopps, MD
The Cleveland Clinic Foundation
Cleveland, O hio Clinical Assistant Professor of Urology
Chapter 133 M edical University of O hio
Toledo, O hio
Chapter 79
J. N athaniel Hamilton, MD
Resident Physician Scott G. Hubosky, MD
Department of Urology Assistant Professor of Urology
M edical University of South Carolina Thomas Jefferson University H ospital
Charleston, South Carolina Philadelphia, Pennsylvania
Misop Han, MD Michael S. Ingber, MD
John H opkins University Clinical Fellow
School of M edicine Glickman Urological and Kidney Institute
Baltimore, M aryland Cleveland Clinic
Chapter 28 Cleveland, O hio
Chapter 23
Paul Hanissian, MD
Assistant Professor Thomas W. Jarrett, MD
Department of O bstetrics and Gynecology Professor and Chairman
Dartmouth M edical School Department of Urology
H anover, N ew H ampshire George Washington University M edical Center
Department of O bstetrics and Gynecology Washington, DC
Dartmouth-H itchcock M edical Center Chapter 129
Lebanon, N ew H ampshire
Chapter 42 Stephan Jeschke, MD
University of Bern
Richard E. Hautmann, MD, MD (hon) Department of Urology
Professor of Urology Inselspital
Department of Urology Bern, Switzerland
University of Ulm M edical Faculty Chapter 86
Chief of Department of Urology
Urologische Universitasklinik Michael A. S. Jewett, MD, FRCSC, FACS
Ulm, Germany Professor of Surgery (Urology)
Chapter 87 Department of O ncology
University of Toronto
Sean P. Hedican, MD Farquharson Clinical Research Chair in O ncology
Associate Professor Division of Urology, Department of Surgical O ncology
Department of Urology Princess M argaret H ospital, University H ealth
University of Wisconsin School of M edicine Toronto, O ntario, Canada
and Public H ealth Chapter 66
M adison, Wisconsin
Chapter 132 Gerald H. Jordan, MD, FACS, FAAP
Professor of Urology
Axel Heidenreich, MD Eastern Virginia M edical School
Professor and Chairman of Urology Director of Adult Reconstructive Surgery
Department of Urology The Devine Center for Genitourinary Reconstruction
RWTH University Aachen Sentara N orfolk General H ospital
Aachen, Germany Devine-Fiveash Urology, Ltd.
Chapter 65 N orfolk, Virginia
Chapters 68, 72 and 78
Contrib utors xix
David B. Joseph, MD, FACS, FAAP Moses M. Kim, MD

Professor of Surgery Scoot Department of Urology
Department of Surgery Baylor College of M edicine
University of Alabama at Birmingham H ouston, Texas
School of M edicine Chapter 139
Chief of Pediatric Urology
Department of Surgery Andrew J. Kirsch, MD, FAAP, FACS
Children’s H ospital Clinical Professor of Urology
Birmingham, Alabama Department of Pediatric Urology
Chapter 101 Children’s H ealthcare of Atlanta
Emory University School of M edicine
George W. Kaplan, MD Atlanta, Georgia
Clinical Professor Chapter 104
Department of Surgery (Urology) and Pediatrics
University of California at San Diego School of M edicine
Chief Department of Urology Adam P. Klausner, MD
Rady Children’s H ospital San Diego Associate Professor, Division of Urology
San Diego, California Virginia Commonwealth University School of M edicine
Chapter 119 Richmond, Virginia
Chapter 13
Evan J. Kass, MD, FAAP, FACS
Chief of Pediatric Urology Eric A. Klein, MD
Department of Urology Chairman
William Beaumont Children’s H ospital Glickman Urological and Kidney Institute
Rouaz O ak, M ichigan Professor of Surgery
Chapter 99 Cleveland Clinic Lerner College of M edicine
Cleveland, O hio
Melissa R. Kaufman, MD, PhD Chapters 21 and 83
Assistant Professor
Vanderbilt University, Department of Urologic Surgery Chester J. Koh, MD, FAAP
N ashville, Tennessee Division of Pediatric Urology
Chapter 49 Childrens H ospital Los Angeles
Los Angeles, California
Louis R. Kavoussi, MD Chapter 105
Chairman and Waldbaum Professor of Urology
Smith Institute for Urology
H ofstra University School of M edicine Harry P. Koo, MD, FAAP, FACS
N orth Shore-LIJ H ealth System Barbara and William Thalhimer Professor
Long Island, N ew York Division of Urology
Chapter 130 Virginia Commonwealth University School of M edicine
Chairman of Urology
Thomas E. Keane, MD Division of Urology/Department of Surgery
Professor and Chair VCU M edical Center-M edical College of Virginia
Department of Urology Richmond, Virginia
M edical University of South Carolina Chapter 67
Charleston, South Carolina
Venkatesh Krishnamurthi, MD
Chapter 29
Howard H. Kim, MD Cleveland Clinic
Cleveland, O hio
Fellow and Instructor
Chapter 12
Department of Reproductive
M edicine and Urology Sanjaya Kumar, MD, MPH
Weill Cornell M edical College
President and Chief M edical O fficer
Assistant
Q uantros, Inc.
M ilpitas, California
N ew York-Presbyterian/Weill Cornell
Chapter 5
M edical Center
N ew York, N ew York Chad A. LaGrange, MD
Chapters 53, 57 and 62
Assistant Professor
Ja-Hong Kim, MD University of N ebraska
Department of Urology O maha, N ebraska
University of California Chapter 126
Chapters 47 and 48
xx Contrib utors
Costas D. Lallas, MD, FACS Ronald W. Lewis, MD

Assistant Professor M edical College of Georgia
Department of Urology Augusta, Georgia
Thomas Jefferson University Chapter 75
Assistant Professor
Department of Urology John A. Libertino, MD
Jefferson Kimmel Cancer Center Professor
Philadelphia, Pennsylvania Department of Urology
Chapters 128 and 131 Tufts University School of M edicine
Boston, M assachusetts
Cheryl T. Lee, MD Chair
Associate Professor Institute of Urology
Department of Urology Lahey Clinic M edical Center
University of M ichigan Burlington, M assachusetts
Ann Arbor, M ichigan Chapter 6
Chapter 16 Mark R. Licht, MD
Urology Associates of South Florida
Michael C. Lee, MD Boca Raton, Florida
Resident Physician Chapter 75
Cleveland Clinic James E. Lingeman, MD
Cleveland, O hio Director of Research
M ethodist H ospital Institute for Kidney Stone Disease
Richard S. Lee, MD Indianapolis, Indiana
Urology Resident Chapter 25
University of Washington
Seattle, Washington Richard E. Link, MD, PhD
Chapter 116 Associate Professor of Urology
Director, Division of Endourology and
M inimally Invasive Surgery
Gary E. Lemack, MD Scott Department of Urology
Professor and Residency Program Director Baylor College of M edicine
Department of Urology H ouston, Texas
University of Texas Southwestern M edical Center Chapter 139
Dallas, Texas
Chapter 34 Larry I. Lipshultz, MD
Professor, Scott Department of Urology
Jeffrey A. Leslie, MD Lester and Sue Smith Chair in Reproductive M edicine
Assistant Professor Chief, Division of M ale Reproductive M edicine
Department of Urology and Pediatrics and Surgery
University of Texas H ealth Science Center at San Antonio Baylor College of M edicine
Pediatric Urologist H ouston, Texas
Department of Urology Chapter 60B
Christus Santa Rosa Children’s H ospital
San Antonio, Texas Jeffrey C. Lou, MD
Chapter 117 Urologic Specialists of Virginia
Richmond, Virginia
Michael Leveridge, MD, FRCSC Chapter 29
Clinical Fellow-Urologic O ncology
Division of Urology Lior Lowenstein, MD, MS
University of Toronto Urogynecologist
Clinical Fellow-Urologic O ncology O bstetrics and Gynecology
Department of Surgical O ncology Ruth and Bruce Rapapport Technion
Division of Urology School of M edicine
University H ealth N etwork Rambam M edical Center
Princess M argaret H ospital H aifa, Israel
Toronto, O ntario Chapter 51
Chapter 66
Charles M. Lynne, MD, FACS
Christina Lewicky-Gaupp, MD Victor A. Politano Professor of Urology
Urogynecology Fellow University of M iami M iller School of M edicine
Department of O bstetrics and Gynecology M iami, Florida
University of M ichigan Chapter 61
Ann Arbor, M ichigan
Chapter 40
Contrib utors xxi
Ziv Maianski, MD Irene McAleer, MD

Visiting Fellow Assistant Clinical Professor
Department of Surgery, M cGill University Department of Pediatrics
Visiting Fellow University of California, San Francisco
Department of Urology Pediatric Urologist
St. M ary’s H ospital Department of Urology
M ontreal, Q uebec, Canada Children’s H ospital Central California
Chapter 58 M adera, California
Chapter 119
John H. Makari, MD, MHA, MA
Assistant Professor Jack W. McAninch, MD
Department of Surgery, Division of Urology Professor of Urology
University of Connecticut School of M edicine Chief of Urology
Farmington, Connecticut San Francisco General H ospital
Attending Surgeon San Francisco, California
Department of Urology Chapters 9, 36 and 77
Connecticut Children’s M edical Center
H artford, Connecticut Kurt A. McCammon, MD
Chapter 107 Assistant Professor and Program Director
David T. Marshall, MD, MS Eastern Virginia M edical School
Associate Professor, Resident Training Program Director N orfolk, Virginia
Department of Radiation O ncology Chapter 81
M edical University of South Carolina
Attending Physician W. Scott McDougal, MD
Department of Radiation O ncology Walter Kerr, Jr. Professor of Urology
M edical University H ospital Department of Urology
Charleston, South Carolina H arvard M edical School
Chapter 30 Chief of Urology
Fray F. Marshall, MD M assachusetts General H ospital
Professor of Urology Boston, M assachusetts
Emory University School of M edicine Chapter 71
Department of Urology, The Emory Clinic John W. McGillicuddy MD
Emory University School of M edicine Assistant Professor of Surgery
Atlanta, Georgia M edical University of South Carolina
Chapter 4 Charleston, South Carolina
Chapter 10
Frances M. Martin, MD
Urology Resident David E. McGinnis, MD
The University of Kentucky Clinical Assistant Professor of Urology
Chandler M edical Center Thomas Jefferson University
Lexington, Kentucky The Bryn M awr Urology Group
Chapter 26 Rosemont, Pennsylvania
Chapter 127
Viraj A. Master, MD
Assistant Professor Edward J. McGuire, MD
Urology and Winship Cancer Institute Professor
Emory University Department of Urology
Attending Surgeon University of M ichigan
Department of Urology Ann Arbor, M ichigan
Emory University H ospital Chapters 18 and 40
Atlanta, Georgia
Chapter 4
Leslie T. McQuiston, MD
Brian R. Matlaga, MD Pediatric Surgery
James Buchanan Brady Urological Institute Dartmouth-H itchcock M edical Center
The Johns H opkins University School of M edicine Lebanon, N ew H ampshire
Baltimore, M aryland Chapter 106
Chapter 25
Aaron J. Milbank, MD
Sarah E. McAchran, MD M etro Urology Robotic Surgery Center
Assistant Professor Woodbury, M innesota
UW M adison School of M edicine & Public H ealth
M adison, Wisconsin
Chapter 46
xxii Contrib utors
Rosalia Misseri, MD Unyime O. N seyo, MD, FACS

Assistant Professor University of Florida College of M edicine
Indiana University School of M edicine Chief, Urology Section
Department of Urology, Riley H ospital for Children N F/SG Veterans H ealth System
Indianapolis, Indiana Gainesville, Florida
Blake W. Moore, MD David M. N udell, MD

Division of Urology El Camino H ospital
Virginia Commonwealth University San Jose, California
Richmond, Virginia Chapter 60B
Chapter 67
Rafael N unez-N ateras, MD
Allen F. Morey, MD Research Fellow
Professor of Urology M ayo Clinic
University of Texas Southwestern Phoenix, Arizona
Dallas, Texas Chapter 128
Chapter 77
Dana A. Ohl, MD
Elizabeth R. Mueller, MD, MSME Department of Urology
Assistant Professor University of M ichigan
Department of Urology and O bstetrics/Gynecology Ann Arbor, M ichigan
M edical Director Chapter 61
Female Pelvic M edicine and Reconstructive Surgery
Joon-Ha Ok, MD
Loyola University M edical Center
M aywood, Illinois Department of Urology and Cancer Center
Chapter 51 University of California at Davis
Sacramento, California
Stephen Y. N akada, MD Chapter 27
The David T. Uehling Professor of Urology Michael C. Ost, MD
Chairman, Division of Urology
University of Pittsburgh M edical Center
UW M adison School of M edicine and Public H ealth
Division of Pediatric Urology, Children’s H ospital
M adison, Wisconsin
of Pittsburgh
Chapter 132
Pittsburgh, Pennsylvania
Kenneth G. N epple, MD Chapter 114
Resident, Department of Urology Francesco Pagano, MD
University of Iowa
Professor of Urology
Iowa City, Iowa
Venetian Institute of M olecular M edicine
Chapter 113
Consultant
John A. N esbitt, MD Department of Urology
Attending Urologic Surgeon S. Antonio H ospital
Department of Surgery Padova, Italy
T.J. Sampson Community H ospital Chapter 88
Glasgow, Kentucky Michael L. Paik, MD
Chapter 80
N orthwest Urological Associates SC
Victor W. N itti, MD Arlington H eights, Illinois
Professor and Vice Chairman Chapter 7
N ew York University School of M edicine Bhavin N . Patel, MD
Attending Physician Resident
N YU Langone M edical Center Wake Forest University
N ew York, N ew York Winston-Salem, N orth Carolina
Thomas E. N ovak, MD Kenneth M. Peters, MD

Fellow, Pediatric Urology Chairman
James Buchanan Brady Urological Institute Department of Urology
Johns H opkins M edical Institutions William Beaumont H ospital
Baltimore, M aryland Royal O ak, M ichigan
Contrib utors xxiii
Jonathan C. Picard, MD Raymond R. Rackley, MD

Assistant Professor Glickman Urological and Kidney Institute
Department of Urology Cleveland Clinic
M edical University of South Carolina Center for Female Pelvic M edicine
Charleston, South Carolina and Reconstructive Surgery
Chapter 14 Cleveland, O hio
Chapter 46
Peter-Pinto, MD
Director, Fellowship Program Michelle L. Ramírez, MD
Urologic O ncology Branch Department of Urology and Cancer Center
N ational Cancer Institute University of California at Davis
N ational Institutes of H ealth Sacramento, California
Bethesda, M aryland Chapter 27
Chapter 137
Shlomo Raz, MD
Kamal S. Pohar, MD Professor of Urology.
Assistant Professor, Department of Urology UCLA School of M edicine
O hio State University James Cancer H ospital Chief, Pelvic M edicine and Reconstructive Urology
Louis Levy Professor of Urologic O ncology Los Angeles, California
O hio State University Chapters 47 and 48
Columbus, O hio
Chapter 22 Pramod P. Reddy, MD
Associate Professor of Clinical Surgery
Hans G. Pohl, MD Cincinnati Children’s H ospital M edical Center
Assistant Professor, Pediatrics and Urology Cincinnati, O hio
George Washington University Chapter 95
Children’s N ational M edical Center
Washington, DC Martin I. Resnick, MD †
University H ospitals School of M edicine
John C. Pope, IV, MD Case Western Reserve University
Associate Professor of Urologic Surgery and Pediatrics Cleveland, O hio
Vanderbilt University Department of Urologic Surgery Chapter 7
Division of Pediatric Urology
Vanderbilt Children’s H ospital Audrey C. Rhee
N ashville, Tennessee M edical College of Georgia
Chapter 107 Augusta, Georgia
Chapter 75
Raj S. Pruthi, MD
Department of Urology Leslie M. Rickey, MD
University of N orth Carolina at Chapel H ill Assistant Professor
Chapel H ill, N orth Carolina Division of Urology, Department of Surgery
Chapter 27 Female Pelvic M edicine and Reconstructive Surgery
University of M aryland School of M edicine
Rajveer S. Purohit, MD Baltimore, M aryland
Clinical Instructor of Urology Chapter 43
Weill M edical College of Cornell University
N ew York, N ew York Hubertus Riedmiller, MD
Chapter 33 Professor and Chairman
Department of Urology and Pediatric Urology
Antonio Puras Baez, MD, FACS Julius M aximilians-University M edical School
Professor Wurzburg, Germany
Chief, Department of Urology
University of Puerto Rico, School of M edicine Richard C. Rink, MD
San Juan, Puerto Rico Robert A. Garrett Professor of Pediatric Urology
Chapter 70 Chief, Pediatric Urology
James Whitcomb Riley H ospital for Children
Susanne A. Quallich, AN P-BC, N P-C, CUN P Indiana University School of M edicine
Andrology N P Indianapolis, Indiana
University of M ichigan
Chapter 61
† Deceased
xxiv Contrib utors
Michael L. Ritchey, MD Anthony J. Schaeffer, MD

Professor of Urology, Department of Urology H erman L. Kretschmer Professor
M ayo Clinic College of M edicine Chairman, Department of Urology
Chief of Surgery, Department of Urology Feinberg School of M edicine
Phoenix Children’s H ospital N orthwestern University
Phoenix, Arizona Chairman, Department of Urology
Chapter 96 N orthwestern M emorial H ospital
Chicago, Illinois
Daniel I. Rosenstein, MD Chapter 8
Associate Chief, Department of Urology
Santa Clara Valley M edical Center Jörg Schede, MD
Clinical Faculty, Stanford University Department of Urology
San Jose, California M ainz M edical School
Chapter 77 M ainz, Germany
Chapter 93
David R. Roth, MD
Professor of Urology and Pediatrics Peter N . Schlegel, MD
Scott Department of Urology and Department of Pediatrics Professor and Chairman
Baylor College of M edicine Department of Urology
Pediatric Urology Service Weill Cornell M edical College
Texas Children’s H ospital Urologist in Chief, Department of Urology
H ouston, Texas N ew York-Presbyterian H ospital
Chapter 112 N ew York, N ew York
Chapter 59
Stephan Roth, MD
Director Curtis A. Sheldon, MD
Department of Urology and Pediatric Urology Director, Urology
University of Witten/H erdecke Professor of Surgery
Klinikum Wuppertal University of Cincinnati College of M edicine
Wuppertal, Germany Cincinnati Children’s H ospital M edical Center
Chapter 94 Cincinnati, O hio
Chapter 95
Eric S. Rovner, MD
Donald G. Skinner, MD
Professor of Urology, Department of Urology
Attending, Department of Urology Professor and Chairman, Department of Urology
M edical University of South Carolina USC Keck School of M edicine
Charleston, South Carolina Los Angeles, California
Ariana L. Smith, MD
Randall G. Rowland, MD, PhD
Fellow in Female Urology, Urodynamics and Pelvic
Professor and Chief of Surgery (Urology)
Reconstructive Surgery
Program Director (Urology)
David Geffen School of M edicine, UCLA
University of Kentucky College of M edicine
Lexington, Kentucky
Chapters 47 and 48
Chapter 26
Howard M. Snyder, III, MD
H. Gil Rushton, MD Professor of Urology
Department of Urology University of Pennsylvania
George Washington University Philadelphia, Pennsylvania
Chairman, Urology Chapter 102
Children’s N ational M edical Center
Washington, DC Jens Sønksen, MD, PhD, DMSci
Chapter 98 Professor of Urology
H ead, Section of M ale Infertility and M icrosurgery
Jay I. Sandlow, MD Department of Urology, H erlev H ospital
Professor and Vice-Chair University of Copenhagen
Departments of Urology and O bstetrics/Gynecology Copenhagen, Denmark
M edical College of Wisconsin Chapter 61
M ilwaukee, Wisconsin
Chapter 54 Douglas G. Stein, MD
Attending Surgeon, Division of Surgical Subspecialties
Harriette M. Scarpero, MD University Community H ospital
Assistant Professor Tampa, Florida
Department of Urologic Surgery Chapter 55
Vanderbilt University M edical Center
N ashville, Tennessee
Chapter 49
Contrib utors xxv
John P. Stein, MD † Cigdem Tanrikut, MD

Associate Professor of Urology Assistant Professor of Surgery (Urology)
USC Keck School of M edicine Adjunct Assistant Professor of Urology and Reproductive
Los Angeles, California M edicine
Chapter 89 H arvard M edical School
Assistant in Urology, Department of Urology
Raimund Stein, MD, FEAPU M assachusetts General H ospital
Assistant Professor of Urology Boston, M assachusetts
Department of Urology Weill M edical College of Cornell University
Johannes Gutenberg University N ew York, N ew York
M ainz, Germany Chapter 60A
Chapter 84
Rodney J. Taylor, MD
Peter L. Steinberg, MD University of Louisville M edical Center
Chief Resident Louisville, Kentucky
Section of Urology, Department of General Surgery Chapter 11
Dartmouth-H itchcock M edical Center
Lebanon, N ew H ampshire Raju Thomas, MD
Chapters 37 and 38 Professor and Chair
Stephen E. Strup, MD Tulane University H ealth Sciences Center
University of Kentucky N ew O rleans, Louisiana
Division of Urology Chapter 135
Lexington, Kentucky
Chapter 126 Joachim W. Thüroff, MD
Urs E. Studer, MD
Professor and Chairman University M edical Center
Department of Urology Johannes Gutenberg University
University H ospital Bern M ainz, Germany
Bern, Switzerland Chapters 84, 90 and 93
Chapters 85 and 86
Edouard J. Trabulsi, MD
David A. Swanson, MD
Associate Professor of Urology
Clinical Professor, Department of Urology Kimmel Cancer Center
The University of Texas M D Anderson Cancer Center Thomas Jefferson University
H ouston, Texas Philadelphia, Pennsylvania
Danielle D. Sweeney, MD Burkhard Ubrig, MD
University of Pittsburgh M edical Center Department of Urology and Pediatric Urology
Division of Pediatric Urology, Children’s H ospital Witten/H erdecke University
of Pittsburgh Klinikum Wuppertal GmbH
Pittsburgh, Pennsylvania Wuppertal, Germany
Shahin Tabatabaei, MD Sandip Vasavada, MD
Assistant Professor of Surgery Associate Professor, Department of Urology
Department of Urology Cleveland Clinic
H arvard M edical School Cleveland, O hio
Assistant Professor of Surgery Chapter 46
M assachusetts General H ospital Davis P. Viprakasit, MD
Boston, M assachusetts Chief Resident, Department of Urology
Chapter 71 N orthwestern University Feinberg School of M edicine
Chicago, Illinois
Samir S. Taneja, MD
Chapter 8
The James M . N eissa and Janet Riha N eissa
Associate Professor of Urologic O ncology Bryan B. Voelzke, MD
Director, Division of Urologic O ncology Assistant Professor
N ew York University Department of Urology
Director, Division of Urologic O ncology H arborview M edical Center and The University of
N YU Langone M edical Center Washington M edical Center
N ew York, N ew York Seattle, Washington
† Deceased
xxvi Contrib utors
Kristofer R. Wagner, MD Hsi-Yang Wu, MD

Director of Robotic Surgery Assistant Professor of Urology
Assistant Professor of Surgery University of Pittsburgh
Division of Urology Children’s H ospital of Pittsburgh
Scott and White H ealth System Pittsburgh, Pennsylvania
Texas A& M H ealth Science Center College of M edicine Chapter 102
Temple, Texas
Chapter 129 Chad Wotkowicz, MD
Chief Resident
Jack R. Walter, MD Department of Urology
Duke University M edical Center Lahey Clinic
Durham, N orth Carolina Burlington, M assachusetts
George D. Webster, MB, FRCS Richard N . Yu, MD

Professor of Urologic Surgery Scott Department of Urology
Division of Urology Baylor College of M edicine
Duke University M edical Center H ouston, Texas
Durham, N orth Carolina Chapter 105
Chapter 35
Helen G. Zafirakis, MD
Alon Z. Weizer, MD, MS Fellow, Urinary Tract and Pelvic Reconstruction
Assistant Professor M D Anderson Cancer Center
Department of Urology H ouston, Texas
University of M ichigan Chapters 20 and 44
Chapter 16 Mark R. Zaontz, MD
Clinical Professor of Urology
O. Lenaine Westney, MD Department of Urology
Associate Professor Temple University School of M edicine
M D Anderson Cancer Center Philadelphia, Pennsylvania
H ouston, Texas H ead, Section of Pediatric Urology
Chapters 20 and 44 Departments of Surgery and Pediatrics
Virtua H ealth System
James Whiteside, MD Voorhees, N ew Jersey
Assistant Professor, Department of O bstetrics Chapter 103
and Gynecology
Dartmouth M edical School A. Jason Zauls, MD
Division of Urogynecology and Reconstructive Pelvic Surgery Chapter 30
Dartmouth-H itchcock M edical Center
Lebanon, N ew H ampshire Ilia S. Zeltser, MD
Chapter 42 Assistant Clinical Professor
Howard N . Winfield, MD, FACS, FRCS(c) Thomas Jefferson University
Professor of Urology and Transplantation Philadelphia, PA
Department of Urology Attending Urologist
University of Iowa Bryn M awr Urology Group
H ospitals and Clinics Academic Urology, LLC
Iowa City, Iowa Rosemont, Pennsylvania
J. Christian Winters, MD Philippe E. Zimmern, MD, FACS

Professor and Chairman Professor
Louisiana State University UT Southwestern M edical Center
N ew O rleans, Louisiana Dallas, Texas
J. Stuart Wolf, Jr., MD Armand Zini, MD

The David A. Bloom Professor Associate Professor
Department of Urology Department of Surgery
Chief, Division of M inimally Invasive Urology M cGill University
University of M ichigan H ead, Division of Urology
Ann Arbor, M ichigan Department of Surgery
Chapter 19 St. M ary’s H ospital
M ontreal, Q uebec, Canada
Chapter 58
■ R E M E M BR A N C E S
D R. JAM ES FR AN C IS G LEN N
M AY 1 0 , 1 9 2 8 – J U N E 1 0 , 2 0 0 9
O n June 10, 2009, on the eve of to his decision. There were no gray areas, and he never com-
the publication of this Seventh promised his core principles. If he was assured of the rightness
Edition, the originator of this of his position, he delivered the message regardless of the polit-
textbook, James F. Glenn, died at ical consequences. Although he usually tried to convince people
the age of 81 in Lexington, with his great sense of humor and intelligence, in the end he re-
Kentucky. I have asked two of mained steadfast in his beliefs. M any others would have taken
his closest friends and urologic the easier road, but Jim Glenn was not an ordinary man, and
colleagues, Everett Anderson and for that reason he will forever be a guide in our lives.
Randy Rowland, to each write Jim Glenn was born in Lexington, Kentucky, on M ay 10,
their thoughts on Dr. Glenn’s ca- 1928. H e attended the local university school for the first
reer. The purpose is not to delin- 12 years of his education and then entered the University of
eate his curriculum vitae, which Rochester, where he received a BA degree in 3 years. The fast
would fill another volume of this track continued with a medical degree from Duke University
text, but to allow the reader to in 3 years. There followed a 2-year residency in General
appreciate who Jim Glenn actually was. Surgery at Peter Bent Brigham H ospital and a 3-year residency
For those of us who trained under him, Dr. Glenn was a in Urologic Surgery at Duke University. With a chosen career
mentor, a role model, and a great friend. Three personal atin academic medicine, he spent the next 2 years on the faculty
tributes defined him: integrity, loyalty, and a principled life. at Yale, followed by 2 years at Bowman Gray. Four years after
H e was always straightforward in his relationships with his completing his urologic residency he returned to Duke as
residents, colleagues, and others with whom he worked. There Chief of Urology. In 4 years he had progressed from
was never any question as to where he stood and whether he Instructor, to Assistant Professor, to Associate Professor, to
would follow through on all that he promised. It was easy to Full Professor—an unbelievable accomplishment. During his
follow someone so open, and though there may have been 17 years at Duke, he trained 67 residents, 12 of whom became
times when honesty was painful, Jim Glenn was always a gen- heads of urology at other institutions.
tleman and true to his word. Apart from his academic and professional achievements,
N early every resident, fellow, and faculty member who Dr. Glenn was known for his warmth, good humor, and con-
worked with Dr. Glenn can relate major events in his or her cern for his patients, house staff, and colleagues. H e derived
life on which Dr. Glenn had a significant influence, both pro- great pleasure in promoting his residents and senior staff. Dr.
fessionally and personally. H e treated all he worked with as Glenn knew every resident’s wife’s name and made every resi-
family and was intensely loyal to all of us. O nce he was your dent accepted into the program quickly feel that he was now a
friend, you could count on him as a friend for life. M any of us member of the Duke urology family. Dr. Glenn entertained his
who became departmental chairs and national and interna- “ family” on many occasions at his home, and when the resi-
tional leaders in urology owe him not only for the opportuni- dency period was over, he would use his many contacts to ob-
ties that he provided for us but also for being available and tain jobs for his residents in academia or private practice.
standing in when we needed help. H e truly loved all of his After leaving Duke, Dr. Glenn served as Dean of Emory
protégées, no matter how much that love was returned by University School of M edicine from 1980 to 1983 and then as
each of us. President of M t. Sinai School of M edicine, M edical Center,
Dr. Glenn had high expectations of his staff and residents, and H ospital from 1983 to 1987. Subsequently he returned
and though all of us on occasion did not meet his expectations, to Lexington and was appointed as Professor of Surgery and
after his expression of displeasure, the incident was forgiven, then Professor Emeritus of Surgery at the University of
and he never carried a grudge. H is ultimate goal was to instill a Kentucky (UK). Dr. Glenn served as Executive Director of the
compulsion for excellence, which he taught by example. M arkey Cancer Center at UK from 1989 to 1993; as Associate
Finally, he lived a life that was based on principles and was Dean for Clinical Affairs, UK College of M edicine, and Chief
unwilling to compromise those principles for political expedi- of Staff, UK H ospital, from 1993 to 1995; and as Interim
ency. H is principles were truth and excellence. H e was a per- Chair, Department of Surgery, from 1996 to 1997.
petual student; when confronted with a challenge, he gathered In addition to his administrative duties at UK, Dr. Glenn
all the data, made a decision based on his principles, and stuck maintained a close relationship with the Division of Urology.
xxvii
xxviii Re me mb rance s
H e was especially helpful in advising the division in the “ art of professional contributions from the British Association of
fundraising.” With his assistance and generosity, three en- Urological Surgeons. In 2007 Dr. Glenn was also awarded the
dowed chairs, one professorship, and two research endow- Félix Guyon M edal by the Société Internationale d’Urologie in
ments were established and funded, totaling over $9 million. Paris for his contributions to the society.
Dr. Glenn was a major contributor to advancements in Dr. Glenn actively supported community as well as univer-
both adult and pediatric urology. H e was quick to recognize sity causes and programs, helping raise money for and con-
changing trends and to adopt the best of these in his constant tributing generously to many organizations: the St. John’s
quest for excellence. Dr. Glenn was a member of 37 profes- Episcopal Church Building Fund, the UK Division of Urology,
sional societies and President of the most prestigious, includ- the Duke University Division of Urology, Transylvania
ing the American Association of Genitourinary Surgeons, the University, the Bluegrass Trust for H istorical Preservation, the
Clinical Society of Genitourinary Surgeons, the International Lexington H istory M useum, and Cardinal H ill Rehabilitation
Society of Urology, the Society for Pediatric Urology, the H ospital.
Society of Pelvic Surgeons, and the Society of University Dr. Glenn shared his wit, cheer, knowledge, and enthusi-
Urologists. H e was elected to Alpha O mega Alpha in medical asm with all people with whom he interacted, playing a con-
school and later became its President. H e was also a past- structive role in community as well as academic organizations.
President of the Southeastern Section and an honorary member We will miss him.
of five sections and of the American Urological Association.
H is curriculum vitae includes 4 textbooks, 6 exhibits, 18 sci- June 16, 2009
entific movies, 37 book chapters, and 279 manuscripts. H e E. Everett A nderson, M D ;
has received the H ugh H ampton Young Award from the Sam D . G raham , M D ;
American Urological Association and the St. Paul’s M edal for R andall G . R ow land, M D , PhD
■ P R E FA C E
In 1969 when the First Edition of Urologic Surgery was pub- H aving observed my 81st birthday and retired from active
lished, the avowed purpose of the work was to present author- clinical practice, I recognize that the time has come to pass the
itative expositions of various surgical procedures, authored by responsibility to others, and I happily do so. Two friends—Sam
acknowledged experts in the field. It was the conviction of the D. Graham Jr., M D, Director of the Johns Cancer Center in
editors that there were atlases and textbooks that presented Richmond, Virginia, and Thomas E. Keane, M D, Chairman of
urology well, but there were no volumes on surgical technique, Urology at the M edical University of South Carolina,
and that urology is—first and foremost—a surgical specialty. Charleston—have already demonstrated their proficiency in
In developing that initial effort, I was joined (and guided) co-editing previous editions. Both Dr. Graham and Dr. Keane
by my good friend and wise mentor William H . Boyce, superb are products of the Duke system, as I am.
clinician, outstanding scientist, and master surgeon. Between As our French friends say, “ Vive urologie!”
us, we were able to recruit some of the most respected uro-
logic surgeons to contribute to the volume. O ver the years, Jam es F. G lenn, BA , M D , D Sc, FA CS, FR CS
that tradition has continued, and I am forever grateful to all of
my colleagues who have given of their time, talent, and exper-
tise to the several iterations of this book.
xxix
SECTIO N I ■ ADRENAL, RENAL, URETER, PELVIS
JERO ME P. RICHIE
CHAPTER 1 ■ ANATO MY O F THE ADRENAL

GLANDS, KIDNEY, URETER, AND PELVIS
ADRENAL Emb ryo lo g y
RICARDO BEDUSCHI AND UNYIME O . NSEYO Embryologically, the ectodermal medullary elements migrate
from the same primordial neural crest that gives rise to the
The adrenal glands are paired and located high in the sympathetic chain. The mesodermal cortical tissues arise
retroperitoneum, on the anterior craniomedial aspect of the from the dorsal cells of the blastema cord at the medial aspect
kidney (Figs. 1.1, 1.2, and 1.3). Their characteristic yellow of the mesonephric bodies. H owever, the ventral cells of these
color distinguishes them from the surrounding fat or pancreas. bodies are the origin of the interstitial cells of the testis or the
They weigh approximately 5 g, but weight and size may theca cells of the ovary. The 8-week embryo has massive
change significantly after prolonged illness or as the result of adrenals, approximately the size of the kidney, and they re-
prolonged adrenocorticotropic hormone (ACTH ) stimulation. main enlarged and very vascular until birth. Rapid regression
The atrophic gland is thin and pale, and its easily recognizable occurs in the adrenal size during the first month. The large
hyperplasia makes it readily visible. The left adrenal gland has adrenal size with hypervascularity may predispose to adrenal
a semicircular or crescent shape. The right gland has an in- hemorrhage in the newborn as well as misdiagnosis for Wilms
verted pyramidal or V-shape. The adrenal gland consists of the tumor or neuroblastoma. The medullary tissue within the
cortex and medulla and arose from the mesoderm (cortex) gland imparts a unique tripartite structure of the head (most
and ectodermal (medulla) elements in the medial aspect of the medial), body, and tail (most lateral). Each adrenal gland
coelomic cavity. resides within the Gerota fascia with the kidney. H owever, in
FIGURE 1.1 The anatomic relationship of the adrenal glands to the aorta and inferior vena cava. Multiple
arterial vessels entering the glands indicate the rich arterial supply, while a single central adrenal vein illus-
trates the limited and relatively constant venous damage.
1
2 Se ct io n I: Ad re nal, Re nal, Ure te r, Pe lvis
FIGURE 1.2 An anterior view of the abdomen

illustrating the anatomic relationship of the adrenal
glands to the surrounding gastrointestinal tract and
organs.
making identification of this vein very challenging. Bleeding

from this site can be profuse and even life-threatening if not
identified and controlled immediately. The left adrenal vein is
much smaller than the right adrenal vein. It usually exits an-
teroinferiorly, draining into the ipsilateral renal vein.
Co nt ig uo us St ruct ure s
Thorough knowledge of the anatomic relationships holds the
key to preventing injury to the contiguous structures during
surgical dissection (Fig. 1.2). The right adrenal gland lies
superior to the upper pole of the right kidney, posterolaterally
FIGURE 1.3
to the IVC. Dissection of the right adrenal gland is limited me-
dially by the duodenum and superiorly by the right hepatic
lobe. Access to the right adrenal gland is more easily obtained
the case of renal ectopy, the adrenal remains in its natural by entering the retroperitoneum behind the liver. The right
position. hepatic lobe can be mobilized from the colon and diaphragm
Ectopic adrenal tissues may develop in certain locations of by transecting the triangular, coronary, and hepatocolic liga-
the body. Although rare, they may undergo neoplastic changes ments, allowing visualization of the right adrenal gland just
or hyperplasia. Ectopic adrenal tissues in most cases consist of superior to the upper pole of the right kidney. M obilization of
cortex only; rarely do they contain cortex and medulla. The the duodenum is also required for easier identification of the
embryological relationship in the urogenital ridge predisposes right adrenal vein. This step is of special interest for large
to adrenal ectopy in the retroperitoneum, the testis, the sper- pheochromocytomas, in which early access to the adrenal vein
matic cord, and the region of the celiac ganglion. is essential. Using the Kocher maneuver, the duodenum can be
retracted medially, allowing easier access to the IVC and a
complete dissection of the right adrenal vein. O nce the right
Vascular Anat o my adrenal vein is controlled, an avascular plane can be devel-
oped toward the lateral aspect of the gland, allowing quick
The arterial supply remains variable; the main sources include and bloodless removal of the gland. Attention should be paid
primarily the branches from the aorta, inferior phrenic artery, to the main arterial trunks as well as the multiple small-caliber
and renal artery. The multiple small-caliber arterial branches arteries, which can be easily controlled with electrocautery
must be appreciated for hemostasis during surgery. The and/or surgical clips.
venous drainage, although less variable, usually represents a The left adrenal gland is usually more medial than the right
bigger challenge, especially during operations on large adrenal gland, and it lies on the upper pole of the left kidney, just lat-
masses. The right adrenal vein is short and empties directly eral to the aorta. The left adrenal gland lies in close contact
into the inferior vena cava (IVC) in its most posterolateral with the spleen and stomach, and it is crossed on its anteroin-
aspect. Large adrenal tumors may obscure its visualization, ferior surface by the body of the pancreas and the splenic
Chap t e r 1: Anatomy of the Ad re nal Gland s, Kid ne y, Ure te r, and Pe lvis 3
artery and vein. A special technical effort must be made to The external oblique fibers are oriented anteriorly and inferi-
prevent inadvertent injury to the tail of the pancreas and/or orly, attaching posteriorly to the iliac crest, and the anterior
capsule of the spleen. Releasing the splenocolic ligament al- fibers attach to the linea alba in the midline (Fig. 1.4A). The
lows free mobilization of the spleen, and gentle blunt dissec- internal oblique fibers are oriented anteriorly and superiorly
tion allows medial mobilization of the left abdominal viscera (Fig. 1.4B). Posteriorly, the fibers of the internal oblique
and adequate exposure of the left adrenal gland. The left attach to the lower four ribs, and anteriorly they attach to the
adrenal vein is usually isolated in the anteroinferior aspect of linea alba. In the upper abdomen, the internal oblique fascia
the gland, and control of this vein is usually less of a problem, splits to enclose the rectus muscle, while inferiorly the fascia
with minimal blood loss (Fig. 1.3). The lowest extent of this only covers the rectus muscle anteriorly. The ilioinguinal and
gland is close to the renal vessel, which remains at risk of in- iliohypogastric nerves are found in the interior oblique fascia
jury during adrenalectomy. anterior to the internal oblique muscle. The transversus abdo-
minis are horizontally oriented fibers that attach to the linea
alba (Fig. 1.4C). The ribs are supported by the intercostal
KIDNEY muscles and fascia as well as the costovertebral (costotrans-
verse) ligament, which must be divided if the rib is to be re-
SAM D. GRAHAM, JR. tracted inferiorly (Fig. 1.5).
The kidneys are located on either side of the vertebral col-
The abdominal wall is composed of three layers of muscle and umn in the lumbar fossa of the retroperitoneum and vary in
fascia that are derived from the same embryonic muscle sheets length in adults from 11 cm to 14 cm, or from approximately
as the intercostal muscles. Each muscle is covered by its own 3.0 to 4.5 times the height of the second lumbar vertebrae
layer of deep fascia and is innervated by the intercostal nerves. (Fig. 1.1). The parenchyma of the kidney is covered by a thin
A
C
FIGURE 1.4 A: Flank incision showing the orientation of the exter-

nal oblique. This incision is subcostal and also shows the relationships
of the latissimus dorsi posteriorly. B: Exposure of the internal oblique
showing the relationship to the intercostal nerve. C: Exposure of the
B transversus abdominis and its aponeurosis.
Transverse
process
Radiate Anterior costotransverse
ligament ligament
Neck of rib
Interarticular
ligament
Intercostal
Synovial muscle
membrane
Anterior
longitudinal FIGURE 1.5 Costovertebral (costotransverse) ligaments
ligament extend from the transverse process of the vertebra imme-
diately above the rib to the neck of the rib. In order to
gain exposure during a thoracolumbar or supracostal
approach, this must be divided to allow the rib to rotate
inferiorly.
transparent capsule, which in turn is covered by a layer of per- by connective tissue septae. Anteriorly, Gerota fascia is closely
inephric fat enclosed in a distinct layer of fascia (Gerota fas- applied to the peritoneum. O n the left, the hilum of the spleen
cia) (Fig. 1.6). The capsule is attached to Gerota fascia by is attached to the ventral aspect of the kidney by a double layer
fibrous trabeculae (1). Gerota fascia is completely fused of peritoneum known as the splenorenal ligament (2).
superiorly and laterally, but it is open inferiorly and to some
extent medially, where it is adherent to the adventitia of the
renal vessels, aorta, and inferior vena cava. Gerota fascia Vascular Anat o my
extends above the kidney to form a special compartment for
the adrenal gland (2). Posteriorly, Gerota fascia is connected to The main renal arteries are branches of the aorta emanating
the sheaths of the psoas and quadratus lumborum muscles from the lateral portion of the aorta at approximately L-2. In
general, the renal arteries divide into segmental branches at
the junction of the middle and final third of their course. A
single left artery most commonly lies dorsal to the renal vein,
and a long right renal artery lies dorsal to the vena cava and
the renal vein. Up to 35% of kidneys have an accessory renal
artery, with 1.5% having more than one accessory artery (2).
As the renal artery approaches the hilum, it has two branches,
the inferior suprarenal (adrenal) and the ureteric arteries
(Fig. 1.6). At the hilus, the main renal artery divides into an
Adrenal
anterior and posterior branch, which further divide into seg-
gland
mental arteries. The kidney can be divided into four segments
based upon the arterial supply (Fig. 1.7). Both the apical and
basilar segmental arteries supply each respective pole of the
kidney anteriorly and posteriorly. The largest segment is the
anterior segment, which is supplied by two segmental arteries
and extends posteriorly to the avascular plane where it meets
Posterior the posterior segment (3).
layer of The renal veins directly join the vena cava. The right renal
Gerota fascia vein is usually less than one-half the length of the left renal
Anterior layer vein and has no significant branches. The left renal vein, how-
of Gerota fascia
ever, is usually joined by the adrenal and inferior phrenic vein
Colon superiorly, the gonadal vein inferiorly, and frequently by lum-
bar vein(s) posteriorly (Fig. 1.8). These collaterals are of great
Peritoneum importance in patients in whom the vena caval ligation or re-
section is contemplated.
FIGURE 1.6 Retroperitoneal anatomy showing Gerota fascia in The renal vein is usually the most anterior structure in
sagittal section. the renal hilum. Posterior to the vein is the renal artery, and
Chap t e r 1: Anatomy of the Ad re nal Gland s, Kid ne y, Ure te r, and Pe lvis 5
Anterior
Posterior
Basilar
Renal artery
and vein
Renal
pelvis
Apical
FIGURE 1.7 Segmental anatomy of the kidney. The relatively avascu-

lar plane between the anterior and posterior segments is the line of
Brödel. In general, calyces tend to extend from the renal pelvis to the
central mass of the segment they supply.
FIGURE 1.9 Transverse section of kidney showing relative anatomy
of vascular structures in the renal hilum.
Co nt ig uo us St ruct ure s (Fig . 1.10)

Posterior to the kidney lies the psoas major and quadratus
lumborum muscles. Posteriorly and superiorly, the upper pole
of each kidney is in contact with the diaphragm. The pleura is
also adjacent to the upper poles of both kidneys, usually
extending down below the level of the twelfth rib posteriorly
and to the eleventh rib anteriorly (1).
Embryologically, when the gut rotates, this leaves the pos-
terior parietal peritoneum covering the upper three-fourths of
the right kidney and is directly related to the hepatorenal
pouch of M orrison. The duodenum is fixed to the original
peritoneal covering of the lower pole of the right kidney by
fusion of the embryonic dorsal mesentery to the posterior
FIGURE 1.8 The complex and varied anatomy of the left renal vein.
N ote that there may be one or even two lumbar veins from the renal
parietal peritoneum (2). O n the left, the rotation of the foregut
vein posteriorly, allowing alternative venous flow if the vena cava is causes a fusion of the embryonic mesogastrium with the origi-
occluded. nal peritoneal covering of the upper anterior kidney, thereby
causing the relationship of the left kidney to the omental bursa
(2). The midportion of the left kidney loses its contact with the
peritoneum due to growth of the tail of the pancreas.
the most posterior structure in the hilum is the renal pelvis. Superiorly, the anteromedial surface of the right kidney is
The hilum is filled with fibrofatty tissue that can usually be in contact with the right adrenal gland. The liver overlies the
easily dissected from these structures to allow access into the anterior two-thirds of the right kidney, and the hepatic flexure
renal sinus (Fig. 1.9). of the colon overlies the lower one-third of the right kidney.
The second portion of the duodenum overlies the renal hilum.
In 90% of patients, the right kidney is lower than the left
Lymp hat ic Anat o my (2).
The medial surface of the left kidney is also in contact
Parenchymal and capsular lymphatics coalesce and drain into with the left adrenal gland. O ther structures anterior and in
the right lumbar or paraaortic chains, respectively. These lym- close approximation to the left kidney are the spleen, the tail
phatics become part of the cisterna chylae superior to the of the pancreas, the stomach, and the splenic flexure of the
renal artery. colon.
Spermatic artery
Aorta
Spleen
Inferior
vena cava
Portal vein
Right
adrenal gland
Duodenum
Right
kidney
Pancreas
Quadratus
lumborum muscle
Psoas
major muscle
Right ureter
Right spermatic
artery and vein
FIGURE 1.10 The kidney in relation to contiguous structures.
References
1. Bergman EV, Bruns P, von M ikulicz J. A system of practical surgery, Vol. 5. 3. Stewart BH . O perative urology: the k idneys, adrenal glands, and retroperi-
N ew York: Lea Brothers, 1904. Bull WT, Foote EM , translators. toneum . Baltimore: Williams & Wilkins, 1975.
2. H ealey JE Jr, Seybold WD. A synopsis of clinical anatom y. Philadelphia:
WB Saunders, 1969.
CHAPTER 2 ■ PARTIAL NEPHRECTO MY

SAMIR S. TANEJA
While partial nephrectomy was described over 125 years ago, nephrectomy. Despite these developments, recent surveys sug-
its widespread use is truly confined to the last 20 years (1,2). gest that partial nephrectomy remains underutilized nationally
Partial nephrectomy is utilized for a number of urologic in the treatment of small renal tumors.
processes, including stone disease, nonfunction within a dupli-
cated moiety, trauma, infection, and renal tumors. Within the
last 10 to 20 years, the major application of partial nephrec- INDICATIO NS
tomy has been in the treatment of small renal tumors as an
alternative to radical nephrectomy (1,2). Downward stage mi- The primary indication for partial nephrectomy is in the resec-
gration, more frequent incidental detection of tumors, better tion of renal tumor. The procedure may also be performed for
imaging techniques, and increasing surgeon comfort have led a nonfunctioning duplicated moiety, trauma, or stone disease,
to increased utilization and expanded indications for partial in addition to a number of less common indications. While it
Chap t e r 2: Partial Ne p hre ctomy 7
is acceptable to remove a solitary kidney or both kidneys if re-

quired for oncologic efficacy, in general, the presence of tumor Re nal Pre p arat io n
in a solitary kidney or bilaterally is considered an absolute in-
In preparing a kidney for partial nephrectomy, full renal mo-
dication for partial nephrectomy. Likewise, cases in which
bilization is most often necessary. The selected incisional ap-
radical nephrectomy would result in a need for permanent
proach can include a transperitoneal subcostal or midline
dialysis due to severe baseline azotemia should be considered
incision, a thoracoabdominal incision, or an extraperitoneal
absolute indication. In these cases, “ absolute” implies that
flank incision, but when performing the operation through the
partial nephrectomy should be contemplated regardless of the
flank, full mobilization is possible, allowing the kidney to eas-
tumor size or stage.
ily stretch to the level of the skin. We have found that other
Relative indications include medical illnesses predisposing
advantages of the flank approach include containment of
to renal disease, pre-existing medical renal disease, renal
postoperative bleeding and/or urine leak, earlier resolution of
stones, recurrent renal infection, mild azotemia, and multifo-
ileus, and direct access to the kidney.
cal tumors associated with a genetic syndrome. An elective
During renal mobilization, minimal handling of the kidney,
partial nephrectomy is defined as that in which the patient has
avoidance of torque on the pedicle, and care to the position of
none of the above risk factors, normal renal function, and a
the ureter to avoid crush injury are advisable. Rough handling
radiologically normal contralateral renal moiety. H istorically,
can lead to subcapsular hematoma, capsule avulsion, va-
elective partial nephrectomy has been recommended only for
sospasm, and the potential for acute tubular necrosis (ATN ).
exophytic or peripherally located tumors 4 cm in size. M uch
Destruction of the renal capsule during mobilization adds to
of the literature on which this recommendation was made was
the difficulty of reconstruction later in the operation.
based upon series in which worsened oncologic outcomes
When mobilizing the kidney, knowledge of variations
were noted for central tumors and those 4 cm in size. Within
in the renal arteriovenous anatomy is essential (Fig. 2.1).
these series, it is notable that many of these larger or central
Anomalous or supernumerary renal vessels are common, and
tumors were removed for absolute indications, potentially bi-
early recognition will avoid inadvertent vascular injury. We
asing the oncologic outcomes. As surgeons have become com-
have found magnetic resonance imaging (M RI) to be useful in
fortable with the technique, indications for elective partial
assessing the number and position of renal hilar vessels (5),
nephrectomy have been expanded to include central tumors
but certainly a good computerized tomographic (CT) image
and those in the T1b (4- to 7-cm) category. Thus far, there is
should allow this as well. In resecting hilar or deep intra-
no apparent decline in cancer control among those series
parenchymal tumors, a good M R or CT angiogram is advis-
reported (2).
able to understand the relationship of vessels to the tumor.
Recent studies have suggested that partial nephrectomy
Polar renal arteries are usually divided to facilitate renal
may result in better long-term renal function than radical
mobility as they usually feed only a small portion of the renal
nephrectomy (3). A large cohort comparison demonstrated a
pole (apical branch) but may greatly limit mobility. In patients
higher likelihood of a glomerular filtration rate (GFR) 45 mL
with a left-sided renal tumor and a retroaortic renal vein, hilar
per minute or 60 mL per minute among those undergoing
mobilization can be difficult, and stretching of the kidney to
partial nephrectomy as compared to radical nephrectomy (4).
the skin may not be possible. As these are often secondary
Because GFR strongly correlates with the likelihood of cardio-
renal veins, division of the vein could be considered if another
vascular mortality and other medical illnesses, in this regard
exists and mobility is limited. Because the renal venous
partial nephrectomy may be beneficial.
anatomy has collateral parallel branches, venous branches
can generally be divided to increase mobility without major
sequelae.
ALTERNATIVE THERAPIES Upon full mobilization of all hilar attachments, the renal
vessels can be followed into the hilum to identify first and
Alternative therapies to open partial nephrectomy include rad- second segmental branchings. This may allow selective renal
ical nephrectomy, laparoscopic partial nephrectomy, laparo- ischemia or arterial ligation if the tumor is located conve-
scopic radical nephrectomy, or laparoscopic/percutaneous niently within one segment. We have found this to be rare, and
ablative procedures. A discussion of candidate selection for more often early ligation of segmental branches results in
open or laparoscopic partial nephrectomy is beyond the scope inadequate ischemia and infarct within nonoperated areas of
of this chapter. Selection in this regard is highly dependent the kidney (Fig. 2.2). Therefore, it is generally preferable to
upon operator experience. clamp the main renal artery.
It is our preference to provide renal ischemia to facilitate
renal incision and margin control, but this is certainly not uni-
SURGICAL TECHNIQ UE formly necessary. Depending upon tumor location and depth,
simple manual compression may be adequate to allow resec-
The technique of partial nephrectomy can be divided into tion. Pitfalls of manual compression during incision include
renal preparation, renal incision, vascular repair and hemo- the potential for subcapsular hematoma, bleeding despite
stasis, and collecting system reconstruction. These funda- compression, poor view of the margin, destruction of the spec-
mental aspects of the operation should be considered imen, and the potential for ATN despite renal perfusion.
individually in order for the surgeon to master the tech- Avoidance of renal ischemia is particularly appealing in pa-
nique. It is most important to remember that despite the de- tients at high risk of ATN due to baseline renal disease and de-
sire to preserve the kidney, partial nephrectomy for tumor is creased GFR, or in those with a solitary kidney in whom
first a cancer operation, and margin control remains the transient renal dysfunction could have deleterious short-term
primary consideration. effects.
Anterior superior
segmental artery
Apical segmental
artery
Inferior suprarenal
artery
Renal artery
Posterior segmental
artery
Anterior inferior
segmental artery
Inferior segmental
artery
FIGURE 2.1 The renal arterial anatomy is generally pre-

dictable, with five major known segments: basilar or inferior,
apical, anterior superior, anterior inferior, and posterior. Based
upon the position of the tumor, a prediction can be made
regarding the number of segments involved. This allows the
direction and angle of the line of incision to be planned.
Tumor
If incision If incision
begins here, Tumor begins here,
then then
area of infarct
here area of infarct
here
A B
FIGURE 2.2 When incising the kidney from the hilar aspect of a tumor, particularly a tumor in the ante-
rior or posterior segment, the incision will often result in infarct radial to the position of the tumor.
Therefore, incising the kidney along the border of the tumor opposite the hilum will allow the tumor to
be “ lifted” from the kidney, exposing only those vessel branches that extend directly into the tumor.
We have utilized renal ischemia primarily to allow good vi- hilum. The closed end of the bag is cut open and filled with ice
sualization of the margin. Prior to clamping the renal artery, for purposes of in situ cooling. The kidney is packed in ice for
12.5 g of mannitol is administered intravenously and allowed 10 minutes prior to clamping the renal artery to allow surface
to circulate for 5 to 10 minutes. The kidney is placed in an cooling. During this time, intraoperative ultrasound may be
intestinal/bowel bag and the drawstring cinched around the performed to assess tumor location and plan the resection.
The renal artery is then clamped with a small spring-loaded planned so as to maintain perfusion to the remaining renal
“ bulldog” clamp. We have found it unnecessary to clamp the segments following resection. In so doing, the surgeon mini-
renal vein in open partial nephrectomy, even for deep resection, mizes the risk of renal infarct.
as the vein is often compressed by stretch of the hilum and/or For tumors located in a single segment, we have generally
manual compression of the parenchyma. In cases of multiple utilized an approach of total renal ischemia. An exception to
arteries, it may be easier to mass-clamp the hilum with a this rule might be in cases of anomalous vasculature in which
straight or angled vascular clamp, but this may give inadequate multiple renal arteries are encountered. In these cases, it may
ischemia and venous hypertension if not properly applied. not be necessary or advisable to clamp all arteries if the tumor
Conventional wisdom states that the kidney should be is confined to a polar region of the kidney.
packed completely in ice for 10 to 20 minutes prior to resec- Tumor position can be best assessed by a combination of
tion in order to cool the core temperature to 20°C. As cold preoperative imaging and intraoperative ultrasound. O ur ap-
ischemia extends the period of safe ischemia from 30 to 40 proach with intraoperative ultrasound has been to pass the
minutes up to a theoretical 3 hours, this cooling is probably probe over the kidney in radial angles to the center of the tu-
necessary for anticipated prolonged resection beyond 30 to 40 mor. This allows assessment of the subcortical extent of the
minutes. In general, it has been our preference to proceed with tumor by assessing the transition from normal kidney to tu-
resection immediately upon placing the arterial clamp, while mor interface in multiple planes (Fig. 2.3).
assigning a member of the operating room team to monitor Renal incision should be carried out at a level adequate to
and maintain the submersion of the kidney in ice throughout provide a 1- to 2-cm margin of normal parenchyma. It should
the resection. In using this approach, we have been able to be noted that recent literature suggests that locoregional onco-
keep the overall cold ischemia time low while maintaining ad- logic control is dependent upon a negative margin, and not the
equate cooling of the parenchyma. thickness of margin.
N onetheless, in planning a minimum 1-cm margin, the fi-
nal specimen often shows a thinner margin due to splaying
Re nal Incisio n and Marg in Co nt ro l and retraction of the normal parenchyma around the more
dense tumor upon incision of the capsule.
Renal incision planning is based upon position of the tumor For tumors that lie within 10 mm of the renal sinus, inci-
and the arterial segment of kidney involved. For tumors lying sion should be carried into visible sinus fat to ensure adequacy
within the anterior and posterior segment, a wedge resection of margin. The same can be said for tumor within 10 mm of
technique is generally employed, whereas tumors located in the collecting system. In cases of tumor abutting the collecting
the apical or basilar segments are generally managed by system, calyceal excision will usually provide an adequate
straight or tangential polar resection. In those cases in which margin. For those tumors invading or lying within the renal
the tumor lies across multiple segments, incision should be sinus fat, it is often difficult to obtain a thick margin due to
Anterior view
Ultrasound
Hilum Tumor
Tumor
Ultrasound
FIGURE 2.3 When performing intraoperative ultrasound for assess-

ment of the renal tumor, the probe is passed over the kidney in radial
A angles to the center of the tumor. This allows assessment of the sub-
cortical extent of the tumor in each angle, by assessing the transition
from normal kidney to tumor interface in multiple planes. O n the ba-
sis of this assessment, the position and line of incision are selected.
juxtaposed blood vessels. In these cases, sharp division of the resection up to the surface of the kidney. A narrow resection
surrounding sinus fat allows the surgeon to maintain a layer bed results in a centrally retracted, “ ice cream cone” defect in
of normal tissue around the tumor capsule. which central suturing can be difficult.
The technique of polar resection usually involves division The technique of wedge resection should start with a cap-
of the renal parenchyma straight across the pole, or, if the tu- sular incision at the leading edge of the resection. The
mor has an anterior or posterior lie, the incision can be carried parenchyma is gently separated with a flat instrument. We
out at a tangential angle. In polar amputation, central vascu- have utilized two orthopedic “ freer” instruments working op-
lar retraction is less likely to occur upon dividing the kidney. posite one another to allow a well-visualized separation of the
As such, the surgeon can sharply amputate the tumor/pole parenchyma (Fig. 2.5). Individual vessels entering the tumor
with a knife or scissors. The central defect is then repaired specimen are identified and directly suture-ligated with 4-0
with direct suture-ligature placement or running closure chromic catgut prior to division with tenotomy scissors.
(Fig. 2.4). Alternatively, a traditional blunt separation of the Directed suture-ligature of vessels as they branch into the
parenchyma with sequential ligation and sharp incision of re- specimen avoids vessel retraction, deeper suture placement,
nal sinus structures can be carried out. This is particularly use- and secondary injury to deeper vessels proximal to the branch
ful when attempting tangential amputation. point. Tenotomy scissors are used to divide the vessel and redi-
The technique of wedge resection within the anterior or rect the line of incision as needed. We have found that simple
posterior segment requires more thought on the part of the blunt division or fracturing of the parenchyma with a knife
surgeon as assessing the depth and width of resection, main- handle inevitably leads to tearing into the renal sinus struc-
taining blood supply to the opposite segment, and avoiding tures, regardless of the tumor position. When it is necessary to
central vessel retraction can all pose a challenge. We have pre- traverse renal sinus structures, including the collecting system,
ferred a wide resection bed to bring the deepest portion of the they should be sharply divided.
FIGURE 2.4 Polar amputation of the kidney is usually done

with a flush blunt or sharp cut across the pole, allowing for a
Tumor 1-to 2-cm margin of normal kidney around the tumor. Such cuts
can be straight across the kidney or tangential in placement.
O nce the tumor has been amputated, the collecting system and
central vessels are closed with interrupted absorbable sutures. A
hemostatic bolster is then placed on the defect and sewn into
place with horizontal mattress sutures pledgeted to the sur-
rounding renal capsule.
A B
We do not routinely employ intraoperative frozen sections

to assess tumor margin. It has been suggested recently that
such margins are rarely informative. Exceptions may be in the
renal sinus when invasion into fat is suspected or when gross
tumor violation is noted. In these cases, the presence of resid-
ual tumor in the sinus or resection bed may warrant consider-
ation for nephrectomy.
Blood vessel Re nal Re co nst ruct io n

Renal reconstruction following tumor excision can be di-
vided into vascular and collecting system repair. As these
structures are juxtaposed, it is often necessary to provide si-
multaneous closure. Renal reconstruction usually involves
three basic tenets: (a) closure of the collecting system; (b) di-
rect suture repair of large vessels; (c) prevention of vascular
A
retraction within the sinus; and (d) radial compression of the
defect.
In the technique of wedge resection, the majority of ves-
sels are sutured-ligated during the incision. Thus, upon re-
moval of the arterial clamp and reperfusion, there is
relatively little bleeding in most cases. M issed vessels or
those partially ligated are generally directly sutured with 4-0
or 3-0 chromic catgut. It is important to note that the per-
fused kidney parenchyma has more turgor than the ischemic
kidney and thus there is a tendency for sutures to “ saw”
through the parenchyma. Sutures should be placed widely
across cut vessels to allow compression of the parenchyma
around them. O pen venous channels are usually controlled
by “ figure-of-eight” suture placement or, in the case of large
openings, a running suture incorporating surrounding tissues
for compression.
The collecting system is closed with interrupted sutures of
B 4-0 polyglycolic acid suture after renal perfusion has been re-
established. While running closure can be tried, tension on the
collecting system opening often tears the fragile calyceal walls
or creates holes along the suture line. For this reason, we have
preferred a single-layer interrupted closure followed by a sec-
ond layer of imbricating parenchymal sutures to reinforce the
closure (Fig. 2.6). In polar resection, the collecting system and
central vessels can often be closed in the same layer of inter-
rupted sutures (Fig. 2.4), either before or after.
Following closure of the collecting system, retrograde in-
stillation of methylene blue in the renal pelvis by a fine-gauge
needle can confirm the integrity of closure and rule out addi-
tional sites of collecting system injury. After repair, the addi-
tion of a tissue adhesive layer can minimize the likelihood of
leak. We have utilized a layer of Gelfoam TM (Pharmacia and
Upjohn, N ew York) infiltrated with fibrin sealant (Tisseal,
Baxter International).
A folded bolster of Surgicel TM (Johnson and Johnson,
C Piscataway, N J) wrapped around fibrillar collagen (Surgicel) is
placed in the defect. The kidney is then gently compressed
FIGURE 2.5 The technique of wedge resection should start with a around the bolster using horizontal mattress sutures of 4-0
capsular incision at the leading edge of the resection. The parenchyma
is gently separated with a flat instrument. We have utilized two ortho- chromic catgut anchored to the renal capsule as a pledget.
pedic “ freer” instruments working opposite one another to allow a Following reconstruction, the kidney is returned to a nor-
well-visualized separation of the parenchyma. Individual vessels enter- mal anatomic lie with no kinking of the artery. The per-
ing the tumor specimen are identified and directly suture-ligated with inephric fat is layed over the defect and interposed between
4-0 chromic catgut prior to division with tenotomy scissors. Directed
suture-ligature of vessels as they branch into the specimen avoids ves-
the lower-pole parenchyma and the ureter to avoid peri-
sel retraction, deeper suture placement, and secondary injury to ureteral scarring. N ephropexy is only required if the kidney is
deeper vessels proximal to the branch point. notably mobile within the fossa.
FIGURE 2.6 Collecting system repair following wedge resection

should aim for a 2-layer closure. The defect is first closed with in-
terrupted 4-0 absorbable sutures anchored to the surrounding
parenchyma. The renal parenchyma is then imbricated around the
closure in a row of interrupted sutures to relieve tension on the
first line. H emostatic materials may then be used over this.
Exposed
collecting duct
A B
after 1995 (7), hemorrhage was uniformly infrequent, occurring

O UTCO MES in 1.5% and 1.2% of patients, respectively. The incidence of
acute renal failure was also much less frequent (3.8% and 1% ,
Co mp licat io ns respectively), requiring dialysis in only 2% of those operated be-
fore 1995 and in 0.6% of those treated thereafter. Urinary fis-
While partial nephrectomy is still considered by most surgeons tula or leak has also been a historically frequent complication in
to represent a technically challenging procedure, outcomes in some early series, but in the same series urine leak was noted in
recent series have suggested morbidity comparable to radical 2.6% and 0.6% of cases before and after 1995.
nephrectomy. Among 1,800 renal tumor resections performed In a phase III multicenter comparison of partial and radical
between 1991 and 1998 in 123 Veterans Affairs M edical nephrectomy, the rates of severe hemorrhage (defined as blood
Centers, no difference in the mortality and morbidity rates loss 1 L) and urinary fistula were 3.1% and 4.4% , respec-
between the radical and the nephron-sparing approach was tively. Reoperation for complications was necessary in 4.4%
observed (6). Certainly the likelihood of morbidity relates to of the nephron-sparing group and in 2.4% of the radical
operator experience and training. nephrectomy group (8). Complications such as arteriovenous
Complications from partial nephrectomy include bleeding, fistula, pseudoaneurysm due to vascular injury, ureteral stric-
urinary fistula, ureteral injury or obstruction, renal dysfunction, ture, and renal loss are extremely rare.
loss of kidney, and arteriovenous malformations. In a recent Renal infarct of small portions of the kidney is common
series comparing two groups of patients operated before and following renal reconstruction. If little perfused parenchyma is
noted upon removal of the arterial clamp, vasospasm may be T1b tumors, for those lesions 4 cm and 4 cm. In an up-
the culprit, and in these cases intra-arterial verapamil may im- dated study, Fergany et al. (11) reported on 10-year outcomes
prove perfusion. If the kidney is not viable, it should be rein 107 patients undergoing open partial nephrectomy from the
moved. The general management of infarct is observation. In same institution. Five- and 10-year CSS of 88.2% and 73% ,
cases of severe hypertension due to infarcted kidney, nephrec- respectively, was observed. In that series, only 10% of patients
tomy should be performed. had elective indication, 50% of tumors were bilateral, and
The fundamental tenet of leak management is maximal 45% were 4 cm in size. If including only the patients with
drainage of the extrarenal collection until output diminishes. In tumors 4 cm, 5- and 10-year CSS improved to 98% and
general, a ureteral stent is not necessary unless there is evidence 95% , respectively.
of ureteral obstruction, blood clots or debris within the collect- A recent update of the University of California Los Angeles
ing system, or a very large collecting system opening. Resolution partial nephrectomy series (12) allows evaluation of 15-year
of urine leak generally requires scarring in the potential space outcomes for the procedure. O verall CSS was 98% , 96% ,
around the kidney during a variable time course of weeks to and 96% at 5, 10, and 15 years of follow-up, respectively.
months. At that point the drain is slowly advanced out. Recurrence was noted in 7% , 13% , and 13% at 5, 10, and
15 years of follow-up, but it is notable that 7% of patients
had metastatic disease at time of surgery.
Re sult s In a multicenter comparison of the outcomes of partial and
radical nephrectomy among 1,454 patients (13), CSS was
A number of studies, both open and laparoscopic, have equivalent among patients undergoing partial or radical
demonstrated excellent long-term oncologic outcomes for pa- nephrectomy for either pT1a or pT1b tumor. O verall CSS at a
tients undergoing partial nephrectomy. Early reports of partial median follow-up of 62 months was 97.8% for T1a and
nephrectomy for tumor included a large subset of patients with 93.8% for T1b tumors undergoing partial nephrectomy.
absolute or relative indication for surgery. Thus, recurrence- Partial nephrectomy for tumor resection is an increasingly
free survival often reflected survival of a nonselected popula- important technique for practicing urologists to master.
tion, including those with a higher tumor stage than in a O ncologically, it is shown to be equivalent to radical nephrec-
contemporary elective partial nephrectomy series. tomy for tumors 7 cm in size, and it results in quite good on-
H afez et al. (9) reviewed the Cleveland Clinic series of 485 cologic control for even larger tumors. The long-term benefits
partial nephrectomies, of which only 9% were electively per- may be greater than initially perceived with regard to preser-
formed. They reported a significant decrease in both 5-year vation of renal function and overall health. Careful preopera-
and 10-year cancer-specific survival (CSS) for lesions 4 cm tive imaging, knowledge of renal anatomy, attention to patient
compared to those lesions 4 cm. Also observed was a statis- and tumor risk factors, and meticulous surgical technique are
tically significant correlation between recurrence and size essential for achieving good surgical outcomes. Complication
4 cm. Based on these data, these authors suggested that rates should be acceptably low if fundamental tenets of surgi-
stage T1 tumors ( 7 cm) should be subdivided into T1a and cal technique are followed.
References
1. Dash A, Vickers AJ, Schachter LR, et al. Comparison of outcomes in elec- 7. Thompson RH , Leibovich BC, Lohse CM , et al. Complications of contem-
tive partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 porary open nephron sparing surgery: a single institution experience.
cm. BJU Int 2006;97:939. J Urol 2005;174:855.
2. Leibovich BC, Blute M L, Cheville JC, et al. N ephron sparing surgery for 8. Van Poppel H , Da Pozzo L, Albrecht W, et al. A prospective randomized
appropriately selected renal cell carcinoma between 4 and 7 cm results in EO RTC intergroup phase 3 study comparing the complications of elective
outcome similar to radical nephrectomy. J Urol 2004;171:1066. nephron-sparing surgery and radical nephrectomy for low-stage renal cell
3. M cKiernan J, Simmons R, Katz J, et al. N atural history of chronic renal in- carcinoma. Eur Urol 2007;51:1606.
sufficiency after partial and radical nephrectomy. Urology 2002;59:816. 9. H afez KS, Fergany AF, N ovick AC. N ephron sparing surgery for localized
4. H uang WC, Levey AS, Serio AM , et al. Chronic kidney disease after renal cell carcinoma: impact of tumor size on patient survival, tumor re-
nephrectomy in patients with renal cortical tumours: a retrospective cohort currence and TN M staging. J Urol 1999;162:1930.
study. L ancet O ncol 2006;7:735. 10. Fergany AF, H afez KS, N ovick AC. Long-term results of nephron sparing
5. H uang GJ, Israel G, Berman A, et al. Preoperative renal tumor evaluation surgery for localized renal cell carcinoma: 10-year followup. J Urol 2000;
by three-dimensional magnetic resonance imaging: staging and detection of 163:442.
multifocality. Urology 2004;64:453. 11. Riggs SB, Larochelle JC, Belldegrun AS. Partial nephrectomy: a contemporary
6. Corman JM , Penson DF, H ur K, et al. Comparison of complications after review regarding outcomes and different techniques. Cancer J 2008;14:302.
radical and partial nephrectomy: results from the N ational Veterans 12. Patard JJ, Shvarts O , Lam JS, et al. Safety and efficacy of partial nephrec-
Administration Surgical Q uality Improvement Program. BJU Int 2000; tomy for all T1 tumors based on an international multicenter experience.
86:782. J Urol 2004;171:2181.
CHAPTER 3 ■ RADICAL NEPHRECTO MY
MICHAEL S. CO O KSO N AND SAM S. CHANG
Renal cell carcinoma (RCC) is the most common malignancy

of the kidney and accounts for about 3% of all adult neo- INDICATIO NS FO R SURGERY
plasms. The estimated number of new cases of RCC in the
The indication for radical nephrectomy is a clinically localized
United States in 2007 was 51,190 with a projected 12,890
solid renal mass in a patient with a normal contralateral kid-
deaths, and this incidence is expected to continue to increase
ney. Patients with solitary kidneys, renal insufficiency, or bilat-
as a result of the expanded use of radiographic imaging cou-
eral renal masses should be considered candidates for
pled with the aging population (1).
nephron-sparing surgery. Increasingly, partial nephrectomy is
While emerging technologies such as ablative techniques
becoming accepted for smaller T1a lesions in the “ elective”
may offer effective treatment for selective patients with
setting. H owever, for larger lesions, radical nephrectomy
smaller primary tumors, surgery remains the mainstay for
remains the treatment of choice. A thorough preoperative his-
curative treatment in the majority of patients with RCC.
tory and physical examination should be performed before the
Furthermore, despite the expanded role of partial nephrec-
procedure. If significant comorbidities are suspected, preoper-
tomy for tumors 4 cm, radical nephrectomy remains an im-
ative consultation with the appropriate physician is recom-
portant treatment option for most large and almost all locally
mended. In an elective radical nephrectomy, the patient should
advanced tumors.
be expected to physically withstand the operation, have a
The role of open radical nephrectomy in the management
reasonable overall performance status, and have a 5-year life
of RCC has changed somewhat over the last decade. Pure
expectancy.
laparoscopic and laparoscopic hand-assisted radical nephrec-
Radical nephrectomy in combination with immunotherapy
tomy have emerged as less morbid alternatives to open surgery
has been demonstrated to improve survival among patients
in the management of low- to moderate-volume (8 to 10 cm or
with metastatic RCC over immunotherapy alone (4).
smaller), localized RCCs without local invasion, renal vein
Accordingly, radical nephrectomy is being offered to an
involvement, or lymphadenopathy (2).
increasing number of patients with a resectable primary tumor
H owever, this has placed an increased emphasis on the
in the setting of metastatic disease as an initial treatment strat-
performance of open radical nephrectomy in a higher per-
egy prior to immunotherapy. Radical nephrectomy may also be
centage of patients who have either comorbid illnesses or ad-
performed for palliation, such as for patients with intractable
vanced tumors that preclude a minimally invasive approach.
pain or life-threatening hemorrhage who fail conservative
Furthermore, the beneficial impact of cytoreductive nephrec-
treatment despite the presence of metastases. The role of radi-
tomy has increased the clinical situations in which open radi-
cal nephrectomy among patients with a solitary metastatic site
cal nephrectomy may be performed in the setting of metastatic
is controversial; however, 5-year survival rates of 30% have
disease (3).
been reported in selected patients, with best results reported in
This chapter focuses on the open surgical approach for
patients with solitary pulmonary metastases (2).
radical nephrectomy.
Although local extension of primary RCC into the per-
inephric fat, vena cava, or ipsilateral adrenal gland may
portend a worse prognosis, in the absence of metastatic dis-
DIAGNO SIS ease these factors alone should not dissuade the surgeon from
attempting a radical nephrectomy. In addition, radical
Typically, RCCs are characterized on computerized tomography nephrectomy has been successfully performed in the setting of
(CT) scan by a solid parenchymal mass with a heterogeneous direct extension of the tumor into adjacent organs such as
density and enhancement with IV contrast injection (between 15 the liver, colon, spleen, pancreas, or psoas muscle. H owever,
and 40 Hounsfield units). H owever, despite modern imaging, surgical removal in this setting is technically difficult and is as-
some benign tumors and complex cysts may be indistinguishable sociated with a higher morbidity and a potentially poor prog-
from cancer and confirmed only after surgical excision. The role nosis. Therefore, it should be attempted only after careful
of percutaneous biopsy or needle aspiration in differentiating an preparation and in cooperation with appropriate surgical
indeterminate renal mass remains controversial and is currently consultants.
used in select cases, such as in patients with known second
primary tumors, suspected metastases, or lymphoma.
Clinical staging in patients suspected of RCC usually in- ALTERNATIVE THERAPY
cludes a contrast-enhanced CT scan of the abdomen, which
may include CT angiography as well as three-dimensional Surgery remains the only effective and potentially curative form
reconstructions, and magnetic resonance imaging (M RI) is of therapy for primary RCC. Along this line, the main challenge
used on occasion, depending on the clinical scenario. to radical nephrectomy in the near future appears to be from
14
Chap t e r 3: Rad ical Ne p hre ctomy 15
more conservative surgical approaches, including nephron- superior for exposure of the upper pole and ipsilateral adrenal
sparing surgery and minimally invasive approaches. Elective gland during radical nephrectomy.
partial nephrectomy, enucleation, and wedge resection have The patient is positioned in the lateral decubitus position
been proven to be nearly equivalent in terms of cancer control with the upper chest at about a 45-degree angle. An axillary
and may afford potential advantages in terms of preserved renal roll is placed under the patient to cushion against pressure on
function and quality of life in properly selected patients (5–7). the brachial plexus, and the elbows are padded to prevent
Radical nephrectomy is also being performed through ulnar nerve injury. The upper arm is draped across the body
laparoscopic approaches, including hand-assisted techniques, and placed on a M ayo stand or padded support. The lower leg
which again have shown equivalent cancer control and signif- is flexed at 90 degrees, and the upper leg is extended over one
icant advantages in terms of reduced pain, shorter convales- or two pillows. The kidney rest is raised and the table is flexed
cence, and improvements in quality of life (7,8). to elevate the flank and adjusted to make the flank horizontal
O pen radical nephrectomy continues to play an important to the floor. The beanbag or inflatable mattress may be help-
role in the management of RCC, and it is essential that any ful, and if utilized can be activated to further support the
surgeon who employs minimally invasive techniques be well patient. The patient is then padded and secured with wide
versed in its performance. adhesive tape and safety straps.
An eleventh- or twelfth-rib incision is made based on sev-
eral factors, including the kidney position, the cephalad ex-
tent of the tumor, and the patient’s body habitus. A general
SURGICAL TECHNIQ UE rule is to incise over the rib so that, when extended medially,
the incision will be over the renal hilum. The incision is then
There are a variety of factors that influence the choice of inci- made off of the tip or over the rib from the posterior axillary
sion during radical nephrectomy. These include location of the line to the tip and extended medially as far as necessary, usu-
affected kidney, tumor size and characteristics, body habitus, ally stopping short of the lateral border of the rectus abdo-
and physician preference. There are advantages and disadvan- minis (Fig. 3.2). The latissimus dorsi is divided, and the upper
tages to each incision, and it is important to be familiar with portion of the incision is carried down to the rib or near its
several approaches to the kidney as no one incision is appro- tip. The incision is usually created between the ribs in the
priate in all settings. The most commonly used incisions for intercostal space, and additional exposure may be obtained
radical nephrectomy are the flank, thoracoabdominal, and by incising the costovertebral ligament. With larger tumors
transabdominal (subcostal or chevron) (Fig. 3.1). and depending on patient body habitus, a partial rib resection
may be accomplished as shown in Fig. 3.3. An Alexander
periosteal elevator is used to deflect the periosteum from
the bone to avoid injury to the intercostal bundle located un-
Flank Incisio n der the inferior portion of the rib. A Doyen elevator is then
used to strip the periosteum from the entire undersurface of
The flank approach can be advantageous for several reasons. the rib to be resected. N ext, a rib cutter is used to divide the
First, it allows direct access to the retroperitoneum and kid- proximal segment of the rib. The posterior layer of the pe-
ney, and the entire procedure can often be performed in an riosteum is then incised carefully, and the pleura is protected
extrapleural and extraperitoneal fashion. In addition, the inci- superiorly.
sion is anatomic in that it follows the track of the intercostal Anteriorly, the external and internal oblique muscles are
nerves with minimal risk of denervation. H owever, in large divided and the transversus abdominis muscle is split in the
tumors, tumors involving the upper pole, or situations where direction of its fibers, taking care not to enter the peritoneum.
vena cava access is critical, a flank approach is often subopti- The peritoneum is swept medially, and the intermediate stra-
mal. Although a flank approach may be performed through tum of the retroperitoneal connective tissue is incised sharply
a subcostal incision, an eleventh- or twelfth-rib incision is to expose the perinephric space. Approaching this in a posterior
FIGURE 3.1 Types of incisions during radical

nephrectomy.
FIGURE 3.2 Technique of eleventh-rib resection. A and B: The incision is made over the eleventh rib.
C: After division of the latissimus dorsi and external oblique muscles, subperiosteal resection of the rib is
performed.
fashion with early identification of the psoas muscle helps

keep proper orientation. A self-retaining retractor such as a Tho raco ab d o minal Incisio n
Balfour, Bookwalter, or Finochietto rib spreaders helps main-
The thoracoabdominal approach allows for excellent expo-
tain exposure. A radical nephrectomy is then performed.
sure of large tumors as well as upper-pole tumors, in particu-
The wound is closed after checking to ensure that no injury
lar on the left. In addition, it affords easy access to the adrenal
to the pleura has occurred (see complications). The table flex
gland and thoracic cavity. The patient is positioned with the
is released and the kidney rest is lowered. The posterior layer
hips flat and with the break of the table located just above the
consisting of the fascia of the transversus abdominis and the
iliac crest. The pelvis can be torqued up to about 30 degrees if
internal oblique is closed in a running fashion with no. 1 PDS
necessary. The patient’s ipsilateral shoulder is rotated 45 de-
(polydioxanone suture) or Prolene. The anterior layer of
grees, and the ipsilateral arm is extended over the table and
external oblique fascia is closed with a running no. 1 PDS or
properly supported on a M ayo stand or padded armrest
Prolene. Alternatively, interrupted figure-of-eight sutures of
(Fig. 3.4). It is important to properly pad all pressure points,
no. 1 Vicryl can be used for both layers. The skin is closed in
including between the legs and the contralateral shoulder. The
accordance with the surgeon’s preference.
FIGURE 3.2 Technique of eleventh-rib resection. D: The incision is carried through the periosteum poste-
riorly and the internal oblique and transversus muscles medially, exposing the paranephric space. A tongue
of pleura lies in the upper portion of the wound. Diaphragmatic slips that come into view are divided, and
the pleura can be retracted upward. E: The paranephric fat is dissected bluntly. (continued)
kidney rest may be elevated to accentuate the proper exten- ence based on patient and tumor characteristics. The incision
sion, and the break in the table is made to optimize the incision. may be made between the ribs, or a portion of the rib may be
After positioning, the patient is secured with wide adhesive removed. The incision is made over the rib beginning at the
tape and safety straps. posterior axillary line. The incision is carried medially across
The thoracoabdominal incision is made over the bed of the the costal cartilage margin to the midline and then carried
eighth, ninth, or tenth rib, depending on the surgeon’s prefer- down the midline to the umbilicus. Alternatively, the medial
the inferior portion of the upper thoracic incision is divided,

and the chest is entered along the entire length of the periosteal
bed. The pleural space is entered, and care should be taken not
to injure the lung. The lung is protected, and the diaphragm is
divided in the direction of the muscle fibers, which helps avoid
injury to the phrenic nerve. A self-retaining retractor such as a
Balfour, Bookwalter, or Finochietto rib spreaders is properly
padded and placed to maintain exposure. A radical nephrec-
tomy is then performed.
After completion of the radical nephrectomy, the table flex
is removed and the diaphragm is closed with interrupted 2-0
permanent sutures with knots placed on the inferior (peri-
toneal) side. After a 20Fr to 18Fr chest tube has been inserted
through a separate incision and properly positioned, the ribs
are reapproximated with 2-0 absorbable sutures. The thoracic
portion of the incision is closed with interrupted figure-of-
eight 1-0 Vicryl sutures through all layers of the chest wall.
The medial portion of the intercostal muscle closure should
include at least a small portion of the diaphragm. An inter-
costal nerve block is administered before closure and may be
accomplished by injecting approximately 10 mL of 1.0% lido-
caine or 0.5% bupivacaine hydrochloride into the intercostal
space of the incision and two interspaces above and below.
The costal cartilage can be reapproximated with 0 chromic
sutures. This is essential to prevent “ clicking” of the ribs,
which is oftentimes bothersome to the patient. The posterior
rectus fascia, the fascia of the transversus abdominis, and the
internal oblique muscles are closed with a running no. 1 PDS
suture. The anterior rectus and the external oblique fascia are
closed with either a running or interrupted no. 1 PDS suture.
Skin closure is determined by surgeon preference. The chest
tube is secured in place with a 0 silk and taped securely in
place.
Transab d o minal (Che vro n o r Ant e rio r

Sub co st al)
Anterior incisions offer several advantages, including excellent
exposure of the renal pedicle and access to the entire intraperi-
toneal contents and contralateral retroperitoneum. With the
patient in the supine position, the operative side is elevated
slightly with a flank roll and the patient hyperextended to ac-
centuate the line of incision. An incision is made from near the
FIGURE 3.3 Rib resection technique. A: After exposure of the rib,
the intercostal muscles are stripped from the upper and lower rib sur- tip of the eleventh or twelfth rib on the ipsilateral side two fin-
faces with an Alexander–Farabeuf costal periosteotome. B: The rib is ger breadths below the costal margin and extended medially
freed from the periosteum by subperiosteal resection or from the to the xiphoid process. The incision is then gently curved
pleura with a periosteum elevator. C: A Doyen costal elevator is across the midline and as far laterally as necessary for expo-
slipped beneath the rib to free it. The proximal and distal portions of
the rib are immobilized with Kocher clamps, and the rib is divided
sure up to near the tip of the contralateral eleventh rib.
proximal to its angle with a right-angled rib cutter. D: The costal O n occasion, only a portion of the contralateral side will
cartilage is cut free with scissors. The cut surface of the rib is inspected be incised just across the rectus abdominis. The incision is car-
for spicules, which are removed with a rongeur and covered with ried down to the anterior rectus fascia, which is then divided
bone wax. (Fig. 3.5). N ext, the external and internal oblique fascia and
muscles are divided and the fibers of the transversus abdo-
portion of the incision may be carried across the midline or minis split. The rectus muscle and posterior rectus sheath are
combined with a low midline to form a T-shape. The latis- divided with electrocautery by placing a straight clamp under-
simus dorsi is divided, and the upper portion of the incision is neath and gently elevating it. The peritoneal cavity is then
carried down to the rib. At this point, a rib resection can be entered, and the falciform ligament is ligated between two
performed as previously described (Fig. 3.3). Kelly clamps, divided, and ligated. To facilitate exposure, use
The peritoneum may be entered by incising the external of a self-retaining retractor such as a Bookwalter (oval or
and internal obliques, the transversus abdominis, and the ipsi- segmented) or an O mni-Flex is helpful. A radical nephrectomy
lateral rectus abdominis. N ext, the costochondral cartilage at is then performed.
FIGURE 3.4 Thoracoabdominal incision. A: The patient is placed in a semirecumbent position using sandbags.
If the chest is entered through the ninth intercostal space, the incision extends from the midaxillary line across the
costal margin at the intercostal space to the midline or across it just above the umbilicus. B: The anterior rectus
sheath and the external oblique and latissimus dorsi muscles are divided. C: The intercostal muscles parallel the
direction of the three abdominal layers and are divided. The costal cartilage and the internal oblique and rectus
muscles are incised. If more exposure is desired, the linea alba and opposite rectus can be divided. D: The pleural
reflection (shaded areas) lies progressively closer to the costal margin in the more cephalic intercostal spaces.
E: The pleura, reflecting as the costophrenic sinus near the costal margin, is exposed beneath the intercostal
muscles. The diaphragm can be seen inferior and dorsal to the pleura. The pleura is opened with care to avoid
injuring the lung, which comes into view with inspiration. After the lung is packed away gently, the diaphrag-
matic surface of the pleura is seen. The diaphragm is incised on its thoracic surface, avoiding the phrenic nerve.
FIGURE 3.4 Thoracoabdominal incision. F: The transversus abdominis muscle is divided, exposing the
peritoneum with the liver lying beneath it. G: The peritoneum is incised, and a rib-spreading retractor
(Finochetto) is inserted, enabling upward displacement of the liver (or the spleen on the left) into the
thoracic cavity and giving wider access to the posterior peritoneum than in an anterior abdominal
incision. (continued)
FIGURE 3.5 Transabdominal chevron incision. A:

With the patient in the supine position and slightly hy-
perextended, an incision is made two finger breadths
below the costal margin to just below the xiphoid
process and then curved gently down across to the tip
of the opposite eleventh rib. B: The subcutaneous tissue
and the anterior rectus sheath are divided bilaterally. A
Kelly or an Army-N avy retractor is insinuated under
the rectus muscle, and the muscle is divided with
electrocautery. C: The external oblique and internal
oblique muscles are divided, and the transversus abdo-
minis is split. The peritoneal cavity is entered in the
midline by tenting up on the peritoneum and incising
sharply with M etzenbaum scissors.
Closure of the wound is performed after the table is re-

turned to the horizontal position. The wound is then closed
in two layers. The posterior layer consisting of the fascia of
the transversus abdominis and the internal oblique laterally
along with the posterior rectus fascia medially is closed with
two running no. 1 PDS sutures, each starting at the lateral
aspect and running medially to the midline. The anterior
layer of external oblique and anterior rectus fascia is closed
in a similar fashion with no. 1 PDS. O n occasion, it is helpful
to place a U stitch of no. 1 Prolene at the apex of the chevron
incision (at the location of the linea alba) before closure,
including the rectus fascia on either side of the midline, secur-
ing this suture after the anterior fascia has been approxi-
mated. The skin is then closed according to the surgeon’s
preference.
Rad ical Ne p hre ct o my

FIGURE 3.6 The right renal artery is identified by palpation beneath
the vein. After identification with a right-angle clamp, the artery is
Irrespective of the choice of incision, certain caveats are uni- cleaned in the same manner as the vein. With a right-angle clamp be-
versal for the safe and successful completion of a radical neath the artery, a suture is passed on a tonsil clamp to the mouth of
nephrectomy. They include a systematic approach with careful the right-angle clamp, and the suture is passed around the artery.
mobilization of Gerota fascia and careful vascular control. For (From Donohue RE. Radical nephroureterectomy for carcinoma of
the renal pelvis and ureter. In: Crawford ED, Borden TA, eds.
a flank approach, the posterior peritoneum lateral to the G enitourinary cancer surgery. Philadelphia: Lea & Febiger, 1982:101,
colon is incised along the length of the descending colon (left with permission.)
side) or ascending colon (right side) and reflected medially.
For left-sided exposure, the lienorenal ligament is incised to
mobilize the spleen cephalad. O n the right side, the hepatic
flexure of the colon is mobilized. The ureter is identified and is passed around the renal vein, followed by a 0 silk suture
encircled with a vessel loop. The gonadal vein is ligated and proximal to the tributaries, and tagged. The venous tributaries
divided routinely on the left and when necessary on the right. are then individually ligated and divided with 2-0 or 3-0 silk
The plane between the mesentery of the colon and Gerota fas- where necessary, leaving the 0 silk suture on the main renal
cia (often referred to as the gonadal space) is then developed vein tagged (Fig. 3.7). The left renal artery and vein are then
using a combination of sharp and blunt dissection. O n the ligated similarly to the technique described previously for the
right side, kocherizing the duodenum is essential and exposes right side.
the vena cava. Using blunt and/or sharp dissection with elec-
trocautery, the retroperitoneal fat overlying the renal vessels is
separated, exposing the renal hilum. It is often helpful to ligate
and divide the ureter before attempting to expose the renal
hilum to allow for mobilization and upward displacement of
the lower pole of the kidney.
The dissection is then carried cephalad along the vena cava
(right side) or aorta (left side). O n the right side, the right re-
nal vein is identified exiting from the vena cava, isolated, and
encircled with a right-angle clamp and a 0 silk suture and
tagged. After identification of the renal artery (exposure from
the anterior approach may be enhanced by the use of a vein re-
tractor on the renal vein), the artery is dissected free and
cleaned for a distance of approximately 2 to 3 cm. With a
right-angle clamp, the renal artery is encircled, and 2-0 silk
ties are passed (Fig. 3.6). The sutures are then separated and
tied, allowing a safe distance for division of the artery, and it is
preferable to leave two ties on the aortic side. A right-angle
clamp is placed under the artery to be divided and gently ele-
vated, and the artery is cut with either a knife (no. 15 blade) FIGURE 3.7 The same technique for ligation is employed on the left
side. A suture is passed around the lumbar vein proximally and distally
or M etzenbaum scissors. The right renal vein is then ligated after the vein has been cleaned, and the vein is ligated. Sutures are passed
with two 0 silk sutures and one additional 2-0 suture ligature around the main renal vein but are not tied until after the branches
on the side of the vena cava. have been ligated. The artery is identified above the vein and cleaned,
O n the left, the renal vein is isolated as it courses over the isolated, and ligated, and the proximal end is sutured with a 5-0 car-
diovascular silk suture. (From Donohue RE. Radical nephroureterec-
aorta. The left adrenal and gonadal veins are identified ema- tomy for carcinoma of the renal pelvis and ureter. In: Crawford ED,
nating from the left renal vein, and, if present, a posteriorly Borden TA, eds. G enitourinary cancer surgery. Philadelphia: Lea &
directed lumbar venous tributary is noted. A right-angle clamp Febiger, 1982:101, with permission.)
Alternatively, a stapling device can be used to control can be oversewn with a running suture or stopped by place-
both the renal artery and vein for either right or left-sided ment of surgical clips. H owever, removal of the ipsilateral
approaches. adrenal may be the most expeditious method of controlling
Depending on the location of the tumor, prior to control of bleeding.
the renal hilum, Gerota fascia may be initially mobilized pos- Failure to recognize a rent in the pleura during flank inci-
teriorly and superiorly using a combination of sharp and blunt sion will result in a pneumothorax. Filling the flank wound
dissection, or this can follow ligation and division of the renal with sterile water or saline and administering a deep inspira-
vessels. Small clips placed along the superior and medial bor- tory breath may help recognize small openings in the pleura.
der are useful to control any potential bleeding during this Small tears recognized intraoperatively can be managed by
portion of the procedure. These should be avoided anywhere closing the pleura with a 3-0 chromic pursestring suture over a
near the renal hilum as they may prove problematic if bleeding 12Fr or 14Fr Robinson catheter. Before it is removed, all air is
is encountered. The adrenal hilum is then dissected from cau- aspirated from the pleural cavity either by suction or by plac-
dal to cranial with the aid of either clips or straight clamps ing the Robinson catheter under water and administering a
and ties. O n the right side, the short posteriorly located right deep inspiratory breath. The air is evacuated from the pleural
adrenal vein should be anticipated as it exits directly from the space and the tube is removed while the pursestring suture is
vena cava. When encountered, the right adrenal vein is iso- simultaneously tied in place. Alternatively, the Robinson
lated, ligated, and divided. The specimen is then delivered and catheter can be temporarily left in place with the chromic su-
meticulous hemostasis is achieved. ture secured and the fascial layers closed around the catheter,
which exits from the corner of the wound. Just before skin
closure, after all air has been evacuated under water seal as de-
scribed above, the catheter is removed. The latter technique is
O UTCO MES helpful when the pleura is attenuated or contains multiple
small holes that are not easily closed. Alternatively, a 22Fr or
Co mp licat io ns 24Fr chest tube may be placed and left to suction and removed
postoperatively.
The potential for bleeding during radical nephrectomy neces- An upright end-expiratory chest X-ray is obtained after all
sitates careful patient preparation and preoperative planning flank incisions to ensure that no significant pneumothorax
to significantly reduce the chance of bleeding. Any medica- exists. A small (usually 15% ), asymptomatic pneumothorax
tions that interfere with platelet function or clotting should be can be followed conservatively with serial chest X-rays and
discontinued. A preoperative hematocrit should be obtained, oxygen therapy. In a symptomatic or large pneumothorax, as-
and a type and screen are in general recommended. In patients piration of the pleural space using a needle or a central venous
with significant anemia or in those in whom significant catheter (Seldinger technique) introduced just over the rib in
blood loss is anticipated, a type and cross-match for possible the anterior fourth or fifth interspace can be therapeutic.
transfusion should be performed. The patient should have H owever, if these attempts are not successful, a chest tube
either two large-bore peripheral IV lines or a central venous should be inserted and placed on suction.
line to allow for rapid infusion of fluids or blood products if Injuries to the colon during radical nephrectomy are un-
necessary. common. In locally advanced tumors suspected of extension
Bleeding during radical nephrectomy may be from a variety into either the colon or mesentery, patients should undergo a
of locations, including the renal hilum, collateral tumor ves- mechanical and antibiotic bowel preparation. Segmental
sels, or adjacent structures. Venous bleeding is usually the colon resection and primary anastomosis should be possible in
most problematic. The first maneuver is to apply direct pres- most cases. Inadvertent injury to the colon during radical
sure to the area of bleeding and allow for appropriate resusci- nephrectomy can usually be repaired primarily; however, in
tation before additional maneuvers are considered. The point situations where there is gross spillage of fecal contents or a
of bleeding is then carefully exposed and controlled by a devascularized segment, a diverting colostomy should be con-
suture ligature. In the case of venal caval injury, pressure can sidered, and a general surgery consultation is advisable.
be applied carefully with sponge sticks, and then an Allis or Defects in the mesentery of the colon should be closed to pre-
Satinsky clamp may be carefully placed; a vascular 5-0 or 6-0 vent internal herniation of peritoneal contents.
Prolene suture is used to oversew the defect. Lumbar veins Right radical nephrectomy is also associated with the po-
should be exposed by gentle retraction of the vena cava, tential for injury to the duodenum and liver. The duodenum
appropriately clamped, ligated with vascular silk suture, and must be carefully mobilized, and care must be taken to prop-
divided. Renal artery bleeding may be controlled by direct erly pad retractors to prevent injury to the bowel and adjacent
pressure on the aorta proximally and distally until adequate structures, including the head of the pancreas. The second
exposure can be obtained, and the artery is then ligated. O nly portion of the duodenum may be injured during a right radical
in certain circumstances will a pedicle clamp or en bloc liga- nephrectomy. Duodenal hematomas should only be observed,
tion be necessary. but rapidly enlarging hematomas will require control of the
Adrenal tears may result in significant hemorrhage during bleeding, and an intraoperative general surgery consultation
radical nephrectomy, in particular on the right side, where the should be obtained. Duodenal lacerations should be repaired
short adrenal vein enters into the vena cava directly posterior. in multiple layers with interrupted nonabsorbable sutures for
Control of the right adrenal vein should be attempted only the mucosal and serosal layers (1). When possible, an omental
after control of the vena cava, adequate exposure, and proper wrap may provide additional support, and all patients should
suction. The vein is then ligated with a 2-0 or 3-0 silk tie or be managed with a nasogastric tube during the postoperative
vascular Prolene. Venous bleeding from a torn adrenal gland period.
Chap t e r 4: Intracaval Tumors 23
Bleeding from superficial liver lacerations may be con- controlled, the spleen is mobilized by dividing the splenocolic
trolled with Bovie electrocautery or an argon beam electroco- and splenorenal ligaments as well as taking down the peri-
agulator. M ore significant bleeding may be repaired with toneal attachments to the diaphragm. The short gastric vessels
absorbable horizontal mattress sutures utilizing a Surgicel or are then ligated, and the hilum of the spleen is dissected free
Gelfoam bolster. Deep liver lacerations, which may involve the from the tail of the pancreas. The splenic artery and vein are
hepatic ducts, could result in bile leakage and should be ligated and divided. The pancreas should be inspected closely
drained following repair; an intraoperative general surgical to rule out inadvertent injury. Following splenectomy, patients
consultation is strongly recommended. Direct invasion of the will have a reduced resistance to pneumococcal organisms and
liver by renal cell carcinoma is rare; however, resection includ- should receive Pneumovax and H ibTITER on a yearly basis.
ing en bloc removal is possible in selected cases. If a major
lobectomy or a partial hepatectomy is to be performed be-
cause of either direct extension or major hemorrhage, a gen- Re sult s
eral surgeon should be present to assist in its performance.
Splenic injury is one of the most common intraoperative Surgical excision remains the only effective and potentially
complications during a left nephrectomy, with an incidence as curative therapy for clinically localized RCC. Pathologic
high as 10% in some series. M ost superficial lacerations or staging remains the best prognostic variable in terms of
tears can be managed conservatively without the need for patient survival, and the most commonly used staging system
splenectomy. Although minor tears may require only some is the American Joint Committee on Cancer recommendations
gentle pressure and the application of a Gelfoam or Surgicel (TN M ) classification (10).
bolster with spray thrombin, closure of a moderate splenic cap- The 5-year survival rate for patients with organ-confined
sular tear is facilitated through the use of nonabsorbable su- tumors treated with radical nephrectomy for T 1 N 0 M 0 tumors
tures over bolsters of Surgicel. M ajor hemorrhage secondary to is between 80% and 91% , whereas that for T 2 N 0 M 0 tumors is
severe splenic lacerations may require splenectomy (9). 68% to 92% (2). For those patients with T 3a N 0 M 0 (tumor in-
The splenic artery and vein are controlled by compressing vading into the adrenal gland) and T 3b N 0 M 0 (tumor invading
these structures, which are located in the splenic hilum near into the renal vein) carcinomas, the 5-year survival rate is 77%
the tail of the pancreas. Initially, this can be accomplished and 59% , respectively. Finally, patients with node-positive
manually by compressing the tail of the pancreas between the disease (N 1-3 M 0 ) have a 5-year survival rate between 5%
thumb and forefinger. O nce bleeding has been temporarily and 30% .
References
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 6. Lam JS, Shvarts O , Pantuck AJ. Changing concepts in the surgical manage-
2007;57(1):43–66. ment of renal cell carcinoma. Eur Urol 2004;45:692–705.
2. Campbell SC, N ovick AC, Bukowski R. Renal tumors. In: Wein A, ed. 7. Lesage K, Joniau S, Fransis K, et al. Comparison between open partial and
Cam pbell-W alsh urology, 9th ed. Philadelphia: WB Saunders, 2007: radical nephrectomy for renal tumors: perioperative outcome and health-
1567–1637. related quality of Life. Eur Urol 2007;51:614–620.
3. Flanigan RC, M ickisch G, Sylvester R, et al. Cytoreductive nephrectomy in 8. Portis AJ, Yan Y, Landman J, et al. Long-term follow-up after laparoscopic
patients with metastatic renal cancer: a combined analysis. J Urol 2004; radical nephrectomy. J Urol 2002;167:1257–1262.
171(3):1071–1076. 9. N aitoh J, Smith RB. Complications of renal surgery. In: Taneja SS, Smith
4. Flanigan RC, Salmon SE, Blumenstein BA, et al. N ephrectomy followed by RB, Ehrlich RM , eds. Com plications of urologic surgery: prevention and
interferon alfa-2b compared with interferon alfa-2b alone for metastatic m anagem ent, 3rd ed. Philadelphia: WB Saunders, 2001:299–325.
renal-cell cancer. N Engl J M ed 2001;345(23):1655–1659. 10. American Joint Committee on Cancer. M anual for staging of cancer, 6th
5. Uzzo RG, N ovick AC. N ephron sparing surgery for renal tumors: indica- ed. Philadelphia: Lippincott Williams & Wilkins, 2002.
tions, techniques and outcomes. J Urol 2001;166:6–18.
CHAPTER 4 ■ INTRACAVAL TUMO RS

VIRAJ A. MASTER AND FRAY F. MARSHALL
A unique feature of renal cell carcinoma (RCC) is its frequent into the muscular branches of the renal veins, with further ex-
pattern of growth intraluminally into the renal venous circula- tension into the main renal vein and then into the vena cava. The
tion, which is also known as venous tumor thrombus. This is the extension of thrombus is variable. Many research reports use a
most common intracaval tumor that the urologist manages, with staging system proposed by Montie, or small variations of this
approximately 4% to 10% of patients having tumor extension system, namely: Level 0, limited to the renal vein; Level I,
extending into the inferior vena cava (IVC) but 2 cm above the Studies have documented approximately 45% to 70% 5-year
renal vein; Level II, 2 cm above the renal vein but under the he- survival rates for patients with venous tumor thrombi. There
patic veins; Level III, involving the intrahepatic portion of the continues to be a reasonable correlation between cephalad
IVC (hepatic veins) but below the diaphragm; and Level IV, ex- extent of the thrombus and survival, although striking sur-
tending above the diaphragm. vival is observed even with suprahepatic tumor thrombus.
IVC involvement was historically considered a poor prog- The critical feature is that there should be an absence of
nostic finding for RCC, but many reports have demonstrated nodal or metastatic disease; otherwise survival is low.
that patients with tumor thrombi can achieve reasonable in-
creased longevity with an aggressive surgical approach.
DIAGNO SIS
The vast majority of the time, the diagnosis of an intracaval
tumor is made on the basis of a cross-sectional imaging
study. H owever, physical examination findings may some-
times be the first sign of this kind of tumor. Asymmetric leg
swelling may be present. Also in men, a unilateral, acute-
onset varicocele may be observed, although possibly the
most sensitive sign is unintentional weight loss. CT scans of
the chest, abdomen, and pelvis without and with intravenous
contrast are the most commonly performed examinations.
Generally, these studies demonstrate the size of the primary
renal tumor and the presence, size, and rough cranial extent
of the tumor thrombus. Additionally, the presence of
metastatic disease can be detected. M ost often M RI of the
abdomen is the next examination performed. H istorically,
this examination has been performed to precisely locate the
cranialmost extent of the tumor (Fig. 4.1). H owever, with
advancement in M RI, this study can be powerful at detecting
the number, size, and location of lumbar veins, which is crit-
ical for achieving a bloodless field (Fig. 4.1). Additionally,
M RI can be highly effective at discriminating between bland
thrombus (benign clot) and tumor thrombus. A bone scan
should also be performed. Given the rather poor clinical
course of patients with brain metastases, it is prudent to
obtain brain imaging. In the modern era of advanced cross-
sectional imaging, it is usually unnecessary to obtain an infe-
rior vena cavogram. An echocardiogram, performed
transthoracically or, if needed, transesophageally, is exceed-
A ingly helpful in understanding subtle issues of tumors that
C
FIGURE 4.1 M RI is helpful in determining (A) bland thrombus ver-
sus tumor thrombus, (B) cranial extent, and (C) number and location
B of lumbar veins.
invade the supradiaphragmatic cava and heart. Tumors that operation easier. We have not noted an advantage of this
are bulky and space-filling in the atrium will certainly approach. M etal coils can obstruct the ability to ligate the re-
require cardiac bypass for safe extraction, while those with nal artery. Ethanol and/or microsphere embolization is prone
tumor thrombus in the intrapericardial IVC or very-small- to reflux from the intended site given the significant intratu-
volume intracardiac tumor thrombus may be treated with an mor arteriovenous fistulas that occur, and indeed may cause
abdominal approach, sparing the patient significant morbid- massive systemic embolization, resulting in death.
ity. If a significant period of time has elapsed since the last
imaging study and presentation to our institution ( 4
weeks), we favor repeat imaging to detect further cephalad SURGICAL TECHNIQ UE
growth of thrombus and the development of metastatic dis-
ease, as surgical management (need for bypass) may change M ultidisciplinary staff communication before the case starts is
with increasing growth. critical to success. The cell-saver machine needs to be on
standby if needed. In addition to a general anesthetic, a tho-
racic epidural can be utilized and may be effective with post-
INDICATIO NS FO R SURGERY operative pain management. Alternatively, an O n-Q pain
pump device (I-Flow Corp, Lake Forest, CA) can replace the
H istorically, these challenging cases were reserved, in the need for an epidural. For a thrombus at the level of the hepatic
main, for those fit to undergo surgery, without evidence of veins, transesophageal sonography is a vital tool for examin-
metastatic disease. Two general lines of evidence have ing the position of the thrombus, ascertaining possible migra-
emerged to expand the indications for surgery. First, the tion, and also looking at cardiac function during the case.
advent of the tyrosine kinase inhibitors in 2005 (sunitinb and The patient’s body habitus and extent of both the primary
sorafenib) and of mTO R inhibitors in 2007 (temsorilimus) and intracaval tumor direct the surgical approach. For renal
provided tools to manage metastatic kidney cancer where pre- tumors with neoplasm extending minimally into the IVC, a
viously therapeutic nihilism was prevalent. Second, data from supra-eleventh-rib or standard thoracoabdominal approach
the EO RTC/SWO G randomized, prospective studies on the with rib excision is ideal (Fig. 4.2), especially in obese patients,
value of cytoreductive nephrectomy emerged to show that pa- and actually can be performed occasionally, in a completely ex-
tients with good performance status, those with pulmonary- traperitoneal fashion. For left-sided tumors and more extensive
only metastatic disease burden, and those whose tumor caval tumors, an anterior incision will provide good exposure.
burden was reduced by 75% after nephrectomy would benefit We have used a thoracoabdominal incision extending from the
from cytoreductive nephrectomy (2). tip of the scapula across the costal margin to the midline
Perhaps the most important issue is whom not to operate halfway between the umbilicus and the xyphoid process for
on. Patients with compromised cardiac status should be right-sided tumors with intrahepatic and supradiaphragmatic
excluded. Additionally, we have observed that overall perfor- intracaval tumor extension. Using this approach, the patient
mance status is an important, sometimes subtle, clue about should be positioned with the right shoulder rotated toward
whom to operate on. Those patients with ECO G performance the contralateral side while the hips remain in the supine posi-
status of 0 or 1 are good candidates, while those with worse tion and the table is slightly extended. Although this incision
performance status have a dismal, moribund clinical course, provides both intra-abdominal and intrathoracic exposure and
regardless of a perfectly performed operation. the dissection is easier for the urologist, cannulating the aortic
arch for cardiopulmonary bypass is more difficult.
We typically use a median sternotomy extending into either
ALTERNATIVE THERAPY a midline abdominal or a chevron incision when the intracaval
neoplasm extends into or beyond the liver and cardiopul-
Renal cell carcinoma is classically described as a surgical dis- monary bypass is considered (Fig. 4.3) (5). The chevron inci-
ease. N either radiation nor chemotherapy is effective as pri- sion is useful in patients with a wide abdominal girth, in those
mary treatment. Since the introduction of multitargeted with bulky primary tumors, and when using liver mobilization
tyrosine kinase inhibitor medications and mTO R inhibitors, and rotation techniques to gain access to the upper retroperi-
especially in patients with intracaval tumors and metastatic toneum and chest. Although these extensive incisions provide
disease, neoadjuvant therapy may be used to potentially excellent exposure, allowing for additional operations to be
shrink tumors and make the operation technically easier. It performed, we recommend limiting the procedure to nephrec-
may also allow for the delineation of those patients who have tomy and caval thrombectomy.
rapidly progressive metastatic disease and allow these patients The patient should be widely prepared with antiseptic solu-
to avoid the morbidity of an operation. This approach has not tion and draped to approach an extensive infra- or supradi-
been specifically used for intracaval tumors particularly, but aphragmatic tumor, and consideration should be given to
with locally advanced tumors with no increased risk of bleed- preparing the neck and groin if venovenous bypass is consid-
ing (3). The use of angioembolization as a means of palliation ered. In the absence of overt metastasis, the incision is ex-
for patients with metastatic RCC has been reported in a few tended to include a median sternotomy, as this approach gives
small case series, but it certainly will not provide a cure, and it the best exposure.
has significant side-effects for the patient (4). M oreover, we The primary renal malignancy is approached first. For a
have observed some cases of parasitization of adjacent organs right renal tumor, the right colon is mobilized along the line of
after embolization, thus requiring nephrectomy down the line. Toldt and reflected medially to gain access to the retroperi-
Some authors have advocated for the use of preoperative em- toneum (Fig. 4.4). For significant tumors via a midline
bolization of the primary tumor with a view to making the approach, incision of the root of the mesentery up to the
FIGURE 4.2 Thoracoabdominal incision extending

from the tip of the scapula across the costal margin
to the midline halfway between the umbilicus and
the xyphoid process of the sternum. The shoulder is
rotated by placement onto a bolster or a 3-L saline
bag, but the pelvis is flat. (From M arshall FF, Reitz
BA. Radical nephrectomy with excision of vena cava
tumor thrombus. In: M arshall FF, ed. M arshall’s
tex tbook of operative urology. Philadelphia: WB
Saunders, 1996:265, with permission.)
FIGURE 4.3 A midline sternotomy can be

performed with a straight vertical incision or
with a chevron incision extending laterally.
The choice may be best made based on the
body habitus of the patient. The large, obese
patient is better suited to the chevron with
cephalad midline extension. The acute angle
of the chevron can be lessened depending on
the choice of retractor. The Bookwalter re-
tractor favors an acute angle, while the he-
patic Thompson retractor favors an almost
inverted-T incision. (From M arshall FF, Reitz
BA. Radical nephrectomy with excision of
vena cava tumor thrombus. In: M arshall FF,
ed. M arshall’s tex tbook of operative urology.
Philadelphia: WB Saunders, 1996:265, with
permission.)
Treitz ligament with placement of the bowel into an intestinal more rapid approach to the renal artery is possible using an
bag retracted onto the chest provides additional exposure. We approach popularized for renal trauma. The transverse colon
tend to use the O mni-Tract retractor (M innesota Scientific is lifted superiorly and the small bowel pulled to the right. The
Inc.) as it provides excellent superficial and deep exposure of posterior peritoneum is incised medial to the inferior mesen-
the surgical field. The entire kidney within the Gerota fascia is teric vein right on the aorta up to where the left renal vein is
mobilized, first by a posterolateral approach developing the seen. At this point, palpation with a finger or ultrasound
plane between the quadratus/psoas muscles and the Gerota probe in the interaortocaval space for the right renal artery or
fascia. After mobilizing the kidney posteriorly, the renal artery the para-aortic space for the left renal artery will identify the
is ligated early to keep blood loss to a minimum. An even artery. A small pediatric Yankaeur sucker can clear enough
medial exposure near the vena cava. Superiorly, dissection

above the adrenal is undertaken using clips and the adrenal
vein is ligated. Inferiorly, the kidney is mobilized along with
ligation of the gonadal vein and ureter. M obilization of the
primary tumor is complete when the kidney remains attached
to the vena cava by the renal vein.
A left-sided renal tumor with caval thrombus requires
dissection on both sides of the abdomen to access both the vena
cava and the left kidney (Fig. 4.6). A midline or chevron
incision usually provides excellent exposure. The descending
colon is reflected medially by incising the line of Toldt. In a dis-
section similar to that for a right-sided tumor, the entire kidney
within the Gerota fascia is mobilized until only the left renal
vein remains. For large, left-sided renal tumors, the pancreas
and spleen can be mobilized to provide greater exposure of the
left upper retroperitoneum (6). The ascending colon is then mo-
bilized medially by incising the line of Toldt, and the duodenum
is reflected by the Kocher maneuver. O nce adequate exposure
to the vena cava is obtained, the remainder of the procedure is
similar to that for a right-sided renal primary tumor.
The extent of the intracaval tumor dictates the length the
FIGURE 4.4 Completed incision for radical nephrectomy with vena cava that needs to be isolated. Dissection should proceed
removal of a right-sided caval thrombus. The right colon has been directly upon the vena cava, using care to prevent potential dis-
widely mobilized and the cava is isolated. (From M arshall FF, Reitz lodgement of caval tumor. If the intracaval tumor extends
BA. Radical nephrectomy with excision of vena cava tumor throm- slightly beyond the ostium of the renal vein into the vena cava, a
bus. In: M arshall FF, ed. M arshall’s tex tbook of operative urology.
Philadelphia: WB Saunders, 1996:269, with permission.) Satinsky vascular clamp can be placed on the caval sidewall be-
yond the tumor. This segment of caval wall can be excised with
the nephrectomy specimen en bloc, and the cava can be over-
space to allow the artery to be controlled with a clip, tie, or sewn with 4-0 polypropylene suture on a cardiovascular needle.
stapler. This move rapidly decompresses the venous back With a more extensive infra- or suprahepatic intracaval
pressure and seems to allow for shrinkage of the thrombus tumor, control of the vena cava must be obtained above and
(Fig. 4.5). Anteriorly, the mesocolon is then reflected medially below the extent of the caval tumor thrombus, as well as the
from the anterior surface of the Gerota fascia until the vena contralateral renal vein. O ften, it may be advantageous to
cava is visualized. A Kocher maneuver provides additional mobilize and rotate the liver to achieve additional surgical
FIGURE 4.5 Rapid exposure of the renal arteries for early proximal vascular control. This technique is
widely used in renal trauma cases. A: After an appropriate incision is made, the first maneuver is to place
the transverse colon onto the chest. B: The small bowel is reflected out of the body toward the right nip-
ple. C: Small bowel contents are placed into a bowel bag or covered in moist laparotomy pads. The root
of the small bowel mesentery should be visible, allowing for excellent visualization of the posterior peri-
toneal incision overlying the aorta from the ligament of Treitz to the aortic bifurcation. The posterior
peritoneum is incised over the aorta medial to the inferior mesenteric vein. The left renal vein is easily
visualized, and using that as a landmark, the right renal artery can be identified and controlled in the
interaortocaval space, while the left renal artery may be controlled in the para-aortic space in a rapid
fashion. (From Brandes SB, M cAninch JW. Surgical exposure and repair of the traumatized kidney. A tlas
Urol Clin N orth A m 1998:6(2):32–33, with permission.)
tumor, a Rummel tourniquet is placed loosely around a seg-

ment of the left renal vein to secure control of this vessel.
Cardiopulmonary bypass can be obviated when vascular con-
trol using a vascular clamp or Rummel tourniquet can be
gained above the superior extent of the tumor. Division of the
diaphragm may aid in gaining vascular control above the su-
perior extent of the tumor thrombus. It must be emphasized
that minimal handling of the primary tumor and intracaval
neoplasm is paramount to prevent inadvertent embolism. A
Rummel tourniquet slightly tightened can be placed above
the level of the caval tumor to prevent inadvertent throm-
boembolism.
After adequate mobilization of the vena cava superior and
inferior to the tumor thrombus with ligation of any lumbar
veins, all vascular clamps or Rummel tourniquets are secured.
A narrow elliptical incision circumscribing the ostium of the
involved renal vein is made. If the tumor is inseparable from
the caval endothelium superior to the renal veins, the involved
cava is excised. The renal primary and caval tumor is removed
en toto under direct vision. O n occasion, we have used a den-
tal mirror to inspect the hepatic veins or a flexible cystoscope
to inspect the cava to ensure complete removal of tumor. If
additional verification is necessary, transesophageal echogra-
phy can be used to evaluate the superior extent of the cava, or
FIGURE 4.6 Completed incision for radical nephrectomy with re- direct intraoperative sonography can be used to evaluate the
moval of Level IV vena cava tumor thrombus with a left renal primary extent of the cava (8).
tumor. N ote the extensive medial visceral rotation performed to safely
remove the tumor for these left-sided lesions. Colon, spleen, pancreas,
and stomach have all been widely mobilized. (From M arshall FF,
Reitz BA. Radical nephrectomy with excision of vena cava tumor
thrombus. In: M arshall FF, ed. M arshall’s tex tbook of operative urol-
ogy. Philadelphia: WB Saunders, 1996:268, with permission.)
exposure to the vena cava in the upper abdomen and lower

chest. Several of these innovative descriptions of hepatic mo-
bilization derive from liver transplantation techniques (6,7).
To maximize surgical exposure, a bilateral subcostal incision
is recommended that can be extended superiorly into a partial
or conventional median sternotomy if additional exposure or
cardiac bypass is necessary. The round ligament and the falci-
form ligament are ligated and divided to facilitate exposure of
the coronary ligaments. The right and left coronary ligaments
of the liver are incised, detaching the liver from the di-
aphragm. The posterior fold between the liver and the right
kidney is incised to further mobilize the right lobe of the liver.
This maneuver allows the liver to rotate medially, typically
providing sufficient exposure of the suprahepatic infradi-
aphragmatic IVC. In addition, the hepatoduodenal and he-
patogastric ligaments can be incised to expose the lesser sac.
O ne can usually appreciate a variable number of short venous
branches draining the caudate lobe into the IVC. O ne or
more of these veins may require ligation to prevent unex-
pected bleeding. If these veins are short, they can be con-
trolled using suture ligatures placed into the liver
parenchyma, although a series of medium clips creating a FIGURE 4.7 Ligation and division of the venous tributaries of the
“ wall of steel” can be more rapid (Fig. 4.7). O ften, mobiliza- caudate lobe of the liver. N ote that there are significant variations in
tion and rotation of the liver will allow the surgeon direct ac- the number, diameter, and location of these short caudate veins.
cess to the main hepatic vein and the porta hepatis, which M ultiple ties or clips are required for control of these short veins. This
may be controlled with a Rummel tourniquet (umbilical tape maneuver allows for proximal control of the cava above the throm-
bus, or of full liver mobilization off the vena cava. (From M arshall FF,
passed through a 16Fr red rubber catheter) if needed. Reitz BA. Radical nephrectomy with excision of vena cava tumor
Inferiorly, a Rummel tourniquet is placed loosely below the thrombus. In: M arshall FF, ed. M arshall’s tex tbook of operative urol-
tumor thrombus and both renal veins. For a right-sided ogy. Philadelphia: WB Saunders, 1996:267, with permission.)
To close the vena cava, a 4-0 or 5-0 cardiovascular minute. A core temperature of 18°C to 20°C is attained within
polypropylene suture on either RB-1 or SH needles is used. 30 minutes while maintaining an 8°C to 10°C gradient be-
Before completing the cavotomy closure, the inferior tourniquet tween the perfusion and the patient’s core temperature. When
is released to allow trapped air to escape through the cavotomy a rectal temperature of 20°C is reached, the aorta is cross-
site. If excision of the cava decreases the vascular diameter by clamped and 500 cc of cardioplegic solution is administered.
50% , reconstruction of the vena cava is recommended to pre- O nce cardiac arrest is achieved, bypass is terminated and the
vent caval thrombosis. Initial cases of vena cava reconstruction patient is temporarily exsanguinated into an oxygen reservoir.
were done using pericardium because it is less thrombogenic, al- The patient’s brain is protected by placing ice bags around the
though more recently prosthetic grafts have been employed. head. At this point, there is no anesthesia, ventilation, or cir-
Venous drainage of the right kidney must always be preserved culation. To reduce the incidence of complications, circulatory
to prevent venous infarction. In some instances, the cava has arrest time is best limited to 45 minutes.
been oversewn to prevent subsequent embolism if the thrombus An elliptical incision is made around the ostium of the re-
below the renal veins is adherent to the caval endothelium, as is nal vein and carried superiorly along the length of the vena
often the case with bland thrombus. Alternatively, an Adams- cava. The incision can extend into the right atrium or ventri-
DeWeese clip can be placed on the IVC for this purpose. For the cle, depending upon the superior extent of the thrombus.
sake of expediency, the endovascular stapler can be used to Using cardiopulmonary bypass and deep hypothermic circula-
quickly divide the vena cava. tory arrest, the thrombus can be removed in a bloodless field
and the interior of the vena cava and heart can be inspected
under direct vision (Fig. 4.8). It is not uncommon to find some
Ab d o minal Ap p ro ache s t o Sup rahe p at ic degree of adherence of the tumor to the endothelium. In this
and Sup rad iap hrag mat ic Thro mb i case, the tumor thrombus can be “ endarterectomized” from
the interior of the vena cava or atrium. Reconstruction of the
(Le ve ls III and IV) vena cava is as previously mentioned.
Following closure of the venacavotomy, cardiopulmonary
With increasing utilization of liver transplantation worldwide,
bypass is begun. The patient is slowly warmed using a 10°C
there has been a spillover of techniques with applicability to
gradient between the bypass machine and a warming blanket.
advanced retroperitoneal surgery (9). For those tumors with
M annitol (12.5 g) is given along with 1 g of calcium chloride
persistent tumor thrombus extension above the diaphragm, ab-
when core temperature reaches 25°C. Electrical defibrillation
solutely complete liver mobilization, followed by careful divi-
is necessary if the heart does not resume spontaneous beating.
sion of the central tendon of the diaphragm, entry into the
Following resumption of cardiac activity, blood is returned to
pericardium, and circumferential dissection of the intrapericar-
the patient from the oxygen reservoir. Following the rewarm-
dial vena cava, will allow for transdiaphragmatic intrapericar-
ing process, which can take up to 1 hour, heparin is neutral-
dial IVC control. It should be emphasized that this maneuver
ized with protamine. The patient is returned to the cardiac
should be performed by those with extensive experience with
intensive care unit intubated.
the anatomy of the vena cava in the pericardium. O ur experi-
Advances in surgery have prompted investigators to de-
ence has been that working with cardiothoracic transplant sur-
scribe alternatives to cardiopulmonary bypass with deep hy-
geons allows for the performance of this maneuver by those
pothermic cardiac arrest to minimize the risks associated with
surgical specialists with an intimate knowledge of mediastinal
bypass and circulatory arrest and/or diminish the morbidity of
anatomy, and we have not experienced problems in four such
the surgical incision. Venovenous bypass may be used as an al-
cases. That said, cardiopulmonary bypass approaches have a
ternative to cardiopulmonary bypass for patients with an infra-
significantly longer track record, and many more cardiac sur-
diaphragmatic tumor and near occlusion of the vena cava who
geons are familiar with this approach, as outlined below.
do not tolerate clamping of the vena cava. Test clamping of the
vena cava should always be performed prior to the clamping
and opening of the cava. Generally, those patients with bulky
Card io p ulmo nary Byp ass, Hyp o t he rmia, thrombus that is completely occlusive have naturally devel-
and Te mp o rary Card iac Arre st fo r Le ve l IV oped venous collaterals and can tolerate clamping of the cava
Thro mb us (Fig. 4.9). Venovenous bypass avoids the risks of cardiopul-
monary bypass while ensuring adequate circulation during the
The need for cardiac bypass exists, in general, for tumor venacavotomy. Traditionally, to establish venovenous bypass,
thrombi that are above the diaphragm and not obviously an incision overlying the saphenofemoral junction is made and
amenable to the techniques for abdominal access of supradi- the saphenous vein is isolated. A similar incision is made in the
aphragmatic thrombus cases. Cardiopulmonary bypass, hy- axilla and the axillary vein is identified. The saphenous and ax-
pothermia, and temporary cardiac arrest greatly facilitate the illary veins are incised and cannulated with a 7-mm he-
resection of a suprahepatic caval thrombus (8). It is best to parinized Gott aneurysm shunt and secured with a Rummel
dissect as much of the kidney and the vena cava as possible tourniquet. Bypass is commenced with clamping of the IVC.
prior to cardiac bypass. Following isolation of the renal tu- Following completion of the procedure, the shunts are re-
mor, the pericardium is opened and retracted with stay su- moved, the axillary vein is reconstructed with 6-0 polypropyl-
tures. Typically, the right atrial appendage is cannulated with ene, and the saphenous vein is ligated. Alternatively, with an
a 32Fr venous cannula and the aorta is cannulated with a 22Fr experienced liver transplantation anesthesiologist, a large-bore
Bardic cannula. H eparin is then administered to maintain an venous cannula such as a Cordis (Cordis Corp, Warren, N J),
activated clotting time 450 seconds. The patient is placed on can be placed into the femoral vein and jugular vein and an ad-
bypass with flow rates maintained between 2.5 and 3.5 L per equate veno-veno bypass created.
FIGURE 4.8 A: The ostium of the renal vein is cir-

cumferentially incised and the right atrium is
opened. B: Following removal of the tumor throm-
bus, the atriotomy and vena cavatomy incisions
are closed. (From N ovick AC, M ontie JE. Surgery
for renal cell carcinoma. In N ovick AC, Streem SB,
Pontes JE, eds. Stew art’s operative urology, Vol. 1,
2nd ed. Baltimore: Williams & Wilkins, 1989,
with permission.)
FIGURE 4.9 The vena cava can have thrombus throughout its entire ex-
tent. Below the renal vein ostia, this is generally a blood thrombus, also
known as a “ bland” thrombus. Attempted extraction of this thrombus is
fraught with complications and is best avoided. In the setting of complete
caval obstruction, the cava can actually be ligated at this point to prevent
thrombus migration. Venous collaterals as shown in the figure are very
well developed in this setting and will drain the lower body. From the
level of the renal veins above, the thrombus is a tumor thrombus. Such
thrombus has been extracted from the contralateral renal vein, lumbar
veins, hepatic veins, right atrium, and right ventricle. (From M arshall FF,
Reitz BA. Radical nephrectomy with excision of vena cava tumor throm-
bus. In: M arshall FF, ed. M arshall’s tex tbook of operative urology.
Philadelphia: WB Saunders, 1996:269, with permission.)
For tumors extending into the right atrium, a minimally in- are ideal candidates for this surgery and have improved long-
vasive cardiac surgical approach using a right parasternal inci- term survival.
sion has been described, and extensive experience has been
documented (10). This approach would enable access to the
right atrium and right subclavian artery for cannulation of arte- Co mp licat io ns
rial inflow. Following isolation of the vena cava and primary re-
nal tumor, an incision below the right clavicle is made to expose Surgery for intracaval tumors is subject to a number of com-
the subclavian artery. A separate incision is made from the lower plications that occur approximately 10% to 30% of the time.
segment of the third rib to the fifth rib along the right sternal Certainly, over time, there is a declining incidence of compli-
border. A 3-cm segment of cartilage from the fourth and fifth cations, likely due to better patient selection and better post-
ribs is resected, and the right internal thoracic artery is ligated operative care. For example, one large 30-year series noted a
and divided. After opening the pericardium, an 8-mm collagen- 40% decline in complications in cases done in the 1980s ver-
coated graft is sewn to the right subclavian artery and a venous sus those done in the 1990s (12).
cannula is placed into the right atrium. Following cardiopul- Intraoperative complications include excessive bleeding
monary bypass, circulatory arrest, tumor excision, and decannu- and coagulopathy. Coagulopathy is more common with pro-
lation, a flap of periosteum, muscle, and pleura is used to close longed cardiopulmonary bypass and cardiac arrest times.
the defect associated with this minimally invasive incision. Intraoperatively, red blood cells, platelets, fresh frozen
plasma, and calcium chloride are routinely administered.
Furosemide and/or mannitol is given if urine output remains
O UTCO MES low. Transient hypotension can occur when clamping the vena
cava. This can be managed with volume expansion. It tends to
The 5-year survival rates in most reported large series vary be less of a problem with bulky vena cava thrombus or com-
from 14% to 68% following complete surgical removal of pletely occluded cava because this situation usually creates
the renal tumor and caval extension. The largest series, com- multiple venous collaterals. H owever, this difference comes at
prising 614 patients from the M ayo Clinic with tumor throm- a price, as the dilated lumbar veins that drain the obstructed
bus and clear cell RCC, had a 50% 5-year cancer specific cava are often simultaneously large and thin-walled. Finally,
survival. H owever, this rate significantly worsened to 15% to embolization of a segment of tumor thrombus can be a poten-
20% in the presence of intercurrent lymph node involvement tially lethal intraoperative complication, and extreme care
or distant metastatic disease, and it was further reduced to should be taken when handling the vena cava to prevent such
4% if both adverse features were present. Differences in an occurrence. O verall mortality has decreased over time but
reported survival may reflect several factors, including local still remains present (1.5% to 7.5% ).
extension of the primary tumor, presence of lymphatic or vis- Postoperatively, several complications can occur due to the
ceral metastases, or invasion into the vascular wall. The level magnitude of the surgical procedure or in those patients who
of caval extension correlating with survival is a matter of ac- also underwent the use of cardiopulmonary bypass. Potential
tive and current debate in the literature. It is in general agreed complications include caval thrombosis, deep venous throm-
that patients with metastatic disease and significant per- bosis, pulmonary embolus, postoperative bleeding, and coag-
inephric fat involvement tend to have a poorer prognosis. The ulopathy. Patients may also develop hepatic dysfunction, renal
majority of patients eventually dying of their disease succumb failure, sepsis, or myocardial infarction. Although the modern
to metastases, which suggests that occult metastatic disease is mortality rate associated with this procedure is approximately
frequently present at the time of surgery (11). Patients with lower over time in modern series, most patients who die of
good performance status who have tumors confined to the complications within the first postoperative month succumb
renal capsule and are without evidence of metastatic disease to multisystem organ failure.
References
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CHAPTER 5 ■ TRANSPLANT NEPHRECTO MY
SANJAYA KUMAR
In the United States, renal allograft survival for all transplants Significant symptoms usually develop due to the retained
is 91% at 1 year and 82% at 3 years since the introduction of graft, necessitating its removal in the future. H owever, the pol-
cyclosporine (9,13). N otwithstanding optimal immune sup- icy of some centers is to remove failed transplants only when
pression, some allografts will fail. Failed allografts frequently they interfere with health (7).
result in a transplant nephrectomy in similar frequency in Graft failure that occurs 1 year after transplant is usually
both cadaveric and living-related transplants. The etiology due to chronic rejection. Progressive withdrawal of immuno-
and timing of graft failure play an important role in the need suppression may allow the patient to retain the graft in the
for transplant nephrectomy. majority (50% to 90% ) of instances (4,7,10,14). M any pa-
tients, however, develop symptoms such as fever, malaise,
gross hematuria, graft tenderness, and thrombocytopenia re-
DIAGNO SIS lated to platelet consumption by the graft. It can be difficult to
distinguish these symptoms from superimposed acute rejec-
Transplant nephrectomy is performed when the graft has tion or infection, and graft nephrectomy may be the only solu-
failed. This may occur in the acute or chronic setting. Renal tion. Thus, the primary indication today to remove a failed
allograft rupture within days of the transplant is usually due graft is graft intolerance by the host after withdrawal of im-
to acute allograft rejection, renal vein thrombosis, or even munosuppression.
acute tubular necrosis (8). Symptoms include severe allograft Rare indications for allograft nephrectomy include the de-
pain, a drop in hematocrit, and hypotension. Renal scan, velopment of a renal mass (11). This may involve lesions unin-
Doppler ultrasound, and computerized tomography (CT) scan tentionally transmitted from the donor or lesions arising in the
can help establish the diagnosis. Urgent transplant nephrec- transplant kidney. CT scan and needle biopsy help confirm the
tomy may be warranted under these circumstances. diagnosis. Intractable urinary problems such as leaks and fistu-
In the chronic setting, graft function deteriorates slowly las rarely require transplant nephrectomy today. Advances in
and the patient becomes azotemic and requires dialysis. urologic endoscopy and percutaneous techniques have virtually
Radiologic evaluation with Doppler ultrasound and renal scan eliminated the need for graft nephrectomy in these patients.
are helpful. Renal biopsy is almost always performed to con-
firm rejection. O nce it is confirmed that renal function is irre-
versible, immune suppression is tapered and sometimes ALTERNATIVE THERAPY
completely withdrawn. The patient is placed on chronic dialy-
sis and the need for graft nephrectomy is ascertained. An alternative to graft nephrectomy is embolization of the
failed allograft. The graft is embolized through femoral arter-
ial access using coils or ethanol. The presence of multiple renal
INDICATIO NS FO R SURGERY arteries is not considered a problem, although it can be techni-
cally challenging to catheterize these small arteries with their
A renal allograft may fail for several reasons. These primarily thickened intimal layer and narrow ostium. Although success-
include rejection, irreversible renal vascular compromise, or sig- ful embolization has been reported in 85% of patients (3),
nificant graft sepsis. Policy regarding graft nephrectomy varies postembolization syndrome can occur in many patients, in-
according to the transplant institution. While most failed grafts cluding graft abscess and sepsis (6). These patients eventually
were removed in the past, the recent trend is to remove the allo- require a nephrectomy. Graft embolization may thus be con-
graft only when necessary. Further, there is some suggestion sidered in patients with a failed renal graft and intolerable
that retaining the primary graft in situ may have a protective ef- symptoms that do not improve with medical management and
fect on the subsequent transplant (1). O ver the years, the inci- in whom transplant nephrectomy has a significant morbidity
dence of graft nephrectomy continues to trend down. The and risk of mortality.
incidence varies from 4% to 8% in some recent series (5,7,14).
Graft failure within the first few weeks following trans-
plant is usually due to accelerated rejection or technical failure SURGICAL TECHNIQ UE
secondary to vascular compromise, and those failing within
the first few months are due to irreversible acute rejection. If available, it is important to review the previous operative
Renal allografts rejected within the first 12 months of trans- notes of the transplant. This will help the surgeon understand
plant are usually removed prophylactically regardless of the the anatomy of the vascular anastomosis and pre-empt any po-
cause, even if these patients are asymptomatic (10,12,14). tential catastrophe. Patients with renal failure usually have
32
Chap t e r 5: Transp lant Ne p hre ctomy 33
FIGURE 5.1 The patient is positioned in the supine position and the
incision is made over the previous lower-quadrant transplant incision.
FIGURE 5.2 The incision is carried through the external and internal
platelet dysfunction. Even though their coagulation parameters oblique muscles to the capsule of the kidney, where a small capsular
incision is made.
are normal, desmopressin (DDAVP) is usually given to improve
platelet function. The adult dose of DDAVP is 0.3 g per kg
body weight.
Upon identifying the kidney, the renal capsule is opened with
The patient is placed in the supine position. An incision is
a knife (Fig. 5.2). A plane of dissection between the renal cap-
made over the previous incision, which is usually is the lower
sule and parenchyma is developed using blunt and sharp dissec-
quadrant (Fig. 5.1). The previous skin scar is excised. If the
tion. This can usually be done bluntly with a finger (Fig. 5.3).
kidney is large and swollen, it may be necessary to extend the
The upper and lower poles of the kidney are mobilized, inside
incision laterally. The external and internal oblique muscles
the capsule, and delivered into the wound. Careful dissection
and, in the lateral part of the incision, the transversalis are in-
proceeds toward the hilum, medially and laterally. The kidney
cised. As a result of previous surgery, rejection, or multiple re-
is tethered at the hilum to the iliac vessels. Great caution is
nal biopsies, the kidney is stuck to the undersurface of the
exercised here so as not to avulse the kidney. Bleeding from the
muscle, the pelvic sidewall laterally, and the peritoneum medi-
cortical surface of the kidney is inevitable but can be controlled
ally. The colon may drape over the entire anterior surface of
with pressure.
the kidney. Under these circumstances, it may be easier to ex-
tend the incision laterally and enter the retroperitoneum above
the superior pole of the kidney. O nce the kidney has been
identified, space is created in the retroperitoneum for a self-
retaining retractor (e.g., Bookwalter). The relationship of the
iliac vessels, bowel, and peritoneum vis-à-vis the kidney is
established so as not to injure them. The kidney is identified
by palpation. In cases of rejection the kidney may be large,
swollen, and friable.
A decision is now made on whether to perform a subcapsular
nephrectomy or to use an extracapsular approach. Depending
on the degree of reaction, one may be able to perform the en-
tire nephrectomy by staying extracapsular and removing all re-
nal tissue. Certainly, the initial attempt can be made to perform
an extracapsular nephrectomy, and as the dissection ap-
proaches the hilum or if dissection is impossible due to the in-
flammatory reaction, one can resort to a subcapsular approach.
Extracapsular graft nephrectomy is possible when the allograft
has to be removed within a few weeks of transplant. O ften, the
planes of dissection may be so effaced that the only recourse
may be to directly enter the renal capsule and perform a sub-
capsular nephrectomy from the outset. Because of the increased
morbidity and mortality of the extracapsular approach, many
centers routinely perform a subcapsular nephrectomy when
indicated in patients with chronic rejection. FIGURE 5.3 The renal parenchyma is enucleated subcapsularly.
Renal artery
Peritoneum Renal vein

Renal capsule
FIGURE 5.4 Intracapsular ligation of renal vessels.
O nce the base of the hilum is reached, the vessels are

identified and ligated. This can be done entirely intracapsu-
larly (Fig. 5.4) or extracapsularly (Fig. 5.5). The advantage
of the former is that damage to the iliac vessels is mini-
mized. O ne disadvantage is that donor material may be left
in situ (14). To ligate the vessels outside the capsule, the re-
flected capsular surface is incised either posteriorly or ante-
riorly. The peritoneum may be adherent to the renal hilum
and iliac vessels. The vessels are carefully dissected. The renal
artery and vein are suture-ligated individually (Fig. 5.6). It is
easier to do this if the artery is an end-to-end hypogastric-to-
renal-artery anastomosis. A permanent suture such as Prolene
or silk can be used for ligation. The knot is tied down to ves- FIGURE 5.5 The hilar vessels are exposed by (A) making an incision
sels. Friable vessels can tear easily. Injuries to the iliac vein close to the renal parenchyma and (B) incising the overlying capsule.
can be repaired with 5-0 Prolene. While small arterial bleed-
ing can be controlled with a fine Prolene stitch, arterial con-
striction must be avoided, and larger defects therefore require
repair with a synthetic graft (Fig. 5.7). Satinsky clamps because it can predispose to infection. The wound is closed in
are helpful in obtaining temporary vascular control. In the layers, if possible, with 0 Prolene. The skin is usually closed in
event that the hilum is plastered to the iliac vessel and the a subcutaneous fashion.
renal artery and vein are not identifiable, en masse ligation
of the hilum may be necessary. Satinsky clamps are placed at
the base of the hilum and the kidney transected distal to the
clamps. The stump is oversewn with Prolene (Fig. 5.8). O UTCO MES
When performing an extremely difficult nephrectomy, it
may be necessary to deliberately enter the peritoneum to Co mp licat io ns
gain proximal control of the iliac artery. The ureter is iden-
tified, dissected, and removed along with the graft. The sur- The complication rate of transplant nephrectomy in recent
geon may not be able to remove the entire ureter. series is acceptable considering the dire comorbidities in this
The wound is gently irrigated with antibiotic solution. patient population. In the past, the complication rate of
Strict hemostasis is obtained, and the wound is closed without transplant nephrectomy was high (24% to 60% ) due to un-
a drain. Bleeding from the capsule can be controlled with elec- derlying uremia and immunosuppression; the mortality rate is
trocautery or an argon beam coagulator. For additional secu- approximately 5% (5,7). With modern immunosuppressive
rity, Surgicel or Gelfoam soaked in thrombin can be placed on drugs, better control of systemic factors, and anesthetic and
the surgical bed prior to closure. A drain is not used routinely surgical advancements, the complication rate has been reduced
Chap t e r 5: Transp lant Ne p hre ctomy 35
FIGURE 5.6 The renal artery and vein are (A) suture-ligated and (B) divided.
considerably. The morbidity and mortality are much higher

when the nephrectomy is performed under emergent circum-
stances. Complications usually ensue from bleeding, infection,
injury to adjacent structures, and systemic causes. Today,
the overall complication rate of transplant nephrectomy
for chronic rejection is about 5% and mortality is 1%
(2,10,14).
Re sult s
Transplant nephrectomy is not necessary in all cases of trans-
plant failure. When indicated, it can be performed successfully
via an extra- or subcapsular approach. The subcapsular ap-
proach is preferred in cases of chronic rejection. Adequate
preoperative patient preparation and meticulous surgical tech-
FIGURE 5.7 If the renal allograft artery is completely removed, it
nique can minimize morbidity and mortality.
may be necessary to cover the defect in the iliac artery with a patch
graft.
Proposed incision
in Renal hilum
B
FIGURE 5.8 En masse ligation of the hilum. A: Satinsky clamps are placed at the base of the hilum.
B: The kidney is transected distal to the clamps and the stump oversewn with Prolene.
References
1. Abouljoud M S, Deiehoi M H , H udson SL, et al. Risk factors affecting 7. O ’Sullivan DC, M urphy DM , M cLean P, et al. Transplant nephrectomy
second renal transplant outcome, with special reference to primary allo- over 20 years: factors involved in associated morbidity and mortality.
graft nephrectomy. Transplantation 1995;60:138–144. J Urol 1994;151;855–858.
2. Bersztel A, Wahlberg J, Gannedahl G, et al. H ow safe is transplant 8. Ramos M , M artins L, H enriques J, et al. Renal allograft rupture: a clinico-
nephrectomy? A retrospective study of 107 cases. Transplant Proc 1995; pathologic review. Transplant Proc 2000;32:2597–2598.
26:3461–3462. 9. Roberts CS, Lafond J, Fitts CT, et al. N ew patterns of transplant nephrec-
3. Gonzalez-Satue L, Riera E, Franco E, et al. Percutaneous embolization tomy in the cyclosporine era. J A m Coll Surg 1994;178:59–64.
of the failed renal allograft in patients with graft intolerance syndrome. 10. Rosenthal JT, Peaster M L, Laub D. The challenge of kidney transplant
BJU Int 2000;86:610–612. nephrectomy. J Urol 1993;149:1395–1397.
4. Gustafsson A, Groth C, H algrimson CG, et al. The fate of failed renal 11. Rosenthal JT. Transplant nephrectomy. In: Glenn’s urologic surgery, 5th ed.
homografts retained after retransplantation. Surg G ynecol O bstet 1973; Philadelphia: Lippincott Williams & Wilkins, 1998:79–83.
137:4. 12. Sharma DK, Pandey AP, N ath V, et al. Allograft nephrectomy—a 16-year
5. Koh YB, Lee IS, M oon JS, et al. Transplant nephrectomy in 927 kidney experience. Br J Urol 1989;64;122–124.
transplants. Transplant Proc 1996;28:1470–1476. 13. United N etwork for O rgan Sharing database: unos.org. or http://
6. Lorenzo V, Diaz F, Perez L, et al. Ablation of irreversibly rejected renal ustransplant.org/tables/K1200205-00.html.
allograft by embolization with absolute ethanol. A m J Kidney D is 1993; 14. Z argar M A, Kamali K. Reasons for transplant nephrectomy: a retrospec-
22:592–595. tive study of 60 cases. Transplant Proc 2001;33:2655–2656.
CHAPTER 6 ■ RENO VASCULAR DISEASE

JO HN A. LIBERTINO AND CHAD WO TKO WICZ
The true incidence of renovascular hypertension has yet to be Digital venous subtraction angiography (DSA) remains a
determined, with estimates ranging from 5% to 10% within definitive and reliable screening test with sensitivity and
the hypertensive population (1). Stenosis or occlusion within specificity near 90% and with lower contrast exposure than
the renal vasculature promotes hypertension via the renin- conventional angiography. 3D-Gd-magnetic resonance an-
angiotensin-aldosterone pathway, resulting in renal insuffi- giography (M RA) in detecting hemodynamically significant
ciency and dialysis dependence over long periods of time. renal artery stenosis (RAS) has been shown to be effective in
Improved diagnostic studies and imaging modalities have the absence of accessory renal arteries. This last-mentioned
provided internists an easier means of attributing hypertension technique, in addition to CO 2 DSA, is useful in azotemic
to renal lesions versus an “ essential” etiology. Technological patient populations.
advances in minimally invasive angioplasty techniques and
stenting have provided alternatives to surgical bypass in select
patient populations. Despite advances in pharmacology and SURGICAL INDICATIO NS
degrees of invasiveness, surgical revascularization remains a
constant in the management of renovascular disease, espe- The last 50 years have seen a dramatic change in the manage-
cially within the atherosclerotic population. The outcomes of ment of renal artery stenosis. The first renal thromboen-
vascular reconstruction are tightly linked to proper preopera- darterectomy was performed by Freeman in 1954 with an
tive evaluation, surgical planning, and sound technique. excellent outcome (3). The ability to restore renal function in
kidneys with compromised inflow serves as a primary indica-
tion for intervention. With such a significant aging popula-
DIAGNO SIS tion, the indications for restoration of flow to preserve renal
function will continue to grow. Percutaneous transluminal re-
In the past, the clinician’s task of identifying potentially curable nal angioplasty was first reported by Dotter and Judkins in
patients in a safe, cost-effective, and reliable manner was difficult. 1964 with equally impressive outcomes (4). M inimally inva-
A single-dose captopril test is reported by some investigators to sive techniques have limited the morbidity and mortality asso-
be a reliable screening test well suited to outpatient settings. In ciated with open surgery in select hypertensive populations
patients with functional renal artery stenosis, angiotensin-con- often plagued with significant cardiac and pulmonary comor-
verting enzyme (ACE) inhibitors lead to a disproportionate in- bidity. In fact, the rates of aortic and renal revascularizations
crease in peripheral plasma renin activity; however, baseline decreased by 73% from 1998 to 2001, while percutaneous
renal insufficiency impairs the sensitivity of this test for detecting procedures increased by 173% (5).
renal artery stenosis. Renal scintigram with isotopic nephrogra- Despite this trend, the basic principles and knowledge of
phy following the administration of captopril has also been used extra-anatomic bypass techniques are essential to the urologist
to diagnose renal artery stenosis. Technetium DTPA (pentetic in training. The use of the hepatic artery, gastroduodenal
acid) scintigraphy has a sensitivity range of 71% to 92% and a artery, and other alternative procedures instead of the aortore-
specificity range of 72% to 97% (2). nal saphenous vein bypass has not only reduced the morbidity
Chap t e r 6: Re no vascular Dise ase 37
and mortality of surgery but has also dramatically changed pressure parameters, these medications help to retrieve renal
the operative potential in an expanded patient population. function, as evidenced by improved glomerular filtration rates
Equally important are the complications associated with these (GFRs). Despite maximal medical therapies, certain individuals
procedures that urologists may encounter. will have progressive renal artery disease with associated isch-
The indications for angioplasty and stenting versus vascu- emia and azotemia. Avoiding dialysis in this patient population
lar bypass are widely variable and continue to adjust with ad- is critical due to the inherent morbidity associated with renal
vances in technology. Fibrous dysplasia and mid–main renal replacement therapy. Identifying the group of suitable patients
artery atherosclerosis are optimal for balloon angioplasty, refractory to medical management will continue to grow in
while renal osteal and branch disease may be more amenable importance as the population at large grows.
to revascularization. Renal artery aneurysms associated with
hypertension can also be managed with revascularization pro-
cedures. Another strong indication for surgical repair is preg-
nant women with noncalcified aneurysms over 2 cm due to
SURGICAL MANAGEMENT
risk of rupture. Patients experiencing disease following bal-
loon angioplasty are better managed surgically, as repeat an- Ao rt o re nal Byp ass Graft
gioplasty has a high complication rate. N ephrectomy may be a
prudent choice in high-risk surgical patients: those with exten- Bypass grafts are particularly suitable for fibrous lesions that af-
sive branch vessel disease, nonsalvageable parenchyma, and fect the long and multiple segments of the renal artery and asso-
failed arterial reconstructions. ciated branches (Fig. 6.1). Autogenous artery (hypogastric and
spleen) and autogenous saphenous veins are all options in prop-
erly selected patients. When exhausted of autogenous resources,
MEDICAL THERAPIES a Dacron interposition graft may be used; however, there are
concerns of thrombosis and some technical difficulty in crafting
Chronic azotemic renovascular disease is common in patients the appropriate diameter to accommodate the native renal
with atherosclerosis, whose prevalence appears to be increas- artery. Hypogastric arteries are an excellent graft choice in the
ing in the aging population. The pharmaceutical industry has pediatric population, unlike in adults, who are often afflicted
been instrumental in the treatment of hypertension in our with atherosclerosis. The autologous saphenous vein remains
patient population. The advent of ACE inhibitors and an- the conduit of choice at our institution due the ease of access and
giotensinogen receptor blockers (ARB) therapy in conjunction size equivalence to the renal artery. The pliability of the venous
with calcium channel blockers have improved the management versus the arterial vasculature provides for more contoured
of renovascular hypertension. In addition to normalizing blood anastomoses, and the limited intima is less thrombogenic.
FIGURE 6.1 A: An aortogram shows a double right renal artery with stenoses at the ostias of both trunks.
B: A postoperative aortogram with the vein graft making a side-to-side anastomosis to the stenotic lower
renal artery and an end-to-end anastomosis to the distal stump of the upper renal artery.
Pro cure me nt o f t he Sap he no us Ve in Inse rt io n o f t he Sap he no us Ve in Graft

The saphenous vein is initially exposed from the contralateral O nce the renal vessels and aorta are completely mobilized,
side, providing operative room for two surgeons and limiting systemic heparin is given and a 30-minute window is observed
operative time. Prior to the date of surgery, the saphenous vein prior to arterial clamping. The vein graft is next orientated to
is outlined with permanent marker and ultrasound assistance. ensure proper implantation, with an end-to-end anastomosis
M obilization begins with a single incision parallel to and be- being the preferred technique to limit nonlaminar flow associ-
low the groin crease over the palpable femoral pulses and ex- ated with end-to-side reconstructions. The aorta is next
tended to the knee after the junction of the saphenous and palpated to locate an area free of atherosclerotic plaque for
femoral vein have been exposed. Incisions should be made the proper location of the aortotomy.
over the femoral vascular complex with limited subcutaneous Preoperative imaging should rule out extensive aortic ath-
dissection to avoid flap devascularization (Fig. 6.2). We rec- erosclerotic disease and avoid the need for plaque endarterec-
ommend using blunt finger dissection with a moist sponge dis- tomy and associated emboli risk. A medium-sized DeBakey
sector for mobilization. clamp is next placed on the anterolateral portion of the in-
In general, we harvest a 20-cm-long vein graft with an frarenal aorta in a tangential manner. A vertical 13- to 16-mm
ideal outer circumference between 4 to 6 mm. Excess vein aortotomy is made without excising any aortic wall or at-
harvesting is advisable in case of technical complications and tempting to perform localized endarterectomy (Fig. 6.4).
the need for revision. Venous tributaries are tied with 5-0 silk, Excision of the aortic wall is not necessary because intralu-
and excess areolar tissue is dissected free, leaving the intima minal aortic pressure spreads the dimensions of the linear aor-
undisturbed. totomy to appropriate dimensions after the clamp is released.
To decrease transmural ischemia, the vein graft is left in The vein graft is anastomosed to the aorta with 5-0 Prolene
situ until the renal vessels are mobilized. If the graft is re- after being adequately spatulated (Fig. 6.5). A microvascular
moved inadvertently, we place in cool Ringer solution or au- Schwartz clamp is placed on the end of the saphenous vein
tologous blood. The distal end of the graft is then intubated graft and the aorta unclamped. The graft will lie anterior to the
with a M arks needle and secured with a silk tie (Fig. 6.3). interior vena cava on the right side and anterior to the renal
Dilute heparinized autologous blood is infused to dilate the vein on the left side. The graft should be relatively mobile to
vein prior to proximal transection to evaluate for untied tribu- limit undue stress on the anastomosis; however, excess length is
taries. O nce the vein is removed, the thigh incision is packed not recommended due to possibility of graft kinking. A second
with moist gauze until the renal revision is complete to ensure Schwartz microvascular clamp is placed on the distal main
that any delayed bleeding caused by systemic heparinization is renal artery or branches. An end-to-end anastomosis is per-
identified and controlled. formed using 6-0 Prolene suture in a continuous or interrupted
fashion, depending on the diameter of the anastomosis
(Fig. 6.6). Interrupted sutures are preferable for diameters of
3 mm or less. Pediatric patients are treated with interrupted
sutures to prevent a “ pursestring” effect with vessel growth at a
later age. Interrupted sutures should be placed at four quadrants
initially to limit additional “ pursestring” effects. Precision is a
FIGURE 6.2 A: Position of patient for harvesting of saphenous vein

graft. B: Line of incision of saphenous vein graft harvest. C: Exposure
of saphenous vein. FIGURE 6.3 H arvest of saphenous vein graft.
thrombus. N ovice urologists should not hesitate to corrobo-

rate with a vascular surgeon in the early part of their career.
Sp le no re nal Art e ry Byp ass

The indications for splenorenal bypass include patients with
diffuse atherosclerotic disease of the aorta or prior aortic
surgery needing left renal artery revascularization.
Lateral and oblique angiography is essential in surgical
decision making to confirm that the celiac axis is free of ather-
osclerotic disease. Recent advances in three-dimensional com-
puterized tomography and magnetic resonance imaging can be
implemented; however, the gold standard remains angiography
because of the dynamic real-time imaging effect. Surgical ex-
ploration and intraoperative evaluation with splenic blood
flow measurements can be helpful as well. Alternative bypass
routes should be considered if splenic blood flow is 125 mL
per minute.
A supracostal eleventh-rib incision is made, and dissec-
tion is carried along the upper border of the rib, avoiding
FIGURE 6.4 The bypass graft is placed along the lateral aortic wall to the neurovascular complex on the underside (Fig. 6.8). The
determine the best position for its placement. (From N ovick AC,
Streem SB, Pontes JE, eds. Stew art’s operative urology. Baltimore: overlying latissimus dorsi, the serratus posterior inferior,
Williams & Wilkins, 1989, with permission.) and intercostal muscles are next divided with electrocautery.
The next group of muscles to be divided includes the exter-
nal and internal obliques and the transversus abdominis
muscle. Intercostal muscle attachments are divided approxi-
mately on the distal inch of the rib until the corresponding
intercostal nerve is identified and spared. This approach al-
lows an extrapleural approach and provides excellent expo-
sure as the rib can pivot downward in a “ bucket-handle”
fashion.
The plane between Gerota fascia and the adrenal gland
posteriorly and the pancreas anteriorly is then entered and the
splenic artery identified at the upper border of the pancreas.
The investing fascia is entered and the splenic artery mobilized
by a purely retroperitoneal approach. Associated pancreatic
feeding vessels are isolated, ligated, and divided. A properly
performed dissection should provide mobilization of the
splenic artery from the hilum to the celiac access, providing a
tension-free anastomosis.
After the splenic artery is mobilized, a sponge soaked with
papaverine is placed on it to permit dilation. A vascular clamp is
placed at the origin, and the artery is divided proximal to the bi-
furcation at the hilum. Splenectomy is not required because the
FIGURE 6.5 Following partial aortic occlusion, an oval aortotomy is
made for end-to-side anastomosis with a spatulated bypass graft. spleen will receive blood supply from the short gastric arteries.
(From N ovick AC, Streem SB, Pontes JE, eds. Stew art’s operative Arterial circumference may be increased with a Fogarty catheter
urology. Baltimore: Williams & Wilkins, 1989, with permission.) or Gruentzig balloon. The left kidney is approached with a pos-
terior approach and the renal artery identified. The renal artery
is ligated distal to the point of obstruction and an end-to-end
must in placing sutures to limit unnecessary vascular trauma anastomosis carried out with 6-0 Prolene in an interrupted or
at the anastomosis that may impair strength or lead to intimal continuous fashion (Fig. 6.9). We have employed the posterior
inflammatory reaction and narrowing of the lumen. approach in over 10 patients at our institution and now prefer it
O nce the anastomosis is complete, the bulldog clamps to the transabdominal technique. In the rare circumstance that
are removed and the anastomosis evaluated for bleeding length is insufficient, a saphenous vein interposition graft may
(Fig. 6.7). Rarely may there be a need to place an additional be required to prevent undue tension (Fig. 6.10).
interrupted stitch. We cannot stress enough the importance of
visualization during these procedures, and we insist on the
use of surgical loupes and fiberoptic lighting. In addition, He p at o re nal Byp ass Graft
the operating staff should have a wide array of equipment
available due to the delicacy of these procedures. Fogarty bal- The hepatic artery arises from the celiac axis and continues
loons of all sizes need to be readily available in the event of a along the upper border of the pancreas until the portal vein
FIGURE 6.6 A: Anastomosis of the graft to the aorta is performed

with interrupted vascular sutures. B: After completion of the aortic
anastomosis, the renal artery is prepared for anastomosis with the
graft. C: A spatulated end-to-end anastomosis of the graft and distal
renal artery is performed. (From N ovick AC, Streem SB, Ponted JE,
eds. Stew art’s operative urology. Baltimore: Williams & Wilkins,
1989, with permission.)
complex, where it branches into ascending and descending O nce mobilized, the right renal artery is mobilized and the
limbs. The ascending branch is a continuation of the main vascular clamps applied to the proximal portion of the hepatic
hepatic artery upward within the lesser omentum; it lies artery and its distal branches. The gastroduodenal artery is
in front of the portal vein and to the left of the biliary tree. divided and the inferior surface of the hepatic artery is mobi-
The descending limb forms the gastroduodenal artery. In lized from the underlying portal vein and common bile duct
the porta hepatis, the hepatic artery divides into the right (Fig. 6.12). A 10- to 12-mm arteriotomy is made in the ante-
and left hepatic branches, which supply the corresponding rior inferior wall of the common hepatic artery, beginning at
lobes of the liver (Fig. 6.11). The right-upper-quadrant the ostium of the gastroduodenal artery. A reversed autoge-
vasculature—the hepatic artery—has marked variability in nous saphenous vein is inserted with an end-to-side anastomo-
up to 48% of patients as documented in living liver donors sis between the vein graft and hepatic artery using 6-0 Prolene
(6). Accessory hepatic arteries provide ischemic insurance suture (Fig. 6.13). A microvascular clamp is placed on the vein
for hepatorenal bypass procedures. It is essential to identify graft after it has been filled with heparin and after the proper
the following arteries prior to attempting anastomosis: alignment and length for the renal artery anastomosis has
common hepatic, gastroduodenal, right and left hepatic been determined. The clamps are removed from the hepatic
arteries. In addition, the portal vein and common bile duct circulation, and a small Schwartz microvascular clamp is
are isolated. paced on the distal renal artery.
FIGURE 6.7 Completed aortorenal bypass operation. (From N ovick AC,

Streem SB, Pontes JE, eds. Stew art’s operative urology. Baltimore: Williams &
Wilkins, 1989, with permission.)
FIGURE 6.8 Supracostal eleventh-rib incision. A:

Posterior view. B: Anterior view. C: The costovertebral
ligament must be divided to allow the rib to pivot inferi-
orly. D: Closure of incision, taking care to spare the in-
tercostal nerves. The diaphragm is not incorporated in
the closure.
FIGURE 6.9 Technique of splenorenal bypass.

N ote that the pancreas is lifted cephalad to expose
the splenic artery.
FIGURE 6.11 N ormal course of the main hepatic artery and its
various branches. (From N ovick AC. Diminished operative risk and
improved results following revascularization for atherosclerotic renal
artery disease. Urol Clin N orth A m 1984;11:435, with permission.)
FIGURE 6.10 An aortogram shows a splenorenal end-to-side bypass.
Ile o re nal Byp ass Ad d it io nal Byp ass O p t io ns

The presence of severe atherosclerotic disease of the aorta may Case reports from various sources vary depending on the
preclude aortorenal bypass and requires alternative vascular anatomy. Superior mesenteric artery, supreceliac aorta and
bypass conduits. O ne option includes the ileorenal bypass, lower thoracic aorta bypass have been performed using auto-
with a caveat being adequate aortic flow to that level of the genous saphenous vein interposition grafts. These procedures
common bifurcation. O ur surgical approach starts with a mid- are high risk and often reserved as last resort procedures.
line abdominal incision with concomitant saphenous vein Simultaneous aortic replacement with renal revasculariza-
graft acquisition. The corresponding colon is mobilized to tion is indicated in the presence of significant aneurysmal dis-
expose the ipsilateral renal vessels and the iliac bifurcation. ease; however, morbidity and mortality are higher.
Vessel loops are applied to the common iliac in standard Transplant renal artery stenosis is best managed with
fashion, and an end-to-side anastomosis is performed with an percutaneous angioplasty. Lohr et al. reviewed 90 transplant
end-to-end anastomosis at the level of the renal artery using a patients with transplant stenosis. Percutaneous transluminal re-
saphenous vein graft (Fig. 6.14). nal angioplasty (PTRA) intervention led to the loss of one graft
FIGURE 6.12 H epatorenal bypass performed with an interposition

saphenous graft anastomosed end-to-side to the common hepatic
artery and end-to-end to the right renal artery. (From N ovick AC.
Diminished operative risk and improved results following revascular-
ization for atherosclerotic renal artery disease. Urol Clin N orth A m
1984;11:435, with permission.)
FIGURE 6.14 Ileorenal bypass with a saphenous vein graft anasto-

mosed end-to-side to the common iliac artery and end-to-end to the renal
artery. (From Novick AC, Streem SB, Pontes JE, eds. Stew art’s operative
urology. Baltimore: Williams & Wilkins, 1989, with permission.)
grafts for primary renal arterial reconstruction and concomi-

tant aortorenal reconstructions (8). PTFE graft size can be
customized to the renal artery, and the high flow rates can re-
tard thromogenicity.
Re no vascular Salvag e Surg e ry

PTRA is the preferred treatment of choice for fibroplastic and
nonostial unilateral lesions sparing the anterior and posterior
FIGURE 6.13 Use of the gastroduodenal artery to perform hepatore- divisions of the renal artery. Complications can occur in the
nal revascularization through direct end-to-end anastomosis with the immediate postoperative period in up to 13% , with restenosis
right renal artery. (From N ovick AC, Streem SB, Pontes JE, eds. rates ranging from 15% to 25% . Lacombe et al. reviewed their
Stew art’s operative urology. Baltimore: Williams & Wilkins, 1989, experience with over 50 failed PTRAs managed via 38 in situ re-
with permission.)
pairs, 10 extracorporeal repairs, and 3 nephrectomies (9).
Although technically difficult, failed PTRAs are surgically cor-
and restenosis in another; however, the rates of graft loss and rectable; however, planes of dissection are often compromised,
restenosis were 11% and 6% with open surgical repair (7). and the increasing use of endoluminal stents precluded throm-
boembolectomy and reimplantation. Revisions for fibromus-
cular dysplasia demonstrated improved outcomes versus
Re nal Art e ry Re co nst ruct io n Using atherosclerosis, which tend to harbor significant inflammatory
Pro st he t ic Graft s changes. These authors recommend surgical revascularization
as the primary treatment in all types of arterial fibrodysplasia,
Autogenous reconstruction using reversed saphenous vein grafts, citing only 17 (2.5% ) postoperative occlusions in their series of
arterial autografts, and transaortic endarterectomy has proven 689 primary revascularizations.
efficacious in the restoration of blood flow and renal function
in numerous clinical studies. Implementation of prosthetic
grafts was initially viewed with some skepticism secondary to Re nal Aut o t ransp lant at io n and Ex Vivo
concerns about durability and the sequelae of possible infec- Be nch Surg e ry
tions. A review by Paty et al. of over 400 prosthetic grafts pro-
vided excellent clinical outcomes with patency rates over 95% O n rare occasions, kidneys with lesions of the renal artery or
at the 7-year period using polytetrafluoroethylene (PTFE) its branches are not amenable to in situ reconstruction. In
FIGURE 6.15 A: An arteriogram shows complex involvement of the right renal artery by disease
extending into the primary branches. B: A postoperative arteriogram shows patent anastomoses.
these circumstances, temporary removal of the kidney, ex vivo grade stenosis, and cognizance of adrenal vasculature during
preservation, microvascular repair (bench surgery), and auto- dissection is important. Delayed bleeding may also occur with
transplantation may permit salvage. This technique should be false aneurysm formation or erosion of graft anastomosis into
considered in patients with traumatic arterial injuries and duodenum or bowel. Infected graft suture lines may lead to
when disease of the major vessels extends beyond the bifurca- delayed bleeding.
tion of the main renal artery into segmental branches, and Intimal dissection can occur, and the use of a double-armed
also when multiple vessels supplying the affected kidney are suture with needle passage from intima to adventitia can
repaired. Bench surgery may also be required in patients with aid in decreasing the chance of dissection and associated
larger aneurysms, arteriovenous fistulas, dissecting aneurysms, embolization or aneurysm formation. Systemic heparinization
or malformations (Fig. 6.15). At our institution we have has some prophylactic benefit for atheroemboli; however, the
performed over 25 autotransplants with renovascular disease lower extremities need to be fully prepped in case a throm-
(renal artery aneurysm and renal artery stenosis) as the pri- boembolectomy is warranted.
mary indication with over 90% success. N ovick described his With respect to overall complications, the leading cause of
experience with 66 renal autotransplants with resolution of morbidity and mortality in nonfibrodysplastic patients is car-
hypertension (no medical therapy) in 55 patients and im- diovascular in nature. This same population is afflicted with
proved or stable renal function in all patients (10). Taken to- cerebrovascular comorbidities in an estimated 30% . We rec-
gether, these clinical outcomes support the role of renal ommend surgical correction of these comorbidities when fea-
autotransplantation and microvascular reconstruction for ren- sible prior to revascularization procedures.
ovascular disease.
O UTCO MES
SURGICAL CO MPLICATIO NS
Balloon angioplasty is primarily used to treat mural dysplasia
Early complications include hemorrhage, graft thrombosis, in a younger patient population with limited atherosclerotic
distal branch vessel embolization, subintimal dissection, false disease. Using this modality, we have seen success rates of 80%
aneurysm, and nephrectomy. Bleeding in the immediate to 85% at our institution. We have performed over 100 surgi-
postoperative period is due to surgical error often accentuated cal revascularizations at our institute for preservation and
by marginal arterial wall integrity. In addition, the presence of restoration of renal function with a success rate of 85% , which
systemic heparinization will stress the coagulation cascade and is equivalent to that of our contemporary colleagues (11). In
promote bleeding at suture holes from Prolene suture. We rec- one of the largest series to date, Lawrie et al. documented
ommend the use of thrombogenic mesh to control bleeding at improved hypertension in 82% of 919 patients observed over
these anastomoses. Enlarged perihilar vessels are seen in high- 6 years (12).
Chap t e r 7: Anatrop hic Ne p hrolithotomy 45
References
1. Libertino JA. Surgery for renovascular hypertension. In: Walsh PC, Retik 7. Lohr JW, M acDougall M L, Chonko AM , et al. Percutaneous transluminal
AB, Stamey TA, et al., eds. Cam pbell's urology, 6th ed. Philadelphia: WB angioplasty in transplant renal artery stenosis: experience and review of the
Saunders, 1992:2521–2551. literature. A m J Kidney D is 1986;7(5):363–367.
2. Setaro JF, Saddler M C, Chen CC, et al. Simplified captopril renography in 8. Paty SK, Darling RC, Lee D, et al. Is prosthetic renal artery reconstruction
diagnosis and treatment of renal artery stenosis. H ypertension 1991;18: a durable procedure? An analysis of 489 bypass grafts. J Vasc Surg 2001;
289–298. 34(1):127–132.
3. Freeman N E, Leeds FH , Elliott WG, et al. Thromboendarterectomy for hy- 9. Lacombe M , Ricco JB. Surgical revascularization of renal artery after com-
pertension due to renal artery occlusion. JA M A 1954;156(11):1077–1079. plicated or failed percutaneous transluminal renal angioplasty. J Vasc Surg
4. Dotter CT, Judkins M P. Transluminal treatment of arteriosclerotic obstruc- 2006;44(3):537–544.
tion: description of a new technic and a preliminary report of its applica- 10. N ovick AC. Surgical revascularization for renal artery disease: current sta-
tion. Circulation 1964;30:645–670. tus. Br J Urol Int 2005;95 (Supp 2): 75–77.
5. Knipp BS, Dimick JB, Eliason JL, et al. Diffusion of new technology for the 11. Libertino JA, Bosco PJ, Ying CY, et al. Renal revascularization to preserve
treatment of renovascular hypertension in the United States: surgical revas- and restore renal function. J Urol 1992:147:1485–1487.
cularization versus catheter-based therapy, 1988–2001. J Vasc Surg 2004; 12. Lawrie GM , M orris GC, Glaeser DH , et al. Renovascular reconstruction:
40(4):717–723. factors affecting long-term prognosis in 919 patients followed up to 31 years.
6. H iatt JR, Gabbay J, Busutil RW. Surgical anatomy of the hepatic arteries in A m J Cardiol 1989;63:1085–1092.
1000 cases. A nn Surg 1994;220:50–52.
CHAPTER 7 ■ ANATRO PHIC NEPHRO LITHO TO MY

ELIZABETH J. ANO IA, MICHAEL L. PAIK, AND MARTIN I. RESNICK
The treatment of nephrolithiasis has undergone a rapid evolu- staghorn calculi. H owever, in specific situations anatrophic
tion over the past 25 years. The introduction and refinement nephrolithotomy remains the best treatment option for renal
of extracorporeal, endourologic, and percutaneous techniques calculi and thus has maintained an important, albeit smaller,
have caused a shift in the first-line management of even com- role in the treatment of these large, complex stones.
plex renal stones. Anatrophic nephrolithotomy is a procedure
that has been used by urologists for 30 years in the removal
of staghorn renal calculi. The original description of anat- DIAGNO SIS
rophic nephrolithotomy was by Smith and Boyce in 1968
(14). The operation they described was based on the principle Diagnosing nephrolithiasis is based on the patient’s history,
of placing the nephrotomy incision through a plane of the kid- physical exam, urinalysis (UA) findings, and radiographic
ney that was relatively avascular. This approach would avoid studies. Patients may have the typical symptoms of flank pain,
damage to the renal vasculature and subsequent atrophy of fever, hematuria, and dysuria or they may be asymptomatic.
the renal parenchyma, hence the term anatrophic. Staghorn Physical examination may reveal costovertebral angle tender-
stones are often associated with urinary tract infections, and ness. The UA may show erythrocytes, leucocytes, and nitrites
the coexistence of these two conditions makes it difficult to or bacteria if the stone is associated with an infection. The di-
eradicate either. Definitive treatment of these stones is gener- agnosis of chronic urinary tract infection is common in pa-
ally advocated because of the significant morbidity and mor- tients with staghorn stones. Urine culture is often positive, and
tality associated with untreated staghorn calculi. Blandy and typical organisms include urea-splitting organisms such as
Singh (3) found that patient survival is reduced with untreated Proteus, Klebsiella, Providencia, and Pseudom onas.
staghorn calculi, with a mortality rate of 28% at 10 years. Common radiographic studies by traditionally obtained in-
Anatrophic nephrolithotomy also involves reconstruction clude plain abdominal radiographs, nephrotomograms, and
of the intrarenal collecting system to eliminate anatomic ob- excretory urograms to identify the stones and the collecting
struction. Thus, this procedure would improve urinary system and, if present, define the degree of obstruction.
drainage, thereby reducing the likelihood of urinary tract in- Retrograde pyelography is usually performed in cases of
fection, which would prevent recurrent stone formation. O ver equivocal findings on excretory urography. Recently, helical
the past 25 years, with the development of less invasive nonenhanced computed tomography scanning with thin cuts
approaches such as extracorporeal shock wave lithotripsy of the kidneys, ureters, and bladder has become the gold stan-
(ESWL), percutaneous nephrolithotomy (PCN L), and uretero- dard for identifying urinary tract stones and radiolucent or
scopic surgery, the role of anatrophic nephrolithotomy and poorly calcified stones. N uclear renal scans can help deter-
other open stone operations has certainly diminished (2). mine differential renal function when such information might
The American Urologic Association N ephrolithiasis Clinical affect the surgical approach. Renal arteriography is usually
Guidelines Panel in 1994 recommended a percutaneous proce- not indicated unless there is suspicion of anomalous arterial
dure with or without ESWL as an initial treatment for complex anatomy, such as in renal fusion anomalies.
Before elective surgery, a metabolic evaluation is recom- not expected to be eliminated with a reasonable number of
mended to attempt to determine an etiology for stone forma- less invasive procedures or staghorn stones associated with
tion and aid in preventing a recurrence. For instance, it is anatomic abnormalities requiring open surgical correction
important to determine the presence of hypercalciuria, hyper- (13).
uricosuria, hyperoxaluria, cystinuria, hyperparathyroidism,
and renal tubular acidosis in multiple urine specimens. The
measurement of serum and urine calcium, phosphorus, creati- SURGICAL TECHNIQ UE
nine, uric acid, and electrolytes should be routine. A 24-hour
urine collection for creatinine clearance as well as urinary cal- After administration of appropriate preoperative intravenous
cium, phosphorus, oxalate, citrate, cystine, and uric acid is (IV) antibiotics and induction of general anesthesia, a Foley
also an integral part of the workup (9). catheter is placed. The patient is then placed in the standard
flank position with elevation of the kidney rest and flexion of
the operating table to achieve adequate spacing between the
lower costal margin and the iliac crest. Three-inch-wide adhe-
INDICATIO NS FO R SURGERY sive tape applied at the shoulders and hips can be used to se-
cure the patient to the table. Adequate padding should be used
The indications for anatrophic nephrolithotomy have changed
to protect pressure points.
somewhat with advances in minimally invasive methods of
A standard flank approach is used. The incision can be
treating stones. H owever, the inability to successfully eradi-
placed through the bed of either the eleventh or twelfth rib,
cate a stone with less invasive methods remains an important
depending on the estimated position of the kidney. If a previ-
indication for open stone surgery. O ther relative indications
ous flank incision has been made for renal surgery, it is prefer-
include select cases of complex stone disease, especially those
able to place the incision above the old scar, ensuring that
with a dilated collecting system, stones associated with uro-
access to the kidney can be achieved through unscarred tissue.
logic anatomic abnormalities, previous renal surgery, certain
After rib resection, when access has been gained into the
features of patient anatomy, comorbid disease, and patient
retroperitoneal space, the Gerota fascia is identified overlying
preference (7,8). Specific urinary tract abnormalities account
the kidney. The Gerota fascia is incised in a cephalad-caudal
for up to 24% of open stone surgeries. These include a
direction, which facilitates returning the kidney to its fatty
ureteropelvic junction (UPJ) obstruction, infundibular steno-
pouch at the end of the operation. The kidney is then fully mo-
sis, calyceal diverticula, ureteral stricture, or the presence of a
bilized, and the perinephric fat is carefully dissected off the re-
crossing vessel. By openly the defect can be corrected simulta-
nal capsule with care taken not to disrupt the capsule. Should
neously. Patient features such as morbid obesity, limb contrac-
the capsule become inadvertently incised, it can be closed at
tures, or certain cases of transplanted kidneys may preclude
that time with chromic catgut sutures. The kidney is now free
proper positioning for endourologic procedures, ESWL, or
to be suspended in the operative field by utilizing a broad tape
percutaneous access (4). The presence of significant comorbid
at each pole. At this point a preliminary portable plain radi-
disease and patient preference must each be considered in
ograph can be obtained.
choosing the best individualized treatment option.
N ext is the renal hilar dissection. The main renal artery
O verall, the goals of open stone surgery should be to re-
and the posterior segmental branch are approached posteri-
move all calculi and fragments, improve urinary drainage of
orly, carefully identified, and dissected (Fig. 7.1A). The renal
any obstructed intrarenal collecting system, eradicate infec-
pelvis and ureter should be identified but not dissected. The
tion, preserve and improve renal function, and prevent stone
avascular plane, or Brödel line, can be identified by temporarily
recurrence (15).
clamping the posterior segmental artery and injecting 20 mL
of methylene blue intravenously. This results in the blanching
of the posterior renal segment while the anterior portion turns
ALTERNATIVE THERAPY blue, allowing identification and marking of the avascular
plane (Fig. 7.1B) (6). Placing the nephrotomy incision through
As open stone surgery accounts for 5% of treatment modal- this plane will achieve maximal renal parenchymal preserva-
ities for staghorn and other complex stones, there are now tion and minimize blood loss. The avascular plane can also be
other less invasive techniques either alone or in combination identified with the use of a Doppler stethoscope to localize the
that have replaced this procedure. M ost staghorn calculi can area of the kidney with minimal blood flow.
now be preferentially treated with percutaneous nephrolitho- M ore extensive renal hilar dissection can be avoided by uti-
tomy, with or without ESWL. The stone-free rates reported lizing a modification of the original procedure described by
vary between 50% and 87% , whereas for anatrophic Smith and Boyce (14). Redman et al. (11) relied on the rela-
nephrolithotomy stone-free rates range from 90% to 100% tively constant segmental renal vascular supply in the identifi-
(7). The advantage of the former is shorter convalescent peri- cation of the Brödel line. They advocated placing the incision
ods; the disadvantage is the possibility of requiring multiple at the expected location of the avascular plane after clamping
different procedures to accomplish a stone-free state. the renal pedicle with a Satinsky clamp in an effort to prevent
Endoscopic therapy with holmium:YAG laser lithotripsy is re- vasospasm of the renal artery and warm ischemia. This modi-
ported to have an overall stone-free rate of 95% (10). ESWL fication can save time and spare extensive dissection of the renal
monotherapy was found to have a 61% stone-free rate 10 hilum. H owever, we continue to advocate precise identifica-
years after its development (8). Despite impressive advances tion of the avascular plane to minimize parenchymal loss.
with the less invasive techniques, anatrophic nephrolithotomy At this point, 25 g of IV mannitol is administered. This will
remains a viable treatment option for large staghorn calculi promote a postischemic diuresis and prevent the formation of
A
B
FIGURE 7.1 Anatrophic nephrolithotomy. A: The main renal artery and branches are isolated. B: The
posterior segmental artery is occluded and methylene blue is administered intravenously. The resulting
demarcation between pale ischemic and bluish perfused parenchyma defines a relatively avascular
nephrotomy plane.
intratubular ice crystals by increasing the osmolarity of the traversed (Fig. 7.4). Small bleeding vessels can be controlled
glomerular filtrate. The main renal artery can now be oc- with 4-0 or 5-0 chromic catgut figure-of-eight suture ligatures.
cluded with an atraumatic bulldog vascular clamp (Fig. 7.2). If renal back-bleeding continues to be a problem despite these
A bowel bag or barrier drape is quickly placed around the kid- measures, the main renal vein can be occluded.
ney, and it is insulated from the body wall and peritoneal con- As the nephrotomy incision proceeds toward the renal
tents with dry gauze packs. H ypothermia is then initiated with hilum, the ideal location to enter the collecting system is at the
iced saline slush covering the kidney. The kidney should be base of the posterior infundibula. The intraoperative radi-
cooled for 10 to 15 minutes before the nephrotomy incision is ograph can be used as a guide to the pelvis and the base of the
made. This should allow achievement of a core renal tempera- calyx. O n occasion, with large posterior calyceal calculi, a di-
ture of 15°C to 20°C, which will allow safe ischemic times lated posterior calyx will be entered initially. The remainder of
from 60 to 75 minutes and minimize renal parenchymal dam- the collecting system can then be identified with a probe and
age (5). The ice slush should be continuously reapplied as opened. If a posterior infundibulum is entered first, the inci-
needed throughout the case. sion is then carried toward the renal pelvis (Fig. 7.5). The
The renal capsule is then incised sharply over the previ- stone is visualized, and all ramifications of the stone are
ously identified line, being careful to avoid extension into the
upper and lower poles (Fig. 7.3). The renal parenchyma can
be bluntly dissected with the back of the scalpel handle. Blunt
dissection minimizes injury to the intrarenal arteries that are
FIGURE 7.2 The main renal artery is clamped and a bowel bag or
rubber dam is placed around the kidney. Dry gauze packs are placed
anterior to the kidney to protect the intra-abdominal organs from FIGURE 7.3 A superficial incision is made in the renal capsule
hypothermia. through the avascular plane.
FIGURE 7.4 The parenchyma is bluntly dissected with the back of a

scalpel handle. The incision closely approximates the avascular plane.
FIGURE 7.6 After the collecting system is opened, calculi are ex-
tracted and total removal is confirmed radiographically.
FIGURE 7.5 The collecting system is carefully incised.
exposed by opening adjacent infundibula into the calices. To FIGURE 7.7 A ureteral stent is passed in an antegrade fashion from
minimize stone fragmentation and retained calculi, the stone the pelvis to the bladder. Traction sutures are placed to mark the walls
of adjacent calices before suturing them together with a running 6-0
should not be manipulated or removed until all of the calyceal chromic suture.
and infundibular extensions are appropriately identified and
incised. This allows for complete visualization and mobiliza-
tion of the collecting system and calculi. Ideally, the stone or manipulation (Fig. 7.7). The routine use of internal ureteral
stones should be removed without fragmentation; however, catheters is encouraged. They provide good urinary drainage,
often it is inevitable that there will be some piecemeal extrac- protect the freshly reconstructed collecting system, and mini-
tion (Fig. 7.6). If this is necessary, a ureteral stent can be in- mize postoperative urinary extravasation. The next step in the
serted to prevent stone migration during manipulation. Each procedure is the reconstruction of the intrarenal collecting sys-
calyx should be inspected for stone fragments. After removal tem with correction of a coexistent anatomic abnormality if
of all stone fragments, the renal pelvis and calices are copi- present. Infundibular stenosis or stricture that results in ob-
ously irrigated with cold saline and the irrigant is aspirated. A struction promoting urinary stasis and recurrent stone forma-
nephroscope can be used to look for residual fragments. A tion should be corrected with caliorrhaphy or calicoplasty.
plain radiograph or ultrasonography are also options. At this The former is the repair of a single narrowed calyx, achieved
time, a “ double-J” ureteral stent is passed from the renal by incising the calyx along its appropriate margin (anterior
pelvis into the bladder if this was not done at the time of stone margin for posterior calices and posterior margin for anterior
FIGURE 7.9 Adjacent infundibula are sutured together starting in the

renal pelvis. Peripelvic fat is depressed during this closure.
FIGURE 7.8 Technique of repairing strictured infundibula. 1: Narrowed

elongated infundibulum. 2: Incision into calyx forms an inverted Y.
3: Pelvic flap is advanced into infundibulotomy. 4: Incision in calyx is
closed transversely.
calices) and suturing those margins to the renal pelvis, result-

ing in a shorter, wider calyx (Fig. 7.8). The infundibulum can
also be incised longitudinally and then closed transversely in a
H eineke-M ikulicz fashion. Calicoplasty is the repair of adja-
cent stenotic calices by suturing the adjacent walls of the
neighboring calices, thus forming a single structure (Figs. 7.9 and
7.10). All intrarenal reconstructive suturing should be accom-
plished with 5-0 or 6-0 chromic catgut sutures. When suturing FIGURE 7.10 The collecting system is completely reconstructed.
the mucosal edges, it is important to avoid incorporation of
underlying interlobular arteries, thus preventing ischemia.
The renal pelvis is then closed, first with reinforcing corner
sutures and then with a running 6-0 chromic catgut suture
(Fig. 7.11). The arterial clamp is briefly released to identify
parenchymal bleeding points, and hemostasis is obtained with
4-0 or 5-0 chromic catgut figure-of-eight suture ligatures be-
fore closing the renal capsule. The renal capsule is closed with
a running lock stitch of 4-0 chromic catgut suture (Fig. 7.12),
or mattress sutures over bolsters can be used. After the capsule
is closed and adequate hemostasis has been achieved, the slush
surrounding the kidney is removed and the renal artery un-
clamped. The kidney is observed for good hemostasis and re-
turn of pink color and good turgor after unclamping. It is then
returned into the Gerota fascia, and the kidney and proximal
ureter are covered with some perirenal fat to minimize the
postoperative scar formation. If the Gerota fascia is unavail- FIGURE 7.11 The renal pelvis is closed with a running 6-0 chromic
able because of prior surgery, omentum can be mobilized suture.
be readily identified intraoperatively. The defect should be

closed immediately with a running chromic catgut suture. The
lung is hyperinflated just before the final suture is placed to
ensure re-expansion of the lung. Chest tubes are not routinely
used but may be necessary if any question remains regarding
the reliability of the pleural closure. A chest radiograph
should be obtained in the recovery room for any patient who
undergoes repair of a pleural defect. Pulmonary embolism
remains a potential complication of any major surgery.
Routine use of elastic support hose and sequential compres-
sion stockings can lower the risk of deep venous thrombosis.
Encouragement of early ambulation is also an important pre-
ventative measure. Significant postoperative renal hemorrhage
should occur in fewer than 10% of patients. Assimos et al. (1)
reported an incidence of 6.4% . Bleeding usually occurs imme-
diately or about 1 week postoperatively. Extensive intrarenal
reconstruction, older age, worse renal function, and presence
of blood dyscrasias were found to be significant risk factors.
Slow bleeding will usually resolve on its own; management in-
FIGURE 7.12 The renal capsule is closed with a running locking 4-0 cludes correction of any bleeding abnormalities and replace-
chromic suture. ment with blood products as necessary. O ral ε-aminocaproic
acid can be successful in certain cases. Bleeding that is brisk or
cannot be adequately treated conservatively will require a
through a peritoneal opening and wrapped around these more aggressive approach. A renal arteriogram can help iden-
structures. The peritoneal opening should be sutured to the tify the lesion, and an attempt at arteriographic embolization
omentum to prevent herniation of the abdominal viscera. can be considered. Re-exploration may be required in the re-
A Penrose or suction-type drain is placed within the Gerota mainder of the cases, with reinstitution of hypothermia and
fascia and brought out through a separate stab incision. This suture ligation of the bleeding vessel(s). Persistent hematuria 1
drain is left in place until minimal drainage occurs, usually by to 4 weeks postoperatively should alert the clinician to the
the third or fourth postoperative day. N ephrostomy tubes are possibility of renal arteriovenous fistula formation or a false
in general avoided because of their potential for causing infec- aneurysm (1). Urinary extravasation should occur infre-
tion or further renal damage. The flank musculature and skin quently with the routine use of perinephric drains and ureteral
are closed in the standard fashion. catheter drainage. Should drainage recur or persist following
Postoperative management after anatrophic nephrolitho- removal of the drain and/or ureteral stent, replacement of the
tomy should follow the same principles that guide manage- ureteral stent should be considered to decompress the system
ment after other major operations. Intravenous fluids are and relieve any obstruction. O ther possible complications
maintained to achieve brisk urine output and until the patient resulting from arterial clamping include renal injury and
is able to tolerate a clear liquid diet. Broad-spectrum IV an- hypertension.
tibiotics are administered perioperatively and continued post-
operatively for 5 to 7 days. Antibiotic coverage is guided by
preoperative urine culture and sensitivity results. The ureteral Re sult s
stent is removed cystoscopically at approximately 7 days post-
operatively in uncomplicated cases. A urine culture is checked When performed for appropriate indications and with meticu-
for persistence of infection. lous technique, anatrophic nephrolithotomy can achieve suc-
cessful removal of all calculi, preservation of renal function,
improved urinary drainage, and eradication of infection.
O UTCO MES Stone-free rates 90% should be achieved. Stone recurrence
rates following anatrophic nephrolithotomy have been re-
Co mp licat io ns ported from 5% to 30% (15). Recurrent calculi usually form
in those with persistent urinary tract infections, persistent
Pulmonary complications are perhaps the most common fol- urinary drainage impairment, and previously unidentified or
lowing anatrophic nephrolithotomy, especially atelectasis. refractory metabolic disturbances (12).
Patients with a history of pulmonary disease should likely un- For large, complex staghorn calculi, especially those associ-
dergo preoperative evaluation with pulmonary function test- ated with some anatomic abnormality leading to impaired uri-
ing and initiation of vigorous pulmonary toilet prior to nary drainage, anatrophic nephrolithotomy remains a
surgery. Postoperatively, patients should be encouraged to first-line treatment. This modality achieves comparable or bet-
breathe deeply, and use of an incentive spirometer should be ter stone-free rates and the achievement of a stone-free state
routine. Early ambulation will also be beneficial. with a single operative procedure. In the long term, treatment
Pneumothorax should occur in fewer than 5% of patients of these staghorn calculi with anatrophic nephrolithotomy
(15). A patient with a history of pyelonephritis or previous should preserve renal function in the involved kidney and, in a
renal surgery is at increased risk. Inadvertent opening of the majority of patients, eradicate stone disease and chronic uri-
pleura, usually during incision and resection of a rib, should nary infection.
Chap t e r 8: Re nal and Re trop e ritone al Ab sce sse s 51
References
1. Assimos DG, Boyce WH , H arrison LH , et al. Postoperative anatrophic 9. Parks JH , Goldfisher E, Asplin JR. A single 24-hour urine collection is in-
nephrolithotomy bleeding. J Urol 1986;135:1153–1156. adequate for the medical evaluation of nephrolithiasis. J Urol 2002;167:
2. Assimos DG, Boyce WH , H arrison LH , et al. The role of open stone 1607–1612.
surgery since extracorporeal shock wave lithotripsy. J Urol 1989;142: 10. Razvi H A, Dendstedt JD, Chun SS, et al. Intracorporeal lithotripsy with
263–267. the holmium:YAG laser. J Urol 1996;156:912.
3. Blandy JP, Singh M . The case for a more aggressive approach to staghorn 11. Redman JF, Bissada N K, H arper DL. Anatrophic nephrolithotomy: experi-
stones. J Urol 1976;115:505–506. ence with a simplification of the Smith and Boyce technique. J Urol 1979;
4. Caldwell TC, Burns JR. Current operative management of urinary calculi 122:595–597.
after renal transplantation. J Urol 1988;140:1360–1363. 12. Russell JM , H arrison LH , Boyce WH . Recurrent urolithiasis following
5. M cDougal WS. Renal perfusion/reperfusion injuries. J Urol 1988;140: anatrophic nephrolithotomy. J Urol 1981;125:471–474.
1325–1330. 13. Segura JW, Preminger GM , Assimos DG, et al. N ephrolithiasis Clinical
6. M yers RP. Brödel’s line. Surg G ynecol O bstet 1971;132:424–426. Guidelines Panel summary report on the management of staghorn calculi.
7. Paik M L, Resnick M I. Is there a role for open stone surgery? Urol Clin J Urol 1994;151:1648–1651.
N orth A m 2000;27:323–331. 14. Smith M JV, Boyce WH . Anatrophic nephrotomy and plastic calyorrhaphy.
8. Paik M L, Wainstein M A, Spirnak JP, et al. Current indications for open J Urol 1968;99:521–527.
stone surgery in the treatment of renal and ureteral calculi. J Urol 1998; 15. Spirnak JP, Resnick M I. Anatrophic nephrolithotomy. Urol Clin N orth A m
159:374–379. 1983;10:665–675.
CHAPTER 8 ■ RENAL AND RETRO PERITO NEAL

ABSCESSES
DAVIS P. VIPRAKASIT AND ANTHO NY J. SCHAEFFER
This opening inferiorly allows the spread of perirenal infec-

INTRO DUCTIO N tions to the pararenal space, pelvis, psoas muscle, and in some
cases, contralateral retroperitoneum.
Renal and retroperitoneal abscesses are uncommon clinical The pararenal space is divided into two compartments: the
entities that often pose a significant diagnostic challenge. anterior compartment, which is bounded by the posterior
N onspecific signs and symptoms frequently lead to a delay in parietal peritoneum and the anterior Gerota fascia, and the
diagnosis and treatment. Early experiences reported mortality posterior compartment, which is bounded by the posterior
rates approaching 50% . In contemporary series with im- Gerota fascia and transversalis fascia. Because the anterior
proved diagnostic imaging allowing early recognition and pararenal space extends across the midline, infections arising
treatment, mortality rates of 15% are noted. H owever, con- in one space may become bilateral. The posterior pararenal
tinued significant morbidity is associated with these insidious space does not cross the midline, and infection within it re-
disease processes. An understanding of the anatomy of the mains unilateral. The retrofascial compartment lies posterior
retroperitoneal space is essential for classification, timely diag- to the transversalis fascia. It is important only in the develop-
nosis, and management of renal and retroperitoneal abscesses. ment of the rare retrofascial abscess from abscesses of the
The retroperitoneal space is bounded by the posterior pari- psoas, iliacus, and quadratus muscles.
etal peritoneum and transversalis fascia (Figs. 8.1 and 8.2). It The term “ renal abscess” includes a wide range of abscesses
is divided into the perirenal space and the pararenal space. arising from within or around the kidney. An intrarenal ab-
The perirenal space surrounds the renal capsule and capsular scess is an abscess located within the renal parenchyma or
artery and is bounded by the renal (Gerota) fascia. The ante- on the renal capsule between the renal parenchyma and capsu-
rior and posterior leaves of Gerota fascia fuse above the lar artery. A perirenal abscess arises within Gerota fascia
adrenal gland, becoming continuous with the diaphragmatic external to the capsular artery. A pararenal abscess is lo-
fascia. A thinner, more variable layer meets between the cated outside of Gerota fascia within the pararenal space
adrenal gland and the kidney. Laterally, the fascial layers join (Table 8.1).
to form the lateroconal fascia, which becomes continuous
with the posterior parietal peritoneum. M edially, the posterior
layer fuses with the psoas muscle fascia and the anterior layer Re nal Tub e rculo sis
fuses with the connective tissue surrounding the great vessels
and organs of the anterior retroperitoneum (i.e., the pancreas, Renal tuberculosis is caused by hematogenous dissemination
duodenum, and colon). Because the perirenal space rarely from an infected source elsewhere in the body. Though both
crosses the midline, perirenal abscesses usually remain unilat- kidneys are seeded with tuberculosis bacilli in 90% of cases,
eral. Inferiorly, the Gerota fascial layers do not fuse, but clinical renal tuberculosis is usually unilateral. The initial lesion
become continuous with the psoas and ureteral coverings (11). involves the renal cortex, and if they fail to heal spontaneously,
FIGURE 8.1 Right sagittal view showing the anterior

pararenal, perirenal, posterior pararenal, and retro-
fascial spaces. (From Simons GW, Sty JR, Starshak RJ.
Retroperitoneal and retrofascial abscess. J Bone Joint
Surg 1983;65A:1041, reprinted with permission from
The Journal of Bone and Joint Surgery, Inc.)
“ putty” kidney and development of a parenchymal or peri-

nephric abscess.
Echino co ccus
Echinococcosis is a benign parasitic infection caused by the lar-
val growth of the canine tapeworm Echinococcus granulosus.
Echinococcal or hydatid cysts occur in the kidney in 3% of
patients with this disease. The hydatid cyst gradually develops
at a rate of about 1 cm per year and is usually solitary and
located in the cortex. The hydatid cyst is composed of a para-
sitic membrane that is surrounded by a nonparasitic pericyst
membrane due to the resultant reactive renal tissue.
FIGURE 8.2 The three retroperitoneal compartments. The striped DIAGNO SIS
and crosshatched areas correspond to the perirenal and posterior
pararenal space, respectively. (From M eyers M A. Dynamic radiology The diagnosis of renal and retroperitoneal abscesses requires a
of the abdomen. In: N orm al and pathologic anatom y, 2nd ed. high index of suspicion, as they typically present with insidi-
N ew York: Springer-Verlag, 1982:107–110, with kind permission of ous, nonspecific signs and symptoms. The physical findings of-
Springer Science and Business M edia.)
ten do not correlate with the severity of disease (4,10). M any
contemporary studies show that only one-third of patients are
correctly diagnosed at the time of hospital admission, with an
the lesions may progress slowly and remain asymptomatic for average delay in diagnosis of 3 to 4 days (10). Presenting
10 to 40 years. As the lesions progress, caseous necrosis and symptoms may include any combination of fever, chills, ab-
parenchymal cavitation occur with fibrous walls that resemble dominal or flank pain, irritative voiding symptoms, nausea,
solid mass lesions. O nce cavities form, spontaneous healing vomiting, lethargy, or weight loss. Patients with renal and
is rare and destructive lesions ensue, with spread of the in- retroperitoneal abscesses more often have a longer duration of
fection to the renal pelvis, resulting in a pyonephroticlike symptoms as compared with patients with pyelonephritis. The
TA B LE 8 . 1
CHARACTERISTICS OF REN AL AN DRETROPERITON EAL ABCESSES
Site Source Organism Cofactors Treatment
Cortical H ematogenous Staphylococcus aureus and IV drug use and Antibiotics

intrarenal other gram positives immunocompromised
patients
Intrarenal Urinary tract Gram negative Anaerobe (2) Pyelonephritis with reflux, Antibiotics drainage,
(Escherichia coli, Proteus, obstruction, (calculous / nephrectomy if
Klebsiella), immunocom- disease) (16) or immuno- non-functional kidney
promised (opportunistic compromised patient or progressive infection
organisms, including Candida
albicans, A spergillus, Torulopsis
glabrata) (12,13)
Perirenal Intrarenal abscess or Gram negative (Escherichia O ften localizes to the Antibiotics drainage,
pyonephrosis eroding coli, Proteus, Klebsiella) lower pole kidney / nephrectomy if
into perirenal space non-functional kidney
or progressive infection
Posterior Spinal infections, Antibiotics drainage,
pararenal perirenal abscesses, / nephrectomy if
or anterior pararenal non-functional kidney
abscesses or progressive infection
Anterior Gastrointestinal M ixture including Antibiotics drainage,
pararenal (colon, appendix, Escherichia coli and / nephrectomy if
pancreas, duodenum) anaerobes non-functional kidney
or progressive infection
majority of patients diagnosed with renal and retroperitoneal

abscesses have underlying, predisposing medical conditions. INDICATIO NS FO R SURGERY
These include diabetes mellitus, urinary tract calculi, previous
urologic surgery, urinary tract obstruction, polycystic kidney Renal and retroperitoneal abscesses are generally lethal if un-
disease, malignancy, and immunosuppression. treated. Therapeutic options include antimicrobial therapy
A palpable flank or abdominal mass is present in about alone or in combination with percutaneous catheter drainage
one-third of cases. The mass may be better appreciated by ex- or open surgical drainage. N ephrectomy is typically reserved
amination of the patient in the knee–chest position. There for those with nonfunctioning kidneys. If a perinephric ab-
may also be signs of psoas muscle irritation with flexion of the scess is due to long-standing obstruction and there is no func-
thigh. tioning renal tissue, a nephrectomy at the time of drainage is
Laboratory tests are helpful but nondiagnostic. Leukocytosis, theoretically attractive. Initially, however, drainage of the ab-
elevated serum creatinine, and pyuria are common. In up to scess should be performed as the primary procedure, with
30% of gram-negative abscesses, the abscess does not involve nephrectomy performed at a later date if necessary. Patients
the collecting system and urine cultures are frequently negative. are frequently too ill for prolonged general anesthesia and sur-
Positive urine cultures will generally correlate with blood gical manipulation. After drainage of the abscess, removal of
cultures in the setting of retrograde gram-negative abscesses. obstruction, and appropriate antimicrobial therapy, many kid-
In abscesses secondary to gram-positive organisms, however, neys may regain sufficient function to obviate future nephrec-
the urine culture and blood culture may reflect different iso- tomy. N ephrectomy, if indicated, can be performed using a
lates. O verall, positive urine cultures coincide with culture standard simple open nephrectomy approach or as a subcap-
results from the abscess in only 40% of cases, and the micro- sular nephrectomy. A small renal abscess confined to one pole
organisms isolated in positive blood cultures are similar to of the kidney may be managed by partial nephrectomy. If the
those in the abscess culture in 60% of cases. infection extends beyond the apparent line of cleavage,
Computerized tomography (CT) of the abdomen and however, it is essential to remove all infection, and the line of
pelvis with intravenous contrast remains the radiographic excision should extend through healthy tissue. If multiple ab-
study of choice and can precisely localize and detect an abscesses are present, internal drainage is difficult and nephrec-
scess 2 cm in size, thereby determining the type of interven- tomy may be required.
tion and its anatomic approach. The presence of gas within a Antimicrobial therapy should be instituted after the urine
lesion is pathognomonic for an abscess. Additional CT find- has been Gram stained and urine and blood cultures have been
ings characteristic of an abscess include a mass with low at- obtained. Broad-spectrum coverage should be guided by the
tenuation, rim enhancement of the abscess wall after contrast, presumptive diagnosis and the presumed pathogen. A third-
obliteration of tissue planes, and displacement of surrounding generation cephalosporin or an aminoglycoside for gram-negative
structures. O ther studies that may be used include ultrasonog- rods and ampicillin for gram-positive cocci are preferred.
raphy or magnetic resonance imaging (M RI). Intravenous piperacillin/tazobactam may be used in patients
with renal insufficiency. Anaerobic coverage with a drug such as antimicrobial therapy with close observation alone has been
clindamycin is warranted when Gram stain reveals a polymicro- advocated in select patients with small perirenal abscesses
bial flora or when a GI source is suspected. If the abscess is ( 3 cm) and stable patient conditions (4,10). Prolonged an-
suspected of staphylococcal origin, a penicillinase-resistant timicrobial therapy without drainage is indicated only if fa-
penicillin, such as nafcillin, should be added. Antimicrobial vorable clinical response and radiological confirmation of
therapy should be re-evaluated when culture and sensitivity abscess resolution indicate that therapy is effective. This form
test results are available. Unfortunately, urine and blood cultures of therapy has proven more successful in children when com-
are frequently sterile, and empirical therapy must be modified pared to adults and least successful in immunocompromised
on the basis of clinical response and changes in imaging patients. If antimicrobial therapy is not effective, prompt per-
studies. cutaneous or open surgical drainage of the pus is mandatory.
Re nal Tub e rculo sis SURGICAL TECHNIQ UE

Surgery for renal tuberculosis is reserved primarily for man-
Pe rcut ane o us Drainag e
agement of local complications, such as drainage of abscesses
or tuberculous cavities or for treatment of nonfunctioning M ost renal and retroperitoneal abscesses are treated with em-
kidneys. If segmental renal damage is obvious and salvage of pirical antimicrobial therapy and immediate percutaneous
the kidney is possible, a drainage procedure or cavernostomy drainage. With resolution of the abscess occurring at least
can be performed (6). Removal of a nonfunctioning kidney two-thirds of the time, minimally invasive therapy eliminates
is usually indicated for advanced unilateral disease compli- operative morbidity and allows for preservation of renal tis-
cated by sepsis, hemorrhage, intractable pain, newly devel- sue. In those patients with a remaining surgical indication,
oped severe hypertension, suspicion of malignancy, inability percutaneous drainage can help delay surgery and allow the
to sterilize the urine with drugs alone, abscess formation patient’s condition to be optimized. The abscess must be con-
with development of fistula, or inability to have appropriate firmed by CT- or ultrasonography-guided needle aspiration
follow-up (3,9,14). If surgery is warranted, it is wise to and must be drainable without injury to other organs.
precede the operation with at least 3 weeks and preferably Contraindications to percutaneous puncture include coagula-
3 months of a four-drug chemotherapy regimen. In adults, tion disorders and calcified masses, which may indicate other
use of isoniazid, 300 mg per day; pyrazinamide, 20 to 25 mg processes. Immediate surgical drainage must be instituted if
per kg daily; rifampin, 600 mg per day; and ethambutol, 15 the procedure fails. After a multiport drainage catheter (8Fr to
to 20 mg per kg daily is recommended unless individual drug 12Fr) is positioned, the abscess should be drained and ade-
resistance exists. quate evacuation should be confirmed by CT or ultrasonogra-
phy. In the setting of abscess septation or multiloculation,
multiple catheters or septal perforation during catheter place-
Echino co ccus ment may be utilized. The catheter should then be connected
to low intermittent suction, and drainage outputs should be
The symptoms are those of a slowly growing tumor; most pa-
monitored daily. If drainage stops abruptly, occlusion of the
tients are asymptomatic or have a dull flank pain or hema-
catheter should be suspected and gentle irrigation with small
turia. H ydatiduria is pathognomonic for the disease but
amounts of normal saline performed. CT or ultrasonography
occurs in only 5% to 25% of cases. As a result of cyst rupture
should be performed periodically to monitor catheter position
directly into the collecting system, patients exhibit passage of
and size of the abscess. Direct instillation of contrast through
grapelike materials in the urine. Excretory urography typically
the drainage tube may be helpful to confirm the catheter posi-
shows a thick-walled cystic mass that is occasionally calcified.
tion or rule out a fistula. To avoid bacteremia, prophylactic
Ultrasonography and CT usually show either a unilocular or
antimicrobial coverage should be given, and the contrast should
multivesicular cyst. Confirmation of the diagnosis is most reli-
be instilled under gravity or by gentle injection. Instillation of
ably made by diagnostic tests using partially purified hydatid
2,500 U of urokinase in 50 mL of normal saline on a daily ba-
antigens in a double-diffusion test (14). Complement fixation
sis may be successful in evacuating an organizing infected
and hemagglutination are less reliable. Diagnostic needle
hematoma. Routine abscess irrigation with antimicrobials is of
puncture is associated with significant risk of anaphylaxis as a
questionable benefit and may promote overgrowth of resistant
result of leakage of toxic cyst contents. Cyst removal is indi-
bacteria. The catheter should be withdrawn gradually as the
cated when an enlarging cyst threatens renal function or pro-
abscess cavity shrinks and the drainage decreases. The usual
duces obstruction.
duration of drainage is 1 to 3 weeks. The catheter is removed
when drainage stops, CT or ultrasonography confirms com-
plete resolution, and fevers and leukocyte count normalize.
ALTERNATIVE TREATMENT
Antimicrobial therapy as the sole treatment is an option with O p e n Surg ical Drainag e
resolution of symptoms in a small percentage of renal ab-
scesses depending on size, location, and other factors (1). In the case of failed percutaneous therapy, open surgical
Small intrarenal abscesses ( 4 to 5 cm) may resolve if they drainage is usually the next step. O pen surgery allows for di-
are treated early at the carbuncle stage or have minimally liq- rect anatomic evaluation and a determination of the extent
uefied through aggressive antimicrobial therapy. Similarly, of the inflammatory process. In addition, more complex
pathology may be delineated, including chronic fistulas sug-

gesting residual stone, foreign body, or persistent renal ob-
struction or, rarely, carcinomas that predispose a kidney to
abscess formation and thus prevent a cure with only simple
drainage.
For open surgical drainage, the incision should be
smaller than that used for routine nephrectomy, and usually
a posterior flank muscle-splitting incision below the twelfth
rib is sufficient. When the retroperitoneal abscess is entered,
the pus should be cultured and the space gently but thor-
oughly explored to ensure that all loculated cavities are
drained. Thorough irrigation of the cavity is essential.
M ultiple Penrose drains should be inserted into the space
through separate stab wounds, and the ends of the drains
should be sutured to the skin and tagged with safety pins.
Fascial and muscular closure may be performed with
chromic catgut suture, but skin and subcutaneous tissue
should be left open to prevent the formation of a secondary
body wall abscess. The wound can be left to heal from
within, or skin sutures may be placed and left untied for
dermal approximation 5 to 7 days postoperatively after
drainage has ceased. The wound should be packed with
gauze and the packs changed daily. The drains should be
left in place until purulent drainage has decreased, and then
removed slowly over several days.
Sub cap sular Ne p hre ct o my

When a kidney is so adherent to surrounding tissues that dis-
section is difficult and hazardous, a subcapsular nephrectomy
is indicated. These conditions may result after multiple or
chronic infections or previous operations resulting in signifi-
cant fibrotic adhesions between Gerota fascia and the perire-
nal fat. Blunt dissection can result in tearing of structures such FIGURE 8.3 Subcapsular secondary nephrectomy showing freeing of
as the bowel wall. Sharp dissection when there is no definable the capsule from anterior surfaces of the kidney.
tissue plane often results in lacerations of the vena cava,
aorta, duodenum, spleen, and other structures. In subcapsular
nephrectomy, dissection beneath the renal capsule enables one Frequently, all landmarks are obscured and the renal artery
to avoid these vital structures. Subcapsular nephrectomy and vein cannot be identified. Sharp dissection is usually re-
should not be performed for malignant disease. quired, and major vessels may be entered before they are rec-
The main difficulty with subcapsular nephrectomy is that ognized. Fortunately, the dense fibrous tissue tends to prevent
the capsule is adherent to the vessels in the hilum, and one their retraction. Frequently, a combination of suture ligatures,
usually must go outside the capsule to ligate the renal pedicle. clips, or a vascular load stapler can be used to divide the renal
In this setting, the renal hilum is usually involved in the in- vessels. After ligation and cutting of the pedicle, the ureter is
flammatory reaction, and separate identification of the vessels identified and cut and the distal end is ligated. If distal ureteral
is difficult. obstruction has caused pyonephrosis, a small, 8Fr to 10Fr red
Kidney exposure is accomplished through the flank using a Robinson catheter may be placed in the distal ureter to allow
twelfth-rib incision. For low-lying kidneys, a subcostal inci- postoperative antimicrobial irrigation. M ultiple drains should
sion may be satisfactory. When the kidney is reached, the cap- be placed and brought through separate stab wounds.
sule is incised and freed from the underlying cortex (Fig. 8.3).
To avoid damage to the duodenum or major vessels, pieces of
capsule may be left behind. H owever, prolonged drainage can
ensue, and as much of the infected tissue should be removed as Lap aro sco p ic Tre at me nt o f Re nal
possible. The capsule is stripped from the surface of the kid- Ab sce sse s
ney and an incision is made carefully in the capsule where it is
attached to the hilum (Fig. 8.4). The vessels may be protected H istorically, the dense perinephric adhesions associated with
by placing a finger in front of the pedicle when cutting the renal abscess disease and the resultant high open conversion
capsule. The dense apron of the capsule can usually be incised rate were relative contraindications to laparoscopic simple
best on the anterior aspect. Controlling bleeding can be difficult and subcapsular nephrectomy. H owever, more recent series
in this procedure, and a harmonic scalpel or bipolar electric involving laparoscopic techniques have shown feasibility in
coagulation device may be utilized to minimize hemorrhage. select patients with possible advantages in postoperative
FIGURE 8.4 Subcapsular secondary nephrec-

tomy showing incision in and removal of a
portion of the renal capsule to expose and lig-
ate the renal pedicle.
recovery and blood loss as compared to open studies. Similar saline irrigation of the abscess cavity should be performed
to the open technique, dissociation and ligation of the renal using a large-bore needle and syringe (Fig. 8.5). The abscess
pedicle remain the most challenging surgical step and may be cavity is then unroofed and the edge is sutured with a running
facilitated with careful dissection using a harmonic or bipolar suture for hemostasis. Any unsuspected connection with the
scalpel and an endoscopic linear stapler for the hilum. Given renal pelvis by an open infundibulum must be closed using 5-0
the potential to limit seeding of the peritoneum with infec- chromic catgut sutures to prevent fistula or urinoma forma-
tious tissue, a retroperitoneal approach has been advocated. tion. After thorough wound irrigation, multiple drains are
H owever, laparoscopic therapies remain technically challeng- placed and closure is undertaken. Drains are managed as pre-
ing, and current reported experiences in the literature are viously described for perinephric abscess.
small (7,17).
Ne p hre ct o my fo r Re nal
Cave rno st o my fo r Se g me nt al Tub e rculo sis
Re nal Tub e rculo sis
When unilateral tuberculosis causes more extensive
Renal tuberculosis sometimes results in caliceal infundibular parenchymal destruction or nonfunction, a partial or total
scarring, causing a closed pyocalix abscess. In cases of sepsis, nephrectomy, respectively, should be performed. Particular
cavernostomy or unroofing of the pyocalix may be necessary. care should be taken to avoid entering the peritoneum or
If the calyx still communicates with the renal pelvis, or if it is pleura. For partial nephrectomy, a guillotine incision is
connected to significant functioning parenchyma, a cavernos- made 1 cm beyond the abscess. If the renal pedicle can be
tomy should not be done as a urinary fistula or urinoma may freed and the polar vessel located and occluded, the incision
result. To minimize wound contamination and tuberculous can be made at the line of demarcation of the ischemia.
spread, thorough needle aspiration of purulent material and In partial nephrectomy, it is important to try to save the
FIGURE 8.5 Cavernostomy drainage of tubercu-

lous renal abscess. (From H anley H G. Cavernostomy
and partial nephrectomy in renal tuberculosis. Br J
Urol 1970;42:661, with permission.)
capsule (if it is not involved with the infection) to cover the thorough postmarsupialization irrigation are critical to pre-
raw surface for hemostasis. Alternatively, fat can be used venting systemic effects. Total or partial pericystectomy can
for hemostasis. The amputated calyx is carefully ligated subsequently be carried out to remove the surrounding peri-
with a 4-0 chromic catgut suture to prevent urinary fistula cyst, and any open calyces can be closed. Penrose drains are
or urinoma formation. left in the cystic cavity until drainage ceases. If large amounts
After nephrectomy, the distal ureter can be ligated and in of renal tissue have been damaged, partial or simple nephrec-
most cases does not need to be brought to the skin because tomy may be required.
tuberculosis of the ureteral stump generally heals with
chemotherapy after nephrectomy. If renal tuberculosis is asso-
ciated with severe tuberculosis cystitis, ureteral catheterization
for 7 days postoperatively to minimize subsequent ureteral O UTCO MES
stump abscess formation should be considered (3).
Co mp licat io ns
Re se ct io n o f Echino co ccal Cyst Complications associated with percutaneous drainage include
the formation of additional abscesses that communicate with
The cyst should be removed without rupture to reduce the the renal collecting system and may require temporary urinary
chance of seeding or anaphylactic-type reaction, which can diversion via percutaneous nephrostomy drainage to affect a
prove fatal in the operating room. In cases where cyst removal cure. Sepsis, the most frequent complication of percutaneous
is impossible because of its size or involvement of adjacent or- drainage, occurs in fewer than 10% of patients. O ther compli-
gans, marsupialization is required. Initially the cyst should be cations, such as transpleural puncture, vascular or enteric in-
isolated with sponges, the contents aspirated, and the cyst jury, and cutaneous fistula, are rare.
filled with a scolicidal agent such as 30% sodium chloride, Additional complications to open or percutaneous drainage
2% formalin, or 1% iodide for about 5 minutes to kill the ger- include prolonged purulent drainage, which may indicate a re-
minal portions. Complete evacuation of all hydatid tissue and tained foreign body, calculus, or fistula.
In the past, mortality rates were reported to be as high as

Re sult s 50% in patients with retroperitoneal or perinephric abscesses.
M ore recent reports indicate a significant improvement in
Cure rates for percutaneous drainage of renal and retroperi-
mortality ( 15% ); this is largely due to more accurate diag-
toneal abscesses range from 60% to 90% (9,16). M ultiloculated,
nosis and drainage using improved imaging techniques, more
viscous abscesses and abscesses in immunocompromised hosts
effective antimicrobial therapy, and better supportive care
are associated with lower cure rates. Large abscesses may re-
(4,5,10).
quire more than one percutaneous access procedure to com-
pletely drain them.
References
1. Best CD, Terris M K, Tacker JR, et al. Clinical and radiological findings in 9. Lorin M I, H su KH F, Jacob SC. Treatment of tuberculosis in children.
patients with gas forming renal abscess treated conservatively. J Urol Pediatr Clin N orth A m 1983;30:333–348.
1999;162:1273–1276. 10. M eng M V, M ario LA, M cAninch JW. Current treatment and outcomes of
2. Brook I. The role of anaerobic bacteria in perinephric and renal abscesses perinephric abscesses. J Urol 2002;168:1337–1340.
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4. Coelho RF, Schneider-M onteiro ED, M esquita JL, et al. Renal and per- 13. O da K, Inoue S, O e H . Renal carbuncle with xanthogranulomatous change:
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31:431–436. 14. Schaeffer AJ. Urinary tract infections. In: Gillenwater JY, Grayhack JT,
5. Edelstein H , M cCabe RE. Perinephric abscess: modern diagnosis and treat- H owards SS, et al., eds. A dult and pediatric urology. Philadelphia:
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Br J Urol 1970;42:661–666. abscess. J Urol 1996;155:52–55.
7. H emal AK, Gupta N P, Kumar R. Comparison of retroperitoneoscopic 16. Yoder JC, Pfister RC, Lindfors KK, et al. Pyonephrosis: imaging and inter-
nephrectomy with open surgery for tuberculous nonfunctioning kidneys. vention. A JR A m J R oentgenol 1983;141:735–739.
J Urol 2000;164:32–335. 17. Z hang X, Z heng T, M a X, et al. Comparison of retroperitoneoscopic
8. Lambiase RE, Deyoe L, Cronan JJ, et al. Percutaneous drainage of 355 nephrectomy versus open approaches to nonfunctioning tuberculous
consecutive abscesses: results of primary drainage with 1-year follow-up. kidneys: a report of 44 cases. J Urol 2005;173:1586–1589.
R adiology 1992;184:167–179.
CHAPTER 9 ■ RENAL TRAUMA

JILL C. BUCKLEY AND JACK W. MCANINCH
Renal injuries occur infrequently in trauma patients, with a re- time of laparotomy provides excellent functional results in the
ported incidence between 2% and 3% (1). The vast majority majority of cases (4). The goal of all renal trauma care is
of renal injuries occur as a result of blunt trauma, are grades I preservation of enough functioning nephron mass to avoid
to III, and can be managed nonoperatively (1,2). Penetrating end-stage renal failure. N ephrectomy is reserved for a life
renal trauma usually occurs in conjunction with other intra- threatening injury where damage control is necessary.
abdominal injuries where urgent laparotomy is performed.
Grade V renal injuries by definition represent life-threatening
renal injuries that require operative exploration and often DIAGNO SIS
nephrectomy. Grade IV renal injuries represent the most con-
troversial management issue in renal trauma care. M any blunt As with all trauma situations, the patient should undergo an
and penetrating grade IV renal injuries can be successfully acute assessment and resuscitation as defined by the American
managed nonoperatively if the patient has been appropriated Association for the Surgery of Trauma (AAST). The hemody-
staged with computerized tomography (CT) and can be namic stability of the patient will determine if an immediate
closely monitored in an intensive care unit (ICU) (3). If radi- operative exploration is required versus radiographic CT
ographic renal staging is not available or the patient requires staging. The type of trauma (blunt versus penetrating), mech-
immediate abdominal laparotomy for an associated nonuro- anism of injury (e.g. deceleration injury), physical examina-
logic injury, renal exploration is indicated after obtaining an tion (presence of a rib fracture or spinous process fracture,
intraoperative single-shot intravenous pyelogram (IVP). In he- abdominal or flank tenderness, flank ecchymosis, etc.), associ-
modynamically stable patients, renal reconstruction at the ated nonurologic injuries, hemodynamics, and degree of
Chap t e r 9: Re nal Trauma 59
hematuria are important to obtain in the initial assessment. If

gross hematuria is not present, a urine dipstick analysis or for-
mal urine analysis should be performed to detect microscopic
hematuria. The degree of hematuria does not correlate with
the degree of renal injury but is useful in guiding the initial
emergency department assessment.
IMAGING
All penetrating trauma should undergo CT radiographic imag-
ing. Any patient sustaining a blunt trauma injury with a positive
physical examination, a deceleration injury, gross hematuria,
microscopic hematuria in the setting of hypotension (systolic
blood presure 90 mmH g in the field or in the emergency
department), or serial decreasing hematocrits should undergo
radiographic CT imaging to stage the renal injury (1,5). FIGURE 9.1 Abdominal computerized tomography (CT) reveals left
Triple-phase CT radiographic imaging allows detailed staging renal laceration after blunt trauma (grade III). Even major renal lacer-
of the renal injury by evaluating the renal hilum, parenchyma, ations occurring after blunt trauma are usually amenable to nonoper-
collecting system, and surrounding tissue, as well as detecting ative management. Renal CT provides detailed information regarding
the depth of laceration, size of perirenal hematoma, tissue viability,
other intra-abdominal injuries. It is important to obtain de- urinary extravasation, and status of the contralateral kidney.
layed images to document that the collecting system is intact,
with contrast passing down into the distal ureter without
extravasation (6). combined with repeat imaging (3,10). If conservative manage-
In pediatric trauma patients, special attention should be ment is chosen, it is the responsibility of the treating physician
given to the degree of microscopic hematuria present, as this to document a stable or improving situation through clinical
alone may warrant CT radiographic imaging. Children are parameters and repeat imaging. All patients who sustain a
often able to maintain their hemodynamics despite underlying major renal trauma should be admitted to the ICU for serial
hypovolemia; thus blood pressure readings can be falsely reas- hematocrits, placed on bedrest, and have repeat CT imaging
suring. Unlike with the adult patient, isolated significant mi- performed 48 hours after the initial staging CT scan or ear-
croscopic hematuria defined as 50 red blood cells per lier if there is a significant change in their clinical course (3).
high-powered field should prompt radiographic CT imaging Active surveillance ensures appropriate management either by
(7,8). As stated above, the type of trauma (blunt versus pene- demonstrating resolution of the renal injury or by prompting
trating), mechanism of injury (e.g. deceleration injury), physi- intervention, such as ureteral stent placement for nonresolv-
cal examination (presence of a rib fracture or spinous process ing urinary extravasation or angioembolization of a segmen-
fracture, abdominal or flank tenderness, flank ecchymosis, tal artery for persistent arterial extravasation (11,12). In all
etc.), and associated nonurologic injuries in hemodynamic sta- cases of severe renal injury, nonoperative management
ble children should all undergo radiographic CT staging of the should only occur after radiographic CT renal staging in
renal injury. hemodynamically stable patients with close peritraumatic
If immediate laparotomy is required, a single-shot IVP monitoring.
should be performed in the operating room. A bolus IV injec-
tion of 2 cc per kg of radiographic contrast is given followed
by a 10-minute plain film of the abdomen and pelvis. It is crit- ANGIO EMBO LIZATIO N
ical to document a functioning contralateral kidney should a
nephrectomy be required of the injured renal unit. With a nor- The minimally invasive technique of angioembolization along
mal single-shot intraoperative IVP demonstrating two intact with radiographic CT imaging has led to a dramatic shift in
renal units and a nonexpanding retroperitoneal hematoma, trauma care in large urban centers where interventional radiol-
exploration can be avoided (9). ogy expertise is available. A clear role has emerged for selective
segmental arterial embolization in a subset of severe renal
injuries to control significant bleeding (13,14). Renal hilar in-
MANAGEMENT juries are life-threatening and require immediate operative
exploration (15). As with all severe renal injuries, selection is
M anagement of the injured kidney is based on consideration critical for successful management, along with having available
of the patient’s mechanism of injury, hemodynamic stability, and capable interventional radiologists or trained vascular or
associated injuries, and accurate radiographic staging of the trauma surgeons. Indications include non–life-threatening
injury (1). The vast majority of blunt traumatic renal injuries bleeding isolated to a segmental renal artery or vein in the
are clinically insignificant. Fewer than 2% of patients with setting of an expanding perirenal hematoma or refractory
blunt renal trauma require renal exploration (1,2) (Fig. 9.1). hypovolemia ( 3 units of blood transfusion). The embolized
H istorically, all penetrating abdominal injuries underwent vessel is typically a segmental artery, as venous bleeding will
laparotomy. N ow, with improved diagnostic radiographic often tamponade provided Gerota fascia is still intact (Fig. 9.2).
imaging, many intra-abdominal and renal injuries can be staged Embolization will lead to nephron loss and should be restricted
and managed with nonoperative active surveillance in ICUs to active arterial extravasation. Selective embolization has
significant renal injury (grade III or greater) in a hemodynami-

cally stable patient. M inimal time is added to the operation,
and outcomes are excellent (4). Successful reconstruction can
be undertaken despite spillage from bowel injury, pancreatic
injury, or other associated injuries (18).
In both blunt and penetrating isolated severe renal
trauma (no other significant intra-abdominal injuries), selec-
tive management is employed to determine if exploration is
indicated based on the hemodynamics of the patient, radi-
ographic CT staging of the renal injury, and clinical assess-
ment (3,19). In our large series of grade IV renal injuries,
28% were isolated kidney injuries, 42% underwent explo-
ration, and the remaining 58% were managed nonopera-
tively. Persistent bleeding requiring multiple blood
transfusions was the primary indication for renal explo-
ration (average transfusion requirement of 8.5 U packed red
blood cells (prbc)). O ur guidelines for intervention are hemo-
FIGURE 9.2 Angioembolization of active segmental arterial dynamic instability causing severe hypotension and shock, a
extravasation. rapidly expanding renal hematoma, persistent hemodynamic
instability despite 3 U prbc, and clinical decompensation (3).
Renal salvage rates were high ( 85% ) for both operative
demonstrated excellent preservation of the remaining kidney and nonoperative management, demonstrating the utility
for not only renal trauma injuries but also for symptomatic and importance of selective management.
angiomyolipomas, spontaneous perirenal bleeds, pseudo-
aneurysms, and iatrogenic renal vascular injuries and has re-
sulted in shorter hospital stays, decreased pain, and fewer
complications by avoiding open exploration (14,16,17). NEPHRECTO MY
Endovascular procedures will continue to expand their role in
the acute trauma setting as comfort and experience with these N ephrectomy should be reserved for critically ill patients dur-
minimally invasive techniques grow. ing a damage control situation and/or renal pedicle avulsions
that require complex vascular reconstruction. Critical to doc-
ument in those acute settings is a functioning contralateral
kidney with a single-shot IVP. These patients are often in
INDICATIO NS FO R RENAL shock, have high injury severity scores, receive large volumes
EXPLO RATIO N of blood transfusions, and overall experience a high mortality
rate. As stated by N ash et al., “ It is not the exploration that
An absolute indication for renal exploration is life-threatening results in the nephrectomy but the injury itself” (20).
hemorrhage from a severely injured renal unit. Relative indi-
cations for operative exploration include ureteropelvic junc-
tion disruption, extensive nonviable renal parenchyma with
urinary extravasation, incomplete radiographic staging, and SURGICAL TECHNIQ UE
limited observational facilities (Table 9.1). In the setting of a
concomitant exploratory laparotomy by the trauma surgeons, Renal exploration in the trauma setting should be carried out
our preference is to formally explore and reconstruct any through a standard midline abdominal incision (Fig. 9.3). This
approach provides complete access to the intra-abdominal vis-
cera and vasculature and also gives the greatest flexibility to
assess and repair a variety of genitourinary injuries. M ajor
TA B LE 9 . 1
bleeding noted on opening the abdominal cavity should be
IN DICATION S FOR REN AL EXPLORATION controlled immediately with laparotomy packs followed by
surgical control and repair. Associated injuries to other ab-
ABSOLUTE dominal organs are usually addressed before examination of
Expanding renal hematoma the kidneys if the patient is stable. The bowel, liver, spleen,
Pulsatile hematoma pancreas, and other organs should be inspected systematically
Complete ureteropelvic junction disruption and carefully. During this period, Gerota fascia maintains its
natural tamponade effect on the perinephric hematoma.
RELATIVE The renal vasculature is routinely isolated before entering
Urinary extravasation associated with nonviable tissue the retroperitoneal hematoma surrounding the injured kidney.
Large area of nonviable renal parenchyma This reduces the risk of uncontrolled renal bleeding and un-
Significant arterial extravasation a planned nephrectomy (21,22). To facilitate access to the
Incomplete staging retroperitoneum, the transverse colon is lifted out of the ab-
domen superiorly and placed on moist laparotomy packs. The
a Interventional radiology is not available or is unable to control the small bowel is rotated to the patient’s right and extracted from
bleeding.
the body to allow access to the great vessels. An incision is
FIGURE 9.4 The colon is reflected medially to allow access to the

retroperitoneum. Gerota’s fascia is sharply opened.
is important as it provides hemostasis and tensile strength

FIGURE 9.3 A midline incision provides the optimal exposure for
abdominal exploration, vascular control, and repair of a variety of for the closure. If necessary for uncontrollable hemorrhage,
genitourinary injuries. clamping of the previously isolated vessels can be done with
vascular clamps or bulldogs.
The following principles are applied to all renal reconstruc-
tions: early vascular control, complete renal exposure, sharp
made in the retroperitoneum over the aorta from the level of debridement of nonviable tissue, oversewing of bleeding vessels
the inferior mesenteric artery to the ligament of Treitz, which for hemostasis, and watertight collecting system closure. If
can be divided for additional exposure. If a large retroperi- available, the renal capsule is loosely reapproximated over
toneal hematoma obscures the aorta, the inferior mesenteric thrombin-soaked Gelfoam or another thrombogenic sub-
vein is identified and the incision into the retroperitoneum is stance. Ideally an omental flap is placed over the recon-
placed just medial to this important landmark. O nce the aorta structed kidney for additional protection and its absorptive
is identified in the lower part of the incision, it is followed properties.
superiorly to the left renal vein, which reliably crosses anteri- M ajor polar injuries are best approached by a polar partial
orly. The renal arteries can be found just posterior to the left nephrectomy. The kidney should be sharply debrided back to
renal vein on either side of the aorta. The right renal artery viable bleeding tissue. End vessels are individually suture-
can be isolated in the interaortocaval location. If it is difficult ligated with 4-0 absorbable sutures to gain hemostasis. The
to identify the right renal artery through this approach, the collecting system is then closed with a continuous watertight
second portion of the duodenum can be reflected to expose 4-0 absorbable suture. M ethylene blue may be injected into
the right renal hilum. The artery is located posterior to the the renal pelvis with simultaneous compression of the ureter
right renal vein. to elucidate any leaks in the collecting system, which may then
The renal artery and vein associated with the injured renal be oversewn however, oversewing is not routinely performed.
unit are individually isolated with vessel loops. These vessels The renal parenchymal defect is covered with thrombin-
are not occluded initially unless uncontrollable bleeding is en- soaked Gelfoam or another thrombogenic bulking agent to
countered. M ost bleeding is successfully controlled with man- enhance hemostasis and is covered with loosely approxi-
ual compression alone. Because the vessels are not routinely mated, interrupted 3-0 absorbable renal capsular sutures. If
clamped, renal perfusion is continuous and warm ischemia is no capsule is available or the defect is too large to close pri-
avoided. marily, an omental pedicle flap can be used to cover the defect
Following proximal vascular control, the kidney is exposed (Fig. 9.7). Its absorbent properties and rich vascular supply
by incising the retroperitoneum just lateral to the colon. The make it an excellent alternative to the renal capsule. Another
colon is reflected medially. Gerota’s fascia is sharply opened, substance we commonly use to cover the renal defect is Vicryl
and the kidney is expeditiously mobilized to allow complete mesh as it is readily available, absorbable, and can easily be
exposure of the renal surface (Fig. 9.4). O nly after complete tailored to the size and shape of the renal defect. A passive
exposure can the extent and number of injuries be determined drain is placed, and it is removed in 48 to 72 hours after con-
(Fig. 9.5/6). M aintaining the renal capsule during mobilization firming closure of the collecting system.
FIGURE 9.7 During a polar partial nephrectomy with reconstruc-

tion, if the renal capsule is not available for defect closure, a Vicryl
mesh patch or the omentum can be used to cover the defect.
FIGURE 9.5/ 6 The kidney is explored. A small gunshot entrance

wound on the anterior aspect of the left kidney is identified. O n the
posterior surface, a complex gaping exit wound is identified. Nonviable
tissue is sharply debrided, segmental vessels are individually suture-
ligated, and the collecting system is closed with a continuous ab-
sorbable suture. Capsular 3-0 Vicryl sutures are used to reapproximate
wound edges.
M ajor injuries to the midportion of the kidney are best re-

paired by sharp wedge resection of the nonviable tissue and
renorrhaphy. Devitalized tissue is sharply removed. Sites of
bleeding are individually ligated with fine absorbable sutures,
and the collecting system is closed with a continuous suture.
Thrombin-soaked Gelfoam bolsters are placed into the defect
to enhance hemostasis and reduce tension on the capsular FIGURE 9.8 Closure of parenchymal defect after central renal injury.
sutures (Fig. 9.8). Interrupted absorbable 3-0 sutures are Capsular sutures of 3-0 Vicryl may be used to sew gelatin foam bol-
placed through the renal capsule, excluding the underlying sters into the repair site. Titanium clips may be placed along the repair
line to identify the area of reconstruction on subsequent imaging stud-
parenchyma, as it provides no additional strength. O mentum ies. Alternatively, if primary renal closure cannot be achieved, an
or Vicryl mesh can be used if primary renal capsular closure omental flap may be tacked over the defect using small interrupted
cannot be achieved. chromic sutures.
extravasation is detected by a perirenal drain or radiographic

imaging, a ureteral stent can be placed with anticipated col-
lecting system closure (3,11).
RENO VASCULAR INJ URIES

Renovascular injuries are closely associated to the grade of
renal injury and are a major cause of partial or total renal
loss. M ain renal artery or vein avulsion, in the acute trauma
situation, is deemed irreparable and results in nephrectomy.
Proximal control of the renal pedicle is critical in these
injuries to avoid life-threatening hemorrhage. Attempts at
complex hilar arterial or venous reconstruction have shown
poor results and should be reserved for the solitary kidney or
bilateral renal hilar injuries in a non–damage-control situa-
tion (1,19,23). If necessary, the left main renal vein can be
suture-ligated with sufficient drainage through the left
adrenal and gonadal vessels. Reconstruction of a partial
venous or arterial hilar injury can be performed with a con-
tinuous fine nonabsorbable suture after obtaining vascular
control (Fig. 9.11).
FIGURE 9.9 Technique of renorrhaphy after stab wound. Gelfoam

bolsters are laid into the capsular defect, and overlying 3-0 Vicryl
sutures are placed superficially to approximate the adjoining renal
PO STO PERATIVE CARE
capsule, thus sealing the reconstructed area.
Gross blood in the urine usually clears within 24 hours, and
patients should be observed on bedrest until this occurs.
Ambulation is resumed once the urine is clear. Routine labora-
tory studies are obtained. In the event of a delayed bleed, renal
angiography and selective angioembolization can be utilized
to control the hemorrhage. Retroperitoneal drains are nor-
mally removed within 48 to 72 hours. If drainage is excessive,
an aliquot may be checked for creatinine; a level similar to
that of serum suggests peritoneal fluid rather than urine. All
strenuous activity is suspended for a minimum of 3 months, at
which time a radiographic CT imaging study is obtained to
document complete renal healing. A radionuclide study can be
obtained to assess renal function.
CO MPLICATIO NS
Delayed renal hemorrhage or development of an arteriove-
nous malformation (AVM ) or pseudoaneurysm usually occurs
in the acute peritrauma period and presents with flank pain
and/or gross hematuria (cardiovascular issues may also de-
velop with AVM ). These situations are best managed by selec-
tive angioembolization, which is a safe and effective treatment
FIGURE 9.10 Completed renal reconstruction after stab wound. The
entire kidney has been mobilized and evaluated for associated wounds. modality. M ild to moderate urinary extravasation is rarely
Titanium clips along the capsular sutures denote the area of repair. clinically significant and can be followed by repeat CT imag-
ing to ensure resolution. Large urinomas can be treated with
percutaneous drainage and may require a ureteral stent if
repeat CT imaging demonstrates persistent or worsening uri-
Renal stab wounds often do not result in displaced or miss- nary extravasation. H ypertension after renal trauma is classi-
ing renal tissue. Frequently, entrance and exit wounds can be cally associated with a Page kidney injury and is otherwise
oversewn, and liquid thrombogenic agents such as FloSeal infrequent. Delayed nephrectomy or preferably, capsulectomy
can be applied, resulting in excellent hemostasis (Figs. 9.9 and and drainage can successfully manage hypertension secondary
9.10). Collecting system injuries that may have occurred will to a Page kidney injury, as this is an anatomical compression
usually resolve with closure of the overlying parenchyma of the renal parenchyma. M edical therapy is otherwise utilized
and should not be aggressively pursued. If delayed urinary as indicated for essential hypertension.
FIGURE 9.11 Repair of partial main re-

nal vein or artery injury using a nonab-
sorbable continuous suture after gaining
vascular control.
critically ill patients with potentially life-threatening hemor-

SUMMARY rhage and in those who cannot be preoperatively staged by
radiographic CT imaging and observed in ICUs. If renal
Radiographic CT staging, improved endovascular minimally exploration is necessary, early vascular control and adherence
invasive techniques, and growing experience have allowed to reconstructive principles will ensure high renal salvage
more successful nonoperative renal trauma care to occur. rates.
Although limited, the role for renal exploration still exists in
References
1. Santucci RA, Wessells H , Bartsch G, et al. Evaluation and management of 12. Breyer BN , M aster VA, M arder SR, et al. Endovascular management of
renal injuries: consensus statement of the renal trauma subcommittee. Br J trauma related renal artery thrombosis. J Traum a. 2008;64:1123–5.
Urol Int 2004;93(7):937–954. 13. Uflacker R, Paolini RM , Lima S. M anagement of traumatic hematuria by
2. Wright JL, N athens AB, Rivara FP, et al. Renal and extrarenal predictors of selective renal artery embolization. J Urol 1984;132(4):662–667.
nephrectomy from the national trauma data bank. J Urol 2006;175(3, 14. Eastham JA, Wilson TG, Larsen DW, et al. Angiographic embolization of
Pt 1):970–975; discussion 5. renal stab wounds. J Urol 1992;148(2, Pt 1):268–270.
3. Buckley JC, M cAninch JW. Selective management of isolated and noniso- 15. H agiwara A, Sakaki S, Goto H , et al. The role of interventional radiology
lated grade IV renal injuries. J Urol 2006;176(6, Pt 1):2498–2502; discus- in the management of blunt renal injury: a practical protocol. J Traum a
sion 502. 2001;51(3):526–531.
4. Wessells H , Deirmenjian J, M cAninch JW. Preservation of renal function 16. Patterson DE, Segura JW, LeRoy AJ, et al. The etiology and treatment of
after reconstruction for trauma: quantitative assessment with radionuclide delayed bleeding following percutaneous lithotripsy. J Urol 1985;133(3):
scintigraphy. J Urol 1997;157(5):1583–1586. 447–451.
5. M iller KS, M cAninch JW. Radiographic assessment of renal trauma: our 17. Farmer CD, Diaz-Buxo JA, Grubb WL, et al. Control of post renal biopsy
15-year experience. J Urol 1995;154(2, Pt 1):352–355. hemorrhage by Gelfoam embolization. N ephron 1981;28(3):149–151.
6. Bretan PN Jr., M cAninch JW, Federle M P, et al. Computerized tomo- 18. Wessells H , M cAninch JW. Effect of colon injury on the management of
graphic staging of renal trauma: 85 consecutive cases. J Urol 1986;136(3): simultaneous renal trauma. J Urol 1996;155(6):1852–1856.
561–565. 19. M aster VA, M cAninch JW. O perative management of renal injuries:
7. Buckley JC, M cAninch JW. Pediatric renal injuries: management guidelines parenchymal and vascular. Urol Clin N orth A m 2006;33(1):21–31, v–vi.
from a 25-year experience. J Urol 2004;172(2):687–690; discussion 90. 20. N ash PA, Bruce JE, M cAninch JW. N ephrectomy for traumatic renal in-
8. M orey AF, Bruce JE, M cAninch JW. Efficacy of radiographic imaging in juries. J Urol 1995;153:609–611.
pediatric blunt renal trauma. J Urol 1996;156(6):2014–2018. 21. M cAninch JW, Carroll PR. Renal trauma: kidney preservation through
9. M orey AF, M cAninch JW, Tiller BK. Single shot intraoperative excretory improved vascular control—a refined approach. J Traum a 1982;22(4):
urography for the immediate evaluation of renal trauma. J Urol 1999;161 285–290.
(4):1088–1092. 22. Carroll PR, Klosterman P, M cAninch JW. Early vascular control for renal
10. Demetriades D, H adjizacharia P, Constantinou C, et al. Selective nonoper- trauma: a critical review. J Urol 1989;141(4):826–829.
ative management of penetrating abdominal solid organ injuries. A nn Surg 23. Knudson M M , H arrison PB, H oyt DB, et al. O utcome after major renovas-
2006;244(4):620–628. cular injuries: a Western trauma association multicenter report. J Traum a
11. Alsikafi N F, M cAninch JW, Elliott SP, et al. N onoperative management 2000;49(6):1116–1122.
outcomes of isolated urinary extravasation following renal lacerations due
to external trauma. J Urol 2006;176(6, Pt 1):2494–2497.
CHAPTER 10 ■ RENAL ALLO TRANSPLANTATIO N
JO HN W. MCGILLICUDDY, JUSTIN D. ELLETT, AND KENNETH D. CHAVIN
Successful transplantation of a kidney allograft and subse- waiting list and 69% lower than those who remain on chronic
quent long-term immunosuppression management demand hemodialysis (1).
medical and surgical precision. The consequences of vascular,
urologic, and infectious complications in renal transplanta-
tion, with their associated morbidity, mortality, and graft loss, SURGICAL TECHNIQ UE
can be devastating. Strict adherence to proper techniques and
sound surgical principles, as outlined in this chapter, can re- The prospective transplantation recipient should be in meta-
duce the incidence of these complications. bolic, fluid, and electrolyte balance to avoid perioperative hy-
perkalemia, unstable blood pressure, pulmonary edema,
dehydration, or difficult operative hemostasis associated with
DIAGNO SIS inadequate dialysis. When dialysis can be scheduled in ad-
vance, as with living donor transplantation, it should be
Renal allotransplantation is performed as a treatment for end- performed on the day before surgery. The patient’s cardiopul-
stage renal disease (ESRD). Although there is no specific study monary status needs to be optimized, and central venous pres-
required to make the diagnosis of ESRD, a thorough preoper- sure monitoring can be useful in select patients. Swan-Ganz
ative evaluation of the patient will include multiple studies to monitoring is rarely necessary.
confirm the patient’s candidacy as a transplant recipient. The abdomen, from 2 to 3 cm above the umbilicus to be-
low the symphysis pubica, is shaved and prepared after the
induction of anesthesia and insertion of an indwelling Foley
INDICATIO NS FO R SURGERY catheter. The bladder is gently distended with approximately
150 mL of a neomycin/bacitracin antibiotic solution. An
The primary indication for renal allotransplantation is ESRD alternative involves a three-way Foley catheter, allowing in-
requiring chronic dialysis. Some patients with poor and deteri- traoperative bladder distention at the time of ureteroneocys-
orating renal function, but who are not yet requiring dialysis, tostomy. Care must be taken to avoid inadvertent bladder
may also be candidates. Patients need to have a creatinine clear- rupture in these patients, who often have small, nondistensi-
ance of 30 cc to be considered for transplantation. ble bladders. Distention greatly facilitates the anterior cys-
Active infections and malignancies are generally considered tostomy later in the procedure and, in addition, protects
contraindications for transplantation due to the immunosup- against possible wound contamination when the bladder is
pressive therapy that is required postoperatively. Comorbidity opened. After instillation of the antibiotic solution, the
in other organ systems, especially cardiovascular and pul- catheter is clamped. The clamp is removed after the cysto-
monary, may impose operative risks or compromise long-term tomy is created.
prognosis significantly enough to preclude transplantation.
Inadequate patient motivation, commitment, compliance,
psychological stability, or social support may also be con- Incisio n and Iliac Fo ssa Disse ct io n
traindications.
A right or left lower-quadrant curvilinear incision is created
from the symphysis pubica to a point 2 cm medial to and just
ALTERNATIVE THERAPY above the anterior superior iliac spine (Fig. 10.1A). While this
is ultimately determined by surgeon preference, the implanta-
ESRD patients may choose from the two modalities of chronic tion of a right kidney on the left side or a left kidney on the right
dialysis for long-term life-sustaining treatment. H emodialysis side brings the renal pelvis anterior, simplifying re-exploration
may be done at home or at a treatment center. Peritoneal dial- and revision should complications arise. The upper half of the
ysis is in general performed by the patient on a continuous incision is extended through the external oblique, internal
ambulatory or overnight schedule. Renal allotransplantation oblique, and transversus abdominis muscles; in the lower half
offers significant quality of life improvements and a long-term of the incision, the anterior rectus fascia is incised. The rectus
survival advantage as compared to dialysis. Studies show that muscle can then be dissected inferiorly to its tendinous inser-
patients on the kidney transplant waiting list have a death rate tion on the symphysis pubica and retracted medially. The infe-
of 6.3 deaths per 100 patient years, which is improved to a rior epigastric vessels are identified as they pass across the
death rate of 3.8 deaths per 100 patient years in those who incision and are preserved if possible. An anterolateral
were transplanted. Correspondingly, the long-term mortality retroperitoneal fascial plane is developed bluntly, permitting
risk in transplant recipients is 20% lower than those on the extraperitoneal entry into the iliac fossa.
65
FIGURE 10.1 A: The incision is depicted for the right abdomen. The renal transplantation, however, can
be performed on either the right or left side. B: The iliac vessels are best exposed with a self-retaining
retractor. Sequential separation, ligation, and division of perivascular tissue containing lymphatics are
essential and must precede skeletonization of the iliac vessels.
With medial retraction of the peritoneum, the spermatic The tissue overlying the arteries and containing the lymphatics
cord in the male patient or the round ligament in the female is sequentially separated, doubly ligated with 3-0 silk, and di-
patient is easily identified. Usually, cord ligation should be vided, a strategy that greatly reduces the incidence of lympho-
avoided to prevent hydrocele formation, testicular atrophy, or cele. As with the vein, the anterior separation of tissue over the
infertility. In women, the round ligament is divided and lig- iliac artery is more easily performed in a cephalad direction.
ated. Further development of the extraperitoneal space in the At this point, palpation of the iliac arteries allows the sur-
iliac fossa is accomplished with exposure of the distal com- geon to determine the most appropriate site for anastomosis.
mon and external iliac arteries. The insertion of a self-retaining If there is moderate or severe atherosclerosis extending along
retractor at this point ensures adequate exposure for the subse- the entire length of the external iliac artery, the internal iliac
quent iliac vessel dissection and vascular anastomoses. artery can be used for an end-to-end anastomosis. M ost com-
The dissection and skeletonization of the iliac vessels must monly, however, an end-to-side anastomosis of the renal
be performed in a manner that allows secure ligation of the di- artery to the external or common iliac artery is preferred as it
vided lymphatics passing along and across these vessels. preserves the internal iliac artery and diminishes the risks of
Usually, this process is best approached on the superior aspect impotency in men and gluteal or pelvic ischemia in the elderly.
of the external iliac artery, working cephalad with a right-angle If the internal iliac artery is to be used, skeletonization of this
clamp toward the internal iliac artery, which crosses the inter- vessel prepares it for end-to-end anastomosis. Before skele-
nal iliac vein. In rare cases, when the donor kidney is very tonization is begun, the lymphatics on the medial aspect of the
large or has an unusually short vein, the internal iliac artery iliac bifurcation should be doubly ligated and divided. The in-
must be sacrificed to allow sufficient mobilization of the un- ternal iliac artery may then be clamped proximally with a
derlying vein. The external iliac vein is similarily skeletonized Fogarty clamp and divided distal to its bifurcation with ap-
as far cephalad as the vena cava if necessary. Posterior venous propriate ligation of the distal stumps deep in the pelvis. The
tributaries can be divided as necessary to permit maximum mobilized internal iliac artery is irrigated with heparinized
anterior mobility of the iliac vein. It is best to ligate all tribu- saline solution.
taries doubly with 2-0 or 3-0 silk in continuity before division
because a double-clamping maneuver may sometimes result in
injury or avulsion of a poorly accessible stump during liga- Allo g raft Po sit io ning and Vascular
tion. If avulsion occurs, establishment of hemostasis risks in- Anast o mo se s
jury to the obturator nerve. Unless the internal iliac artery
already has been selected for an end-to-end allograft anasto- Before recipient vessel anastomotic sites are selected, place-
mosis, right-angle clamp dissection is used to partially skele- ment of the allograft lateral or anterior to the iliac vessels
tonize the common and external iliac arteries (Fig. 10.1B). should be considered, all anatomic factors being taken into
Chap t e r 10: Re nal Allotransp lantation 67
account. The iliac vein is prepared for the end-to-side renal proximal and distal to the proposed arteriotomy. This anasto-
vein anastomosis by placement of clamps proximal and distal mosis usually is placed just cephalad to the level of the venous
to the proposed venotomy. Fogarty clamps or a single broken- anastomosis. The location of clamp placement must be care-
back Satinsky clamp usually serves this purpose well. A longi- fully selected so as not to disrupt existing arteriosclerotic
tudinal incision is made on the anterior or anteromedial portion plaques and precipitate embolization or thrombosis. A longi-
of the iliac vein segment with a no. 11 blade and extended as tudinal incision is made on the anterior or anterolateral por-
necessary with Potts right-angle scissors. The isolated segment tion of the iliac artery segment with a no. 11 blade and
of the iliac vein is irrigated with heparinized saline. After this, extended as necessary with Potts right-angle scissors. If the
four 5-0 cardiovascular sutures are placed at the superior and surgeon prefers, a 4.8- or 5.6-mm aortic punch can be used to
inferior apices and at the midpoints of the medial and lateral prepare an ideal oval arteriotomy. The isolated segment of the
margins of the venotomy. These sutures later are passed iliac artery is irrigated with heparinized saline. This anastomo-
through corresponding points on the donor renal vein or vena sis is performed with 6-0 Prolene continuous or interrupted
cava patch for a four-quadrant, end-to-side anastomosis. sutures after initial fixation of the end of the renal artery to
If a cadaveric kidney is used, the allograft is removed from the apices of the arteriotomy, leaving one suture untied to
cold storage or perfusion preservation at this point. With allow for better visualization of the intima.
living-related transplantation, the flushed and cooled graft is Less commonly, when the internal iliac artery is to be used
obtained from the live donor in an adjacent operating room. for the arterial anastomosis, an end-to-end anastomosis is
The kidney is secured in a sling containing ice slush and then performed with the renal artery (see Fig. 10.2B). The two
held in position for the vascular anastomosis by the assistant. vessels are positioned to allow a gentle upward curve from the
A clamp is used to secure the sling to relieve the assistant from iliac bifurcation to the kidney by fixing the superior and infe-
holding the kidney in position with the hands, which might rior arterial apices with interrupted 6-0 Prolene sutures. The
accelerate warming or compress the kidney during the perfor- anastomosis is completed with continuous or interrupted
mance of the vascular anastomoses. sutures. A preference for interrupted sutures instead of a run-
The previously placed sutures through the iliac vein are ning suture in this end-to-end anastomosis prevails when one
passed through the corresponding points of the donor renal needs to avoid absolutely any pursestring effect that might
vein or vena cava conduit and secured, bringing the renal vein occur from a running suture or to achieve optimal accommo-
into juxtaposition with the iliac vein (Fig. 10.2A). The medial dation of the two vessels to each other when a size or thick-
and lateral sutures are retracted to separate the venotomy ness discrepancy exists.
opening and facilitate rapid anastomosis without inadvertent Upon completion of the anastomoses, the vascular clamps
suturing of the back wall. With the table rotated laterally, the are released, venous clamps before arterial. Any bleeding
superior suture is used as a running suture down the medial along the line of the anastomoses is controlled with a combi-
side of the renal vein to meet the inferior suture running up. nation of topical hemostatic agents, direct pressure, and
The lateral suture line is then run in a similar fashion after the suture repair. The sling around the kidney is removed, and any
table has been rotated medially. bleeding identified in the hilum or on the surface of the kidney
The external iliac artery is prepared for the end-to-side is controlled, taking care to avoid injuring the hilar vessels.
renal artery anastomosis by placement of Fogerty clamps M aintenance of adequate perfusion pressure is essential and
FIGURE 10.2 A: The renal vein is brought into exact juxtaposition with the iliac vein phlebotomy by
previously placed four-quadrant sutures. A running suture anastomosis will follow. B: The renal artery is
positioned to the end of the internal iliac artery by superior and inferior apical sutures. Subsequent place-
ment of interrupted sutures completes the anastomosis. N ote the occluding bulldog clamp on the renal
vein. C: The completed venous and arterial anastomoses are demonstrated.
ice slush prior to beginning implantation. Finally, some recipi-

ents have a deep inferior epigastric artery that is suitable for an
end-to-end 7-0 suture interrupted anastomosis of a small lower-
pole artery, which may be essential for ureteral viability (3).
Ure t e ral Co nsid e rat io ns

When the recipient urinary bladder is functional, ureteroneo-
cystostomy is the preferred technique for establishing urinary
tract continuity unless the donor ureter is absent, very short,
abnormal, or damaged. Ureterectasis is not a contraindica-
tion. When the donor ureter is not suitable for reasons listed
above, the recipient ureter may be used for ureteroureteros-
tomy or ureteropyelostomy (4). If a recipient ureter is not
available but the bladder is large, psoas hitch or Boari flap
techniques may be used for ureteroneocystostomy or pyelo-
cystostomy.
Some patients are prepared for kidney transplantation by
creation of an ileal loop or isolated ileal stoma to divert urine
from a dysfunctional or absent bladder. O ther patients may
come to transplantation with pre-existing bladder augmenta-
tions or continent urinary diversions utilizing ileum and
colon. The nuances of techniques in these settings are beyond
the scope of this discussion.
Typically, 95% of all renal transplantations are per-
formed with various modifications of the Lich-Gregoir (5),
Politano-Leadbetter (6), or Shanfield (7) techniques for allo-
graft ureteral implantation into the bladder. In our experience,
FIGURE 10.3 A donor aorta Carrel patch encompassing two renal the Lich technique is appropriate in almost all cases (8).
arteries is positioned by apical sutures to an iliac arteriotomy fash- Previous filling of the bladder facilitates identification and
ioned to accommodate the length and width of the patch. opening of the bladder. The detrusor muscle is separated from
the bladder mucosa for a length of 2 to 4 cm. A small mucosal
can be achieved with judicious intravenous hydration and the opening is created, and the ureter is pulled down and brought
use of mannitol and a dopamine drip as needed. into position near the site of cystotomy by gentle traction
(Fig. 10.4). This avoids any excess handling of the ureter,
which is important because the ureter of the transplanted kid-
Mult ip le Re nal Ve sse ls ney receives its blood supply exclusively from the renal vessel
branches that course in its adventitia. In male patients, it is im-
Although the Carrel patch may frequently be used with single portant to pass the ureter beneath the spermatic cord. The
arteries and veins, a cadaveric kidney with multiple renal ureter is trimmed to an appropriate length and spatulated
arteries perfused through the aorta is especially well suited to about 1 cm.
an end-to-side anastomosis of a Carrel patch encompassing Two 5-0 polydioxanone sutures (PDS) are used to bring the
the multiple arteries (Fig. 10.3) (2). If the vessels are close to ureteral orifice down to the cystostomy and to construct the
each other, a single Carrel patch is sufficient. The Carrel patch anastomosis incorporating bladder mucosa and ureter. The
of donor aorta is fashioned to accommodate the multiple ves- ureter is routinely stented with a 6Fr, 12-cm double-J stent to
sels, and its anastomosis to the common or external iliac reduce major ureteral complications (9). The detrusor muscle
artery is performed as previously described. is then reapproximated over the stented ureter to provide an
If the donor renal vessels are 2 cm apart or the allograft antireflux mechanism. Kidneys with a double ureter can also
comes from a living donor where taking a Carrel patch is not be transplanted successfully. These ureters should be dissected
possible, there are several strategies for arterial anastomosis: en bloc within their common adventitial sheath and peri-
(a) double end-to-side renal arteries to iliac artery, (b) end- ureteral fat so that the ureteral blood supply is protected. The
to-end superior renal artery to internal iliac artery with end-to- technique of ureteroneocystostomy is essentially the same as
side inferior renal artery to external iliac artery, and (c) im- with a single ureter except that the ureters are brought
plantation of an accessory artery end-to-side into the larger through together side by side in a nonconstricting tunnel. The
main renal artery, with the larger renal artery anastomosed to distal end of each ureter is spatulated, and the adjacent mar-
the internal, external, or common iliac artery. If two renal gins are approximated with 5-0 PDS.
arteries are of similar diameter, the spatulation edges of the re- Rarely, situations occur in which ureteroneocystostomy
nal arteries can be joined by the “ trousers technique” with run- unexpectedly cannot be performed and native ureters are not
ning 6-0 or 7-0 Prolene sutures to create a single bifurcating available. In this setting, cutaneous ureterostomy is preferred.
artery (2). An accessory-artery-to-main-renal-artery anastomosis Alternatively, an ileal loop may be created at the time of trans-
should be performed with an ex vivo bench technique in cold plantation. Ureterosigmoidostomy should be avoided.
Chap t e r 10: Re nal Allotransp lantation 69
FIGURE 10.4 Ureteroneocystostomy. A: A small Robinson

catheter or heavy silk suture with donor ureter attached is
brought into the bladder through an oblique hiatus. B: The
completed transplant ureteroneocystostomy is demonstrated.
Four interrupted sutures secure the spatulated ureteral orifice.
Pe d iat ric Kid ne ys

Although en bloc transplantation of kidneys from very young
children is often desirable (10), it is not necessary to trans-
plant both kidneys from young children en bloc; each kidney
can be used for a different recipient, as is the case with adult
cadaveric donors, using Carrel patches of donor aorta and
vena cava (Fig. 10.5) (11). A Carrel patch is mandatory in
these cases because direct implantation of a small vessel into a
much larger or diseased vessel may result in thrombosis or
produce functional stenosis as the kidney grows. When the en
bloc technique is used, the two ureters are implanted sepa-
rately and stented. Pediatric kidneys have proven to be excel-
lent donor grafts for carefully selected adults and children.
Avoidance of older recipients or diabetics with advanced arte-
riosclerosis will minimize the potential for thrombosis. Rapid
growth and hypertrophy occur in the immediate posttrans-
plantation period. If early rejection can be avoided, these allo-
grafts achieve adult size and function in adult recipients
within several weeks.
Pe d iat ric Transp lant at io n FIGURE 10.5 Small pediatric cadaver renal vessels are anastomosed
to larger recipient iliac vessels using Carrel patches of donor aorta and
In small children, the iliac fossa is not large enough to accom- vena cava. N ote donor right kidney in right iliac fossa with renal
modate a kidney from an adult donor, and the pelvic vessels in pelvis posterior to renal vessels.
is often necessary. The ureteral implantation is carried out as

previously described.
Wo und Clo sure

Except in unusual cases, the space of Retzius and iliac fossa
are not drained. Jackson-Pratt suction may be employed, but
Penrose drains are never used. If good hemostasis has been ob-
tained, and if the principles of implantation as outlined in this
chapter have been followed, there is no need for postoperative
drainage other than a urethral catheter. The optimal period of
Foley catheter drainage is debatable. We prefer to remove the
catheter at 72 hours unless the patient has worrisome hema-
turia, large diuresis, or poor bladder function, or had a techni-
cally difficult neoureterocystostomy.
In preparation for closure, the wound is thoroughly irri-
gated with antibiotic-containing saline. Depending on surgeon
preference, a heavy absorbable or nonabsorbable suture is
used to approximate transversus abdominis and internal
oblique muscles in a single-layer closure; the adjacent fascia is
included inferiorly at the tendinous insertion of the rectus
muscle. N ext, the rectus fascia anteriorly and the fascia of the
external oblique are approximated in the same manner.
The subcutaneous tissue is thoroughly irrigated with saline
and then may be approximated with interrupted 2-0 or 3-0
FIGURE 10.6 Anatomic relationships of an adult donor kidney in a Vicryl sutures. These sutures are placed about 3 cm apart and
small child are shown with renal vessel anastomoses to the inferior
vena cava and aorta. include both edges of the Scarpa fascia and the underlying fas-
cia. In this manner, one can obliterate dead space in the subcu-
taneous area in which a seroma in an immunosuppressed
patient might cause dehiscence and become secondarily in-
a small child are so small that the disparity between the donor fected. The skin is approximated with a running 4-0
renal vessels and the recipient vessels precludes the technique M onocryl suture in a subcuticular fashion or with surgical
described for adults. In these small children, graft implantation staples.
must use the recipient aorta and vena cava, which is best
accomplished through a right-sided retroperitoneal or, in chil-
dren 10 kg, a transperitoneal midline abdominal incision that
provides ready access to the great vessels as well as the urinary O UTCO ME
bladder. After the right colon is reflected medially, the vena
cava is freed from the level of the right renal vein inferiorly to Co mp licat io ns
its bifurcation or beyond. Posterior lumbar veins are doubly
ligated with 5-0 silk and divided as needed. M obilization of the Early vascular complications of kidney transplantation in-
vena cava is important to facilitate the end-to-side anastomosis clude arterial thrombosis, venous thrombosis, and anasto-
of the renal vein, which is performed with running 6-0 Prolene motic bleeding. These each occur in 1% of cases unless the
sutures, as described for the adult (Fig. 10.6). Performing the recipient or donor vessels are diseased or small caliber. Renal
venous anastomosis superiorly allows room for an end-to-side or iliac artery stenosis may lead to allograft ischemia or
anastomosis of the renal artery to the inferior abdominal aorta. thrombosis days or even years posttransplant in 2% to 12%
Aortic mobilization should be limited to its distal portion, from of cases (12).
the level of the inferior mesenteric artery, and including both Urologic complications are slightly more common than
common iliac arteries. The segment of the aorta to be used for vascular complications but less likely to lead to graft loss.
the end-to-side renal artery anastomosis can be isolated in any When donor ureter and recipient bladder are normal, early
number of ways, but most simply by applying a small vascular ureteral necrosis, ureteral anastomotic leak, or obstruction
Satinsky clamp. The end-to-side anastomosis is performed with each occur in 1% of cases. Compromised ureteral blood
interrupted 6-0 Prolene sutures. supply during donor nephrectomy and abnormal bladder are
Important to the revascularization of an adult kidney in the most likely factors increasing these risks. Ureteral stenosis
small children is the need to anticipate the impending con- months or years posttransplant is most often a result of
sumption of several hundred milliliters of effective blood vol- chronic rejection. Lymphocele occurring in 6% to 10% of
ume by the renal allograft. Initiation of volume loading before transplants may be considered a urologic complication if it
beginning the vascular anastomoses will avoid hypotension causes extrinsic ureteral obstruction or bladder compression.
after release of the vascular clamps. Immediately after estab- Lymphocele requires intervention posttransplant only if it
lishing circulation in the graft, the anesthesiologist must be becomes infected or causes pain, iliac vein compression, or
continually attentive to the blood pressure. A dopamine drip allograft ureteropyelocaliectasis. Infectious, cardiovascular,
Chap t e r 11: Ure te ral Comp lications Following Re nal Transp lantation 71
metabolic, pharmacologic, and psychosocial complications TA B LE 1 0 . 1

of transplantation are beyond the scope of this presentation.
Acute rejection superimposed on preservation injury pro- 2007 AN N UAL REPORT OF THE U.S. ORGAN AN D
duced irreversible failure in more than half of all cadaver TRAN SPLAN TATION N ETWORK AN D THE
SCIEN TIFIC REGISTRY OF TRAN SPLAN T RECIPIEN TS:
donor renal allografts in the early days of transplantation. In
TRAN SPLAN T DATA 1997 TO 2006
recent years the rate of irreversible acute rejection is 10% in
nearly all programs. Chronic allograft nephropathy, however, Living donor Cadaveric donor
continues to contribute significantly to long-term graft loss
and morbidity. 3-mo patient survival 99.3% 98.3%
1-yr patient survival 98.0% 95.8%
Re sult s 3-mo graft survival 97.3% 95.3%
1-yr graft survival 95.1% 91.3%
The 2007 Annual Report of the U.S. O rgan Procurement and
Transplantation N etwork documents 1-year patient survival
at 98.0% and 95.8% , depending on whether the graft was
from a living or cadaveric donor, respectively. It also docu- From the Department of H ealth and H uman Services, H ealth
ments 5-year allograft survival for living donor and cadaveric Resources and Services Administration, O ffice of Special Programs,
donor renal transplantation of 80.2% and 69.8% , respec- Division of Transplantation, Rockville, M D; United N etwork for
O rgan Sharing, Richmond, VA; and University Renal Research and
tively, as seen in Table 10.1. Education Association, Ann Arbor, M I.
References
1. Wolfe RA, Ashby M A, M ilford EL. Comparison of mortality in all patients 8. Franz M , Klaar U, H ofbauer H . Incidence of urinary tract infections and
on dialysis, patients on dialysis awaiting transplantation, and recipients of vesicorenal reflux: a comparison between conventional and antirefluxive
a first cadaveric transplant. N Engl J M ed 1999;341:1725–1730. technique of ureter implantation. Transplant Proc 1992;24(6):2773–2774.
2. Belzer FO , Schweizer RT, Kountz SL. M anagement of multiple vessels in 9. Wilson CH , Bhatti AA, Rix DA. Routine intraoperative ureteric stenting
renal transplantation. Transplant Proc 1972;4:639–644. for kidney transplant recipients. Cochrane D atabase Syst R ev 2005;(4):
3. M erkel FK, Straus AK, Anderson O , et al. M icrovascular techniques for CD004925.
polar artery reconstruction in kidney transplants. Surgery 1976;79:253. 10. Kinne DW, Spanos PK, DeShazo M M , et al. Double renal transplants from
4. Welchel JD, Cosimi AB, Young H H , et al. Pyeloureterostomy reconstruc- pediatric donors to adult recipients. A m J Surg 1974;127:292–295.
tion in human renal transplantation. A nn Surg 1975;181:61–66. 11. Salvatierra O Jr, Belzer FO . Pediatric cadaver kidneys: their use in renal
5. Bruskewitz R, Sonneland AM , Waters RF. Extravesical ureteroplasty. transplantation. A rch Surg 1975;110:181–183.
J Urol 1979;121(5):648–649. 12. Sebastia C, Q uiroga S, Boye R. H elical CT in renal transplantation: normal
6. Tocci PE, Politano VA, Lynne CM . Unusual complications of transvesical findings and early and late complications. R adiographics 2001;21:
ureteral reimplantation. J Urol 1976;115(6):731–735. 1103–1117.
7. Texter JH Jr, Bokinsky G, Whitesell AI. Simplified experimental uretero-
neocystostomy. Urology 1976;7(1):21–23.
CHAPTER 11 ■ URETERAL CO MPLICATIO NS

FO LLO WING RENAL TRANSPLANTATIO N
RO DNEY J. TAYLO R
H istorically, the incidence of urologic complications following in lower morbidity and rare loss of a kidney or patient due to
kidney transplantation, manifested primarily as ureteral leaks these complications. H owever, despite these changes, the need
or obstruction, was as high as 10% (1,5). These complications for diligence in diagnosing and quickly addressing complica-
often resulted in significant morbidity, graft loss, and occa- tions remains as true today as in the past.
sional patient death. Improvements in surgical techniques, im- The most common cause for ureteral complications follow-
munosuppression, and methods for easily diagnosing and ing kidney transplantation is technical error (1,5,7). Damage
treating the complications have not only led to a significant to the ureteral blood supply during graft recovery or trans-
decline in the rate of urologic complications to the current replantation may result in ureteral ischemia and subsequent leak
ported incidence of 2% to 2.5% (4,7,9) but have also resulted or obstruction. Additional technical errors, such as excessive
tension at the ureteroneocystostomy site or hematoma devel- method to differentiate a urine leak from other fluid collec-
opment within the tunnel, may also cause problems (4,7). tions such as lymphoceles or hematomas (2). A cystogram
With careful attention to detail, most of these problems can should be performed if a bladder leak is suspected.
be minimized, especially in the early postoperative setting.
Long-term or delayed ureteral obstruction may be the result of
ischemic changes secondary to chronic rejection or a continu- Ure t e ral O b st ruct io n
ation of the spectrum of damage associated with the organ
harvest and transplantation, and although not all these prob- Ureteral obstruction can also be the result of ureteral ischemia
lems are preventable, the incidence can be markedly reduced but usually occurs later than ureteral leaks and usually pre-
with good surgical technique (1,4). The types of ureteral com- sents as acute graft dysfunction. It may occur years after the
plications can be divided into ureteral leaks and ureteral transplant and in this situation may represent vascular injury
obstruction. associated not only with the technical complications but also
with chronic rejection (1,7,8). The spectrum of ureteral isch-
emic injury extends from early necrosis and urinary leakage to
delayed ureteral obstruction, presenting months to years after
DIAGNO SIS the actual transplantation.
Ureteral obstruction, usually manifested by graft dysfunc-
Urinary Le aks tion, requires evaluation, and again an ultrasound and nuclear
renal scan are the most common screening studies. Additional
In current practice, most surgeons utilize an extravesical radiographic studies such as a computerized tomography (CT)
ureteroneocystostomy that uses a shorter ureter, decreasing scan may be of assistance in some cases. With both ureteral
the likelihood of ureteral ischemia, and utilizes a limited cys- leak and obstruction, endourologic techniques can be both
tostomy that rarely leads to leakage from the bladder (4,10). diagnostic and therapeutic.
Therefore, virtually all urinary leaks currently seen after trans-
plantation are ureteric. The majority of these leaks that occur
early after transplantation are usually present with excessive INDICATIO NS FO R SURGERY
drainage from the wound, unexplained graft dysfunction, or a
pelvic fluid collection. Signs and symptoms can also include Anything that causes graft dysfunction or results in disruption
fever, graft tenderness, and lower-extremity edema (8). It is of the urinary tract in a renal transplant patient is of utmost
critical to differentiate a suspected urinary leak from a lym- concern and requires rapid diagnosis, control, and treatment.
phocele, as the management is entirely different. In the case of ureteral leakage or obstruction, the goals of
Urinary leaks in the early postoperative period can be di- treatment include careful and accurate diagnosis of the exact
vided into two types according to the timing of presentation. cause and site. To correct the leak caused by excessive tension,
The first usually occurs within the first 1 to 4 days and is it is often possible to do a repeat ureteroneocystostomy as
almost always related to technical problems with the implan- soon as the diagnosis is made. In most other cases, especially
tation. In this case, the heel of the ureter has usually retracted with the current techniques of extravesical reimplantation, a
out of the tunnel. This is usually caused by excessive tension at different operative procedure is often more suitable (5,7).
the site of the anastomosis. This complication appears to be If the graft dysfunction problem has a physical cause such
more common with extravesical ureteroneocystostomies and as a leak or an obstruction and is not associated with an acute
may be the result of too much shortening of the ureter and rejection episode, then treatment is directed at stabilization of
subsequent tension on the anastomosis when the kidney is the renal function, minimization of morbidity, and restoration
positioned in the pelvis (8). Some investigators have recom- of the continuity and function of the urinary tract. If there is
mended the use of a ureteral stent to lessen the likelihood of concomitant rejection, then definitive operative therapy is
this complication (4,5). We recommend placing the kidney in withheld pending the treatment of rejection (7,8).
its eventual position before deciding how much to shorten the
ureter. The old adage “ measure twice and cut once” applies in
this circumstance. ALTERNATIVE THERAPY
The second type of early ureteral leak is associated with dis-
tal ureteral ischemia, which may be a consequence of injury Immediate open operative surgical intervention has been re-
during the donor organ recovery, technical causes such as tun- placed, to a large extent, by early endourologic intervention
nel hematoma, or distal stripping of the blood supply. This type (1,6–8). The placement of a percutaneous nephrostomy can
usually presents between 5 and 10 days posttransplant (7). divert a leak or relieve obstruction and allow more definitive
Urinary leaks are often suspected because of increased diagnosis. As described by Streem, endourologic management
drainage from the wound while at the same time associated algorithms can select patients for whom the likelihood of suc-
with decreased urinary output. This is especially true in pa- cessful nonoperative management is good. Depending on the
tients with limited pretransplant urine production. In patients selection criteria, the results of management of distal ureteral
with normal pretransplant urinary output, wound drainage leaks with stenting and a nephrostomy tube show that ap-
and graft dysfunction are the key signs. The drainage fluid proximately one-third of patients do well long term and
should be tested for blood urea nitrogen (BUN )/creatinine to require no additional treatment. For ureteral strictures or
see if it is compatible with urine. The preferred radiographic stenoses, approximately 45% of patients, carefully selected,
tests include an abdominal ultrasound and nuclear renal scan. will avoid an open operative repair (8). For the other patients,
A renal scan demonstrating extravasation is the most sensitive percutaneous access can allow stabilization of renal function
and a more critical assessment before open surgical repair is

carried out. In a few cases, percutaneous access can offer long-
term treatment with chronic stent management. This choice,
in my opinion, is of limited application in most patients with a
well-functioning graft because of the long-term risks (i.e.,
stone formation, infection, etc.) and inherent costs. H owever,
in patients who are not operative candidates and for some
patients with marginal graft function, chronic endourologic
treatment can be an alternative to definitive repair (5).
SURGICAL TECHNIQ UE
There are many procedures available to restore the continuity
of the urinary tract (1–3,5–7). In our experience in dealing
with a difficult ureteral stenosis or a leak from significant
ureteral ischemic necrosis, we favor the use of the native
ureter to replace the transplant ureter. Advantages of this
repair include the following: The native ureter is usually non-
refluxing, the results are reliable, there is a low likelihood of
recurrence of the primary problem, and a tension-free anasto-
mosis with good blood supply is easily attained. The focus of
this operative description is on that surgical choice. O ther op-
erative alternatives include reimplantation of the ureter, Boari
flap ureteral replacement, pyelovesicostomy and psoas hitch
with reimplantation. As with many operative procedures, hav-
ing a variety of alternatives available enhances the likelihood
of a successful result.
Surgical access to the transplanted kidney and ureters
(transplant and native) is usually achieved by reopening the FIGURE 11.1 Relationship of the transplanted kidney and its vascu-
old incision. O n occasion, if extensive mobilization of trans- lature to the recipient’s iliac vessels and ureter.
planted kidney is anticipated or access to the contralateral
native ureter is planned, a midline incision is another option demonstrates the relationship of the transplanted kidney, ves-
(7). Surgical access to repair an early ureteral leak is usually sels, and ureter to the recipient’s iliac vessels and ureter. N ote
simplified because dense fibrosis has not yet occurred, the that this figure depicts a donor left kidney on the right side, as
fascial layers are easily opened, the peritoneum and its con- the renal pelvis is posterior to the renal vessels.
tents are freely mobilized medially and cephalad, and the In terms of the recipient, it is critical to know the status
kidney and ureter are identified without much difficulty. A of the recipient’s urinary tract. This is especially true if the
primary repair can often be performed, and in most cases a recipient has a history of ureteral reflux or has undergone
repeat ureteroneocystostomy at a new site in the bladder is nephroureterectomy and might not have a suitable native
the best choice. Use of a mechanical retractor greatly simpli- ureter available to use for repair. Finally, the status of the re-
fies exposure and allows excellent access to the pelvis. We cipient’s urinary bladder in terms of capacity, compliance, and
also recommend the use of loupe magnification (2 to 3 ) to function can be important in determining which other repair
enhance the repair. options are available.
If the repair has been delayed because of attempted en- Additional preoperative preparation involves stabilization
dourologic management or because of delay in presentation or of the patient and function of the graft. It is important to delay
diagnosis, then access to the ureter and kidney can be much any open operative repair until concurrent rejection episodes
more challenging and hazardous. In these cases, mandatory have been adequately treated and renal function stabilized. All
preoperative preparation includes a review of the operative patients should be treated with preoperative antibiotics based
note, especially if the operation was performed by someone on anticipated contaminants or cultures obtained from the
else. It is important to know whether the kidney to be oper- urine. If there is a likelihood that bowel might be needed (an
ated on was the donor’s right or left kidney. It is critical to unusual circumstance) to repair the urinary tract, then a full
know the position of the ureter and renal pelvis in relation to bowel preparation is indicated.
the renal vessels (below or above), and this depends on which The goals of surgery are to repair the ureteral defect,
kidney was used and into which side of the recipient’s pelvis it re-establish continuity of the urinary system, get rid of all for-
was transplanted. Additional information to be sought in- eign bodies as quickly as possible, and avoid graft or patient
cludes the type of vascular anastomosis performed (end-to- loss. With a well-planned and executed procedure, these goals
end versus end-to-side, etc.) and whether or not the iliac should be easily obtained in essentially all cases.
vessels (especially the iliac vein) were mobilized. All of this in- Delayed surgical repair because of attempted endourologic
formation can help determine the likely position of the kidney management, delayed diagnosis, or late presentation of ob-
in relation to the transplanted and native ureter and the antic- struction can make surgical exposure of the kidney and ureter
ipated ease in gaining access to these structures. Figure 11.1 challenging. As noted earlier, access is almost always achieved
through the old transplant incision, and cephalad extension of

the incision is often needed in these cases because of per-
inephric fibrosis, the increased size of the kidney posttrans-
plant, and the need to achieve access to the iliac vessels and
native ureter. It is usually possible to extend the incision sev-
eral centimeters cephalad. Additional exposure, if needed, can
also be obtained by extending the inferior aspect of the inci-
sion across the midline, although this is rarely needed and
should be delayed until the need presents itself.
With delayed repair, the normal tissue planes are obliter-
ated and a dense fibrosis has occurred around the graft. This
makes it easy to violate the “ renal capsule” and get into sig-
nificant bleeding. As a routine, it is preferable to operate from
a position of “ known to unknown” with good exposure. The
surgeon should also plan to gain vascular control proximally
and distally if it appears that the kidney may need to be mobi-
lized to permit access to the renal pelvis. A three-way Foley
catheter should always be placed into the bladder before the
start of surgery to allow for irrigation and filling with an an-
tibiotic solution.
To ensure a safe and adequate exposure, I usually open the
peritoneum early in cases where there is dense fibrosis. This
allows better cephalad exposure, protects the bowel, and gives
good access to the bladder.
Because the transplant ureter usually crosses the external
iliac vessels below the renal vessels, one should take care to
avoid these structures while gaining access to the ureter. This
is a critical feature of this operative procedure because exact
visualization of the renal vascular structures is often difficult,
and many times one is operating based on the expected, not
visualized, location of these structures. In some cases a percu-
taneous nephrostomy tube will be placed as well as a ureteral FIGURE 11.2 M obilization of the native ureter distally with the
stent. If present, the nephrostomy tube should be accessible proximal segment ligated.
during a procedure as injection of saline or methylene blue
may aid in identifying the ureter and renal pelvis. In some
cases, because of the dense fibrosis, the ureter is identified proximal end of the ureter is doubly ligated. In our experience
only when it is actually cut. The routine placement of a of 50 cases, this has not resulted in problems of hy-
ureteral stent is of limited value in most cases because the fi- dronephrosis with the native kidney or ureter requiring any
brosis is so dense that it is hard to discern the presence of the further intervention. Figure 11.2 shows the native ureter mo-
catheter. If the ureter is not in dense fibrosis, then access is bilized distally and doubly ligated proximally in preparation
usually easy. for a ureteropyelostomy.
O nce access to the bony pelvis is obtained, careful dissec- The operative positioning of the native ureter depends
tion along the lateral wall of the bladder usually leads to the on access to the transplant ureter and/or pelvis. In addition,
ureter. O nce it is identified, care must be used in mobilizing whether a side-to-side ureteral anastomosis or a ureteropy-
the ureter to avoid any further vascular injury. When the site elostomy is to be performed may make a difference in the exact
of leakage and/or obstruction has been identified, the most positioning of the native ureter. All of these factors relate to the
commonly used repairs include (a) a repeat ureteroneocys- extent of fibrosis and the appearance of the transplant ureter.
tostomy, (b) use of the bladder (Boari flap or bladder hitch) to To prevent any additional future problems, a tension-free,
help bridge the gap, or (c) use of a native ureter to perform a widely spatulated anastomosis of well-vascularized ureter to
ureteroureterostomy or ureteropyelostomy. Repeat uretero- either the transplant ureter or renal pelvis is critical (Fig. 11.3).
neocystostomies are indicated only to repair early leaks when The anastomosis is performed using 5-0 M axon (Davis
the problem was from tension at the anastomosis or distal and Geck, Danbury, CT) or polydioxanone (PDS, Ethicon,
ureteral ischemia and a well-vascularized, minimally fibrosed Somerville, N J) in a watertight single layer. The critical aspect
ureter is present. In most circumstances, especially late, with a is to obtain a mucosa-to-mucosa approximation to avoid ten-
lot of periureteral reaction or ischemia, our preferred option is sion, devascularization, and urinary leak. A 12-cm 4.7 double-
the use of the ipsilateral native ureter if it is present and of ad- J stent is routinely used on all anastomoses. The anastomosis
equate caliber. If not, then a Boari flap is an excellent choice. may in addition be wrapped in omentum or peritoneal flap, if
Access to the native ureter is obtained by identifying it as available, to decrease further the risk of leak. The wound is
it crosses the common iliac vessels. Care must be used in well irrigated with antibiotic solution, and if no preoperative
mobilizing the ureter down into the pelvis to the level of the infection was present, we close the wound without a drain. If
superior vesical artery to avoid injury to the ureter blood sup- there is concern about urinary leak, lymphatic leak, or possible
ply. The ureter is divided well above the iliac vessels, and the infection, one or two Jackson–Pratt drains are indicated. The
FIGURE 11.3 Anastomosis of spatulated native ureter to (A) transplant ureter and (B) transplant renal pelvis.
fascia is closed in layers with a 0 or no. 1 permanent monofila-

ment suture. The subcutaneous tissue is not closed. The skin is Re sult s
usually closed with staples. A nephrostomy tube, if present, is
We have performed over 50 native-to-transplant uretero-
removed at day 5 to 7 after an antegrade nephrostogram has
ureterostomies or ureteropyelostomies to treat ureteral ob-
been obtained to be sure that there is no leak. The ureteral
struction or ureteral leaks or to deal with damaged ureters at
catheter is left in for 4 to 6 weeks.
the time of the transplant. In our experience, all kidneys
involved have been “ salvaged” and none lost to urologic com-
plications. There have been no significant postoperative compli-
O UTCO MES cations and no patient deaths. We have not had to repeat any
procedures in any of the patients we have treated and have not
Co mp licat io ns had any recurrence of either leak or stricture. As noted earlier,
we routinely tie off the proximal native ureter, do not do a
Complications that can occur postprocedure include infec- nephrectomy, and have not had any problems related to the
tion, urinary leak, bleeding, recurrence of the stricture, and native kidney. We feel that routine native nephrectomy
possible loss of graft. In all series, these are uncommon com- is not indicated, and if one is ever subsequently indicated, a
plications (1,7). laparoscopic nephrectomy would be our choice.
References
1. Banowsky LHW. Surgical complications of renal transplantation. In: Glenn 6. M artin DC, M ims M M , Kaufman JJ, et al. The ureter in renal transplanta-
JF, ed. Urologic surgery, 4th ed. Philadelphia: JB Lippincott, 1991:252–266. tion. J Urol 1969;101:680–687.
2. Bretan PN Jr, H odge E, Streem SB, et al. Diagnosis of renal transplant fis- 7. Rosenthal JT. Surgical management of urological complications after
tulas. Transplant Proc 1989;21:1962–1966. kidney transplantation. Sem in Urol 1994;12:114–122.
3. Gerridzen RG. Complete ureteral replacement by Boari bladder flap after 8. Streem SB. Endourological management of urological complications follow-
cadaveric renal transplant. Urology 1993;41:154–156. ing renal transplantation. Semin Urol 1994;12:123–133.
4. Gibbons WS, Barr JM , H efty TR. Complications following unstented 9. Taylor RJ, Rosenthal JT, Schwentker FN , et al. Factors in urologic compli-
parallel incision extravesical ureteroneocystostomy in 1,000 kidney trans- cations in 400 cadaveric renal transplants. J Urol 1984;131:336A.
plants. J Urol 1992;148:38–40. 10. Thrasher JB, Temple DR, Spees EK. Extravesical versus Leadbetter-
5. Khauli RB. Surgical aspects of renal transplantation: new approaches. Urol Politano ureteroneocystostomy: a comparison of urological complications
Clin N orth A m 1994;27:321–341. in 320 renal transplants. J Urol 1990;144:1105–1109.
CHAPTER 12 ■ RENAL AUTO TRANSPLANTATIO N
VENKATESH KRISHNAMURTHI AND DAVID A. GO LDFARB
Renal autotransplantation is usually considered a last resort in bladder-based flaps can reach beyond the area of obstruc-
the spectrum of surgical treatment for extensive ureteral tissue tion, successful re-establishment of urinary tract continuity
loss. It is valuable for any disease where intervention on the may be compromised by excessive tension at the site of
kidney would expose it to prolonged warm ischemia resulting reconstruction.
in permanent renal damage. This is the case for complex distal The causes of proximal ureteral obstruction include mul-
renal arterial disease and large kidney tumors where renal tiple failed repairs of ureteropelvic junction (UPJ) obstruc-
preservation is imperative. The basic techniques have evolved tion (failed pyeloplasty or endoscopic repair), desmoid tumor
as a consequence of developments in the field of renal allo- (with or without the Gardner syndrome) obstructing the
transplantation, particularly an improved understanding of re- proximal ureter, and extensive ureteral stricture. Prior to
nal preservation. The advantages of back-table reconstruction pursuing autotransplantation, these patients have generally
include optimal exposure, use of optical magnification been managed with indwelling ureteral stents and/or percu-
(loupes), a bloodless surgical field, and incorporation of renal taneous nephrostomy tubes. They are completely stent-
preservation techniques (intracellular flush solutions and dependent and often have developed recurrent episodes of
hypothermia) (7). pyelonephritis.
An uncommon condition that is amenable to autotrans-
plant would be the loin-pain hematuria syndrome (2). This is
characterized by flank pain with gross or microscopic hema-
DIAGNO SIS turia for which exhaustive diagnostic testing has failed to dis-
Since there are a variety of indications for autotransplanta- close a specific etiology. Aggressive treatment is driven by the
tion, diagnostic studies will vary accordingly. Extensive chronic pain that accompanies the syndrome.
ureteral loss is usually documented by computerized tomogra- Finally, some centers have used ex vivo back-table excision,
phy (CT) scan, intravenous urography, retrograde urography, reconstruction, and autotransplantation for large renal can-
antegrade urography, or a combination of these imaging cers that are not felt to be amenable to in situ repair (8,9).
modalities. Complex renal vascular diseases are typically
screened with CT or magnetic resonance (M R) angiography.
Due to the distal nature of renal vascular disease (branch dis-
ease) amenable to autotransplant, almost all candidates may ALTERNATIVE THERAPY
also have catheter-based arteriographic studies. Renal tumors
An alternative to renal autotransplantation in patients with
are assessed by CT or magnetic resonance imaging (M RI).
proximal ureteral obstruction is ileal ureteral substitution;
Extensive investigation is typical for the loin-pain hematuria
however, ileal substitution may not be possible in patients
syndrome. Patients have usually had the full spectrum of radi-
with a history of extensive intestinal surgery, such as those
ographic testing to assess the renal vasculature, parenchyma,
patients with the Gardner syndrome who have undergone
and collecting system. They have also had diagnostic
total proctocolectomy with ileostomy or ileal pouch cre-
ureteroscopy. M ost have had visceral pain blocks that have
ation. Additionally, the long-term consequences of intestinal
failed to provide durable pain relief.
interposition within the urinary tract are not completely
known and must be considered when utilized in younger pa-
tients. Therefore, for patients in whom an ileal substitution
INDICATIO NS FO R SURGERY does not seem favorable, autotransplantation may be the
only option.
Autotransplantation of the kidney is an acceptable treatment Complex renal vascular disorders are also an indication for
option for patients with impassable proximal ureteral obstruc- renal autotransplantation. These are most often arterial disor-
tion and extensive ureteral loss (1). Complex renal vascular ders such as stenoses or aneurysms involving the segmental re-
lesions requiring ex vivo repair can also be successfully man- nal arteries and are difficult to treat with in situ methods. As
aged with renal autotransplantation (7). an extension of the techniques routinely applied in renal allo-
Urinary tract disorders that require consideration for transplantation, the renal hilum can be readily accessed while
autotransplantation include proximal ureteral obstruction the kidney is on the “ back table.” Revascularization to branch
that cannot be managed with bladder-based methods of re- vessels or excision of aneurysms deep in the hilum is much
pair (Boari flap, with or without psoas hitch). Such repairs easier on the back table and thus can be accomplished satis-
can rarely extend beyond the pelvic ureter. M oreover, even if factorily prior to autotransplantation.
76
Chap t e r 12: Re nal Autotransp lantation 77
N onabsorbable sutures are most often selected for vascular

TECHNIQ UE O F RENAL procedures. Although silk suture has favorable handling and
AUTO TRANSPLANTATIO N tying characteristics, its popularity has waned with the develop-
ment of synthetic, nonabsorbable sutures such as polypropy-
Surg ical Inst rume nt at io n lene. In comparison to silk, synthetic monofilament sutures
are relatively inert in tissue, have a low coefficient of friction
Renal autotransplantation is a combination of living donor and thereby result in less tissue drag, and tend to retain a
nephrectomy and standard renal transplant within the same greater amount of tensile strength over time. Vascular sutures
patient. A satisfactory performance of these procedures requires are swaged onto fine, one-half-circle or three-eighths-circle
instrumentation to facilitate fine vascular repairs. Although the needles. The vascular needle should be large enough to pene-
specific instrument is a matter of individual preference, instru- trate tissue yet small enough so as not to cause hemorrhage
mentation for vascular surgical procedures should include from the needle holes. A common practice in vascular repair is
(a) noncrushing vascular clamps designed for blood vessel to use a continuous suture with needles swaged onto both
occlusion, (b) forceps with fine tips designed to atraumatically ends. This construction allows for greater flexibility in accom-
grasp vessel walls as well as suture needles, (c) needle holders plishing the repair (e.g., closure from both directions). In select
with fine tips to grasp small needles yet prevent unwanted nee- instances, specifically that of pediatric vascular surgery, ab-
dle movement, and (d) an assortment of silastic vessel loops and sorbable monofilament suture with a long half-life (e.g., poly-
umbilical tapes for atraumatic vessel manipulation. dioxanone suture) can be used to allow anastomotic growth.
Vascular clamps are manufactured in a variety of shapes and Another essential component for autotransplantation of
sizes. Their selection depends upon the size of the vessel to be the kidney is retraction. We prefer to use a self-retaining, ring-
occluded and the desired direction of vessel wall occlusion (lon- based retractor system that is fixed to the table. For flank ex-
gitudinal, transverse, or oblique). The jaws of vascular clamps posure, the Bookwalter retractor (Codman & Shurtleff, Inc.,
should have rows of interdigitating teeth that allow vessel wall Raynham, M ass.) provides for excellent exposure of the kid-
apposition without endothelial damage. Vascular clamps ney and renal hilum. We have modified the medium oval ring
should be applied by compressing the jaws only to the point on the Bookwalter by creating a modest angle (20 to 30 de-
necessary for blood flow cessation. O veraggressive application grees) along the two ends of the ring. This enables the ring to
can result in endothelial damage and subsequent dissection. better “ fit” the patient’s flank during the operative procedure.
For small, delicate vessels or relatively inaccessible areas, A standard oval ring works very well in the iliac fossa. Lastly,
spring-loaded (bulldog) clamps are useful devices. These also for midline intraperitoneal abdominal incisions, we have uti-
come in a variety of sizes, strengths, and shapes. Additionally, lized both the Bookwalter retractor system and the Thompson
plastic varieties with soft padded jaws may be useful for retractor (Thompson Surgical Instruments, Inc., Traverse City,
extremely delicate vessels. M ich.). We feel that the Thompson retractor provides better
Vascular forceps must have tines that are in direct apposi- exposure in more obese patients as the side bars of the retrac-
tion, and the tips should be fine enough to grasp the vascular tor can be placed further from the incision. O ne disadvantage
adventitia as well as a suture needle. Forceps with rows of in- of this feature, however, is that the side bars tend to be closer
terdigitating teeth serve to accomplish both of these purposes. to the operating surgeon and can be difficult to work around.
In contrast, forceps designed for stable needle grasp, such as
diamond jaw forceps, do not allow for reliable manipulation
of tissue. Re nal Aut o t ransp lant at io n:
Vascular needle holders should have fine tips to grasp fine O p e rat ive Ap p ro ache s
suture needles. The two common choices in vascular needle
holders are a ring-handled needle holder and the spring- The selection of the incision for renal autotransplantation de-
loaded type. N eedle holder selection, again, is a matter of in- pends on (a) the patient’s prior surgical history and (b) the in-
dividual preference; however, spring-loaded needle holders dication for autotransplantation. When the autotransplant is
generally allow for precise needle placement without large de- being performed for urinary tract conditions (as opposed to
grees of wrist rotation. Ring-handled needle holders enable a vascular disorders), we prefer to place the kidney into the con-
more stable needle grasp and facilitate accurate placement in tralateral iliac fossa. This approach allows the renal pelvis and
deep structures or through densely calcified vessels. ureter to be the most superficial structures so that the urinary
To some degree, the selection of vascular suture is also a tract can be reaccessed without needing to dissect or retract the
matter of individual preference. The caliber of the suture main renal vessels. Although the kidney can be placed in either
should be as fine as possible, without risking suture line dis- iliac fossa through a midline intraperitoneal incision, a
ruption, to minimize bleeding through suture holes. In most retroperitoneal flank donor nephrectomy works quite favor-
cases, suture sizes between 2-0 and 7-0 will be applicable for ably (4). Following completion of the flank approach for the
vascular procedures in the abdomen and pelvis. At the level of “ donor” nephrectomy, the patient is placed back in the supine
the aorta, a 2-0 or 3-0 suture should suffice, and 4-0 is almost position, the contralateral iliac fossa is reprepped and draped,
always suitable for the inferior vena cava. As one progresses and exposure of the iliac vessels is commenced. In theory, this
to smaller vessels, including the common and external iliac combination of two separate procedures may result in longer
arteries and veins, a 5-0 and 6-0 suture is most often satisfac- total operative time; however, this must be counterbalanced by
tory. Repair of small vessels, such as segmental renal arteries, the benefit of extraperitoneal procedures and improved expo-
may require a 7-0 or 8-0 suture. sure along both the flank and iliac operative fields.
A midline intraperitoneal approach is also quite satisfac- times necessary to cauterize the cut end of the rib or obtain
tory for renal autotransplantation. We prefer to use this tech- hemostasis with bone wax. The retroperitoneal space is then
nique when the autotransplant is being performed for vascular entered along the tip of the removed rib, and, once retroperi-
conditions, since the midline approach enables dissection of toneal entry is verified, the abdominal contents are swept off
any abdominal structure. During repair of vascular disorders, the undersurface of the flank musculature. These muscles are
arterial conduits (e.g., hypogastric artery) are often necessary then further opened in the direction of the incision.
for reconstruction, and these vessels can be easily exposed The next step in the flank exposure is mobilization of the
through a midline intraperitoneal approach. In contrast to diaphragm and pleura. The neurovascular bundle associated
two retroperitoneal procedures, the midline approach does with the removed rib is identified and is swept inferiorly and
require mobilization and retraction of the small bowel and laterally. The attachments of the periosteum and diaphragm
colon, which may add to postoperative ileus. A transverse in- against the adjacent lower rib are then divided sharply with
traperitoneal approach is not recommended because it is very the electrocautery. We prefer to continue this division all the
difficult to expose structures caudal to the aortic bifurcation, way back to the insertion of the diaphragm on the psoas mus-
such as the iliac vessels. cle, or lumbocostal arch. This allows for excellent exposure,
Lastly, a laparoscopic approach has been quite effectively and, by completely mobilizing the pleura and diaphragm, avoids
utilized for the donor nephrectomy portion (3,6). In order to retraction-related tears on the pleura. Finally, the kidney can
efficiently utilize the laparoscopic approach, however, the kid- be mobilized within Gerota fascia since the procedure is being
ney extraction incision is made over the ipsilateral iliac vessels done for benign conditions. O nce the kidney is suitably mobi-
so that the autograft can be implanted at this location. As lized, the self-retaining retractor can be positioned to retract
mentioned previously, when autotransplantation is performed everything but the kidney and associated structures.
for urinary tract disorders, placement of the kidney in the ipsi- At the time of kidney mobilization, intravenous mannitol
lateral iliac fossa puts the urinary tract structures in the most 12.5 g is given. A second 12.5-g dose is usually given just prior
posterior location, which is suboptimal should further proce- to renal artery clamping. The perinephric fat is then com-
dures become necessary. pletely removed. The renal artery and vein are skeletonized to
as proximal a level as possible. The renal artery should be dis-
sected so that an adequate length is maintained for the im-
Te chniq ue o f Flank Do no r Ne p hre ct o my plantation and the diseased portion can be reconstructed;
however, it is extremely important not to dissect the artery too
Following satisfactory induction of general endotracheal anes- close to the aorta, since a minimal amount of artery must be
thesia and placement of the necessary arterial and central ve- maintained for suitable control. Too short of a stump on the
nous monitoring lines, a Foley catheter is placed in the aorta can lead to catastrophic complications; however, too
bladder. The patient is then placed on his or her side with the short of a stump on the kidney side can be reconstructed
kidney that will be operated on facing “ up.” The “ down” leg through a variety of techniques. O ne must differentiate the
is then bent and the “ up” leg is maintained in a straight posi- dissection of the renal artery during an autotransplant from
tion. Pillows are placed between both legs, and the greater that of in situ revascularization procedures. In revasculariza-
trochanter along the table surface is padded with egg crate tion procedures, the aorta is more accessible and may be more
mattresses. The kidney rest is maximally elevated and the readily controlled, in contrast to flank exposures.
table is fully flexed. This enables a maximum distance be- O n the right side, the renal vein should be dissected all the
tween the lower ribs and the iliac crest. An axillary roll is way to the inferior vena cava (IVC), and the juxtarenal IVC
placed, and the arms are padded and secured to a double arm must also be exposed. It is essential to mobilize the IVC poste-
board. The patient is then adequately secured to the table rior to the insertion of the renal vein, as the posterior wall of
prior to preparation and drape of the operative field. the IVC must be easily clamped during extraction of the kid-
We prefer to utilize an incision over the course of the ney. O n the left side, the adrenal, gonadal, and lumbar venous
eleventh rib. Although selection of the twelfth rib may be suit- branches should be divided.
able in many instances, the exposure of the kidney through the The ureter is dissected usually to the level of its crossing over
bed of the eleventh rib always provides for adequate exposure the iliac vessel. In cases of proximal ureteral obstruction, the
of the kidney and renal hilum. Although an approach through ureter should be dissected approximately to the level of ob-
the eleventh rib has a slightly greater chance of pleural entry, struction, but more importantly, it must be dissected to only a
this is easily managed by evacuation of the entrained air or by length suitable for reimplantation. A generous amount of peri-
placement of a thoracostomy tube. The most important aspect ureteral tissue should be maintained with the ureteral dissec-
of flank donor nephrectomy is exposure of the renal hilum, tion. We prefer to include the gonadal vein and intervening
and the disadvantage of approaching this through the twelfth tissue along with the ureter. In cases where the ureter is dilated
rib is that the hilum may be at the most superior portion of the due to chronic obstruction, the need to maintain an adequate
operative field. Additionally, exposure through the twelfth rib amount of periureteral tissue is less important due to the devel-
bed may require significant caudal retraction on the kidney opment of neovascularity. The ureter is then divided above the
during mobilization, which may add to trauma to the kidney. level of the obstruction (if present), and a satisfactory diuresis is
After the skin is incised sharply, the subcutaneous tissue verified by observing urine flow from the cut end of the ureter.
and flank musculature are divided with the electrocautery. The kidney should be palpated to ensure a turgid feel. A
The anterior surface of the eleventh rib is exposed, and the soft kidney with no urine production should raise concern for
rib is then dissected in a subperiosteal plane. The rib can be arterial spasm. In these situations, the kidney should not be
dissected in a subperiosteal manner. O nce the rib is mobilized handled, and warm saline can be placed as an initial maneu-
to a suitable posterior location, it is transected. It is some- ver. If the kidney turgor has not improved and the spasm has
not abated after a period of several minutes, papaverine can

be applied topically along the renal artery adventitia.
When the kidney is firm and there is an adequate diuresis
of urine, it is acceptable to proceed with removal. M annitol
(12.5 g) is given intravenously. The renal artery is then
clamped and transected and the kidney mobilized so that the
renal vein is placed on stretch. The renal vein, or inferior vena
cava, is then clamped, and the vein is divided sharply at a suit-
able location. The kidney is then passed off to a separate team,
who will commence with both surface hypothermia and in
situ cold perfusion.
Attention is directed toward securing the renal vessels.
The renal vessels can be secured with any combination of ties,
clips, or suture ligatures. O ur typical practice is to place two
ties with 0 silk. When two ties are not possible, we may use a
single clip and oversew the renal artery stump with a 5-0
polypropylene suture. The left renal vein can be similarly con-
trolled (Figs. 12.1 and 12.2). O n the right side, however, it is
FIGURE 12.3 Control of the renal vein includes a small cuff of IVC.
FIGURE 12.1 Control of left renal hilum. N ote that the renal vein is
clamped as close to the IVC as possible.
FIGURE 12.4 Securing the IVC with a running suture.
essential to remove the kidney with a small (few millimeters)

margin of IVC (Figs. 12.3 and 12.4). In this situation, the
vena cava is closed with a 4-0 polypropylene suture. We
generally place one suture at each apex and run toward the mid-
point. It is not essential to run this closure in an over-and-
back manner as the low-pressure venous system is unlikely to
leak between the suture lines. It is also important to leave a
suitable margin of vein above the clamp so the cavotomy can
be safely closed. If the renal vein is inadvertently transected
directly on the clamp, two options exist. O ne option would
be to place a larger clamp below the existing clamp and to re-
move the first clamp. If this option is pursued, it is imperative
to make sure that the second clamp is properly placed and
that the walls of the vena cava are firmly apposed. Another
FIGURE 12.2 A small stump of left renal artery is preserved to ensure option, which may be potentially safer, would be to reap-
safe ligation. proximate the IVC walls in a horizontal mattress fashion by
sewing “ under” the clamp. In all cases, we recommend that adequate diuresis and a firm kidney are verified, the renal
the vena caval clamp be released slowly so that it can be reap- artery is clamped and divided, the renal vein or IVC is
plied immediately should there be unexpected significant clamped, and the vein is divided. The kidney is passed off to a
bleeding from the vena caval closure. separate team, who will commence surface hypothermia and
O nce the renal vessels are secured, the operative field is in situ cooling. The main renal vessels are secured, and the
irrigated and inspected for hemostasis. The retractor is then field is inspected. As the kidney is being perfused, the iliac
removed, and the flank musculature and fascia are closed in fossa can be prepared by a separate surgical team.
two layers. Following completion of the flank procedure, gen-
eral anesthesia is maintained and the patient is repositioned
for the renal transplant procedure.
Back-Tab le Pre p arat io n o f t he
Re nal Aut o g raft
Do no r Ne p hre ct o my via a Mid line
O nce removed, the kidney is placed in a basin containing ice
Int rap e rit o ne al Ap p ro ach slush. The renal artery is cannulated and in situ perfusion with
The patient is placed in the supine position. General endotra- cold preservation solution started. Cannulation may be
cheal anesthesia is induced. The appropriate arterial and cen- achieved with a large-gauge angiocatheter (14 gauge) or a
tral venous monitor lines are placed. A Foley catheter is placed metal-tipped cannulation device.
in the bladder in a sterile manner. Surgical preparation should Since there is minimal ischemic time during renal autotrans-
include the field from the nipples to the lower thighs. The gen- plantation, almost any electrolyte solution can be used to pro-
italia should be shaved and prepped and covered with a sterile vide in situ cooling for the kidney. In our center, we routinely
surgical towel. Both groins should be available for access use a Euro-Collins solution. We prefer to perfuse the kidney
should there be a need for saphenous vein procurement. with an entire volume of perfusate (approximately 1,000 mL);
For renal autotransplantation, a midline incision from however, it is necessary to perfuse a kidney only until the ve-
xiphisternum to pubic symphysis should be employed. The nous effluent is clear. In cases of multiple arteries, all arterial
subcutaneous tissues and linea alba are divided with the elec- branches need to be separately perfused as these represent end
trocautery, and the abdominal wall can be retracted with a vessels to the kidney. Very small vessels may require manual
self-retaining retractor. It is important to ensure complete perfusion with a syringe and a small-caliber (22-gauge) angio-
neuromuscular blockade so that the abdominal wall can be cath tip. O nce the kidney has been perfused, the renal vascula-
retracted maximally. For right-sided autotransplantation, we ture can be prepared. The renal vein should be dissected back
prefer to mobilize the right colon and duodenum medially to to its segmental branches. Small venous tributaries can be lig-
expose the entire infrarenal vena cava, left renal vein, and ated with silk ties and divided. Large segmental branches
abdominal aorta. For left renal autotransplantation, the left should be preserved, and it is imperative to maintain at least
colon should be mobilized medially so that the left renal vein 50% of the total venous drainage of the kidney. O nce the vein
can be accessed as it crosses over the aorta. Following mobi- is skeletonized back to its segmental branches, it can be re-
lization, the viscera are retracted with the self-retaining retrac- tracted away from the artery, which can then be similarly dis-
tor. The kidney can be mobilized within Gerota fascia, as sected. The lymphatic tissue surrounding the artery is sharply
mentioned previously. The ureter should be mobilized with a excised and secured along the segmental arterial branches.
generous amount of periureteral tissue until the point of Large lymphatic trunks in this location should be secured with
obstruction or to a level where it crosses the iliac vessels. When silk ties in order to prevent a lymph leak, particularly if the im-
autotransplantation is being performed for vascular condi- plantation of the kidney is going to be placed in a retroperi-
tions, the ureter does not always need to be divided as the renal toneal location. O nce the artery has been mobilized to its
vascular reconstruction can be performed in a basin containing segmental branches, it should be ready for implantation. Any
iced slush placed on the patient’s abdomen. We prefer to divide remaining perinephric fat should be removed, and we also
the ureter so that the kidney can be taken off the operative field prefer to perform a needle biopsy of the kidney at this time to
and exposed maximally on the back table, during which time provide any additional histologic information.
the iliac fossa can be prepared by a separate surgical team. In cases of renal vascular disease, the renal artery should be
With the kidney fully mobilized and the ureter divided, the dissected distally, beyond the level of the disease. The diseased
renal vessels are dissected. Because cases of renal autotrans- segment of the artery or arteries should be excised, and the re-
plantation for vascular diseases usually involve arterial disor- maining normal artery or branch artery can be reconstructed
ders, it is necessary to completely skeletonize the renal vein so in a variety of techniques (Fig. 12.5).
that it can be mobilized away from the posterior renal artery.
Accurate preoperative judgment is essential to determine the
feasibility of in situ repair. H owever, even in cases in which in Imp lant at io n o f t he Re nal Aut o g raft
situ repair is thought to be unfeasible, intraoperative findings
may dictate otherwise, and the surgeon should be prepared to Exp o sure o f t he Iliac Ve sse ls
reconstruct the kidney in situ. H owever, in cases of proximal As mentioned previously, the site for renal autograft implanta-
ureteral obstruction and in cases of vascular disease requiring tion can be exposed by a second surgical team while the kid-
ex vivo repair, the kidney has to be removed and reconstructed ney is being prepared on the back table (5). A standard
on the back table. As previously described, the vessels are lower-quadrant oblique (Gibson) incision can be used to enter
dissected as proximally as is necessary to correct the lesion. the retroperitoneum when two separate incisions are utilized
Intravenous mannitol (12.5 g) is administered. After an for autotransplantation. O f particular importance with the
FIGURE 12.5 The native hypogastric artery can often be used as an in- FIGURE 12.6 This figure demonstrates regional control of the
terposition graft in complex branch renal artery repair. The hypogastric external iliac artery and vein. It also shows the final appearance of the
artery must be free of significant vascular disease to be useful. transplanted kidney.
retroperitoneal approach, large lymphatic trunks should be vein, and (b) the inflow artery should be adequately free of ath-
ligated prior to division to prevent postoperative lymphocele. erosclerotic disease. The second point deserves further elabora-
We typically expose the full length of the external iliac artery tion in that, not only should the anastomotic site be acceptable,
followed by the external iliac vein. The external iliac artery is but the location for clamp placement should also be “soft.” If
almost always free of branches until the most distal aspect, there is concern over the suitability of the artery, a “softer” loca-
where the epigastric vessels arise. The external iliac vein can tion should be explored both proximally and distally.
often have posterior tributaries (e.g., obturator vein), and divi-
sion of these vessels lends significant mobility to the external Re nal Aut o g raft Re vascularizat io n
iliac vein. The internal iliac or hypogastric vein is a large Revascularization of the kidney is commenced by anastomosis
trunk, often comprised of three veins, entering along the pos- of the renal vein to the iliac vein (or vena cava) (Fig. 12.6). We
terior aspect. Division of this vessel must be approached with typically occlude the iliac vein with a tangentially occluding or
extreme care as the hypogastric vein is very short and very Satinsky-type clamp. An appropriate-length venotomy is
wide and loss of control of this vein can lead to massive hem- made on the anterior wall, and the lumen is irrigated with
orrhage. We prefer to divide this vein only when the iliac vein heparinized saline. The kidney is brought into the operative
needs to be mobilized lateral to the external iliac artery due to field, and a continuous anastomosis is completed by first plac-
a short renal vein. O ur approach to dividing the hypogastric ing sutures at both apices of the venotomy and then running
vein(s) is to (a) medially mobilize the external, internal, and around each “ side.” For anastomosis to the iliac vein, both 5-0
common iliac arteries, (b) obtain control of the external iliac and 6-0 polypropylene sutures are acceptable, and when the
vein and common iliac vein (we prefer to encircle these vessels vena cava is used for outflow, 5-0 polypropylene is suitable.
with silastic loops), and (c) divide the hypogastric vein only We perform the arterial anastomosis following completion
after flow is interrupted both proximally and distally. It can be of the venous anastomosis. The iliac artery (common or exter-
very difficult to obtain enough distance between two ties; con- nal) is occluded with vascular clamps both proximally and
sequently, we have found that titanium clips provide satisfac- distally. Alternatively, a single clamp (Satinsky type) can be
tory occlusion along the proximal aspect. If another tie cannot used for arterial occlusion as well, but the disadvantage to this
be placed on the distal aspect (insertion into the external iliac approach is that the artery cannot be unclamped without
vein), this orifice can be suture-ligated after occluding flow in restoring the high-pressure antegrade flow. Following clamp
the external and common iliac veins. control, the periadventitial tissue at the proposed site of anas-
In contrast to an extraperitoneal approach, the iliac vessels tomosis is sharply excised, an arteriotomy is made with a
can be exposed directly when using an intraperitoneal no. 11 blade, which is then further fashioned to match the
approach. Lymphatic trunks are simply cauterized, and simi- caliber of the renal artery, and the lumen is irrigated with
lar exposure of the iliac vessels is obtained. Another distinc- heparinized saline. We commonly use a continuous 6-0 or 7-0
tion of an intraperitoneal approach is that it is often easier to polypropylene suture to complete the end-to-side anastomosis
expose larger vessels for implantation, specifically the com- to the iliac artery.
mon iliac artery and infrarenal vena cava. These vessels are Following completion of the vascular anastomoses, we re-
more accessible and larger caliber, features that may facilitate lease the venous clamp first, then the distal arterial clamp, and
renal vascular anastomoses. last the proximal areterial clamp. This allows the anastomoses
Important points in selecting the target for renal autograft to be “ tested” in a low- to high-pressure direction. O nce hemo-
implantation are that (a) the vessels should be adequately mobile stasis is ensured, the operative field and kidney are bathed in
to allow for tension-free anastomoses to the renal artery and warm saline solution, after which the kidney is inspected for
“ normal” bladder capacities. The bladder, which is readily

distensible, is filled by instillation of saline solution. The
perivesical fat over the intended site of ureteral reimplantation
is removed with electrocautery dissection. O ccasionally, large
veins in the perivesical fat must be ligated, for which we prefer
to use absorbable suture to avoid potential migration into the
anastomosis.
We then trim the ureter at an appropriate length. For renal
autotransplantation, the ureter is not excessively long and, in
general, does not need to be trimmed to any significant degree
(1 to 2 cm at most). Additionally, unlike the ureter received
with a deceased donor renal allograft, the viability of the auto-
graft ureter can be ensured during the nephrectomy.
Periureteral vessels are ligated with absorbable ties, and the
ureter is spatulated for a distance of 8 to 12 mm. The detrusor
musculature is then divided with the electrocautery, with care
FIGURE 12.7 The location and creation of the extravesical uretero-
neocystostomy is demonstrated. taken to avoid entering the bladder mucosa. The bladder
mucosa is entered sharply, and the ureter is anchored at this site
with one or two absorbable sutures placed at the “ heel” and
uniform perfusion. The renal cortex may take several minutes “ toe” of the anastomosis, respectively. We prefer to complete
to become homogenously perfused (pink-appearing), and soon the typical extravesical ureteroneocystostomy with a continu-
after this occurs, urine production should be seen from the ous 5-0 polydioxanone suture. Routine use of an indwelling
distal ureteral end. double J stent is dependent on surgeon preference; however, if
there are concerns over the integrity of the anastomosis or the
Ure t e ro ne o cyst o st o my viability of the ureteral end, use of a stent is recommended.
In general, we prefer to reimplant the autograft ureter in an
extravesical manner (Figs. 12.7 and 12.8). We do not feel that Clo sure o f Incisio n
creation of an antireflux tunnel is essential.
Unlike dialysis-dependent patients who are undergoing re- Prior to closing the incison, we ensure an appropriate position
nal allotransplantation, nearly all patients who are undergo- for the kidney. In most cases, the kidney can be placed on the
ing autotransplantation have “ normal” urine volumes and psoas muscle, with the lateral aspect of the kidney directed lat-
erally and the hilum directed medially. This position places the
urinary tract in a medial position, should later access be neces-
sary. O nce the kidney is positioned, cortical perfusion should
be verified and the hilum should be palpated to ensure a
strong arterial pulse. Additionally, satisfactory drainage from
the renal vein can be ensured by the palpation of a soft, easily
compressible renal vein.
We reapproximate the musculature most often in a single
layer. When a midline incision is used, we always close this
with a single layer of no. 1 polydioxanone or polypropylene.
For most retroperitoneal incisions, one layer is satisfactory. In
cases where the abdominal wall is thin and the musculature is
attenuated, closure in two layers can provide adequate re-
approximation.
O UTCO MES
The end points for outcomes vary according to the indication for
the procedure (ureteral obstruction, renal vascular disease, loin-
pain hematuria syndrome). Preservation of the affected kidney is
very high. Several reports have demonstrated 90% technical
success rates for renal autotransplantation that seem durable.
Understand that autotransplantation for a diseased kidney is a
more complicated endeavor than renal allotransplantation.
Simultaneous donor and transplantation procedures are per-
formed on the same individual, which is an enormous physio-
logical burden. The kidney being autotransplanted is often
anatomically compromised. This is in contrast to the donor kid-
neys in standard allotransplantation, which are normal, and for
FIGURE 12.8 Final appearance of a tunneled anastomosis. which the reported technical loss rates are 5% .
nonetheless, early recognition and repair are required to avoid

CO MPLICATIO NS catastrophic limb-threatening problems. With respect to the
ureter, there is potential for urine leak or obstruction. Attention
Complications of using autotransplantation may derive from the to creating a tension-free anastomosis by using a ureter with a
procurement of the kidney or may be related to the implantation well-preserved blood supply is important. Given the diseased
of the kidney. The main complications arising from procurement status of the vessels or ureter, a ureteral stent is recommended.
would be bleeding and injury to adjacent viscera (colon, pan- Finally, when kidneys are autotransplanted into a retroperi-
creas, spleen, liver). From the implantation portion of the proce- toneal position, lymphocele is possible. M eticulous ligation of
dure there may be vascular problems. The biggest concern is the perivascular lymphatics will help to prevent this complication. A
potential for arterial or venous thrombosis. Attending to proper retroperitoneal drain for a brief period may also help avoid this
vascular technique and ensuring appropriate geometric align- complication. If a lymphocele is causing graft dysfunction, it can
ment of the kidney in its final location will help prevent vessel be drained percutaneously or surgically.
kinking. Recipient vessel dissection or embolization is rare;
References
1. Bodie B, N ovick AC, Rose M , et al. Long-term results with renal auto- 6. M eraney AM , Gill IS, Kaouk JH , et al. Laparoscopic renal autotransplan-
transplantation for ureteral replacement. J Urol 1986;136:1187–1189. tation. J Endourol 2001;15:143–149.
2. Chin JL, Kloth D, Pautler SE, et al. Renal autotransplantation for the loin 7. N ovick AC, Straffon RA, Stewart BH . Experience with extracorporeal re-
pain–hematuria syndrome: long-term followup of 26 cases. J Urol 1998; nal operations and autotransplantation in the management of complicated
160:1232–1236. urologic disorders. Surg G ynecol O bstet 1981;153:10–18.
3. Gill IS, Uzzo RG, H obart M G, et al. Laparoscopic retroperitoneal live 8. van der Velden JJ, van Bockel JH , Z wartendijk J, et al. Long-term results of
donor right nephrectomy for purposes of allotransplantation and auto surgical treatment of renal carcinoma in solitary kidneys by extracorporeal
transplantation. J Urol 2000;164:1500–1504. resection and autotransplantation. Br J Urol 1992;69:486–490.
4. Goldfarb DA. O pen donor nephrectomy. In: N ovick AC, Jones JS, eds. 9. Z incke H , Sen SE. Experience with extracorporeal surgery and autotrans-
O perative urology at the Cleveland Clinic. Totowa: H umana Press, plantation for renal cell and transitional cell cancer of the kidney. J Urol
2006:111–116. 1988;140:25–27.
5. Goldfarb DA, Flechner SM , M odlin CS. Renal transplantation. In: N ovick
AC, Jones JS, eds. O perative urology at the Cleveland Clinic. Totowa:
H umana Press, 2006:121–132.
SECTIO N II ■ BLADDER
CHARLES B. BRENDLER
CHAPTER 13 ■ ANATO MY O F THE BLADDER

CLINTO N W. CO LLINS AND ADAM P. KLAUSNER
GENERAL DESCRIPTIO N Pe rit o ne al Fo ld s

The bladder is a hollow, muscular retroperitoneal organ with As seen from a typical laparascopic approach to the abdomi-
a capacity of 400 to 500 mL in the normal adult. When empty, nal cavity, the anterior surface of the peritoneum has three
it is a pelvic organ, lying behind the pubic symphysis. H owever, characteristic deflections, also called folds. The midline fold is
when distended, it can be palpated above the pubic symphysis called the “ median umbilical ligament,” and the paired para-
and can protude well into the abdomen during an episode of median folds are called the “ medial umbilical ligamants.”
severe urinary retention. Fortunately, the anatomy itself is less confusing than the ter-
minology. In relation to the bladder, the median umbilical fold
is the most important of these structures as it contains the
urachal ligament. Attaching to the bladder anteriorly at its
PERITO NEAL RELATIO NSHIPS dome, this ligamentous structure, containing fatty and vascu-
lar tissue, tethers the bladder to the umbilicus. This stucture,
The peritoneum covers the superior bladder and a portion of the which represents the obliterated urachus, contains paraumbil-
posterior bladder. In women, the peritoneum continues posteri- ical veins and must be ligated when divided during surgical ex-
orly onto the surface of the uterus and rectum, establishing the posure of the bladder. The bladder muscle, also called the
vesicouterine and rectouterine pouches, respectively (Fig. 13.1) “ detrusor,” is attenuated where the urachal ligament attaches,
(1). In men, the peritoneum continues along the surface of the predisposing this area to the formation of diverticuli.
rectum, establishing the rectovesical pouch of Douglas. The two Retropubic and perivesical fat is present anteroinferior and
leaves of the peritoneum embryologically coalesce to form the lateral to the bladder.
anterior and posterior layers of the Denonvilliers fascia (rec-
tovesical fascia), a critical landmark in the performance of a
radical retropubic prostatectomy (Fig. 13.2) (13).
I. Ve sicoute rine p ouch
II. Ve sicoute rine p ouch

(cul-d e -sac of Doug las)
B
II A. Blad d e r
C
I
B. Ute rus
A
C. Re ctum
FIGURE 13.1 Sagittal view of female

pouches.
85
86 Se ct io n II: Blad d e r
Peritoneal folds also connect the bladder to the pelvic side-

walls and consist of the median, medial, and lateral umbilical
folds as well as the sacrogenital folds. The median umbilical
fold and medial umbilical folds originate at the bladder and
terminate at the umbilicus. They contain the urachus and the
obliterated umbilical arteries, respectively. The lateral umbili-
cal folds attach the bladder to the pelvic sidewalls and contain
the inferior epigastric arteries. The sacrogenital folds connect
the bladder to the sacrum (Fig. 13.3) (7).
The bladder is also fixed to the symphysis pubica by the
pubovesical ligaments in women and the puboprostatic liga-
ments in men. The dorsal vein of the clitoris or penis passes
between these paired ligaments. These ligaments represent an
important surgical landmark as they form the anteromedial
portion of the retropubic space, also called the space of
Retzius. The space of Retzius is bound anteriorly by the trans-
versalis fascia, inferiorly by the puboprostatic (pubovesical)
ligaments, and infralaterally by the lateral ligaments of the
bladder (Fig. 13.4).
FIGURE 13.2 Lateral view of the male pelvis showing the peritoneal
reflection and the pouch of Douglas.
HISTO LO GIC STRUCTURE

LIGAMENTO US ATTACHMENTS The lumen of the bladder is lined by transitional epithelium,
also called “ urothelium.” This unique epithelium is character-
In the pelvis, the bladder is supported anatomically by two ized by its outer layer of “ umbrella cells,” which are sealed
types of ligaments: fibroareolar (true) ligaments and peri- closely together and communicate via tight junctions. The
toneal folds. True ligaments provide support for the bladder term transitional denotes the ability of these outer cells to un-
laterally via the lateral ligament of the bladder and posteriorly dergo significant transitions in shape depending on the state
via the vesicovenous plexus. The lateral ligament derives from of bladder filling. Thus, the cells are puffy and cuboidal when
the transversalis (endopelvic) fascia as it courses over the leva- the bladder is empty and become flat and elongated when the
tors and attaches the bladder to the tendinous arch of the en- bladder is distended (6). Beneath these umbrella cells, the
dopelvic fascia. This ligament contains the inferior vesical and transitional epithelium contains additional layers of cells (usu-
vesicodeferential arteries in the lateral extensions, as well as ally about seven) and a distinct layer of basal cells. Deep to the
the pudendal plexuses of nerves and vessels. In addition, in transitional epithelium lies the lamina propria, composed of
men, this ligament contains the vasa deferentia. The posterior fibroelastic connective tissue through which vessels course.
ligaments provide posterolateral support to the bladder. These Wisps of smooth muscle also course within the lamina pro-
ligaments are connective tissue condensations in which the pria, and this portion of the lamina propria is sometimes
vesicovenous plexus drains into the internal iliac veins. referred to as the muscularis mucosa (Fig. 13.5).
B I
C
A. pubovesical ligament
II B. archus tendineus levatorani

C. endopelvic fascia
D
D. cardinal ligament
E. uterosacral ligament
E
III I. bladder
II. uterus
III. rectum FIGURE 13.3 Axial view of the
female pelvis illustrating the liga-
mentous supports of the bladder.
Chap t e r 13: Anatomy of the Blad d e r 87
A. bladder
B. dorsal vein of the penis
D C. pubic symphysis
C
D. retropubic space of Retsius
FIGURE 13.4 Lateral view of a portion of

the male pelvis showing the space of Retzius.
The space of Retzius is bound anteriorly by
B
the transversalis fascia, inferiorly by the pub-
oprostatic (pubovesical) ligaments, and infra-
laterally by the lateral ligaments of the
bladder.
The distinction between the muscularis mucosa and the (Fig. 13.6), is considered invasive cancer and is treated more
muscularis propria, or true muscular layer of the bladder aggressively; it usually requires surgical removal of the entire
that lies deep to the lamina propria, is critical in the staging bladder. Within the muscularis propria, detrusor smooth mus-
and prognosis of urothelial cancer. Cancer that is confined to cle bundles course in inner longitudinal, middle circular, and
the urothelium or lamina propria, even when surrounded by
wisps of muscularis mucosa, is considered superficial disease
and is mainly treated via local resection or with intravesical
immuno- or chemotherapeutic agents. H owever, cancer that
penetrates into the muscularis propria, characterized histo-
logically by large, distinct detrusor smooth muscle bundles
FIGURE 13.6 Confocal immunohistochemical imaging showing rabbit

FIGURE 13.5 M icroscopic cross-sectional image of normal human detrusor bundle. A: Densely packed hexagonal shaped detrusor smooth
bladder. N ote wisps of smooth muscle (arrow ) within the lamina propria muscle cells. B: Interstitial area between smooth muscle bundles con-
(star). (Courtesy of Dr. M arigny Roberts.) taining interstitial cells and fibroblasts.
outer longitudinal orientations. In addition, interstitial cells

surround and percolate within the muscle bundles and may be
important in the maintenance or modulation of bladder mus-
cle tone (8). These muscle layers are less distinct in the upper
aspect of the bladder. H owever, they become quite prominent
at the bladder neck, although composed of finer fibers. In
men, the middle layer of circular detrusor smooth muscle
forms a preprostatic layer that has robust expression of alpha
receptors (mainly alpha 1a) and contributes to continence at
the bladder neck. Furthermore, the success in treatment of be-
nign prostatic hypertrophy (BPH ) with alpha blockers stems,
in part, from a pharmacologic reduction in tone in the smooth
muscle surrounding the prostate and bladder neck (2). In
women, the bladder neck differs dramatically, having a less
distinct middle layer of smooth muscle (1,5).
URETERO VESICAL J UNCTIO N

AND TRIGO NE
The spiral fibers of the ureter become more longitudinally ori-
ented near the bladder and are encased in the fibromuscular
Waldeyer sheath from a distance just proximal to its entrance FIGURE 13.7 Anterior view of the bladder of a man opened and
into the bladder wall through its course to the trigone (1,11). demonstrating intravesical anatomy. N ote that the trigone continues
into the prostatic urethra.
O bliquely, the ureters enter the bladder posteroinferiorly and
course approximately 2 cm toward the ureteral orifice, nar-
rowing as the intramural ureter is compressed by the detrusor
of the bladder surrounding it. The ureter lies just beneath the referred to as the interureteric ridge. This ridge is helpful in
bladder mucosa with a muscular layer backing (1). identifying orifices endoscopically (Fig. 13.7). The trigone is
A distinct landmark is formed at a triangle located between composed of three distinct layers: (a) a superficial layer de-
the ureteral orifices and the bladder neck, referred to as the rived from the longitudinal layer of ureteral smooth muscle;
bladder trigone. Layers of ureteral and bladder smooth muscle (b) a deep layer that is continuous from the Waldeyer sheath,
coalesce here as a raised ridge of tissue between the two orifices inserting at the bladder neck (Fig. 13.8); and (c) the detrusor
FIGURE 13.8 Lateral view of ureter as it enters the blad-

der via the intramural tunnel. N ote that the Waldeyer
sheath extends from the bladder to encase the distal ureter
just proximal to the bladder and fuses to the ureteral mus-
culature. The Waldeyer sheath is a continuation of the deep
trigone and connects by a few fibers to the detrusor muscle
at the ureteral hiatus.
FIGURE 13.9 Lateral pelvic sidewall

demonstrating the vasculature and
innervation of the deep pelvis. The
arterial supply of the bladder is from
the superior lateral vesical artery and
the inferior vesical artery enclosed in the
posterior pedicle.
layer, derived from the outer longitudinal and middle circular recognize that the arterial supply to the bladder may arise from
layers of smooth muscle (1). The unique anatomic structure of any portion of the internal iliac. In terms of venous drainage,
the intramural ureter and trigone contributes to the intrinsic veins from the bladder drain predominantly into lateral
continence mechanism that prevents vesicoureteral reflux dur- plexuses and then empty into veins within the lateral prostatic
ing bladder filling and voiding. ligaments and ultimately into the internal iliac veins (1).
BLO O D SUPPLY INNERVATIO N

M ultiple blood vessels supply the urinary bladder; however, Se nso ry Inne rvat io n
the exact vascular anatomy can vary somewhat between
individuals. Less variable is the presence of two more distinct In the bladder, there are two types of sensory (afferent) nerve
collections of vessels, referred to as the lateral and posterior fibers: alpha-delta and C fibers. Alpha-delta fibers are par-
pedicles (Fig. 13.9). In men, the lateral and posterior pedicles tially myelinated and carry information to the central nervous
are also called the lateral and posterior ligaments. In women, system regarding bladder fullness and wall tension. These sen-
these vascular pedicles are part of the cardinal and uterosacral sory fibers are responsible for initiating the normal voiding
ligaments. The blood vessels within these pedicles branch reflex. O n the other hand, C fibers are unmyelinated nociceptive
from the superior and inferior vesical arteries. The superior fibers that mainly carry information to the central nervous
vesical artery arises from the internal iliac close to its origin system regarding noxious or painful stimuli. Although these C
from the common iliac. It can also arise as a branch from the fibers comprise about 70% of the total afferent nerves supply-
umbilical artery, which branches off of the proximal internal ing the bladder, they are generally silent and only become sen-
iliac. The inferior vesical artery branches off of the internal iliac sitive during inflammation, irritation, or suprasacral spinal
artery at a more distal location. H owever, it is important to cord injury. Prolonged activation of C fiber afferents may be
responsible for the development of pathologic voiding reflexes

associated with some forms of overactive bladder.
Mo t o r Inne rvat io n
M otor innervation to the bladder arises from three sets of
nerves: (a) the parasym pathetic sacral (pelvic) nerve, arising
from the sacral spinal cord between S2 and S4; (b) the sym pa-
thetic thoracolumbar (hypogastric) nerve, arising from the
spinal cord between T10 and L2; and (c) the som atic pudendal
nerve, which also arises between S2 and S4.
Preganglionic parasympathetic motor efferent fibers exit
between S2 and S4 via pelvic nerves, with nerve bodies located
in the sacral parasympathetic nucleus (SPN ). The SPN is lo-
cated in the intermediolateral region of the sacral spinal cord.
Importantly, an increase in parasympathetic tone, supplied by
these nerves, is the main trigger for a coordinated contraction
of the detrusor muscle that leads to voiding. In the bladder
body, sympathetic fibers supply beta receptors contributing to
smooth muscle relaxation during filling and also synapse
prejunctionally along axons of parasympathetic nerves. This
anatomic relationship may allow for additional reduction of
detrusor smooth muscle tone during the filling phase, a process
that is likely necessary to prevent involuntary contractions
and urge incontinence. The only somatic (voluntary) motor fibers
in the lower urinary tract supply the external urethral sphinc-
ter, sometimes called the rhabdosphincter (9). Preganglionic
somatic motor efferent fibers exit between S2 and S4 with
nerve bodies located in the O nuf nucleus in the anterolateral
horn of the sacral spinal cord. These somatic fibers run in the
pudendal nerve, modulating striated (voluntary) urethral
sphincter contraction.
FIGURE 13.10 Autonomic and somatic innervation of the lower uri-

nary tract. There is extensive motor outflow to the bladder and ure-
The Mict urit io n Re fle x thral sphincter from the spinal cord. Parasympathetic outflow (as
show n in gray) is conveyed by the pelvic nerve and leads to bladder
Sensory or “ afferent” fibers from the bladder are contained in contraction during voiding and contraction of urethral smooth muscle
the pelvic, hypogastric, and pudendal nerves. The pelvic and during filling. Sympathetic outflow originates from the thoracolum-
pudendal nerves enter the sacral spinal cord via dorsal root bar cord, travels in the hypogastric nerve (as show n in black ), and
leads to bladder relaxation and bladder neck contraction during fill-
ganglia, with the most prominent projection passing antero-
ing. Somatic outflow also originates from the sacral cord and travels
lateral toward the SPN . Afferent fibers in the hypogastric via the pudendal nerve (dashed line). O utflow leads to contraction of
nerves also enter the spinal cord via dorsal root ganglia in the the urethral sphincter during filling and relaxation during voiding
lumbar spinal cord. Afferent fibers from the external urethral (possibly nitric oxide-mediated).
sphincter pass through the O nuf nucleus in the sacral spinal
cord. All of these inputs relay sensory information to the lat-
eral pons, referred to as the pontine storage center. After pro-
cessing in higher brain centers, motor signals are then relayed St o rag e Re fle x
back through the pontine micturition center (PM C) located in
the Barrington nucleus in the dorsal medial pons. These pon- Storage is facilitated by bladder afferent stimulation of the
tine centers receive input indirectly through relay neurons in the O nuf nucleus, which increases the tone of the external ure-
periaqueductal gray (PAG) or directly from lateral spinal tract thral sphincter via the somatic pudendal nerve. The pontine
neurons. There is also input from the cerebellum, basal gan- storage center, in the lateral pons, also stimulates the O nuf nu-
glia, thalamus, hypothalamus, and cerebral cortex (4,12). cleus and the pudendal nerve output to the external urethral
Therefore, these PM Cs are responsible for the coordination of sphincter. Simultaneously, the hypogastric (sympathetic) nerve,
urine storage and voiding. Thus, damage to the spinal cord receiving input from pelvic afferents, inhibits the detrusor
between the sacral motor outflow and the PM Cs leads to a muscle and bladder ganglia while stimulating the internal ure-
characteristic pattern of neurogenic detrusor overactivity (in- thral sphincter (bladder neck), which has robust expression of
voluntary contractions) and detrusor sphincter dyssynergia (lack alpha-1 receptors. As mentioned earlier, pharmacologic reduc-
of coordination between the bladder and urethral sphincter). tion in this bladder neck tone with alpha blockers is a main-
In this situation, the coordinated spinal bulbo spinal reflex stay for the treatment of BPH as well as detrusor-sphincter
is converted to an uncoordinated spinal spinal reflex. dyssynergia and other forms of voiding dysfunction (Fig. 13.10).
Emp t ying Re fle x

Emptying is mediated through the PM C, which stimulates
PMC
parasympathetic motor or “ efferent” fibers whose cell bodies
are in the SPN . Parasympathetic outflow via the pelvic nerve
causes detrusor contraction and inhibition of the internal
pons motor response
sphincter (bladder neck), processes that facilitate emptying. relayed to sacral
In addition, signals from the PM C also inhibit sympathetic spinal cord
outflow from the hypogastric nerve, leading to relaxation of
the bladder neck, a process that also facilitates emptying.
Furthermore, signals from the PM C also inhibit the motor
outflow to the pudendal nerve, leading to relaxation of the
striated urethral sphincter, again facilitating emptying (Fig.
13.11) (10).
sacral
SPN
spinal cord
LYMPHATICS pelvic
nerve
ON
The lymphatic drainage of the bladder is to the external iliac pelvic

nerve
vein, the hypogastric nodes, or the presacral promonotory. A delta
fibers in
pelvic excitatatory
nerve stimulus for
bladder
CO NTIGUO US STRUCTURES distension
bladder
contraction
In men, the bladder joins the prostate and is anterior to the

seminal vesicles and ampulla of the vas deferens. In women,
pudendal
the bladder is in more direct contact with the pubococcygeus nerve
portion of the levator ani. Superiorly, the bladder is covered
by peritoneum in both men and women. Posteriorly in
EUS
women, the bladder is adjacent to the uterus and vagina. In
men, the posterior bladder is adjacent to the seminal vesicles FIGURE 13.11 M icturition phase of bladder function. As shown in
and rectum. this diagram, micturition is stimulated by bladder distention. Sensory
fibers carry information about bladder distention to the sacral spinal
cord. Signals then ascend via pathways in the dorsal columns to the
pontine micturition center (PM C). The PM C is the main center for
coordination of lower-urinary-tract function. Information may pass
through projections from the periaqueductal gray (PAG) to the PM C (3).
M otor responses then relay information back to the sacral spinal cord,
ultimately triggering an excitatory stimulus for bladder contraction.
References
1. Brooks JD. Anatomy of lower urinary tract and male genitalia. In: Wein 7. H inman F. A tlas of urosurgical anatom y. Philadelphia: WB Saunders,
AJ, Kavoussi L, N ovick A, et al., eds. Cam pbell-W alsh urology, 9th ed. 1993.
Philadelphia: WB Saunders, 2006:56–68. 8. Johnston L, et al. A m J Physiol R enal Physiol 2008;294(3):F645–655.
2. Caine M , Raz S, Z iegler M . Adrenergic and cholinergic receptors in the hu- Epub January 2, 2008.
man prostate, prostatic capsule and bladder neck. Br J Urol 1975;47: 9. Juenemann KP, Lue TF, Schmidt RA, et al. Clinical significance of sacral
193–202. and pudendal nerve anatomy. J Urol 1988;139(1):74–80.
3. Ding Y-Q , Wang D, N ie H , et al. Direct projections from the periaqueduc- 10. Raz S. Fem ale urology, 3rd ed. Philadelphia: WB Saunders, 2008.
tal gray to pontine micturition center neurons projecting to the lum- 11. Tanagho EA. Anatomy of the lower urinary tract. In: Walsh PC, Retik AB,
bosacral cord segments: an electron microscopic study in the rat. N eurosci Stamey TA, et al., eds. Cam pbell’s urology, 6th ed. Philadelphia: WB
L ett 1998;242:97–100. Saunders, 1992:40–69.
4. Erickson V, Roppolo JR, Booth AM , et al. l’ranssynaptic labeling of neu- 12. Vizzard M A, Erickson VL, Card JP, et al. Transneuronal labelling of neurons
rons within CN S which control the bladder or penis of the cat. Soc in the adult rat brainstem and spinal cord after injection of pseudorabies
N eurosci A bstr 1995;21:1872. virus into the urethra. J Com p N eurol 1995;355:629–640.
5. Gosling JA. The structure of the bladder and urethra in relation to func- 13. Weyrauch H M . Surgery of the prostate. Philadelphia: WB Saunders, 1959.
tion. Urol Clin N orth A m 1979;6:31–38.
6. H icks M . The mammalian urinary bladder: an accommodating organ. Biol
R ev 1975;50:215–246.
CHAPTER 14 ■ SIMPLE AND PARTIAL
CYSTECTO MY
JO NATHAN C. PICARD AND J. NATHANIEL HAMILTO N
Additionally, the risk of developing urothelial cancer of the

SIMPLE CYSTECTO MY bladder is significantly increased in patients who have received
previous pelvic irradiation (relative risk 4.6) (7). Some au-
Simple cystectomy is performed in the setting of benign dis-
thors have even cited a risk for malignant degeneration in the
ease requiring urinary diversion or locally invasive nonuro-
setting of chronic irritation such as interstitial cystitis (6).
logic malignancy. Simple cystectomy involves removal of the
bladder without resection of adjacent structures or perfor-
mance of a formal lymph node dissection. The other pelvic
organs are also left intact; to preserve sexual function, the
Alt e rnat ive The rap y
prostate, seminal vesicles, and urethra are spared in the male
Radical cystoprostatectomy in men and radical cystectomy in
patient and the uterus, anterior vagina, adnexa, and urethra
women should be considered as alternatives to simple cystec-
are spared in the female patient. Removal of a defunctional-
tomy in the setting of possible prostate cancer or urothelial
ized bladder is often very beneficial and can prevent many
carcinoma (UCC) and can be considered as alternatives in
complications.
nonurologic malignancies that are locally invasive into the
bladder or in many benign diseases of the bladder. In the ma-
jority of patients, continued observation, hyperbaric oxygen,
Diag no sis analgesic prescription, and other symptomatic treatments are
the initial options, with simple cystectomy only being offered
Preoperative evaluation should include a complete history and as a final intervention in patients with refractory disease.
physical examination. Specifically, a thorough investigation In patients with nonurologic malignancies that are locally
into the etiology of the voiding dysfunction, radiation treat- invasive into the bladder, simple cystectomy can be considered
ments, prior pelvic surgeries, and all other interventions lead- if the resection can be accomplished with negative margins.
ing up to this evaluation should be performed. Biopsy should Laparoscopic and robotic-assisted laparoscopic techniques
be undertaken if primary bladder malignancy is a considera- are also being refined and are certainly an option for appro-
tion. Preoperative imaging of the abdomen and bladder are priately trained surgeons, despite the fact that these proce-
usually helpful, and we prefer a contrasted CT scan of both dures are often difficult due to the challenges of previously
the abdomen and pelvis with delayed images to allow for visu- irradiated fields, previous surgery, and chronic infection or
alization of the ureters and any abdominal or pelvic pathology inflammation.
that would preclude the procedure.
Surg ical Te chniq ue

Ind icat io ns fo r Surg e ry
Simple cystectomy can be undertaken extraperitoneally to
Urinary diversion is indicated for patients who have refractory avoid abdominal adhesions due to multiple previous surgeries
conditions such as severe radiation or chemical cystitis, in- or radiation; however, we prefer an intraperitoneal approach
tractable bladder pain from interstitial cystitis, severe urinary as these patients also frequently require concomitant urinary
incontinence, neurogenic bladder, extensive trauma, large diversion. Antithrombotic medication, pneumatic compres-
vesical fistula, or recurrent pyocystis. Simple cystectomy can sion cuffs, or compression stockings should be strongly con-
also be undertaken for invasive nongenitourinary cancers that sidered prior to induction of anesthesia. The patient is
are not amenable to resection with partial cystectomy. positioned supine on the operating room table with the
Previous attempts at urinary diversion without concomi- anterior superior iliac spines positioned over the inferior por-
tant simple cystectomy have led to complications in 54% to tion of the table break or kidney rest. The table is flexed to
80% of patients (1, 2, 7). Complications include pyocystis, in- facilitate exposure, and the bed is slightly tilted in the
tractable hemorrhage, severe pain or spasms, and the sensa- Trendelenburg position until the abdomen is parallel to the
tion of incomplete emptying. In these patients, the salvage floor. When urethrectomy is planned, a modified lithotomy
cystectomy rate ranges from 20% to 30% (1, 2, 7). We there- position provides improved exposure to the perineum. The ab-
fore recommend concomitant simple cystectomy when perma- domen and pelvis are then prepped with an antibiotic solution
nent urinary diversion is undertaken. extending from the costal margin superiorly to the perineum,
92
Chap t e r 14: Simp le and Partial Cyste ctomy 93
including the penis in men and the vagina in women. The

patient is draped, and a Foley catheter is inserted following
sterile procedures. The bladder is allowed to drain completely.
Filling the bladder with 150 to 200 mL of sterile water may
facilitate the dissection.
An intravenous antibiotic agent should be administered
prior to skin incision. A lower midline incision extending from
the umbilicus to the pubic symphysis is made using a no. 10
blade scalpel and deepened with Bovie cautery to the anterior
rectus fascia. The anterior rectus fascia should be opened
sharply, and the rectus abdominis muscles in the midline
should then be separated to facilitate entry into the space of
Retzius.
The extraperitoneal space lateral to the bladder should be
bluntly developed by extending the dissection from the blad-
der neck cranially to the dome of the bladder. In benign condi-
tions, incising the anterior bladder wall may facilitate the
dissection. The peritoneum should be incised lateral to the
bladder in a posterior direction. The ureters can often be iden- FIGURE 14.2 The plane between the bladder (anterior) and the vasa
tified as the peritoneum is divided and reflected. They should deferentia and seminal vesicles (posterior) is dissected.
then be dissected from their surrounding attachments, with
care being taken to maintain a sufficient amount of peri-
ureteral tissue. The ureteral dissection should be continued suture and divided. The bladder is then drained and the Foley
proximally and distally. In women, care must be taken to catheter removed. Bovie cautery is used to transect the bladder
avoid the uterine artery during the distal ureteral dissection. in an anterolateral direction, and the posterior bladder wall is
When the superior vesical arteries are encountered crossing then divided to expose the previously exposed vasa deferentia
anterior to the distal ureters, they should be ligated with 2-0 and seminal vesicles (Fig. 14.3). The lateral vascular pedicles
silk ties and divided (Fig. 14.1) to allow for improved expo- should be readily visible and can be ligated with 2-0 silk ties
sure of the distal ureter and maximization of the ureteral and divided. At this point, the bladder should be free and can
length. The ureters are then clipped close to their insertion be removed. The urethra is oversewn with 3-0 Vicryl suture,
into the bladder and divided sharply. They can be packed and the prostatic surgical capsule is oversewn with 0 Vicryl
away to prevent injury during the remainder of the bladder suture (Fig. 14.4). If significant prostatic hyperplasia prevents
dissection. adequate closure of the capsule, a simple prostatectomy
In male patients, we begin our posterior dissection several should be considered followed by closure of the prostatic sur-
centimeters anterior to the peritoneal reflection and enter the gical capsule as previously described.
plane between the bladder (anterior) and the vasa deferentia In female patients, the posterior dissection begins anterior
and seminal vesicles (posterior) (Fig. 14.2). This dissection is to the peritoneal reflection. The plane between the bladder
continued to the prostatovesical junction using a combination and the anterior vaginal wall is entered and is developed with
of blunt and sharp dissection. Attention is then returned to the sharp and blunt dissection. An intravaginal sponge stick is
anterior dissection of the prostatovesical junction. The veins beneficial for traction and identification of the proper planes.
overlying the prostate and bladder can be ligated with 3-0 silk During this dissection the lateral pedicles are ligated with 2-0
FIGURE 14.1 The vesical pedicles are clipped and divided. FIGURE 14.3 The bladder neck is incised anteriorly.
Although there are no data directly related to simple cystec-

tomy, the overall complication rate of partial cystectomy is
classically reported as 11% to 29% , and the complication rate
for simple cystectomy is likely similar.
PARTIAL CYSTECTO MY
Partial cystectomy is a full-thickness excision of abnormal
bladder and a margin of adjacent normal bladder with the
goal of preserving adequate bladder function and capacity.
Traditionally, this surgery has been utilized in the manage-
ment of localized urachal adenocarcinoma, an isolated UCC
associated with a diverticulum, localized unifocal urothelial
carcinoma in favorable locations, or in patients who are un-
FIGURE 14.4 The bladder is removed. The urethra is oversewn. The able or unwilling to undergo radical cystectomy. This proce-
prostatic surgical capsule is oversewn. dure offers the advantages of full-thickness resection of the
diseased bladder in conjunction with a pelvic lymph node
dissection for pathologic review while allowing for conserva-
silk ties and divided as they are encountered. Upon reaching
tion of the native bladder and preservation of potency and
the bladder neck, the Foley catheter is removed and Bovie
continence.
cautery is used to transect the urethra. The urethral stump is
then oversewn with 3-0 Vicryl sutures. Some authors advocate
complete urethrectomy including the meatus in patients who
have cystectomy performed for interstitial cystitis.
Diag no sis
After the cystectomy is complete, the wound is copiously
Preoperative evaluation before undertaking a partial cystec-
irrigated with sterile water. A closed drainage system, such as
tomy should include a thorough history and physical exami-
a Jackson-Pratt or Blake drain, is almost universally placed in
nation with a focus on prior pelvic surgeries or procedures
the pelvis because this procedure is frequently performed in
and previous bladder pathology. Cystoscopy should be per-
the setting of chronic inflammation or infection. Attention is
formed with biopsy of the lesion for histological diagnosis.
next turned to creation of the urinary diversion of the sur-
Additional mapping biopsies should be performed to confirm
geon’s choice.
unifocality of the disease and to exclude carcinoma in situ.
The abdominal wall is closed beginning with the rectus fas-
Both noncontrasted and contrasted CT scans of the abdomen
cia. The edges of the rectus fascia are reapproximated using a
and pelvis should be performed to assist with staging. Delayed
0 looped polydioxanone (PDS) suture in a running fashion.
images of the urinary collecting system should be performed if
The wound is copiously irrigated with sterile water. If there is
upper-tract UCC is a consideration. Findings such as upper-
a large amount of subcutaneous tissue, the Scarpa fascia can
urinary-tract involvement with disease, metastatic lesions,
be reapproximated using a 3-0 or 4-0 Vicryl suture to mini-
enlarged lymph nodes 1 cm, or other pelvic pathology may
mize the dead space. The skin is closed with a subcuticular 4-0 preclude utilizing this procedure.
M onocryl suture or skin staples.
O ut co me s Ind icat io ns fo r Surg e ry
Surgical outcomes are generally very good, although the avail- Partial cystectomy has emerged as the treatment of choice for
able literature is limited. O ne series suggested a mortality rate localized urachal adenocarcinoma. The urachus is an embry-
of 0% with no morbidities directly attributable to the cystec- ological remnant that persists in approximately 30% of the
tomy itself (2). Likely, the most important aspect of simple population and is capable of malignant transformation. In
cystectomy is the morbidity that is prevented by removing the this setting, open partial cystectomy or laparoscopic partial
bladder at the time of urinary diversion. In patients not under- cystectomy should be undertaken with en bloc resection of the
going concomitant cystectomy with urinary diversion, major involved bladder with a 2-cm margin of normal tissue, umbili-
complications and hospitalization occur in 50% with cus, peritoneum, and posterior rectus fascia with concomitant
20% requiring a salvage operation (1, 2, 7). pelvic lymphadenectomy. The 5-year survival rate in this set-
ting is approximately 88% (3).
In the setting of UCC, partial cystectomy is indicated only
Co mp licat io ns in highly selected patients with limited disease, patients who
are not candidates for radical cystectomy due to comorbid
For both partial cystectomy and simple cystectomy, the usual conditions, and patients who refuse radical cystectomy.
risks associated with urologic surgeries exist, including pul- Selection criteria should include no history of previous urothe-
monary embolus, myocardial infarction, bleeding that requires lial cancer, localized disease that is unifocal in nature without
transfusion, ileus, and wound complications such as infections coexisting carcinoma in situ (CIS), and disease that is present
or seromas. The majority of complications are related to the in an area of the bladder that is amenable to complete resec-
urinary diversion rather than the simple cystectomy itself. tion with a negative margin. Patients must have a bladder
Chap t e r 14: Simp le and Partial Cyste ctomy 95
volume that allows for resection of the diseased site with an sharply, followed by separation of the rectus abdominis mus-
adjacent 2-cm margin while still maintaining adequate func- cles in the midline to facilitate entry into the space of Retzius.
tional capacity with normal compliance. We do not recom- Using blunt dissection, the tissues are dissected down to the
mend partial cystectomy if resection of the bladder neck is level of the bladder dome at the reflection of the peritoneum.
required. For dome or anterior tumors, it is possible to remain extra-
A special circumstance exists in the patient who presents peritoneal; however, for posterior tumors, an intraperitoneal
with a bladder diverticulum containing a UCC. Because of approach is recommended.
the thin, amuscular walls of the diverticulum, these lesions are
often associated with higher-stage disease. Additionally, at-
tempted transurethral resection of a UCC within a diverticu- Ext rap e rit o ne al Part ial Cyst e ct o my
lum has a higher risk of perforation. For these reasons, this
pathology is particularly amenable to partial cystectomy. The extraperitoneal space lateral to the bladder is developed
O ther indications for partial cystectomy include resection bluntly, extending from the bladder neck cranially to the dome
of nonurologic cancers in the bladder, including pheochromo- of the bladder. The anterior aspect of the bladder is exposed to
cytoma, paraganglioma, rhabdomyosarcoma, osteosarcoma, the peritoneal reflection, which is mobilized where it is readily
lymphoma, and adjacent tumors that are locally invasive into separable. A bilateral pelvic lymph node dissection is under-
the bladder, such as invasive colorectal cancer. Partial cystec- taken using the bifurcation of the common iliac artery as the
tomy may also be indicated in benign diseases such as a symp- cranial limit, the pubic symphysis as the caudal limit, the gen-
tomatic diverticulum. itofemoral nerve as the lateral limit, and the bladder as the
medial limit of the dissection. All nodal tissue is dissected and
sent for pathologic review. Prudent use of silk ties or titanium
clips, especially at the cranial and caudal limits of the dissec-
Alt e rnat ive The rap y tion, may limit the risk of lymphocele formation.
The bladder is freed from its surrounding attachments, with
Any malignant bladder tumor that is removable by partial cys-
care being taken to preserve the perivesical fat overlying the re-
tectomy can also be removed by radical cystectomy, although
gion of interest. Blunt dissection is the primary approach,
morbidity may be increased. There have also been many ad-
along with judicious use of cautery to minimize the risk to ad-
vances in endoscopic tools and techniques. Some tumors may
jacent peritoneal contents. The superior vesical pedicle may be
now be approached endoscopically via an aggressive
divided to provide adequate exposure of the resection site. This
transurethral approach or laparoscopically with a simple cys-
division may be performed with a LigaSure (Valleylab) device
tectomy. In regards to urothelial cancer, intravesical agents—
or in the traditional manner with hemostats and 2-0 silk ties.
including chemotherapy and bacille Calmette-Guérin (BCG)
O nce the bladder is freed, the area of the tumor should be lo-
immunotherapeutic agents—have also been utilized to man-
calized with preoperative or intraoperative cystoscopy.
age some of these patients. Radiotherapy and chemotherapy,
Several sutures are placed some distance from the known
alone or in combination, are also alternatives to cystectomy in
pathology. At this point, the bladder should be drained com-
the setting of muscle-invasive UCC. For many benign indica-
pletely to prevent urinary spillage. The free wound edges can
tions, simple cystectomy is an alternative.
be covered with laparotomy pads moistened with sterile water.
The bladder is incised using Bovie cautery in an area at least
2 cm away from the expected lesion. The incision is extended
Surg ical Te chniq ue to allow for visualization of the pathology. The tumor is excised
using Bovie cautery with a 2-cm margin on all sides, and the
Antithrombotic medication, pneumatic compression cuffs, or specimen is removed en bloc with the overlying perivesical fat
compression stockings should be strongly considered prior to and any adherent peritoneum (Fig. 14.5).
induction of anesthesia. The patient is positioned supine on In general, we do not recommend this operation when
the operating room table with the anterior superior iliac ureteral reimplantation is necessary. H owever, in the event that
spines positioned over the inferior portion of the table break a ureteral reimplantation is needed to complete the partial cys-
or kidney rest. The table is flexed to facilitate exposure, and tectomy, the ureter should be divided and the proximal ureter
the bed is tilted slightly in the Trendelenburg position until the reimplanted into the bladder via the Politano-Leadbetter tech-
abdomen is parallel to the floor. The abdomen and pelvis are nique or the simple nipple reimplantation technique. A 4-0
then prepped with an antibiotic solution extending from the Vicryl suture should be used for performing an interrupted
costal margin superiorly to the perineum, including the penis ureterovesical anastomosis over a ureteral stent.
in men and the vagina in women. After the patient is draped, a O nce excision of the tumor is completed and adequate he-
Foley catheter is inserted following sterile procedures. The mostasis is ensured, the bladder can be closed in two layers
bladder is then allowed to drain completely. At this point, fill- utilizing a running 4-0 Vicryl suture on the urothelium and a
ing the bladder with 150 to 200 mL of sterile water may facil- running, locking 2-0 Vicryl suture to close the muscularis
itate the dissection. layer (Fig. 14.6). Special consideration should be given to the
An intravenous antibiotic agent should be administered apices of the closure because these are the most frequent
prior to skin incision. A lower midline incision from just below sites of urinary leakage after closure. A suprapubic cystostomy
the umbilicus (around and including the umbilicus if for urachal is contraindicated in the setting of UCC; however, it can be
adenocarcinoma) to the pubic symphysis is made using a no. considered for other pathologies. The wound is copiously
10 blade scalpel and deepened with Bovie cautery to the ante- irrigated with warm sterile water. A closed drainage system,
rior rectus fascia. The anterior rectus fascia should be opened such as a Jackson-Pratt drain or Blake drain, can be placed in a
Int rap e rit o ne al Part ial Cyst e ct o my

Partial cystectomy through an intraperitoneal approach is often
necessary with tumors on the posterior bladder wall. The ex-
traperitoneal space lateral to the bladder is bluntly developed
by extending the dissection from the bladder neck cranially to
the dome of the bladder. The posterior rectus sheath and peri-
toneum just inferior and lateral to the umbilicus are divided
sharply to enter the peritoneal cavity. The bowel is retracted
into the upper abdomen using a retraction system such as the
Buchwalter or O mni-Tract system. Trendelenburg can be
steepened to assist in packing the bowel away. The peri-
toneum is incised over the iliac vessels, and the node dissection
is undertaken using the same landmarks as described in the
extraperitoneal approach. The procedure follows the steps
previously described; the posterior aspect of the bladder is
freed to allow adequate exposure, and the superior vesical
artery is divided as needed. The lesion is located, and stay su-
tures are placed some distance away from the site of disease.
After the bladder dissection is complete, the bladder is
drained. The bladder is then incised, and the tumor is excised
FIGURE 14.5 A 2-cm margin of normal bladder is taken around the
with a 2-cm margin followed by bladder closure and manage-
tumor. ment of the Foley catheter and drains as previously described
in the extraperitoneal approach.
dependent position within the area of dissection. To minimize
fistula formation, this drain should not be placed directly ad- O ut co me s
jacent to the cystotomy closure. The anterior rectus fascia is
reapproximated using a 0 looped PDS in a running fashion, In modern partial cystectomy series for the management of
and the wound is copiously irrigated with sterile water. If there UCC, outcomes are good, with a 5-year overall survival rate
is a large amount of subcutaneous tissue, the Scarpa fascia can of 64% to 70% and a 5-year disease-specific survival rate of
be reapproximated using a 3-0 or 4-0 Vicryl suture to minimize 74% to 84% (4, 5, 8). H owever, UCC is well known for its
the dead space. The skin is closed with a subcuticular 4-0 high recurrence rates. In partial cystectomy series, recurrence
monocryl suture. rates range from 28% to 49% , with an approximate recur-
The drain is removed on postoperative day 2 or 3 or when rence rate of 20% to 25% in locally advanced or metastatic
the output is 30 mL per shift. The catheter is removed on disease. Because of this high recurrence rate, most authors
postoperative day 7. If complete bladder healing is a concern, agree that lifelong cystoscopy and repeat abdominal and
a low-pressure cystogram can be performed. pelvic imaging should be performed in these patients. Disease
recurrence requires aggressive treatment similar to treatment
for recurrence with other treatment modalities, including re-
peat transurethral resection, use of intravesical agents,
chemotherapy and/or radiation protocols, and radical cystec-
tomy with urinary diversion when indicated.
The success of partial cystectomy for urachal adenocarci-
noma with en bloc resection of the urachus, umbilicus, and
surrounding soft tissues with negative margins has resulted in
an 88% 5-year disease-free survival rate (3). Local recurrence
rates are approximately 18% with aggressive resection.
Furthermore, a review of multiple small surgical series would
suggest no survival benefit to radical cystectomy over ex-
tended partial cystectomy with en bloc resection, but a ran-
domized trial has not been done.
Co mp licat io ns
For both partial cystectomy and simple cystectomy, the usual
risks associated with urologic surgeries exist, including
pulmonary embolus, myocardial infarction, bleeding that
requires transfusion, ileus, and wound complications such as
infections or seromas. O ther more specific complications in-
FIGURE 14.6 The bladder is closed in two layers. clude reduction of bladder capacity, urinary leakage, fistula
Chap t e r 15: Rad ical Cyste ctomy in Me n 97
formation, and lymphocele formation. Recurrence is a concern determine how much bladder capacity can be removed while
and is discussed previously. The overall complication rate of still allowing good function. Preoperative urodynamic testing
partial cystectomy is classically reported as 11% to 29% . may be of some benefit in accurately assessing preoperative
O f special consideration is the reduction in functional ca- bladder capacity.
pacity during partial cystectomy. There are no good data to
References
1. Eigner EB, Freiha FS. The fate of the remaining bladder following 5. Kassouf W, Swanson D, Kamat AM , et al. Partial cystectomy for muscle in-
supravesical diversion. J Urol 1990;144:31–33. vasive urothelial carcinoma of the bladder: a contemporary review of the
2. Fazili T, Bhat TR, M asood S, et al. Fate of the leftover bladder after M .D. Anderson Cancer Center experience. J Urol 2006;175:2058–2062.
supravesical urinary diversion for benign disease. J Urol 2006;176: 6. Lamm DL, Gittes RF. Inflammatory carcinoma of the bladder and intersti-
620–621. tial cystitis. J Urol 1977;117:49–51.
3. H err H W, Bochner BH , Sharp D, et al. Urachal carcinoma: contemporary 7. N eulander EZ , Rivera I, Eisenbrown N , et al. Simple cystectomy in patients
surgical outcomes. J Urol 2007;178:74–78. requiring urinary diversion. J Urol 2000;164:1169–1172.
4. H olzbeierlein JM , Lopez-Corona E, Bochner BH , et al. Partial cystectomy: 8. Smaldone M C, Jacobs BL, Smaldone AM , et al. Long-term results of selec-
a contemporary review of the M emorial Sloan-Kettering cancer experience tive partial cystectomy for invasive urothelial bladder carcinoma. Urology
and recommendations for patient selection. J Urol 2004; 172:878–881. 2008;72:613–616.
CHAPTER 15 ■ RADICAL CYSTECTO MY

IN MEN
MO HAMED A. GHO NHEIM
O ne of the first detailed operative descriptions of radical patient has either an elevated serum calcium or alkaline
cystoprostatectomy and pelvic lymphadenectomy was proba- phosphatase.
bly provided by M arshall and Whitmore in 1949 (2). In
the 1950s and early 1960s, the operation was attended with
significant mortality and morbidity. Although more com- INDICATIO NS FO R RADICAL
plex urinary diversions are increasingly employed, contem- CYSTECTO MY IN MEN
porary cystectomy is associated with very low mortality.
Furthermore, the advent of nerve-sparing cystectomy and The major indication for cystectomy in men is carcinoma of the
orthotopic bladder substitution has significantly reduced func- bladder. In general, the operation is carried out for the following:
tional losses and provided many patients with good locore-
1. Patients with superficial tumors in whom endoscopic
gional control as well as a good quality of life. The technique,
control has failed in spite of adjuvant intravesical chemo-
herein described, is based on cumulative experience of 20
and/or immunotherapy. Although these measures have
years during which 1,000 cystectomies were carried out at
proved effective in the management of such cases ( T1), an
the Department of Urology, M ansoura University, Egypt.
important minority fail. H igh tumor grade, multifocal le-
sions, diffuse carcinoma in situ, and involvement of the
prostatic urethra were all reported as high-risk factors.
DIAGNO SIS 2. Infiltrating tumor without evidence of distant metastasis.
The diagnosis of transitional-cell carcinoma is generally made These include tumors infiltrating the muscle layers (P2 ,
by transurethral resection of the tumor in the bladder (see P3a ) or the perivesical fat short of the pelvic wall (P3b ).
Chapter 111). O nce the diagnosis has been established, it is Infiltration of adjacent organs (P4 ) or involvement of the
important to know the histologic stage, particularly if the regional lymph nodes is not considered a contraindication
tumor invades the muscularis propria. Invasion of the mus- for the procedure.
cularis mucosa is not considered as constituting a muscle- The radical operation in men includes the removal of the
invasive tumor. The clinical staging of transitional-cell bladder, its peritoneal covering, the perivesical fat, the lower
carcinoma can generally be performed by abdominal and ureters, the prostate, the seminal vesicles, and the vasa deferen-
pelvic computerized tomographic (CT) scans. O ccasionally tia. In the standard procedure, as much as possible of the mem-
radionuclide bone scans are indicated if there is either sym- branous urethra is also removed, and total urethrectomy is carried
ptomatic bone pain or abnormalities on the CT scan, or if the out only if there is involvement of the prostatic urethra (4).
generally employed. Alternatively, a midline incision encircling

ALTERNATIVE THERAPY the umbilicus can also be utilized. For obese patients a lower
abdominal muscle-cutting transverse incision is preferred.
Alternatives to radical cystectomy include local therapy, par- Under such circumstances it provides a wide and direct expo-
tial cystectomy, intravenous chemotherapy, radiation therapy, sure of the pelvis.
or a combination of chemotherapy and radiation therapy. Local Initially, the abdominal and pelvic cavities are explored.
therapy in invasive disease generally results in progression of The growth is palpated, its degree of mobility determined, and
the disease and death of the patient within 5 years. Systemic its relation to the adjacent structures assessed. The endopelvic
chemotherapy or radiation therapy is associated with a 25% and aortic lymph nodes are palpated, and frozen sections are
5-year survival, though the combination of the two modalities taken if necessary. The general peritoneal cavity, omentum, in-
results in significant synergy, with up to 50% 5-year survival. testinal tract, kidney, spleen, and liver are thoroughly exam-
ined. If the decision is to proceed with the radical operation,
the intestines are packed out of the pelvis, and the retropubic
SURGICAL TECHNIQ UE space is opened by blunt dissection. Any small bleeders are co-
agulated. This dissection is extended inferiorly and laterally
Pre p arat io n o f t he Pat ie nt until the ventral surface of the bladder and prostate are ex-
posed. The peritoneal incision is extended inferiorly on either
In view of the extent of surgery and the length of the operative side of the urachal remnant. The urachal remnant is dissected
time, a thorough medical evaluation and anesthetic consulta- off its attachment with the umbilicus and clamped. In this
tion are required. manner a triangular peritoneal flap with its apex pointing su-
Bowel preparation is necessary before surgery. If it is periorly is raised and will be removed later en bloc with the
planned to use the small bowel, oral neomycin and a low- bladder.
residue diet are all that are needed. M ore rigorous preparation
with full bowel prep is required if the colon is utilized.
Patients with histories of thromboembolic disease or vari- Lymp had e ne ct o my
cose veins should receive a prophylactic dose of heparin
(5,000 U subcutaneously) the night before the operation and The peritoneal incision, on either side, is extended posterolat-
every 12 hours thereafter until ambulation. A parenteral erally along the lateral border of the external iliac and com-
broad-spectrum antibiotic is given just before induction of mon iliac vessels up to the aortic bifurcation. The vas deferens
anesthesia and continued postoperatively for 3 days. The re- is identified and ligated near the internal ring. The fascia on
gion extending from the midchest to the midthigh should be the iliopsoas is incised and reflected medially. The triangle
cleaned and prepared on the night before surgery. of M arceille is exposed by retracting the common and exter-
nal iliac arteries medially and dissecting the space between
these vessels and the medial border of the psoas muscle (3).
Ane st he sia and Inst rume nt at io n Dissection of the fibrolymphatic tissues in this space will expose
the obturator nerve as it emerges from the medial border
Full relaxation of the abdominal muscles by an appropriate of the psoas muscle (Fig. 15.1). The fibrofascial sheath cover-
anesthetic is necessary throughout the entire procedure. ing the distal half of the common iliac and the external iliac
H ypotensive anesthesia would provide an additional advan- vessels is then opened and stripped medially to remove the
tage and would reduce blood loss.
The choice of instruments depends mainly on the surgeon’s
preference. Standard retractors of various sizes and curves as
well as long curved and angled scissors are needed. Long
curved clamps should also be available.
Po sit io n and Init ial Exp o sure

The patient is put in the supine position with a Trendelenberg
tilt. Slight bending of the knees would further help in the re-
laxation of the abdominal muscles, facilitate retraction, and
provide a wider exposure. If a total urethrectomy is planned,
the patient is put in a slight lithotomy position for access to
the perineum.
The surgical area to be sterilized and draped extends from
the lower chest down to the root of the penis. A self-retaining
catheter is introduced into the bladder and kept indwelling for
its evacuation throughout the procedure.
FIGURE 15.1 Dissection of the triangle of M arceille. The psoas mus-
A long, vertical, right paramedian incision extending from cle is retracted laterally and the iliac vessels medially. The obturator
the symphysis pubis inferiorly to a point halfway between the nerve is exposed in the floor of the triangle as it emerges from the
umbilicus and xyphoid process of the sternum superiorly is medial border of the psoas muscle.
FIGURE 15.2 The lymphadenectomy. A: The fibroareolar tissue has been dissected from the anterior and
medial aspects of the psoas major muscle. The external and common iliac arteries are exposed and skele-
tonized. B: Further dissection exposes the external vein. The obturator fossa is cleared with separation of
the obturator nerve. C: Further dissection of the internal iliac artery and its branches prior to their control.
D: The lateral dissection is completed. The anterior division of the internal iliac artery is divided with con-
trol of its parietal branches. The ureter is divided and the ligature on its stump is used for traction.
perivascular lymphatics and lymph nodes. The vessels are gen- the ligated ureteric stump of the ureter, finger dissection along
tly retracted, laterally and immediately below and medial to its posteromedial border opens the space of Denonvilliers lat-
the cleaned external iliac vein, and the obturator space is en- erally. The step greatly helps in the definition of the plane be-
tered. By working right on the psoas and obturator muscles, tween the bladder and rectum, which will be required at a
one can strip all the pelvic fascia medially without difficulty. later stage in the operation. The phases of the lateral dissec-
The obturator neurovascular bundle is included in the stripped tion are illustrated in Figure 15.2.
mass. The obturator nerve is identified and separated from the The endopelvic fascia on either side on the prostate is then
vessels, which are divided and ligated as they leave the pelvis opened by the tip of a blunt pair of scissors (Fig. 15.3). The
through the obturator foramen. Dissection is facilitated and optimal site for the creation of this opening is a white line
the operating time reduced by the use of electrocoagulation to marking the fusion of the parietal fascia lining the pelvic sur-
control lymphatic and small blood vessels throughout the face of the levator ani with the visceral fascia covering the lat-
lymphadenectomy. eral surface of the prostate. A right-angled clamp is used to lift
the fascia from the underlying venous plexus, and it is further
incised medially until the prostatic ligaments are reached. By
Cyst o p ro st at e ct o my blunt dissection, this plane is further developed posteriorly on
either side of the prostate. Further anterior dissection is de-
The fibrolymphatic mass is now reflected medially. The inter- ferred to the final stages of the procedure to minimize the pos-
nal iliac artery is dissected free, and its anterior division is di- sibility of sudden blood losses from inadvertent injury of the
vided and ligated. The ureter is identified where it crosses the prostatic venous plexus.
common iliac bifurcation, dissected free for 3 to 4 cm, di- The specimen is now lifted ventrally by applying traction
vided, and its distal end ligated. While traction is applied on on the median umbilical ligament (urachus). The two planes
FIGURE 15.5 The cul-de-sac formed by the fusion of the two layers
of the fascia of Denonvilliers is opened by the tip of a blunt pair of
long scissors. Thereafter, the tip of the surgeon’s forefinger would feel
the apex of the prostate and the catheter in the urethra. If the forefin-
ger is directed laterally, it will appear through the previously created
openings on either side of the prostate. Thus a thick, wide, fascial
FIGURE 15.3 The bladder and prostate are retracted medially by a band is defined (the vesicoprostatic pelvic fascia). It is divided piece-
Deaver retractor. The reflection of the endopelvic fascia from the ven- meal between clamps (arrow and interrupted line).
tral surface of the levator ani to the prostate is opened. Blunt dissec-
tion would further develop this space and expose the lateral surface of
the prostate.
Denonvilliers. This cul-de-sac is opened by the blunt tip of

developed along the posteromedial borders of the ureter on long angled scissors. O nce this is completed, the tip of the sur-
either side are easily joined together by blunt dissection. As a geon’s forefinger can readily feel the apex of the prostate as
result, the peritoneal reflection from the anterior surface of well as the catheter in the urethra in the midline. Alternatively,
the rectum to the back of the bladder could be stretched and if it is directed laterally, it will appear through the previously
safely incised by diathermy. The potential space between the created openings on either side of the prostate (Fig. 15.5).
rectum posteriorly and the bladder, seminal vesicles, and In this manner, a thick and wide fascial band is created on
prostate anteriorly is opened by blunt dissection (Fig. 15.4). either side, connecting the bladder, vesicles, and prostate ante-
As the prostatic apex is reached, this space becomes obliter- riorly with the pararectal fascia posteriorly (the vesico-
ated as a result of fusion of the two layers of the fascia of prostatopelvic fascia). This is divided piecemeal between
clamps, which are underrun by 2-0 polyglactin sutures.
The bladder is now free laterally and posteriorly, and the
mass is left to drop in the pelvis. Attention is now focused on
the anterior and final phase of the procedure. The pubopro-
static ligaments are identified by applying traction on the
prostate in a cephalad and posterior direction. These ligaments
are carefully severed at the point of their insertion in the pubic
bone. The prostatic venous plexus is controlled by one or two
sutures of 3-0 polyglactin acid placed near the prostatic apex.
A transverse incision is made proximal to these sutures with a
long scalpel and extended with sharp dissection by scissors,
exposing the urethra, within which the catheter can be pal-
pated (Fig. 15.6). The catheter is then withdrawn; the urethra
is clamped and transected; the distal end is ligated; and the
specimen is removed. Final hemostasis is achieved by inserting
deep 2-0 polyglactin sutures between the edges of the levator
ani muscles on either side (Fig. 15.7). N o attempt is made to
reperitonealize the pelvis. Two tube drains are placed in the
pelvic cavity and brought out through separate incisions in the
abdominal wall. The wound is closed in layers with particular
FIGURE 15.4 The peritoneum of the floor of the Douglas pouch is
attention for careful closure of the anterior rectus sheath. This
incised by diathermy. The space between the rectum posteriorly and is closed with interrupted sutures of nylon with the knots tied
the bladder and seminal vesicles anteriorly is dissected and opened. to the inside.
and further steps are carried out perineally without urethral

transaction.
A midline incision in the perineum is usually employed.
The skin, subcutaneous tissue, and bulbocavernosus muscle
are incised in the midline. The Foley catheter can now be
palpated in the urethra. The urethra is dissected sharply
from the overlying corpora cavernosus. Further dissection is
carried out in the direction of the glans penis. Traction on
the urethra results in inversion on the penis, allowing dissec-
tion of the urethra as far as the coronal sulcus. The penis is
then allowed to restore its normal position. The urethral mea-
tus is circumscribed sharply, and the glans penis is incised in
the midline to allow dissection of the fossa navicularis. The
entire penile urethra is now free. The glans penis is recon-
structed by a few sutures of interrupted 3-0 chromic catgut.
Attention is now focused on dissection of the bulbar
FIGURE 15.6 The puboprostatic ligament is incised and the prostatic urethra. The relatively avascular tissues ventral to the bulbar
venous complex controlled. The membranous urethra is thus exposed. urethra and beneath the symphysis pubis are dissected first.
Thus, the corresponding part that had been previously dis-
sected in the pelvis can be reached, and the pelvic and perineal
exposures joined. Dissection is further developed laterally and
posteriorly with control of the bulbar urethral arteries. In this
manner the urethra is freed totally, and the whole specimen is
removed in one block.
Rad ical Cyst o p ro st at e ct o my w it h O rt ho t o p ic

Blad d e r Sub st it ut io n
A standard radical cystoprostatectomy is performed except
that the final stages of the operation must be done with atten-
tion to detail to avoid damage to the urethra and periurethral
musculature. The integrity of these structures has a central
role in the functional success of orthotopic substitution.
Following lymphadenectomy and control of the pedicles, the
endopelvic fascia on either side of the prostate is opened by
the tip of a blunt pair of scissors. A right-angled clamp is used
to lift the fascia from the underlying venous plexus, and then
it is further incised medially until the puboprostatic ligaments
are reached. These ligaments are carefully severed at the point
of their insertion in the pubic bone. The prostatic venous
plexus is controlled by one or two suture ligatures of 3-0
polyglactin just distal to the vesicoprostatic junction. A trans-
verse incision is made proximal to these sutures and extended
by sharp dissection with scissors toward the apex of the
prostate. The catheter is palpated in the urethra, the anterior
wall of which is then incised just distal to the prostatic apex.
FIGURE 15.7 The specimen is removed. Final hemostasis is achieved The exposed Foley catheter is transected, clamped, and held
by two to three interrupted sutures of 3-0 polyglactin between the two for traction. At this point, three stay sutures of 4-0 polyglactin
medial borders of the levator ani muscles.
are placed through the urethra at the 3, 9, and 12 o’clock po-
sitions, incorporating the mucosa as well as the periurethral
musculature (Fig. 15.8). These sutures prevent retraction of
Variat io ns o n a The me the urethra following its complete transection and are used
later for the urethroileal anastomosis. The posterior urethral
O ne -St ag e Cyst o p ro st at o ure t hre ct o my wall is then incised to expose the dorsal fibrous raphe formed
Urethrectomy is indicated in a subpopulation of patients with by the fascia of Denonvilliers, which is lifted from the anterior
multifocal tumors, diffuse carcinoma in situ, or tumor involv- surface of the rectum by a right-angled clamp and divided.
ing the bladder neck and/or the prostate. Following incision of The divided fascia is then included in two posterior stay
the puboprostatic ligaments and control of the prostatic ve- sutures at the 5 and 7 o’clock positions for its later incorpora-
nous plexus described, traction is applied on the cystectomy tion in the urethrointestinal anastomosis.
specimen in a cephalad direction. The urethra is dissected
from the urogenital diaphragm with a long pair of dissecting Rad ical Cyst o p ro st at e ct o my w it h Ne rve Sp aring
scissors. In this manner, 2 to 3 cm of the membranous urethra This procedure was initially described by Schlegel and Walsh (5).
can be mobilized. The pelvis is temporarily packed with gauze, It can be carried out in an antegrade or a retrograde manner,
FIGURE 15.8 Preparation of the urethral stump for orthotopic substitution. A: The anterior wall of the
urethra is transected. Three stay sutures of 4-0 polyglactin are placed through the urethra at the 3, 9, and
12 o’clock positions. B: Transection of the urethra is completed and further stay sutures applied. These
will prevent retraction of the urethral stump and will be later used for the urethroileal anastomosis.
though in our practice we prefer the antegrade approach. evaluation of 425 cystoprostatectomy specimens at our insti-
During radical cystectomy there are two points where the neu- tution, there was histological evidence of adenocarcinoma of
rovascular bundle could be injured: (a) posterolateral to the the prostate in 21.2% of cases and concomitant noncontigu-
prostate and (b) behind the seminal vesicles. If the extent of ous TCC in 6.4% (9). In view of all of these observations, we
the pathology allows the surgeon to avoid these areas, potency feel that the potential oncologic risks of prostate-sparing cys-
can be preserved. tectomy outweigh any small and possible functional benefits.
Bilateral lymphadenectomy with creation of the space be- Properly conducted radical cystoprostatectomy with ortho-
tween the rectum posteriorly and the bladder, seminal vesicles, topic substitution should remain the standard for treating
and prostate anteriorly is carried out as previously described. invasive bladder tumors.
By a combination of blunt and sharp dissection, the lateral
surface of the seminal vesicles is freed from the medial aspect
of the vesicoprostatopelvic fascia. This allows the control of Po st o p e rat ive Manag e me nt
these ligaments at a more ventral plane. As a result, the neu-
rovascular pathway behind the seminal vesicles is avoided. Intravenous alimentation and nasogastric suction are main-
These pedicles are controlled by a series of simple interrupted tained until normal bowel activity is resumed. Systemic antibi-
sutures of 3-0 Vicryl. The use of heavy clamps, clips, and otics are continued for 3 days postoperatively. Chest exercises
diathermy should be avoided. The dorsal vein complex is now and physiotherapy to the lower limbs should be carried out.
controlled, and the urethra isolated carefully from the adja- Subcutaneous heparin should be administered if indicated.
cent fascia. The urethra is then transected, and the Foley The tube drains are removed when drainage becomes 100 mL
catheter is clamped and held for traction. The prostate can per day. It is advisable to estimate the creatinine content of the
thus be elevated superiorly. A right-angle clamp is used to fluid to ensure that it is not the result of a urinary leak.
identify branches of the neurovascular bundle to the prostate. Patients with an ileal conduit can be discharged on the 10th to
These are ligated and divided, freeing the prostate from all its the 12th postoperative day. Following orthotopic substitution,
lateral attachments. patients are usually kept in the hospital for 3 weeks. Before
discharge, a pouchography is carried out to make sure that
there are no leaks from the neobladder or from the ure-
Pro st at e -Sp aring Rad ical Cyst e ct o my throileal anastomosis.
Several authors have advocated retaining the prostate in some

selected patients for whom orthotopic diversion is contem- O UTCO MES
plated (6,7). It was suggested that preserving the prostate in
whole or in part can circumvent problems related to conti- Co mp licat io ns
nence and results in the preservation of erectile function.
H owever, serious concerns were raised by other authorities of The two most serious complications that may occur during
the possible increased oncological risks following such a pro- the procedure are excessive blood loss and rectal perforation.
cedure. In a review by H autmann and Stein it was reported Sudden massive bleeding is usually venous in origin, arising
that the incidence of prostatic carcinoma in cytoprostatectomy from tributaries of the external iliac vein during the lym-
specimens ranged between 29% and 46% and that of prostate phadenectomy: the deep circumflex iliac vein laterally and an
TCC between 33% and 58% (8). In a prospective pathologic abnormal obturator vein medially. Since both are located near
the inguinal ligament, good retraction, illumination, and suc- sutured over the repair for additional security. The pelvic cavity
tion are needed. A laceration of the external iliac vein is then is then thoroughly irrigated with 1% solution of kanamycin in
sutured with 5-0 Prolene. saline. At the end of surgery, while the patient is still under
Another source of bleeding is in relation to the dorsal vein anesthesia, anal dilation is carried out up to three to four fin-
complex. Dissection of this area has to be deferred to the final gers to establish adequate decompression. Generally, by follow-
phase of the procedure. This venous complex is usually injured ing these principles, one can avoid the need for a temporary
when the puboprostatic ligaments are incised. Compression of proximal colostomy.
the bleeding area by a piece of gauze (4 8) and the tip of a The postoperative mortality following contemporary cys-
long thin blade of a Deaver retractor is necessary until the dis- tectomy is 2% or less (10). The most common postoperative
section of the urethra is completed. Thereafter, bleeding is complication is prolonged ileus. This is treated by nasogastric
controlled by one or two interrupted 3-0 sutures of suction, intravenous alimentation, and hyperalimentation if
polyglactin acid placed between the two medial borders of the necessary. Septic complications, including abdominal and/or
levator ani muscles. pelvic abscesses, wound sepsis, and septicemia, are not un-
H owever, the most serious source of bleeding is from the common. These are treated by the appropriate antibiotics and
internal iliac vein or one of its tributaries. Sudden excessive drainage of the infected collection. This is best achieved by
bleeding occurs from the depth of a narrow deep recess. Blind ultrasound-guided aspiration and/or insertion of a percuta-
attempts to control the bleeding with clamps usually fail and neous tube drain. Wound dehiscence should be immediately
result in more damage. In our experience, one has to achieve repaired by proper closure using tension sutures. Urinary col-
an initial temporary control by packing. O ne or two 4 8 lections (urinoma) are drained under ultrasound guidance. If
pieces of moist gauze are sufficient. The pack is tightly and the source of leak is the ureterointestinal anastomosis, a per-
constantly compressed for a few minutes and then is left in cutaneous nephrostomy tube is inserted until healing is
place. The operator should proceed with further operative achieved and checked with an antegrade study.
steps until the specimen is removed. N ow, the working space
is wide enough to allow manipulations under vision. The ipsi-
lateral external iliac and common iliac veins as well as the Re sult s
main stem of the internal iliac artery are controlled by bulldog
clamps. The gauze pack is then removed. There will still be Radical cystectomy has evolved as the standard therapeutic
some back bleeding, but with the help of a little suction, the modality for muscle-invasive bladder cancer. It can be accom-
bleeding vessels are readily located and easily secured by su- plished with very low mortality, and technical innovations
ture ligation using 4-0 silk. with nerve sparing and orthotopic substitution can provide
The other serious intraoperative complication is rectal per- many patients with a good quality of life with minimal func-
foration. This usually takes place during the final phase of the tional losses.
operation if the space between the prostate and rectum was All contemporary series demonstrate that radical cystec-
not adequately and completely opened. Under such circum- tomy can result in a substantial rate of cure with overall sur-
stances, traction on the specimen will lead to tenting of the an- vival ranges between 48% and 53% (1,11). For low-stage
terior wall of the rectum. Sharp dissection with scissors or tumors ( P2), the survival could be as high as 75% . With fur-
application of clamps would result in an injury of the anterior ther stage progression, the survival expectancy is decreased.
wall of the rectum well below the peritoneal reflection. If this Radical cystectomy with pelvic lymphadenectomy also pro-
injury is recognized, the tear is meticulously repaired. The vides a survival advantage for cases with nodal disease (5-year
edges are trimmed and closed in two layers using 3-0 survival in the range of 20% ) (7). Evidence has also been pro-
polyglactin acid: the first through and through, and the sec- vided that adjuvant cisplatin-based polychemotherapy im-
ond inverting as a fascia muscular layer (Lembert technique). proves the chances of survival among patients with advanced
An omental flap is raised, brought down to the pelvis, and locoregional disease (12).
References
1. Frazier H A, Robertson JE, Dodge RK, et al. The value of pathologie fac- 8. H autmann RE, Stein JP. N eobladder with prostatic capsule and seminal-
tors in predicting cancer-specific survival among patients treated with radi- sparing cystectomy for bladder cancer: a step in the wrong direction. Urol
cal cystectomy for transitional cell carcinoma of the bladder. Cancer Clin N orth A m 2005;32:177–185.
1993;71:3993–4001. 9. Saad M , Abdel-Rahim M , Abol-Enein H , et al. Concomitant pathology in
2. M arshall VF, Whitmore WF Jr. A technique for the extension of radical the prostate in cystoprostatectomy specimens: a prospective study and
surgery in the treatment of vesical cancer. Cancer 1949;2:424–428. review. BJU Int 2008;102.
3. M cGregor AL. A synopsis of surgical anatom y, 9th ed. Bristol: John 10. Skinner DG, Crawford ED, Kaufman JJ. Complications of radical cystec-
Wright and Sons, 1963:99. tomy for carcinoma of the bladder. J Urol 1980;123:640–643.
4. Schellhammer PF, Whitmore WF Jr. Transitional cell carcinoma in men 11. Skinner DG. M anagement of invasive bladder cancer: a meticulous pelvic
having cystectomy for bladder cancer. J Urol 1076;115:56–60. node dissection can make a difference. J Urol 1982;128:34–36.
5. Schlegel PN , Walsh PC. N euroanatomical approach to radical cystoprostec- 12. Soloway M S, Lopez AE, Patel J, et al. Results of radical cystectomy for
tomy with preservation of sexual function. J Urol 1987;138:1402–1406. transitional cell carcinoma of the bladder and the effect of chemotherapy.
6. H orenblas S, M einbardt W, Ijzerman W, et al. Sexuality preserving cystec- Cancer 1994;73:1926–1931.
tomy and neobladder: initial results. J Urol 2001;166:837–840. 13. Stockle M , M eyenburg W, Wallek S, et al. Adjuvant polychemotherapy of
7. Vallencien G, Abou El-Fettouh H , Cathelineaux, Baumert H , et al. non-organ-confined bladder cancer after radical cystectomy revisited: long-
Cystectomy with prostate sparing for bladder cancer in 100 patients: 10-year term results of a controlled prospective study and further clinical experi-
experience. J Urol 2002;168:2413–2417. ence. J Urol 1995;153:47–52.
CHAPTER 16 ■ RADICAL CYSTECTO MY
IN WO MEN
ALO N Z. WEIZER AND CHERYL T. LEE
In 2007, 67,000 new cases of bladder cancer were diagnosed patients with muscle-invasive disease, other indications for
in the United States; over 17,000 occurred in women, with cystectomy are well supported by the literature.
4,000 dying from their disease (1). Although most urothelial
carcinomas are noninvasive, up to one-third of patients pre-
sent with muscle-invasive disease. In addition, 30% to 40% of No n–Muscle -Invasive Dise ase
patients presenting with non–muscle-invasive tumors will
progress to muscle invasion. O nce patients progress to muscle- Radical cystectomy may be considered an alternative to intra-
invasive disease, their 5-year survival declines substantially. vesical therapy in patients with high-grade lamina-propria–
Radical cystectomy remains the most effective single-modality invasive disease, especially in the setting of associated carci-
treatment for these patients and also for those with refractory noma in situ with the potential for improved survival benefit.
non–muscle-invasive disease, with a reported 10-year survival The presence of additional adverse histologic features, such as
of 70% to 80% in patients with organ-confined tumors (2). mixed histology, lymphovascular invasion, inverted growth
Improvements in processes of care, particularly at high-vol- pattern, or nested variant, should also drive consideration of
ume centers, have led to a reduction in perioperative mortal- early cystectomy. Patients with non–muscle-invasive disease
ity, further strengthening the role of cystectomy (3). refractory to intravesical therapy (bacille Calmette-Guérin)
H istorically, radical cystectomy in women has posed sev- are at significant risk of progression, and repeated courses of
eral technical challenges and concerns, including (a) bleeding intravesical therapy can compromise overall survival (5); this
from the paravaginal tissues and venous plexus around the may be due to the 30% incidence of understaging in patients
urethra, which can be brisk and tedious to control; (b) an in- with noninvasive disease.
traoperative position change for the surgeon during urethrec-
tomy; and (c) vaginal reconstruction, which can be complex,
requiring tissue flaps to maximize organ function. Int ract ab le Lo cal Symp t o ms
M ore recently, additional challenges have related to female
organ preservation. Radical cystectomy in women has tradi- Radical cystectomy can be considered in patients with persis-
tionally been equated with anterior exenteration, including tent local symptoms related to tumor or intravesical therapy
resection of the bladder, urethra, uterus, ovaries, and the ante- side effects failing conservative management without the pres-
rior one-third of the vagina. This approach is certainly indi- ence of invasive disease. This decision requires an active dis-
cated for extensive posterior invasive bladder tumors at risk cussion between the physician and patient to balance the risks
for reproductive organ involvement. H owever, tumor involve- of surgical intervention with the impact of the symptoms on
ment of adjacent reproductive organs is rare, suggesting that the patient’s quality of life.
the routine removal of female reproductive and sex organs is
not necessary to achieve local cancer control (4). M oreover,
the increasing attention to preserving quality of life after can- Failure o f O t he r Primary Fo rms
cer surgery provides another incentive to spare part or all of
the reproductive organs and urethra when feasible and when
o f Int e rve nt io n
dictated by the diversion choice. Patients undergoing organ preservation strategies are at life-
long risk of local recurrence. These patients require surveil-
lance and management of recurrence with transurethral
INDICATIO NS FO R SURGERY resection. While some recurrences can be managed with in-
travesical therapies, patients with high-grade noninvasive and
Radical cystectomy is indicated for patients with muscle- invasive tumors should be considered for cystectomy. In most
invasive urothelial malignancy or non–muscle-invasive disease series of patients undergoing primary chemoradiation for
refractory to transurethral resection and intravesical therapy. bladder cancer, 30% to 40% require radical cystectomy for
While radical cystectomy is well accepted as a standard for recurrence of disease or intractable local symptoms (6).
104
Chap t e r 16: Rad ical Cyste ctomy in Wome n 105
O THER O PERATIVE Ext e nt o f Surg e ry

CO NSIDERATIO NS When proceeding to definitive surgical treatment in the female
bladder cancer patient, the physician should consider the
Eld e rly/ Mult ip le Me d ical Co mo rb id it ie s woman’s age, sexual function, and childbearing status in con-
junction with her clinical stage. For premenopausal patients
While cystectomy is readily applied to younger populations, with carcinoma in situ, early invasive disease (T1), or anterior
the elderly often have limited access to radical surgery and are low-volume T2 disease, radical cystectomy should be per-
counseled toward nonsurgical interventions. H owever, cystec- formed with intent to preserve the vagina, uterus, and ovaries,
tomy is often the best treatment option for invasive bladder potentially preserving sexual and reproductive quality of life.
cancer in the elderly who are in reasonably good health (7). In addition, we must consider the need to maintain body im-
Invasive bladder cancer is not an indolent disease, and death age for women by offering continent and orthotopic diver-
from uncontrolled urothelial carcinoma is high in the first 3 to sions. Table 16.1 outlines our paradigm for the extent of
4 years. Thus, for a healthy 75-year-old woman, the invasive surgical intervention. Indications for urinary diversion are
bladder cancer is her biggest health risk. Furthermore, the risk outlined in Section 7 of this text.
of radiation therapy and chemotherapy is substantial, with the
continued need for bladder surveillance and the potential need
for subsequent cystectomy in patients who have continued to ALTERNATIVE THERAPY
age with progression of their medical comorbidities and of
their bladder cancer (6). Improved perioperative care allows Alternatives to cystectomy include observation, systemic
cystectomy to be done with a low operative mortality, sup- chemotherapy, radiation therapy, or a combination of chemo-
porting an expedient cystectomy as the overall safest and most therapy and radiation along with aggressive transurethral
effective approach (8). resection of the tumor. These modalities have historically been
TA B LE 1 6 . 1
IN DICATION S FOR SURGICAL EXTEN T OF RADICAL CYSTECTOMY IN WOMEN
TYPE EXTEN T IN DICATION
I Cystectomy alone T2
Preserve reproductive organs/vagina/urethra Childbearing potential desired
(for neobladder) Potentially sexually active
II Cystectomy plus TAH a/BSO b (if uterus and T2
ovaries are present) Postchildbearing
Preserve vagina/urethra (for neobladder) Postmenopausal
Potentially sexually active
IIa Cystectomy plus TAH (if organs present) T2
Preserve vagina/urethra (for neobladder) Postchildbearing
Premenopausal; grossly normal ovaries
Potentially sexually active
III Cystectomy plus TAH /BSO (if organs present) T2 or T3
plus anterior vaginectomy Posterior wall tumor away from bladder neck
Preserve urethra for neobladder
IIIa Cystectomy plus TAH (if organs present) plus T2 or T3
anterior vaginectomy Posterior wall tumor away from bladder neck
Preserve urethra for neobladder Premenopausal; grossly normal ovaries
IV Cystectomy plus TAH /BSO (if organs present) plus T2 or T3
anterior vaginectomy and urethrectomy Tumor at bladder neck or urethra
IVa Cystectomy plus TAH (if organs present) plus T2 or T3
anterior vaginectomy and urethrectomy Tumor at bladder neck or urethra
Premenopausal; grossly normal ovaries
aTAH , total abdominal hysterectomy.
b BSO , bilateral salpingo-oophorectomy.
Source: Urinary D iversion, 2nd ed., 2005, pg 191, O rthotopic bladder replacement in women, Cheryl T. Lee and James E. M ontie, Table 20.1, with
kind permission of Springer Science and Business M edia.
reserved for surgically ineligible patients, those refusing

surgery, or the elderly. M ore recently newer chemoradiation Ant e rio r Exe nt e rat io n
regimens have been proposed, even for non–muscle-invasive
Access to the urethra and vagina is necessary during the ante-
tumors, in an effort to provide greater sexual and urinary
rior pelvic exenteration in women. A modified lithotomy posi-
quality of life in bladder cancer patients (9).
tion is used with Allen, Lloyd-Davies, or Yellofin stirrups. The
vagina and perineum must be well prepared with an iodine or
Betadine scrub. An infraumbilical vertical midline incision
gives ideal exposure; however, patient habitus or a planned
PREO PERATIVE CARE extended lymph node dissection may necessitate an extension
O ptimization of preoperative nutritional status will reduce the of this incision another 2 to 3 cm superiorly. The urachal rem-
risk of perioperative complications. Patients are encouraged to nant provides a convenient handle for traction on the bladder
augment their diet with protein and caloric supplements if (Fig. 16.1). The peritoneum is divided along the lateral umbil-
they have anorexia or significant unintended weight loss. ical ligaments (Fig. 16.2), and the round ligament is clipped
Although some have abandoned bowel preparation in patients and divided. A self-retaining retractor, such as the Bookwalter
with diversions utilizing small intestine (10), the current au- device, will maintain exposure. The fallopian tubes and
thors still prefer formal bowel preparation prior to cystec- ovaries are present and nonfunctional in this predominantly
tomy. In the majority of patients, preparation consists of a postmenopausal population and thus are ultimately removed
clear liquid diet and either GoLytely (Braintree Laboratory, with the uterus, cervix, and anterior vagina. The gonadal ves-
Braintree, M A) or Phospho-Soda (Fleet Corporation, sels and suspensory ligament are divided above the ovaries
Lynchburg, VA) solutions on the day prior to surgery. Wound (Fig. 16.3). The ureters are mobilized with substantial peri-
prophylaxis is achieved in the perioperative period with a ureteral adventitia to preserve optimal blood supply and later
second-generation cephalosporin antibiotic administered over divided at the bladder hiatus (Fig. 16.4). Ligation and division
a 24-hour period. of the uterine and vaginal arteries branching from the hy-
pogastric artery is usually required to accomplish this.
The lateral blood supply to the bladder and uterus is iso-
lated as it courses from the internal iliac artery and vein. The
SURGICAL TECHNIQ UE endopelvic fascia and the perirectal “ fat pad” are exposed
with medial traction on the bladder and ureter. The index fin-
ger is used to bluntly develop a plane just medial to the
Anat o mic Co nsid e rat io ns well-defined superior vesical artery, aiming obliquely toward
the perirectal tissue. This will isolate the superior vesical
Fe male Co nt ine nce artery, which requires ligation. Several small associated arter-
An understanding of the female continence mechanism in ies and veins are controlled with ligaclips or the Gyrus device
women is critical prior to creation of an orthotopic neoblad- (Gyrus ACM I, M A), thus dividing the lateral pedicle under di-
der. There are two continence mechanisms in women (11). rect vision (Fig. 16.5). M edial traction on the bladder with fin-
O ne is in the proximal urethra, which is innervated via the gers above and below the pedicles enhances exposure.
pelvic plexus that courses adjacent to the bladder neck and
vagina. These nerves often are transected during a radical cys-
tectomy. In the middle to lower third of the urethra there is an
intermingling of smooth and striated muscle fibers called the
rhabdosphincter muscle that is innervated via the pudendal
nerves and appears to be the critical sphincter mechanism for
continence in women. Because the rhabdosphincter is present
in the middle to lower urethra, the entire bladder and bladder
neck can be resected in a woman without compromising even-
tual continence. Complete resection of the bladder is necessary
to minimize the transitional epithelium left in situ and thus re-
duce the risk of local tumor recurrence and also hyperconti-
nence after orthotopic urinary diversion.
Fe male Se xual Funct io n

A similar pelvic plexus supporting erectile function exists in
both men and women. Anterior exenteration with removal of
the urethra has been shown to result in clitoral devascularization
with decreased sexual arousal. In addition, resection of the
vagina is often associated with disruption of the autonomic
neurovascular plexus, further compounding the impact on
sexuality. Preservation of all or the lateral portions of the vagi- FIGURE 16.1 The urachal remnant provides a convenient handle for
nal wall as well as the urethra can avoid injury to the pelvic traction on the bladder through the case and is divided between Kelly
plexus and may reduce the impact on sexual function (12). clamps and ligated.
FIGURE 16.4 Each ureter is mobilized with a large amount of peri-

FIGURE 16.2 The division of the peritoneum follows the course of ureteral adventitial tissue to preserve optimal blood supply. The ureter
the lateral umbilical ligament until the round ligament is identified, is divided a short distance above the bladder.
clipped, and divided.
This is warranted for a deeply invasive posterior bladder

wall cancer. Alternatively, partial or complete preservation of
the reproductive organs can be considered, especially if ortho-
topic urinary diversion is planned, as described below. To mo-
bilize the anterior pelvic organs, an incision is made in the
posterior peritoneum down to the rectovaginal cul-de-sac.
Blunt and sharp dissection in the midline mobilizes the poste-
rior vaginal wall; this mobility will allow the posterior vaginal
wall to be rolled anteriorly away from the rectum for vaginal
reconstruction.
A Betadine-soaked sponge stick is placed in the vagina, ele-
vating the apex of the vagina just posterior to the cervix.
Cautery is used to open the apex of the vagina in the midline;
this incision is carried laterally down the anterior vaginal wall
on each side (Fig. 16.6A–C). The Gyrus device is useful in this
manuever, greatly minimizing venous bleeding from the vagi-
nal wall. Additional bleeders from the adjacent tissue may be
controlled with 2-0 Vicryl suture ligatures. This dissection is
continued to the bladder neck. If cutaneous diversion is
planned, the endopelvic fascia and pubovesical attachments
are sharply divided and the proximal urethra is mobilized.
Depending on the tumor location, a portion of the proximal
urethra can be sharply dissected off of the anterior vaginal
wall, which is transected at the bladder neck, leaving a portion
of the anterior vaginal wall intact within the pelvis. This pre-
serves a greater portion of the vagina and allows for an easier
FIGURE 16.3 The fallopian tubes and ovaries, if present, are com- vaginal reconstruction later. The dissection then moves to the
monly removed with the uterus and bladder. The gonadal vessels, sur- perineum after reasonable hemostasis has been ensured in the
rounded by the suspensory ligament, are divided and ligated cephalad pelvis.
to the ovary.
After division of the lateral pedicles on each side, the tech- Ure t hre ct o my
nique is modified depending on the type of extirpative proce-
dure to be performed. In a classic anterior pelvic exenteration, To perform the urethrectomy, the labia are retracted laterally
the bladder, uterus, bilateral fallopian tubes and ovaries, ante- with suture ligatures. Army-N avy or self-retaining retractors
rior vaginal wall, and urethra are removed en bloc (Fig. 16.6). provide exposure to the urethral meatus. An inverted
FIGURE 16.5 Division of the lateral pedicle is one of

the more important technical aspects of the procedure.
The endopelvic fascia should be well exposed with
blunt dissection. A perirectal fat pad lying adjacent to
the rectum defines the lower limit of the lateral pedicle
coursing from the internal iliac vesical. M edial traction
on the urachal remnant and retraction of the ureter me-
dially allow an index finger to create a plane just me-
dial to the origin of the superior vesical artery outlining
the lateral pedicle. The caudad extent of blunt dissec-
tion is the perirectal fat tissue. A: The medial traction
on the bladder with the surgeon’s nondominant hand
easily exposes the entire pedicle. B: The superior vesical
artery is ligated, but the remainder of the small vessels
can be controlled with clips on both sides.
U-shaped incision is made around the urethra (Fig. 16.7A), If the tumor characteristics permitted partial anterior
and the urethra is mobilized anteriorly and laterally. Retur- vaginectomy, and a portion of the anterior vaginal wall was
ning to the pelvic approach, suture ligatures are placed in the preserved within the pelvis below the bladder neck, the poste-
venous plexus anterior to the urethra, analogous to control of rior vaginal flap is apposed to this anterior stump within the
the dorsal venous plexus in men. Further simultaneous ante- pelvis (Fig. 16.8). The lateral walls are then closed sequen-
grade dissection can help to direct the retrograde dissection tially from within the pelvis with running Vicryl suture. Using
from the perineum until there is a continuum from the pelvis this approach, a circumferential urethral incision would have
to perineum. Ultimately, from the perineal approach, the ante- been used (Fig 16.7B), and the prevaginal tissues identified in
rior vaginal wall posterolateral to the urethra is divided to the perineum would then be sutured to the retropubic tissues
connect with the pelvic dissection, permitting removal of the with running or interrupted Vicryl suture. A vaginal pack
entire specimen. Alternatively, a circumferential periurethral soaked in Betadine is left in the vagina for 24 hours.
incision can be made, preserving a portion of the anterior
vagina located posterior to the urethra (Fig. 16.7B and C).
Subsequent simultaneous antegrade and retrograde dissection
will allow complete urethral mobilization and excision, as Re p ro d uct ive O rg an Pre se rvat io n
noted above.
In appropriately selected patients, all or part of the female re-
productive tract can be preserved. Certainly, the age, child-
bearing status, and sexual function of the patient must be
Vag inal Re co nst ruct io n considered when planning radical extirpative procedures
(Table 16.1). If the disease is felt to be organ-confined and
The vagina is reconstructed by rotating the apex of the poste- located favorably, it is reasonable in young women with child-
rior vaginal wall anteriorly to create a foreshortened vagina bearing potential to spare the reproductive organs, since it is
that maintains the previous width (Fig. 16.8). A stay suture in increasingly clear that most female organs are uninvolved by
the apex of the posterior vaginal wall brings the vaginal wall primary bladder cancer and that local recurrence is uncom-
to the perineum, if a total anterior vaginectomy was required; mon (4). When orthotopic diversion is planned in the sexually
this flap of vagina is sutured to the periurethral vaginal tissue active postmenopausal woman with a tumor site away from
anteriorly in the midline and then sequentially on each side. the trigone or bladder neck, the anterior vagina should be
After two to three interrupted sutures are placed on each side preserved.
from the perineum, additional sutures higher up on the vagi- The surgical approach begins with a similar midline inci-
nal wall are more easily placed from the pelvic exposure. A sion as described for anterior pelvic exenteration followed by
watertight closure provides optimal hemostasis of the par- the development of the extravesical space. The urachus is di-
avaginal tissue. vided, and peritoneal flaps are developed on either side of the
FIGURE 16.6 The classic anterior pelvic exenteration includes removal of the bladder, uterus, bilateral fal-
lopian tubes and ovaries, anterior vaginal wall, and urethra. A and B: An incision is made with cautery at the
apex of the vagina. This is often facilitated with a Betadine-soaked sponge stick placed in the vagina on up-
ward traction. The incision should be as close as possible to the posterior aspect of the cervix. C: The inci-
sion is then carried around laterally along the anterolateral aspect of the vagina. There is commonly a rich
blood supply to the lateral aspect of the vagina, and this is most easily controlled with multiple suture liga-
tures in a stepwise fashion. The incision stops just before the endopelvic fascia. D: With this dissection, the
entire anterior vaginal wall, posterior bladder wall, and urethra are removed en bloc.
FIGURE 16.7 A: Attention is now turned to the perineum, where an

inverted U-shaped incision is made around the urethral meatus and
the anterior and lateral aspects of the urethra are mobilized.
Dissection returns to the pelvic exposure, where suture ligatures are
placed in the venous plexus anterior to the urethra, analogous to con-
trol of the dorsal venous complex in men. Incisions in the anterolat-
eral vaginal wall are connected between the perineum and the pelvic
dissection. The entire specimen can then be removed. B and C:
Alternatively, a circumferential periurethral incision can be made
preserving a portion of the anterior vagina located posterior to the
C urethra.
bladder. The round ligament is still-ligation, and the ureters formation when orthotopic diversion is planned. In this cir-
are mobilized as described previously. A sponge stick is placed cumstance, an omental flap can be used to cover any signifi-
in the vagina to readily identify the vaginal apex and cervix cant vaginal reconstruction.
and also to provide countertraction. The plane between If appropriate, the uterus, fallopian tubes, and ovaries
the posterior bladder and anterior vaginal wall is developed should be left in situ. This is an optimal choice for the sexually
(Fig. 16.9). This dissection must hug the anterior vaginal wall active female with low-volume or early-stage disease who has
so as not to compromise the cancer surgery but also to avoid concerns about future fertility. If hysterectomy is required
the troublesome bleeding that can be encountered when the after vaginal-sparing surgery, a sharp incision is created at the
dissection is in the wrong plane. An advantage of this ap- vaginal apex and carried circumferentially around the cervix,
proach is avoidance of the rich vascularity of the vagina, preserving as much vaginal tissue as is feasible. The vaginal
which is appreciated when the entire anterior vaginal wall is cuff is closed using 3-0 Vicryl in a continuous fashion, fol-
resected. During this dissection, care should be taken to avoid lowed by an additional layer of 2-0 Vicryl interrupted
entry into the vagina, which could increase the risk of fistula Lembert sutures.
FIGURE 16.9 When partial or complete female pelvic organ preser-

vation is planned with or without orthotopic urinary diversion, a
plane is created sharply between the posterior bladder wall and ante-
rior vagina. Care should be taken to avoid entry into the vagina as this
increases the risk of fistula formation. Vaginotomies should be closed.
(from Lee CT, M ontie. O rthotopic bladder replacement in women.
FIGURE 16.8 Several methods of closure of the vagina are feasible. In: JE Kreder KJ, Stone AR eds. Urinary Diversion, 2nd edition.
O ne that appears to supply strong support of the pelvis uses the pos- O xfordshire, UK: Taylor and Francis, 2005: 190, with permission).
terior vaginal wall as a flap to create a neovagina. This foreshortens
the vagina but does not narrow it as a side-to-side closure does and
thus provides for a better return of sexual function, if appropriate. A
suture is placed in the apex of the posterior vaginal wall from above;
this is used to bring the posterior flap of the vagina down to the per-
ineum. Several sutures are placed from below, incorporating a full
thickness of the periurethral vaginal tissue to the posterior vaginal
wall flap. Sutures closer to the apex of the vagina are more easily
placed from the pelvic exposure.
Re t ro g rad e Disse ct io n and

Ure t hral-Sp aring Te chniq ue
In planning for orthotopic diversion, modifications in the
technique of pelvic exenteration are necessary when ap-
proaching the bladder neck and urethra. It is important to
maintain the integrity of the endopelvic fascia and thus pre-
serve the support of the external sphincter. Dissection of the
lateral wall of the vagina should also be avoided to prevent in- FIGURE 16.10 In the situation in which an orthotopic diversion is
jury to the neurogenic innervation of the rhabdoid sphincter. planned, neither the endopelvic fascia nor the anterior venous plexus
Lastly, the bladder neck must be removed entirely to minimize is disturbed. An incision is made in the anterior urethra just distal to
postoperative urinary retention. the junction with the bladder neck. The urethra is divided completely,
and the dissection of the bladder off the anterior vaginal wall can be
O nce the bladder has been mobilized off the vagina down done in either an antegrade or retrograde fashion.
to the bladder neck, fine sutures are used anteriorly in the
periurethral tissue as necessary for hemostasis of the venous
plexus. The urethra is amputated sharply at the junction with prefer six to eight fine absorbable sutures using 2-0 to 3-0
the bladder neck, avoiding distal mobilization or dissection of M onocryl, taking small bites on the urethra. M obility of the
the urethra (Fig. 16.10). After the bladder has been removed, intestinal reservoir to the urethra is generally not a problem in
a sample of the urethra is circumferentially excised from the women, although it can be in men.
specimen or the urethral stump (if necessary) and sent for In the initial experience with orthotopic diversion, the con-
frozen section to ensure a negative urethral margin. Exposure cern for stress incontinence was such that anterior urethral
is often ideal for the enterourethral anastomosis. The authors fixation sutures were placed to prevent hypermobility of the
urethra. This maneuver is not only unnecessary (unless docu- over 70 years of age, including 8% of patients over 80 years.
mented stress incontinence from hypermobility is evident pre- In addition, 35% of our patients are obese (body mass index
operatively) but is also counterproductive by contributing to 30 kg per m 2 ), and 38% of patients have an American
increased urinary retention or “ hypercontinence.” A possible Society of Anesthesiologists class of 3 or higher, suggesting
additional mechanism for postoperative urinary retention may greater operative risk. Adding to the patient complexity are the
be exacerbation of a pre-existing but previously insignificant 30% of patients receiving neoadjuvant systemic chemotherapy
cystocele. After the cystectomy, the urethra is fixed anteriorly (most frequently consisting of gemcitabine, carboplatin, and
and the patient voids by Valsalva maneuver after relaxing the paclitaxel), which impacts nutritional status prior to surgical
external sphincter. If a cystocele is present, the increased ab- intervention.
dominal pressure needed for voiding across the fixed urethra O ur median operative time was 6 hours for women, which
and bladder neck could be blunted by the cystocele. is comparable to the operative time for men; this time in-
cluded anesthetic induction and reversal. O ur median length
of stay for women undergoing cystectomy is 8 days, reflecting
Po st o p e rat ive Care our willingness to offer cystectomy to an often medically com-
plex group of patients. Urinary diversion consisted of 57%
Establishment of a critical care pathway is useful for cystec- ileal conduit, 40% orthotopic neobladder, and 3% cutaneous
tomy patients (8). Compliance with the ideal postoperative continent diversion, reflecting our growing use of orthotopic
course is difficult after cystectomy because of a high frequency diversion in women.
of comorbid disease and complications, which may delay
discharge even if they are not life-threatening. Epidural anal-
gesia, patient-controlled analgesia, and nonsteroidal anti- CO MPLICATIO NS
inflammatory agents are useful adjuncts to provide better
postoperative pain control, which translates into better pul- Cystectomy remains a difficult operation in men or women,
monary hygiene, ambulation, and return of bowel function. with a mortality rate of 2% to 3% . Twenty percent to 30% of
The authors no longer routinely utilize nasogastric decom- patients will have a complication delaying discharge. M any of
pression postoperatively, though it can be helpful intraopera- the specific complications after cystectomy are a consequence
tively. O verall, excellent pain control, judicious use of of the urinary diversion. Complications from the cystectomy
diuretics to combat fluid retention, and aggressive pulmonary portion include bleeding with subsequent coagulation abnor-
toilet are important strategies to prevent complications. Early malities and rectal injury. Pelvic bleeding can be more difficult
ambulation, intermittent compression stockings, and 5000 U to control in women. Since 1995, the median blood loss in
of subcutaneous heparin sulfate are currently used for deep women has been 1,011 cc. A rectal injury should be extremely
venous thrombosis prophylaxis. Routine perioperative par- rare in women and seen only in association with prior surgery
enteral nutrition is not necessary in the well-nourished patient; or radiation therapy. The most frequent complications experi-
however, the clinician should consider this therapy in the early enced in our female cystectomy series were prolonged ileus in
postoperative period for nutritionally debilitated patients or 15% of patients, anemia in 9% , incisional complications in
those likely to have prolonged ileus. In our experience, ap- 5% , and dehydration or failure to thrive in 5% . Thirty-day
proximately 10% to 20% of patients need postoperative nu- mortality was under 1% .
tritional support. The postoperative care after cystectomy requires a dili-
gence over and above that seen with other urologic proce-
dures. Some complications are preventable. A regimented,
O UTCO MES reproducible plan for the technique of cystectomy and diver-
sion is enormously helpful to prevent errors during a 4- to
From July 1995 through January 2008, we have performed 6-hour operation. Some complications are unavoidable, but
1,058 cystectomies; 240 (23% ) patients were women. The me- recognition early in their evolution may drastically minimize
dian age in women was 70 years old. For us, age has not been the negative consequences, and a high index of suspicion is es-
a deterrent to providing definitive treatment in a patient with sential. Early recognition of a complication may prevent a cas-
a reasonable life expectancy. This is reflected by the fact that cade of other successive complications that may ultimately
40% of patients undergoing cystectomy at our institution are lead to increased morbidity or mortality.
References
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CHAPTER 17 ■ BLADDER DIVERTICULECTO MY

MICHAEL S. CO O KSO N AND SAM S. CHANG
A bladder diverticulum is the protrusion or herniation of the hiatus (paraureteral or H utch diverticulum) and both postero-
bladder mucosa through the detrusor muscle fibers as a re- lateral walls (2,3,5,8).
sult of a structural defect in the bladder or as a secondary
change due to chronic dysfunctional voiding (8). The wall of
the diverticulum is composed of the following layers from
inside out: mucosa, subepithelial connective tissue or lamina DIAGNO SIS
propria, isolated and thin muscle fibers, and adventitial tis-
sue (Figs. 17.1 and 17.2) (7). Diverticula may be congenital Congenital diverticula are more common in men than in women,
or acquired, the latter developing secondary to increased and while they may be discovered incidentally in adulthood,
intravesical pressure (5,8). The most frequent causes of the peak incidence is 10 years of age (2,8). In contrast, acquired
increased bladder voiding pressure and the eventual forma- diverticula have a peak incidence of 60 years of age and are
tion of an acquired diverticulum are benign prostatic hyper- almost exclusively found in men (5). Acquired bladder diver-
plasia, urethral strictures, contracture of the bladder neck or ticula are commonly asymptomatic, although irritative and/or
urethral valves, and neurogenic voiding dysfunction, such as obstructive voiding symptoms, pelvic pain, and hematuria
detrusor–sphincteric dyssynergy. The diverticula are located may arise from complications thereof, including infection,
in the weakest points of the bladder, such as the ureteral stones, obstruction, and tumor.
FIGURE 17.1 Posterior view of bladder and diverticulum: ampulla of FIGURE 17.2 Lateral view of bladder and diverticulum: seminal
vas deferens (1); ureters (2 and 2 ); posterior longitudinal bundle vesical (1); ureter (2); prostate (3); anterolateral longitudinal fibers of
of the outer layer of the detrusor (3); diverticulum (4); circular fibers the outer layer of the detrusor (4); diverticulum (5); fine, circularly
of the middle layer of the detrusor around the diverticular neck (5). oriented fibers around the diverticular neck (6).
(2,8). A video urodynamics study can provide not only im-

portant anatomic information but also information regard-
ing bladder function and voiding pressure, which may be of
special interest in cases where neurogenic voiding dysfunc-
tion is suspected (8).
Cystourethroscopy should be performed to exclude ure-
thral stricture disease and/or bladder neck contractures but is
most important to rule out occult pathology such as a stone or
carcinoma within the diverticulum (1). The entire surface of
the diverticulum should be visualized, and the relative location
of the ureteral orifices should be noted to assist in planning for
any potential surgical procedure. The differential diagnosis
includes “ pseudodiverticular” images observed in cystograms
such as bladder ears, hourglass bladder, and vesical hernias.
O ther diagnoses include urachal cysts, prostatic utricle cysts,
or müllerian duct cysts and blind-ending bifid ureters. O ther
less frequent congenital anomalies should also be considered,
such as vesicourachal diverticulum, incomplete bladder dupli-
cation, and septation of the bladder (2).
INDICATIO NS FO R SURGERY
Patients who have poor bladder emptying after relief of ob-
struction or who are unable or unwilling to undergo surgical
treatment of the bladder diverticulum may be effectively treated
with clean intermittent catheterization (CIC) or an indwelling
catheter (8). In such patients, and in the absence of future com-
plicating factors, surveillance of the bladder diverticulum and
monitoring of the upper tracts, including renal function, may be
all that is required. Importantly, long-term CIC and periodic re-
nal ultrasound may be a viable option in these patients.
In general, the indications for surgical intervention include
chronic infections, stones, and premalignant changes such as
dysplasia or carcinoma in situ and frank carcinoma (8). A
large diverticulum may be the cause of deficient voiding and
chronic urinary infection or obstruction of the ureter and even
of the posterior urethra in children, whereas a paraureteral or
hiatal diverticulum is usually associated with different degrees
of reflux (4,5). In addition, spontaneous diverticular rupture
or complications related to the size or location of the divertic-
B ulum are indications for surgery. With the aim of improving
FIGURE 17.3 Contrast-enhanced computerized tomography scan functional voiding, we recommend the simultaneous resection
demonstrating a large posteriorly based bladder diverticulum seen on of all poorly emptying bladder diverticula if the patient must
(A) transverse and (B) sagittal images. undergo open prostatectomy, cystolithotomy, ureteroneocys-
tostomy, or YV-plasty of the bladder neck. Similarly, a vesical
Given the nonspecific nature of the presenting symptoms, diverticulum should never be operated on without previously
diverticula are most commonly diagnosed by radiographic or simultaneously correcting the cause, whether anatomic or
imaging, including ultrasound, intravenous pyelogram functional (neurogenic bladder), of the outlet obstruction that
(IVP), voiding cystourethrogram (VCUG), and contrast- provoked it.
enhanced computerized tomography (CT scan) (Fig. 17.3). Although occurring in a small subset of these patients (0.8%
Diverticula are also found on ultrasound of an empty and to 10% ), urothelial carcinoma can develop within bladder diver-
full bladder performed for the study of bladder outlet ob- ticula at a mean age of 65 years (range, 45 to 80) (1).
structive symptoms in men or repeated urinary infections in Approximately 75% to 80% of these tumors are urothelial car-
women. Cystograms obtained by IVP or through retrograde cinoma, while 20% to 25% are squamous cell carcinomas likely
instillation of contrast medium may provide information induced from chronic stasis of urine and infection. Because of
with regard to the number, location, size, and urinary reten- this potential malignant risk and the fact that these tumors can
tion volume of the diverticulum. H owever, a VCUG with be difficult to diagnose, some have advocated prophylactic di-
lateral, oblique, and postvoid images is important in defin- verticulectomy. Alternatively, a more conservative strategy may
ing the extent of the diverticulum and of particular use in be offered that should include surveillance cystoscopy and uri-
congenital cases to rule out possible vesicoureteral reflux nary cytology obtained at 6- to 12-month intervals.
the bladder as needed throughout the procedure. The bladder

ALTERNATIVE THERAPY is approached via an infraumbilical midline extraperitoneal
incision, although alternatively a Gibson incision may be
Many children with congenital diverticula who are asympto- used. The linea of the rectus fascia is divided in the midline,
matic do not require therapy, and a conservative approach has along with the transversalis fascia, and the pelvis is exposed.
been advocated (2). Saccules and small diverticula may be In the case of benign bladder pathology, the dissection is car-
treated successfully by electrocoagulation of their mucosa when ried into the space of Retzius and the anterior bladder wall
the primary obstructive disease is endoscopically resolved. In and vesical neck are identified. After reflecting the peritoneum
addition, laparoscopic approaches to bladder diverticulum may cephalad off the bladder dome, a transverse cystotomy is per-
be effective as an alternative to open surgery with the distinct formed at this level. This provides better exposure of bladder
advantage of shortened convalescence time (6). contents and facilitates placement of a small self-retaining
retractor and additional stay sutures. The trigone, ureteral ori-
fices, bladder neck, and all possible diverticular orifices are
PREO PERATIVE ASSESSMENT clearly visualized from the bladder dome opening.
In cases of intradiverticular tumor, some have advocated the
Aside from the laparoscopic approach, there are essentially instillation of 40 mg of mitomycin C by urethral catheter before
two methods of surgical therapy: (a) transurethral resection of the surgery. Intraoperatively, we carefully protect the surgical
the diverticular neck and (b) open diverticulectomy. In either field with moist, sterile towels draped around the wound to
case, infection must be adequately treated prior to surgery. If avoid possible tumor contamination during diverticulectomy.
the lesion is acquired due to obstruction, the obstruction must The bladder mucosa should also be thoroughly inspected to
be relieved prior to repair of the diverticula to prevent recur- rule out papillary tumors that may have gone unnoticed on the
rence and subsequent treatment failure (9). If the diverticulum previous endoscopic examination. The mouth of the diverticu-
is due to high detrusor pressure of neurological origin, this lum can also be packed with a small gauze pad to avoid or min-
must also be addressed prior to surgical correction. imize potential tumor spillage.
Diverticulum excision has been described in three different
approaches: extravesical; intravesical, also known as trans-
SURGICAL TECHNIQ UE vesical; and the intravesical and extravesical combination. The
most commonly used procedures and the points of technique
Transure t hral Re se ct io n that we use are the following.
Endoscopic management may be important in the management Int rave sical o r Transve sical Dive rt icule ct o my
of elderly patients, those that are not good open surgical If the diverticulum is small ( 2.5 cm diameter), we perform
candidates, or those with a smaller diverticulum that can be intravesicalization and eversion of its wall, grasping and trac-
addressed at the time of a transurethral resection of the tioning its bottom gently with an Allis- or Péan-type clamp in-
prostate (8). Transurethral resection of the neck of small to serted through its neck. If this maneuver is performed
midsized diverticula in situations where the opening is not carefully and fibrosis secondary to infection is absent, the
immediately impinging on the ureter is a well-recognized treat- majority of these diverticula are rapidly and easily removed.
ment (10). If the opening is small, a Collins knife or right-angle The mucosa of the everted diverticular neck is divided using
hooked electrode can be used to open the ostium of the diver- electrocautery, and the defect of the bladder wall is sutured
ticulum to allow for subsequent inspection of the entire diver- with 3-0 chromic catgut or Vicryl using separate submucosal
ticular wall and facilitate drainage. Transurethral resection or and muscular sutures in two separate layers. In case of a sac-
fulguration of the mucosa with a rollerball electrode can then cule, a fine ligature of the neck and resection of its everted
be used to ablate the mucosa of the inner wall. mucosa will suffice.
In the case of tumor within a bladder diverticulum, caution If this maneuver is not feasible because of peridiverticular
must be exercised. Because there is no muscular backing, adhesions, we proceed to sharply split the mucosa around the
transurethral resection of bladder tumors within diverticula diverticular orifice and dissect with scissors as far as the
carries a high risk of perforation. Cold-cup biopsy and fulgura- periadventitial space. In this way, the diverticular neck remains
tion may be appropriate for low-grade, low-stage tumors. The separated from the bladder wall and is pulled toward the vesical
holmium laser may also be of use in this unique situation be- cavity with Allis-type clamps. At the same time, the adventitial
cause it has a small fiber and a shallow depth of penetration adhesions that fix the diverticular sac are freed gently with a
(only 0.3 to 0.5 mm) and would certainly lower the risk of per- small moist gauze and the sac is drawn into the bladder. The
foration or injury to adjacent structures. In those patients with bladder wall is then closed as mentioned previously (Fig. 17.4).
high-grade or large diverticular carcinomas, in particular those
with narrow openings in which the risk of endoscopic perfora-
Co mb ine d Int rave sical and Ext rave sical
tion or inadequate resection is high, open diverticulectomy/
partial cystectomy or total cystectomy has been advocated.
Dive rt icule ct o my
In a large diverticulum complicated with peridiverticulitis or
in a paraureteral location, it is obligatory to place a 7Fr or 8Fr
O p e n Surg ical Te chniq ue catheter into the ipsilateral ureter before dissection. This will
allow for easy identification of the ureter and hopefully avoid
A Foley catheter is placed in the bladder on the surgically pre- inadvertent ureteral injury. If the dissection is extensive, a
pared field to allow for passive drainage and active filling of double-J ureteral catheter remains indwelling for a short
FIGURE 17.4 Technique of intra-

vesical diverticulectomy.
period of time (usually 2 to 3 weeks). These diverticula must toward the surface is useful. We also recommend completely
be excised by a combined intra- and extravesical approach, filling the diverticular sac with a moist gauze to unfold its wall
first identifying and dissecting the diverticular neck. For this, and delimit its margins as accurately as possible. Dissection
the maneuver of inserting the surgeon’s index finger into the must begin at the diverticular neck, which is incised extravesi-
diverticulum and gently tractioning the upper face of its neck cally with electrocautery and separated from the bladder wall,
suction drain within it (first described by Pousson in 1901 and

Geraghty in 1922). The bladder wall is closed with absorbable
3-0 interrupted or continuous absorbable sutures, and a two-
layer closure is preferable when possible. We leave a 10Fr
closed suction drain in the space of Retzius and a urethral
18Fr or 20Fr Foley catheter, which may both be removed after
5 or 6 days. For more extensive cases, those requiring large
cystotomies, or in situations where there is prolonged drain
output, a Foley catheter may be left in place for 10 to 14 days
and a cystogram may be indicated prior to catheter removal.
O UTCO MES
Co mp licat io ns
The most serious specific complication of excision of a blad-
der diverticulum is an injury to the intramural or pelvic ureter
during dissection of a large diverticulum. With prior place-
ment of an ipsilateral ureteral catheter, this injury should be
FIGURE 17.5 Procedure of combined intravesical–extravesical diver- avoidable or at least recognizable and promptly repaired. A
ticulectomy. A finger is inserted into the bladder diverticulum from small ureterotomy can be easily sutured with absorbable 5-0
within the bladder. or 6-0 chromic or Vicryl. If the ureter has been severely dam-
aged or its section is complete and near the vesical hiatus, the
distal ureter must be abandoned, and it is preferable to carry
out ureteral reimplantation following the technique of
Leadbetter–Politano with or without vesical mobilization to
the psoas muscle (“ psoas hitch” ). M ore extensive injuries
to the ureter may require a bladder tube (Boari flap) or a
transureteroureterostomy. End-to-end suture of ureteral edges
must never be performed in precarious conditions because it is
highly likely that it will be complicated by urinary fistula or
ureteral stenosis, which will further aggravate the situation.
O ther complications include urinary fistula, rectal injury,
and pelvic abscess. Less serious complications include vesical
urine leakage, which may cease spontaneously if the Foley
catheter is maintained for additional days, providing the
obstructive pathology has been resolved.
Re sult s
FIGURE 17.6 Procedure of combined intravesical–extravesical diver-
ticulectomy. O nce the diverticulum has been dissected, the mouth of
With transurethral resection, approximately one-third of these
the diverticulum is excised sharply. lesions are cured or significantly improved. For benign dis-
ease, an open excision of the diverticulum is in general cura-
tive for that particular lesion, although correction of the
underlying cause (e.g., outlet obstruction) is required to pre-
whose orifice is sutured with 3-0 chromic catgut using extra- vent formation of additional diverticula or recurrence. In cases
mucosal separate stitches (Figs. 17.5 and 17.6). of diverticula involving carcinoma, the prognosis has in gen-
Tractioning the edges of the diverticular mouth toward the eral been poor and attributed to the difficult and often delayed
surface with Allis-type clamps allows the sac wall to be dis- diagnosis with early escape from the confines of the bladder
sected from neighboring tissue with scissors and a small moist through the thin mucosal backing. H owever, more contempo-
swab. It should always be borne in mind that the ureteral rary reports suggest relatively high rates of survival (about
course may have been modified by the great diverticular vol- 70% 5-year survival), attributed in part to earlier detection
ume, and the ureter may be closely adhered to its wall if through improved radiographic imaging and a lower thresh-
repeated infectious processes have occurred. This dissection old for cystoscopy in the presence of hematuria, coupled with
will be difficult if extensive peridiverticulitis is present, and it early aggressive surgical treatment (1). N evertheless, due to
is more advisable simply to denude it of its mucosal lining the relative paucity of cases, treatment recommendations for
with fine scissors or with the cutting current and the ball these unique situations will continue to be based largely on
electrode from inside the diverticular cavity and then place a patient characteristics and surgeon preferences.
References
1. Baniel J, Vishna T. Primary transitional cell carcinoma in vesical divertic- 6. Parra RO , Jones JP, Andrus CH , et al. Laparoscopic diverticulectomy:
ula. Urology 1997;50:697. preliminary report of a new approach for the treatment of bladder divertic-
2. Canning DA, Koo H P, Duckett JW. Anomalies of the bladder and cloaca. ulum. J Urol 1992;148:869.
In: Gillenwater JY, Grayhack JT, H owards SS, et al., eds. A dult and pedi- 7. Peterson LJ, Paulson DF, Glenn JF. The histopathology of vesical divertic-
atric urology, 3rd ed. St. Louis: M osby–Year Book, 1996:2445. ula. J Urol 1973;110:62P.
3. H utch JA. A natom y and physiology of the bladder, trigone, and urethra. 8. Rovner ES. Bladder and urethral diverticula. In: Wein A, ed. Cam pbell-
N ew York: Appleton Century Crofts, 1972:8. W alsh urology, 9th ed. Philadelphia: WB Saunders, 2007:2361.
4. Jarow JP, Brendler CB. Urinary retention caused by a large bladder diver- 9. Q uirinia A, H offmann AL. Bladder diverticula in patients with prostatism.
ticulum: a simple method of diverticulectomy. J Urol 1988;139:1260. Int Urol N ephrol 1993;25:243.
5. M iller A. The aetiology and treatment of diverticulum of the bladder. Br J 10. Vitale PJ, Woodside JR. M anagement of bladder diverticula by transurethral
Urol 1958;30:43. resection: reevaluation of an old technique. J Urol 1979;122:744.
CHAPTER 18 ■ BLADDER AUGMENTATIO N

ANNE PELLETIER CAMERO N, R. DUANE CESPEDES, AND EDWARD J. MCGUIRE
Bladder augmentation, also referred to as augmentation neurogenic population, who often only maintain fecal conti-
cystoplasty or enterocystoplasty, is the addition of tissue to the nence with purposeful constipation. We avoid this segment if
bladder to increase its capacity. The goal of this procedure at all possible. The stomach is used only in the event that both
is to create a large capacity and compliant bladder to the small and large bowel are not suitable for augmentation. It
achieve continence, decrease detrusor overactivity, and protect has a thick wall and produces little mucus, but most urologists
the renal units from vesicoureteric reflux and high storage are not familiar with its mobilization, and, although the
pressures. The most common indication for bladder augmen- hydrochloric acid production is bactericidal, the associated
tation is the neurogenic bladder that has failed conservative hematuria-dysuria syndrome can be troublesome. The
therapy. The majority of neurogenic bladder disorders can segment chosen should be based on the patient’s past medical
be managed with medical therapy, but a significant minority and surgical history, findings during the procedure, and the
will require augmentation cystoplasty. In the past, these pa- surgeon’s experience (2,3).
tients would have been treated with an incontinent urinary
diversion such as an ileal conduit. With the advent of clean
intermittent catheterization (CIC) and decreased morbidity
of the procedure, augmentation has almost replaced inconti-
nent diversion as bladder management for this typically Bladder augmentation is indicated for the following:
young population, resulting in great improvements in pa-
tient quality of life. Patients with incontinent diversions like 1. Severe medically refractory neurogenic detrusor overactiv-
ileal conduits more frequently develop urinary infections ity. This is most commonly due to spinal cord injury or
and upper-tract deterioration compared to those with a spina bifida.
large, low-pressure reservoir employing the urethra as a con- 2. Poorly compliant bladder from neuropathic conditions
tinence method (1). secondary to pelvic radiation or intravesical chemother-
M ost urologists are familiar with the use of ileum and apy, or bladder scarring from surgical or traumatic injury.
prefer to use this segment for bladder reconstructions. It must 3. Idiopathic detrusor overactivity refractory to all therapy.
be noted that each bowel segment has its own advantages and 4. Prolonged bladder defunctionalization after long-term
disadvantages, but none is universally superior (2). catheter drainage, cutaneous vesicostomy drainage, or
The ileum, 25 cm from the ileocecal valve, when detubular- bilateral cutaneous ureterostomy.
ized for augmentation, ensures low pressures, produces only a 5. Inflammatory conditions such as interstitial cystitis or
moderate amount of mucus, and results in the least metabolic bilharzial or tuberculosis bladder dysfunction.
disturbances of all the bowel segments. The sigmoid is low 6. Patients previously diverted who are candidates for undi-
pressure if detubularized, is thicker than ileum allowing version.
reimplantation of ureters, has a large lumen and a long mesen- 7. Intractable autonomic dysreflexia that is associated with de-
tery, but has more mucus production and a greater risk of trusor hyperactivity or irritation from indwelling catheters.
subsequent urinary infections.
The cecum is typically only used in conjunction with the Incontinence from detrusor overactivity in patients who do
terminal ileum. The ileocecal valve can be used as an antire- not suffer from identifiable neurogenic disease (i.e., idiopathic
flux mechanism for ureter reimplantation; however, the result- detrusor overactivity) can be an indication for augmentation
ing diarrhea and malabsorption become problematic in the cystoplasty if other treatments, including medication, sacral
Chap t e r 18: Blad d e r Aug me ntation 119
nerve stimulation therapy, botulinum toxin detrusor injection, of urethral closing function, or both. Accurate assessment
and myomectomy, have failed. of urethral function in cases where the bladder is very
Interstitial cystitis is a difficult disease to manage by any poorly compliant or grossly hyperreflexic is difficult.
means. Treating it with augmentation cystoplasty has been dis- Incontinence due to an open urethra as demonstrated on
appointing unless supratrigonal cystectomy is also performed, upright cystogram will persist after augmentation. This con-
but success with this approach has not been universal (4). dition is associated with low thoracic or lumbar spinal cord
Patient selection is critical in the success of augmentation injury, myelodysplasia, long-term urethral catheter drainage,
cystoplasty. Patients unwilling or unable to catheterize are not and certain pelvic surgeries, such as abdominal perineal re-
candidates for this procedure. Postoperatively, even those section or radical hysterectomy. These conditions are best
patients who do not have neurologic bladder dysfunction treated by urethral closure at the time of the augmentation.
require CIC 39% to 89% of the time (3,4). We counsel all aug- This can be achieved with a tight pubovaginal sling, an ar-
mentation patients at our institution that they will have to self- tificial urinary sphincter, or deliberate surgical closure of
catheterize at least temporarily after surgery. Persons with the bladder neck.
progressive neurologic or cognitive diseases, such as multiple Vesicoureteric reflux is also a common complication of
sclerosis and dementia, may be poor augmentation candidates neurogenic bladder and is almost always driven by increased
since their ability to perform CIC may deteriorate with time. bladder pressures. “ Low-pressure reflux” is a condition in
This makes them dependent on others for catheterization, which reflux occurs at relatively low detrusor pressures and
which puts them at risk for recurrent urinary tract infections can be very difficult to diagnose. O ur practice is to ignore
(UTIs) and bladder perforation. Patients unable to self- reflux and augment the bladder, and the reflux in most cases
catheterize because of their anatomy should be considered for resolves provided the augmentation is a low-pressure and
a continent catheterizable stoma along with the augmentation. compliant reservoir. O ther authors support this stance and
In some instances, certain bowel segments may be unavail- have found that simply augmenting the bladder resolves
able because of pre-existing disease. The small bowel should vesicoureteric reflux in 86% of patients, and success does not
not be used if extensive pelvic radiation has been performed. depend on the grade of reflux or the bowel segment used for
The large bowel is contraindicated if the patient has a history augmentation (5).
of colon cancer, diverticulitis, or ulcerative colitis. Any
disease, such as Crohn disease, or prior surgery that results in
a critically short or abnormal bowel is another contraindica-
tion to augmentation cystoplasty using bowel, especially if the ALTERNATIVE THERAPY
removal of the segment will have adverse effects on bowel
absorptive function. Recently, several options have become available for in-
Chronic renal failure is a relative contraindication to aug- tractable detrusor overactivity or poor compliance. Botulinum
mentation cystoplasty since both the ileum and colon absorb toxin injections of the detrusor have been shown to be effec-
urinary solutes that may result in worsening renal function tive in both the neurogenic and nonneurogenic populations
and metabolic disturbances. H owever, in many cases the blad- (6). Given the procedure’s low morbidity, it should be tried
der dysfunction itself is the cause of the renal deterioration, before augmentation cystoplasty; however, it is still not
and the procedure will slow the decline in their renal function approved by many regulatory agencies. Its high cost and need
(2). In such instances gastrocystoplasty has been suggested for repeat injections are a barrier to its widespread use. Sacral
because of the stomach’s limited adverse effects on metabolic nerve stimulation has been available since 1997 for the treat-
balance. ment of refractory urgency and urge incontinence of nonneu-
rogenic etiology (7). Autoaugmentation of the bladder, also
know as partial detrusor myomectomy, is the excision of the
detrusor muscle over the dome and anterior wall of the blad-
DIAGNO SIS der. This allows the bladder epithelium to distend outward,
improving storage capacity and bladder compliance (8). This
The decision to perform an augmentation cystoplasty is significantly less morbid procedure has the advantage of not
complex and is not guided by a single test or office visit. It is a incorporating any mucus-producing bowel into the bladder,
last resort once all conservative measures such as medications, the almost uniform ability to void spontaneously after the
clean intermittent catheterization, and minimally invasive procedure, and no increased risk of malignancy. In general,
procedures have failed. “ Failure” in this context is defined as patients achieve less improvement in compliance than after
persistent incontinence, recurrent symptomatic UTIs, urosep- formal enterocystoplasty. The gains in bladder capacity and
sis, vesicoureteric reflux, or hydronephrosis. These clinical compliance in patients with neurogenic bladder are small, so
problems are common in patients with neurogenic bladder the routine use of myomectomy is not recommended in these
dysfunction and are all secondary to uncontrolled detrusor patients. We continue to use this technique, especially in
pressure and poor compliance. These variables are control- younger patients with intractable idiopathic urge inconti-
lable with an augmentation cystoplasty. nence, with favorable results.
The basic evaluation includes a urodynamic study, prefer- For patients in whom a low-pressure diversion is required
ably using fluoroscopy to evaluate bladder compliance, the but the patient is unable to self-catheterize, an ileovesicos-
status of the bladder neck, and the presence of vesicoureteric tomy, or “ bladder chimney,” can be a good option (9). In the
reflux. neurogenic patient whose only other option is an ileal conduit,
Incontinence in this population is often a complex prob- an ileovesicostomy provides the same benefits of decreasing
lem. It can be a result of elevated detrusor pressures, a lack storage pressures and eliminating urethral incontinence, but it
does not involve dissection of the ureters or bladder removal,

thus significantly reducing both early and late morbidity.
Laparoscopic bladder augmentation using ileum has been
reported, but this technique is still under investigation (10).
O ther nonautologous tissues (Teflon, Silastic, human dura,
Gore-Tex, bovine dura) have been utilized to augment the blad-
der; however, complications with the anastomosis, contrac-
ture, fistulas, infections, and stone formation have precluded
their use (2). An innovative alternative is the tissue-engineered
autologous bladder. A small clinical trial in children with spina
bifida augmented with their own urothelial and muscle cells
grown on a biodegradable bladder-shaped scaffold has promis-
ing results with little morbidity (11). Clinical trials are under
way to better study this novel alternative.
SURGICAL TECHNIQ UE
FIGURE 18.1 The peritoneum is dissected off the posterior bladder
Preoperatively all patients require a urine culture one week to the level of the trigone and 2 to 3 cm above the level of the ureters.
prior to the surgery date and urine sterilization with antibi-
otics based on sensitivities. Serum electrolytes including creati-
nine should be drawn at baseline for future comparison and to
help dictate the segment of bowel best suited for the patient.
Patients with idiopathic detrusor overactivity should start a
clear liquid diet for 2 to 3 days prior to the operative procedure.
N o antibiotic or mechanical bowel preparation is needed if
ileum is the bowel segment to be utilized for the augmentation.
Patients with neurogenic conditions can be treated with a
3-day clear liquid diet and enemas without mechanical bowel
preparation or oral antibiotics if ileum is the segment to be
utilized. This bowel regime has been well supported in the
general surgery literature and has been shown to be safe, even
in children undergoing augmentation cystoplasty (12).
When large bowel is the segment to be used, a mechanical
preparation is required along with oral antibiotics. M echanical
bowel preparation in neurogenic patients may take slightly
longer than in patients with normal bowel function and should FIGURE 18.2 A U-shaped incision is made on the bladder with the
be done gently over a 2- to 3-day period. transverse portion just superior to the trigone and the limbs of the in-
A nasogastric tube is inserted after induction of anesthesia cision extending to the dome of the bladder.
but is removed prior to extubation. We have eliminated the
use of routine nasogastric tube drainage after bowel surgery.
This is based on results of a trial showing that bowel function posteriorly on the bladder starting just above the ureters,
returns more swiftly and there are no increases in complica- creating an anteriorly based bladder flap with a posteriorly
tions in neurogenic bladder patients undergoing augmentation facing opening (Fig. 18.2). This approach will allow a tension-
treated without postoperative nasogastric tube drainage (13). free augmentation.
After preparation of the skin from xiphoid to genitalia, a A 25- to 30-cm segment of ileum at least 20 cm proximal
urethral catheter is placed and positioned so that the bladder to the ileocecal valve is selected and marked with sutures.
can be filled and emptied during the case. In general, if an Before harvesting the bowel, the surgeon should fold this
anti-incontinence procedure is necessary, it is performed first. section of ileum in two and ensure that it can easily reach the
A midline incision is the best approach for augmentation bladder without tension; if not, a new section should be
cystoplasty. A Pfannenstiel incision can be used, but it is suit- selected. The mesentery is incised on either end of the 25-cm
able only when ileum will be used since a colonic augmenta- segment, and both ends of the ileum section are divided using
tion through a Pfannenstiel incision is a rather difficult standard stapling devices (Fig. 18.3).
operative procedure. It should be kept in mind that occasion- The exact length of ileum required varies between individ-
ally it is only discovered intraoperatively that the ileum is uals, but enough length should be used to allow an estimated
unusable and one is forced to use colon. 4 hours between catheterizations after the bowel is fully
After entry into the peritoneum, a self-retaining retractor is “ stretched” over the ensuing months. Ileal continuity is then
placed (the Bookwalter is our preference in the adult), and the achieved using one of the hand-sewn or stapled techniques
bladder is filled with saline and identified. The peritoneum is and the mesenteric defect closed. To prevent stone formation,
dissected off the bladder down to the level of the trigone the ileal ends are oversewn with running 2-0 chromic catgut
posteriorly (Fig. 18.1). A wide U-shaped incision is made to exclude the staples (Fig. 18.3), and then the antimesenteric
FIGURE 18.5 The posterior wall of the augment is completely closed.
FIGURE 18.3 Approximately 15 cm proximal to the ileocecal valve,

a 25-cm segment of bowel is selected, the mesentery cleared, and the
segment removed using standard stapling techniques. The segment of
ileum is oversewn at the ends to exclude the staples and then opened
along the antimesenteric border.
surface of the bowel is opened using electrocautery. The

posterior wall of the ileum is folded back on itself and sutured
together using a running 2-0 delayed absorbable synthetic
stitch such as Vicryl (Figs. 18.4 and 18.5). The required size of
the augmentation opening on the bladder is roughly measured,
and the superior, anterior wall of the ileum is partially closed
with running 2-0 Vicryl to match this opening (Fig. 18.6).
FIGURE 18.6 The superior, anterior wall of the augment is partially

closed. The size of the augment opening should roughly correspond to
the size of the opened bladder.
A large-bore suprapubic (SP) tube is placed through the

lateral bladder wall, not the bowel segment, prior to suturing
the augment onto the bladder. The SP tube allows reliable
postoperative drainage and irrigation of mucus until the
suture lines are healed. Alternatively, a large-bore urethral
catheter can be left in place. The choice of an SP tube or a
urethral catheter, or both, is surgeon dependent, although we
prefer a urethral catheter since it is simpler to remove. The ileal
FIGURE 18.4 The ileal segment is folded, and closure of the posterior segment is then sewn onto the opened bladder using running
wall is initiated using a running absorbable suture. 2-0 Vicryl, with the initial suture placed at the most inferior
FIGURE 18.9 View of the completed enterocystoplasty.
Although this is our preferred technique, other methods of

performing an augmentation exist. O ne such method involves
splitting the bladder sagittally from just above the bladder
neck and ending near the level of the ureters posteriorly to
FIGURE 18.7 Initial suture placement for enterocystoplasty. N ote
that the bladder flap opens anteriorly.
form a “ clam shell” (3). A 23- to 30-cm segment of ileum is
isolated and divided completely along the antimesenteric
border (Fig. 18.10). The posterior wall of the augment is
portion of the bladder opening posteriorly (Fig. 18.7). Suture closed with running 2-0 Vicryl and then either anastomosed to
lines must be watertight and full thickness, and the bladder the bladder as a “ patch” or folded again and partially closed
mucosa must oppose the bowel mucosa. O nce the posterior to form a “ cup.” A cup is especially useful if the patient’s own
closure is finished, the anterior closure is completed in a simi- bladder is very small, but it sometimes requires the use of up
lar fashion (Fig. 18.8). The completed enterocystoplasty is to 40 cm of bowel. In both cases, the anastomosis is started on
shown in Fig. 18.9. A closed-suction drain is placed near the the posterior wall until approximately one third is closed, and
suture line and brought through the skin on the side opposite then the anterior wall is closed. The lateral walls are closed
the SP tube. The abdomen is closed in standard fashion. If a last, and any redundant bowel is closed to itself.
continence procedure has been performed, it is imperative that Postoperatively, fluid and electrolyte management is im-
a urethral catheter can be easily passed. portant due to large third-space losses and suction drainage.
Although the nasogastric tube is not left in place, it is impor-
tant to remember that bowel function is often deranged in the
neurogenic bladder patient, and recovery of bowel motility
may be significantly delayed. The abdominal drain is re-
moved once drainage is consistently minimal. The bladder is
irrigated via the catheter while in hospital and after discharge
at least three times per day with 30 to 60 mL of saline to clear
mucus. Typically a cystogram is performed at 2 to 3 weeks,
and if no urinary extravasation is noted, the patient begins
CIC. If an SP tube was originally placed, the patients can per-
form CIC with the SP tube clamped until proficient at CIC.
At 3 to 4 weeks, the SP tube is removed and the patient con-
tinues CIC every 2 to 3 hours during the day and twice at
night. It typically requires up to 6 to 12 months for the aug-
ment to stretch to full capacity, during which time more fre-
quent CIC is necessary. This may be distressing to the patient
at first. Continuing the regimen of anticholinergic therapy
will help maintain native bladder compliance and maximize
capacity. As capacity increases, the CIC intervals can
lengthen, and, ultimately, most patients are able to wait 4 to
5 hours between catheterizations during the day and catheter-
ize only once at night. Patients who are able to void per ure-
thra must document consistently small postvoid residuals
FIGURE 18.8 Closure of the anterior aspect of the enterocystoplasty. before CIC is stopped. In some cases, apparent early normal
FIGURE 18.10 Augmentation cystoplasty with formation of a cup patch. A: Isolation of a distal ileal
segment. B and C: Isolated ileal segment opened on antimesenteric border and double-folded to create a
reservoir. D: Cup patch reservoir sutured to the bladder-incised sagittal plane.
voiding deteriorates over time, and in some cases the bowel the complications were manageable and consisted primarily of
segment can become overstretched and either rupture or be- prolonged ileus, transient urinary extravasation, or stomal
come overly capacious and defunctionalized. Patients who problems. Surgical interventions were necessary in only 15%
are able to void postoperatively should be followed with in- of patients, with stomal revisions being most common.
termittent postvoid residuals. Daily irrigation to clear mucus Small-bowel obstructions occur in approximately 3% of pa-
is essential, especially for the first few months. tients, similar to the rate reported in urinary diversions. The rate
Routine electrolytes, creatinine, blood urea nitrogen, and of bladder stones varies from 13% to 21% (2,4), but it has been
upper-tract studies should be performed at regular intervals. It reported to be much higher (3). Stone formation is lowest in
is unlikely that vitamin B12 deficiency should develop because those patients who void spontaneously but is five times higher in
a short ileal segment is usually used. those who catheterize urethrally and ten times higher in those
with continent cutaneous stomas (2). Stones usually form sec-
ondary to retained mucus or exposed staples as a nidus. Routine
CO MPLICATIO NS bladder irrigation, treatment of infections, and excluding staples
at the time of surgery minimize stone formation.
A comprehensive long-term study of 122 patients by Flood Although patients with bacteriuria and recurring urinary
and colleagues reported an overall 28% early and 44% late infection remain as bacteriuric after augmentation as they
complication rate in a complex group of patients (4). M ost of were before the surgery, the infections and their resulting
complications are ameliorated by the procedure. This results infections and can easily be identified by the classic hourglass
from improved control of detrusor pressure, which is the ulti- appearance on a cystogram. Reaugmentation is the only solu-
mate goal of treatment of any bladder dysfunction. Since tion to this rare problem, but prevention by creating a very
bacteriuria is extremely common, especially if the patient is per- large bladder opening initially (Fig. 18.2) is the key.
forming self-catheterization, routine urine culture is not helpful. Augmentation cystoplasty has gained widespread use in
Bacteriuria is only considered an infection if the patient becomes both the pediatric and adult populations such that there are
symptomatic (fever, pain, foul-smelling urine, incontinence, or many women of reproductive age who are currently living with
increased mucus production) (3). The treatment of asympto- a bladder augmentation. There are small case series indicating
matic bacteriuria, unless it is a urease-splitting organism, is of an increase in pyelonephritis, ureteric dilatation or obstruction,
no benefit and will only promote antibiotic resistance. renal deterioration, and premature labor in these women.
Reservoir perforation is perhaps the most feared compli- These potential complications should be actively screened for
cation, with reported rates of up to 6% (4). Perforation is a during the pregnancy, and bacteriuria should be aggressively
catastrophic event, and the patient may quickly become sep- treated. Women with an augmentation cystoplasty alone,
tic, but the presentation is variable, and patients with spinal without any contraindications to vaginal delivery, should be
cord injury may not present with the classic signs of an acute allowed to deliver vaginally, thereby avoiding any possible injury
abdomen (3). Fortunately, fatalities are uncommon if diag- to the pedicle of the augmented bowel during Caesarean section.
nosed early. Different theories have been proposed to explain Women who have a bladder outlet procedure along with their
the etiology of bladder perforation. O bviously, acute trauma augmentation should be counseled about the risks and benefits
can rupture the augmented bladder, but the majority of per- of vaginal delivery versus cesarean, and if the latter is chosen,
forations are nontraumatic. Infrequent catheterization, re- their urologists should be present for the procedure (2,3).
current urinary infections, and bowel ischemia secondary to
recurrent overdistention have all been implicated (3).
Clinical suspicion of a perforation must always be high in
this population, and the method of diagnosis is a cystogram RESULTS
both filled and post drainage. Standard treatment is open
repair of the rupture, which is typically at the bowel-to- Achieving a successful augmentation cystoplasty depends on
bladder junction. three factors: performing the procedure for the correct indica-
M etabolic acidosis that requires bicarbonate treatment is tions only after exhausting all other conservative measures,
uncommon if patients are properly selected and a reasonable proper patient selection, and good operative technique. In
length of bowel is used. Patients should be screened for this selected patients with neuropathic bladders requiring im-
disturbance at least annually. proved compliance and capacity, augmentation cystoplasty
The development of tumors has been reported with the use has a high likelihood of improving compliance and capacity
of all bowel segments. Although the risk to any individual and can be equally efficacious in the nonneurogenic patient
patient is small, after 5 years annual cystoscopic surveillance with intractable bladder symptoms. An augmentation is less
should be considered, especially if a colonic segment is used. successful in treating the symptoms of interstitial cystitis and
If the bladder is extremely small or the bladder incision is by itself does not guarantee continence, especially in patients
not generous, the “ augmentation” may ultimately become no with high rates of intrinsic sphincter deficiency (ISD), such as
more than a large, nondraining bladder diverticulum. This in the case of myelomeningocele and radiation cystitis, who
complication may be manifested by recurrent urinary tract will often require an anti-incontinence procedure.
References
1. M adersbacher S, Schmidt J, Eberle JM , et al. Long-term outcome of ileal 8. Gurocak S, De Gier RP, Feitz W. Bladder augmentation without integration
conduit diversion. J Urol 2003;169(3):985–990. of intact bowel segments: critical review and future perspectives. J Urol
2. Greenwell TJ, Venn SN , M undy AR. Augmentation cystoplasty. Br J Urol 2007;177(3):839–844.
Int 2001;88(6):511–525. 9. Tan H J, Stoffel J, Daignault S, et al. Ileovesicostomy for adults with neuro-
3. N iknejad KG, Atala A. Bladder augmentation techniques in women. Int genic bladders: complications and potential risk factors for adverse out-
Urogynecol J Pelvic Floor D ysfunct 2000;11(3):156–169. comes. N eurourol Urodyn 2008;27(3):238–243.
4. Flood H D, M alhotra SJ, O ’Connell H E, et al. Long-term results and com- 10. Lorenzo AJ, Cerveira J, Farhat WA. Pediatric laparoscopic ileal cysto-
plications using augmentation cystoplasty in reconstructive urology. plasty: complete intracorporeal surgical technique. Urology 2007;69(5):
N eurourol Urodyn 1995;14(4):297–309. 977–981.
5. Juhasz Z , Somogyi R, Vajda P, et al. Does the type of bladder augmentation 11. Atala A, Bauer SB, Soker S, et al. Tissue-engineered autologous bladders
influence the resolution of pre-existing vesicoureteral reflux? Urodynamic for patients needing cystoplasty. L ancet 2006;367(9518):1241–1246.
studies. N eurourol Urodyn 2008;27(5):412–416. 12. Gundeti M S, Godbole PP, Wilcox DT. Is bowel preparation required before
6. Kim DK, Thomas CA, Smith C, et al. The case for bladder botulinum toxin cystoplasty in children? J Urol 2006;176(4, Pt 1):1574–1576; discussion
application. Urol Clin N orth A m 2006;33(4):503–510, ix. 1576–1577.
7. van Kerrebroeck PE, van Voskuilen AC, H eesakkers JP, et al. Results of 13. Erickson BA, Dorin RP, Clemens JQ . Is nasogastric tube drainage required
sacral neuromodulation therapy for urinary voiding dysfunction: outcomes after reconstructive surgery for neurogenic bladder dysfunction? Urology
of a prospective, worldwide clinical study. J Urol 2007;178(5):2029–2034. 2007;69(5):885–888.
CHAPTER 19 ■ MANAGEMENT O F THE
DISTAL URETER FO R NEPHRO URETERECTO MY
J. STUART WO LF, JR.
The traditional therapy for urothelial cell carcinoma of the re- bony abnormalities are seen on other imaging studies. A com-
nal pelvis or ureter is nephroureterectomy, including a 1-cm plete blood count, serum electrolytes with creatinine, and liver
cuff of bladder around the ureteral orifice. When performed function tests should also be obtained. If the creatinine is ele-
using open surgery, this entails a long midline or thoraco- vated, a renal scan to determine differential function may aid
abdominal incision or two incisions (a flank incision for the in decision making.
nephrectomy and a lower midline or Gibson incision for
the distal ureterectomy). Because of the morbidity associated
with the extension of the incision for the distal ureterectomy, INDICATIO NS FO R SURGERY
alternative approaches such as the “ pluck” and “ intussuscep-
tion” techniques were devised. The advent of laparoscopic Radical nephroureterectomy with complete distal ureterec-
nephroureterectomy, which further reduces morbidity by elim- tomy is the standard therapy for upper-tract urothelial tumors,
inating the flank incision for the renal portion of the proce- using either laparoscopic (standard or hand-assisted) or open
dure, has stimulated the development of additional minimally surgical techniques. N ephrectomy without complete ureterec-
invasive approaches to the distal ureter. Although there is tomy should be avoided due to a 30% incidence of recurrence
some advantage in terms of reducing the intensity and dura- in the ureteral stump (2). Patients with a positive cytology but
tion of convalescence with these less invasive approaches, without an identifiable lesion on imaging or ureteroscopy
since intact extraction of the specimen is recommended after should be followed closely rather than undergo nephroureterec-
laparoscopic nephroureterectomy (owing to the importance of tomy without a definitive diagnosis.
pathologic staging and the propensity for urothelial carci-
noma to implant into wounds), an open surgical approach to
the distal ureterectomy does not necessarily mean a much ALTERNATIVE THERAPY
larger incision than would be required for the nephrectomy
Endoscopic resection and fulguration are acceptable for pa-
portion of the case.
tients with low-grade, low-stage, and small-tumor burdens.
An alternative for a distal ureteral tumor is a distal ureterec-
tomy with a ureteroneocystostomy or other reconstruction.
DIAGNO SIS Topical therapy with bacille Calmette-Guérin or mitomycin C
may be attempted for patients with carcinoma in situ who
The most common presenting symptom or sign of upper-tract
have limited renal function or bilateral disease.
urothelial tumors is hematuria, which occurs in approxi-
mately 75% of patients, and the second most common symp-
tom or sign is flank pain, present in approximately 30% of
patients (3). The subsequent evaluation entails an upper-tract
SURGICAL TECHNIQ UE
imaging study with intravenous urography, computerized
tomography, magnetic resonance imaging, or retrograde pyel- O p e n Surg ical Te chniq ue s
ography. M ost patients will have a filling defect that suggests
upper-tract urothelial tumor. Both sides of the urinary system Int rave sical Ap p ro ach
need to be evaluated due to the potential for bilateral tumors. O pen surgical distal ureterectomy can be used in conjunction
The combination of urinary cytology positive for upper- with any technique of nephrectomy. After completing the
tract urothelial tumor with radiographic abnormality consis- nephrectomy and proximal ureteral dissection, place the
tent with an upper-tract urothelial tumor is adequate for patient in the supine position, with or without flexion of
diagnosis if nephroureterectomy is intended. If either cytology the table. Insert a three-way 20Fr urethral catheter into the
or imaging is not definitive, or if a nephron-sparing approach bladder. M ake a lower midline incision, divide the rectus
is being considered, then ureteroscopy and biopsy are recom- fascia, develop the space of Retzius, and place a self-retaining
mended. In either case, cystoscopy is essential due to the high retractor. Fill the bladder with saline and then open it longitu-
association with urothelial tumors of the bladder. dinally between two stay sutures. Place additional stay sutures
O nce urothelial malignancy is diagnosed, metastatic evaluat the apices of the bladder incision. Pack the dome of the
ation consists of an abdominal and pelvic computerized tomo- bladder with a gauze sponge, and use a bladder blade to re-
gram and a chest radiograph. A bone scan is performed if tract the bladder dome cephalad. Insert a ureteral catheter or
there is bone pain, the alkaline phosphatase is elevated, or feeding tube in the targeted ureteral orifice and sew it in place
125
excise the ureter. Tie a 2-0 absorbable suture around the right-
angle clamp to close the bladder mucosa, or use running 4-0
absorbable suture. Close a second layer over the resection site
using 2-0 absorbable sutures. M anage drains and catheters as
above.
Lap aro sco p ic Ext rave sical Blad d e r Cuff

Te chniq ue (6)
This technique is similar to the open surgical extravesical ap-
proach. Place the patient in a modified flank position for
transperitoneal laparoscopic nephrectomy. Using flexible cys-
toscopy, insert a ureteral catheter. At the conclusion of the
laparoscopic nephrectomy, dissect the ureter distally and place
clips on the ureter to prevent extravasation of tumor cells.
Retract the ureter cephalad and continue dissecting it distally
to the bladder. After inserting a 10-mm port in the lower ab-
domen to facilitate resection of the distal ureter, incise the
bladder just anterior to the ureter using electrocautery. Upon
entering the bladder, the ureteral catheter identifies the ureteral
orifice. Excise the posterior portion of the bladder cuff and de-
tach the ureter after dividing the ureteral catheter. Suture the
bladder closed using laparoscopic techniques (recently, robotic
assistance has been described to facilitate this step). M anage
drains and catheters as above.
FIGURE 19.1 A ureteral catheter is secured to the ureteral orifice.
Tenotomy scissors and electrocautery are used to dissect free the in-
tramural ureter. (From Lange PH . Carcinoma of the renal pelvis and End o sco p ic Te chniq ue s
ureter. In: Glenn JF, ed. Urologic surgery, 4th ed. Philadelphia: JB
Lippincott Co, 1991:273, with permission.)
Except for the “ pluck” procedures, all of the endoscopic
techniques described in this section have been developed
specifically for use in conjunction with laparoscopic
with a 4-0 suture. Use electrocautery cutting current to incise nephroureterectomy. The techniques are described below in
the mucosa 1 cm around the ureteral orifice. Dissect the intra- the settings in which they were initially described or are in
mural ureter using tenotomy scissors and pinpoint electro- common use at this time. The hand-assisted approach to
cautery (Fig. 19.1). laparoscopic nephroureterectomy may be preferable with
Dissect the entire distal ureter free to join the point of pre- particular techniques, as indicated below, but any approach to
vious dissection completed during the nephrectomy portion of nephroureterectomy—laparoscopic or open surgical—can be
the procedure. Close the posterior bladder wall in two layers used in conjunction with any of the following techniques, with
(2-0 absorbable sutures for the serosa and muscle and 4-0 ab- modifications.
sorbable sutures for the mucosa), and close the anterior blad-
der incision similarly. Insert a pelvic drain through a separate
stab incision. Leave the urethral catheter in place for 3 to 5 Transve sical Blad d e r Cuff Te chniq ue :
days. Some perform a cystogram to ensure the bladder has Sing le Po rt (5)
healed prior to removing the catheter, while others remove the After completing a hand-assisted laparoscopic nephrectomy
catheter and perform a voiding trial. with the patient in the modified flank position, dissect the ureter
At times, the dissection of the distal ureter may be difficult to the bladder. Place clips on the ureter to prevent tumor
and the ureter may need to be dissected extravesically as well. spillage.
This may require division of the superior vesical artery to pro- Without repositioning the patient, fill the bladder with
vide access to the distal ureter. fluid through a three-way urethral catheter. M ake an incision
for a 10-mm laparoscopic port in the midline, three finger
breadths above the pubis. Using the surgeon’s hand via the
Ext rave sical Ap p ro ach hand-assist port, push the bladder upward toward the abdom-
A completely extravesical approach is best performed through inal wall. Insert a spinal needle through the incision into the
a Gibson incision. After entering the retroperitoneal space and bladder to ascertain proper angle and depth of entry, and then
identifying the distal ureter, retract the bladder to the con- insert a 10-mm laparoscopic port directly into the bladder
tralateral side. Divide the superior vesical artery to facilitate through the extraperitoneal space. Using a 24Fr resectoscope
dissection of the distal ureter. Identify the ureteral hiatus and with a Collins knife through this port, and with the surgeon’s
dissect the intramural ureter using electrocautery. Cephalad hand alternately elevating the ipsilateral hemitrigone and re-
traction on the ureter will help identify the bladder mucosa. tracting the ureter, incise around the ureteral orifice and intra-
Use a right-angle clamp to secure the ureteral orifice, and then mural ureter with the Collins knife (Fig. 19.2). During the
Chap t e r 19: Manag e me nt of the Distal Ure te r for Ne p hroure te re ctomy 127
nephrectomy and transurethral access with a 24Fr resecto-

scope with a Collins knife (12).
Transve sical Blad d e r Cuff Te chniq ue : Tw o Po rt s (4)

Prior to performing the nephrectomy portion of the procedure,
place the patient in the lithotomy position. Perform cystoscopy
to evaluate the bladder mucosa and distend the bladder. Under
cystoscopic guidance, place two 5-mm balloon-tipped laparo-
scopic ports into the bladder just above the pubic bone on
both sides of the midline, placing both ports to wall suction to
prevent extravasation and overdistention of the bladder. Insert
a 5-mm endoloop through the ipsilateral port, and then insert
a 6Fr ureteral catheter cystoscopically into the targeted ureter.
Exchange the cystoscope for a resectoscope with a Collins
knife, which is used to incise around the ureteral orifice. Using
a grasper inserted through the other laparoscopic port that is
passed through the endoloop, retract the ureteral orifice ante-
riorly. After freeing up 3 to 4 cm of ureter, suspend the ureter
from the anterior bladder wall with the grasper (Fig. 19.3);
then remove the ureteral catheter and tighten the endoloop
around the ureter to occlude the lumen.
After removing the laparoscopic ports, place a urethral
catheter to gravity drainage. Perform the nephrectomy portion
of the procedure after repositioning, and with cephalad trac-
tion dissect the ureter distally such that the distal ureter can be
pulled into the operative space for intact removal. Again, a
urethral catheter is left in place for 1 week, with the option of
FIGURE 19.2 The surgeon’s hand elevates the ipsilateral hemitrigone

while the Collins knife is used to incise around the ureteral orifice.
(Adapted from Gonzalez CM , Batler RA, Schoor RA, et al. A novel
endoscopic approach towards resection of the distal ureter with
surrounding bladder cuff during hand assisted laparoscopic
nephroureterectomy. J Urol 2001;165:484.)
resection, controlling the height of the urethal catheter

drainage bag controls the filling of the bladder. As soon as the
ureter is detached, placing the drainage bag on the floor mini-
mizes extravasation of urine and irrigant. N ote that once the
bladder has been opened into the retroperitoneum, it collapses
quickly, so take care to keep the dissection at equal depth all
around the orifice so that once the bladder collapses the ureter
can be pulled free easily.
After specimen removal, remove the bladder port. N either
the port site nor the resection site needs to be closed, but
placement of a pelvic drain through a laparoscopic port site is
optional. The initial description of this technique includes a
cystogram performed on postoperative day 7 to verify lack of
extravasation prior to catheter removal, but in the author’s
experience with this technique the cystotomy is adequately
healed by this time and a voiding trial is sufficient.
Transure t hral Blad d e r Cuff Te chniq ue

This technique is similar to the transvesical bladder cuff tech-
nique except that the resection is performed transurethrally,
which obviates the need for placement of a transvesical port.
O ne option is to use a flexible cystoscope with an electrocautery FIGURE 19.3 The Collins knife is used transurethrally while a
grasper elevates the ureter and the endoloop is around the resected
probe to perform the periureteral dissection (11). Another alter- orifice. (Adapted from Gill IS, Soble JJ, M iller SD, et al. A novel tech-
native is to position the patient in a combined lithotomy- nique for the management of the en bloc bladder cuff and distal ureter
semiflank position that allows simultaneous laparoscopic during laparoscopic nephroureterectomy. J Urol 1999;161:432.)
a cystogram to confirm adequate bladder healing prior to Use a resectoscope and a rollerball to ablate the intramural
catheter removal. ureter until the staple line is visible.
Ure t e ral Unro o fing Te chniq ue (10) Pluck Te chniq ue

Prior to performing the nephrectomy portion of the proce- Place the patient in the lithotomy position prior to performing
dure, place the patient in the lithotomy position. Perform cys- nephrectomy. Insert a ureteral catheter into the targeted
toscopy and insert a ureteral dilating balloon (5 mm diameter, ureteral orifice cystoscopically. Incise the ureteral orifice and
10 cm length) into the targeted intramural ureter. Inflate the surrounding bladder cuff with a Collins knife to the level of
balloon to 1-atm pressure with dilute contrast material using retroperitoneal fat. Alternatively, use a loop resectoscope to
fluoroscopic guidance. Exchange the cystoscope for a resecto- resect the orifice and intramural ureter. Place a 24Fr urethral
scope with a Collins knife, and incise the ureteral tunnel at the catheter to gravity drainage. Take the patient out of lithotomy
12 o’clock position along the entire length of the intramural position and perform the nephrectomy. Dissect the ureter dis-
ureter. Remove the dilating balloon and use a rollerball elec- tally, and with cephalad traction on the ureter detach it from
trode to cauterize the edges and floor of the intramural ureter. the bladder. Leave the urethral catheter in place for 7 days,
Insert a 7Fr 11.5-mm balloon occlusion catheter into the renal removing it after cystography or a voiding trial.
pelvis and inflate it at the ureteropelvic junction, to prevent A modification of this technique is to pass a 7Fr, 11.5-mm
urine extravasation. Connect this catheter, and a urethral balloon occlusion catheter into the renal pelvis, snugging it
catheter, to gravity drainage. down at the ureteropelvic junction, to minimize urine extrava-
Take the patient out of the lithotomy position and perform sation. M itomycin can be instilled into the renal pelvis
the nephrectomy. O nce completed, mobilize the distal ureter to through this catheter (9).
the ureteral hiatus, dividing the superior vesical artery if neces-
sary. Ligate and incise the remaining distal ureter and bladder
cuff using an endoscopic stapler (Fig. 19.4), removing the
ureteral balloon occlusion catheter just prior to engaging the
Co mb ine d O p e n and End o sco p ic
stapler. Leave the urethral catheter in place for 3 to 5 days, re- Te chniq ue
moving it after cystography or a voiding trial demonstrates no
urinary extravasation. A modification of the technique, which Ure t e ral Int ussusce p t io n (St rip p ing ) Te chniq ue (1)
allows for nephrectomy to be performed before ureterectomy, Initially, in the lithotomy position, insert either a stone basket
is to address the distal ureter with a stapler as described above or ureteral catheter into the targeted proximal ureter.
and then reposition the patient into the lithotomy position. Reposition the patient and perform nephrectomy, dissecting
FIGURE 19.4 A: The endoscopic stapler is placed across

the ureterovesical junction. B: Close-up view of the stapler
across the ureterovesical junction. C: Staples are seen
securing the bladder cuff. (Adapted from Clayman RV.
Laparoscopic ureteral surgery. In: Clayman RV, M cDougall
EM , eds. L aparoscopic urology. St. Louis, M O : Q uality
M edical Publishers, 1993:360.)
Chap t e r 19: Manag e me nt of the Distal Ure te r for Ne p hroure te re ctomy 129
FIGURE 19.5 The proximal ureter is divided and se-

cured to the ureteral catheter. The ureter is then intus-
suscepted as the catheter is removed. (Adapted from
Angulo JC, H ontoria J, Sanchez-Chapado M . O ne inci-
sion nephroureterectomy endoscopically assisted by
transurethral stripping. Urology 1998;52:204.)
the ureter to the pelvic brim. Clip the proximal ureter, and Place a urethral catheter for 7 days, following a normal
then divide the ureter cephalad to the basket/ureteral catheter. cystogram or voiding trial. This technique should not be used
Advance the stone basket into the retroperitoneum and open for distal or midureteral tumors.
and close it to entrap the ureteral wall, or, if a ureteral catheter
has been used, tie it to the ureter with a 0-silk suture (Fig.
19.5). Apply gentle traction to the stone basket/ureteral O UTCO MES
catheter to intussuscept the ureter into the bladder (Fig. 19.6).
Then use a Collins knife mounted on a resectoscope inserted Survival after nephroureterectomy is strongly dependent on
transurethrally (after repositioning into the lithotomy posi- the grade and stage of the tumor (7). Five-year survival rates
tion) to incise the bladder cuff around the intussuscepted following a radical nephroureterectomy for low-grade tumors
ureter while exerting traction on the stone basket/ureteral are 40% to 87% , compared to 0% to 33% for high-grade dis-
catheter out of the urethra. ease. Five-year survival estimates according to stage are as fol-
lows: stage Tis/Ta,/T1, 60% to 90% ; stage T2, 43% to 75% ;
stage T3, 26% to 33% ; stage T4/N /M , 0% to 5% (7).
CO MPLICATIO NS
Early complications include hematuria, retroperitoneal
hematoma, and retroperitoneal abscess. Ureteral intussuscep-
tion may be technically unsuccessful in 10% of patients.
Prolonged urinary extravasation can in general be managed
conservatively with urethral catheter drainage. Although not
yet reported clinically, there is the potential for calculi to form
on the staple line when the ureteral unroofing technique is
used, or for urothelial cells to survive in between the staples.
O ther factors to be considered in the choice of technique in-
clude the risk of tumor spillage, the addition of a bladder inci-
sion, the timing of the ureterectomy relative to nephrectomy,
the need for repositioning, the approach to nephrectomy that
is desired, and surgeon preference. O f these, the potential for
tumor cell spillage is probably the most important with regard
to outcome. The technique to excise the distal ureter is proba-
bly not a factor for recurrence as long as there is no spillage of
tumor cells in the retroperitoneum. O f note, isolated retrovesi-
cal recurrences following “ pluck” ureterectomy have been re-
ported. There is not yet enough reported experience with the
newer endoscopic techniques to allow reliable comparison of
the risk of local, regional, and port site recurrences among the
new techniques and the standard open surgical techniques,
FIGURE 19.6 The catheter is retracted through the bladder wall
and urethra. (Adapted from Angulo JC, H ontoria J, Sanchez-Chapado
although one group has reported a greater intravesical recur-
M . O ne incision nephroureterectomy endoscopically assisted by rence rate after the intussusception technique compared to
transurethral stripping. Urology 1998;52:204.) open surgical bladder cuff (8).
References
1. Angulo JC, H ontoria J, Sanchez-Chapado M . O ne incision nephroureterec- Cam pbell-W alsh urology, 9th ed., Vol. 2. Philadelphia: Saunders-Elsevier,
tomy endoscopically assisted by transurethral stripping. Urology 1998;52: 2007:1653–1685.
203–207. 8. Saika T, N ishiguchi J, Tsushima T, et al. Comparative study of ureteral
2. Bloom N A, Vidone RA, Lytton B. Primary carcinoma of the ureter: a stripping versus open ureterectomy for nephroureterectomy in patients
report of 102 new cases. J Urol 1970;103:590–598. with transitional carcinoma of the renal pelvis. Urology 2004;63:
3. Flanigan RC. Urothelial tumors of the upper urinary tract. In: Wein AJ, 848–852.
Kavoussi LR, N ovick AC, et al., eds. Cam pbell-W alsh urology, 9th ed., 9. Seifman BD, M ontie JE, Wolf JS Jr. Prospective comparison between hand-
Vol. 2. Philadelphia: Saunders-Elsevier, 2007:1638–1652. assisted laparoscopic and open surgical nephroureterectomy for urothelial
4. Gill IS, Soble JJ, M iller SD, et al. A novel technique for the management carcinoma. Urology 2001;57:133–137.
of the en bloc bladder cuff and distal ureter during laparoscopic 10. Shalhav AL, Elbahnasy AM , M cDougall EM , et al. Laparoscopic
nephroureterectomy. J Urol 1999;161:430–434. nephroureterectomy for upper tract transitional cell cancer: technical
5. Gonzalez CM, Batler RA, Schoor RA, et al. A novel endoscopic approach aspects. J Endourol 1998;12:345–353.
towards resection of the distal ureter with surrounding bladder cuff during 11. Vardi IY, Stern JA, Gonzalez CM , et al. N ovel technique for management
hand assisted laparoscopic nephroureterectomy. J Urol 2001;165:483–485. of distal ureter and en bloc resection of bladder cuff during hand-assisted
6. McGinnis DE, Trabulsi EJ, Gomella LG, et al. H and-assisted laparoscopic laparoscopic nephroureterectomy. Urology 2006;67:89–92.
nephroureterectomy: description of technique. Techniques Urol 2001;7:7–11. 12. Wong C, Leveillee RJ. H and-assisted laparoscopic nephroureterectomy
7. Sagalowsky AI, Jarrett TW. M anagement of urothelial tumors of the renal with cystoscopic en bloc excision of the distal ureter and bladder cuff.
pelvis and ureter. In: Wein AJ, Kavoussi LR, N ovick AC, et al., eds. J Endourol 2002;16:329–332.
CHAPTER 20 ■ VESICO VAGINAL FISTULA

HELEN G. ZAFIRAKIS AND O . LENAINE WESTNEY
A vesicovaginal fistula (VVF) is an epithelialized or fibrous of the vaginal cuff, an unrecognized bladder injury adjacent to
communication between the bladder and vagina. Physically, the cuff suture line, or cuff abscess.
psychologically, and socially, it is a source of major distress for
the patient contending with urine leakage from the vagina.
Documentation of VVFs exists from as early as 1550 B.C . in TA B LE 2 0 . 1
the Eber papyrus of ancient Egypt (10). In 1845 James M arion
Sims, considered the father of American gynecology, began his ETIOLOGIES OF VESICOVAGIN AL FISTULAS
exploration into the challenges of treating the condition in
I. Congenital
M ontgomery, Alabama (10). H e is credited with developing
A. Cloacal abnormality
the foundation of VVF repair and establishing sound surgical
principles for repair of fistulas. II. Acquired
The causative factors leading to VVF formation can be A. Iatrogenic
broadly categorized into congenital and acquired (Table 20.1). 1. Postsurgical
The majority of cases fall into the iatrogenic and obstetric a. H ysterectomy
trauma subcategories. In underdeveloped countries, the lead- b. Cesarean section
ing cause of VVFs is obstetric trauma, in which prolonged labor c. Dilatation and curettage
causes ischemic pressure necrosis of the bladder and anterior d. Pelvic laparoscopy
vaginal wall. In contrast, obstetric trauma accounts for only 5% e. Incontinence procedure
of VVFs in nations where modern healthcare is present. The f. Transvaginal biopsies
leading cause of VVFs in industrialized countries is iatrogenic g. Intravescial formalin instillation
surgical trauma, accounting for 82% to 91% of VVFs. h. Failed vesicovaginal fistula repair
N inety-one percent are due to gynecologic procedures, with 2. Radiation
80% due to abdominal hysterectomy (9). The incidence of B. N oniatrogenic
VVF after transabdominal hysterectomy is 1.0 in 1,000, as 1. O bstetrical trauma
opposed to 0.2 in 1,000 after transvaginal hysterectomy. The 2. Infection
incidence is highest (2.2 in 1,000) with laparoscopic hysterec- 3. Locally advanced pelvic tumor
tomy (7). The most common location for a posthysterectomy 4. Foreign body
VVF is the apex of the vaginal vault or “ cuff” corresponding 5. Pelvic trauma/fracture
to an intravesical location just superior to the trigone (9). M odified from Rackley RR, Appell RA. Vesicovaginal fistula: current
Theoretically, the fistula develops secondary to the uninten- approach. A UA Update Series 1998;21:161–168.
tional inclusion of full-thickness bladder wall during closure
Chap t e r 20: Ve sicovag inal Fistula 131
cases where a VVF is due to a complicated operation or after

DIAGNO SIS obstetric trauma, this rationale holds true. H owever, indepen-
dent studies by Blaivas et al. and Blandy et al. demonstrated
Classically, the postoperative VVF presents with “ continuous” comparable results with early (6 to 12 weeks) repair in cases
urine leakage from the vagina. The time of presentation peaks related to an uncomplicated hysterectomy (1,2). O nce surgical
at 7 to 10 days after surgery but may be variable, with some repair is decided upon, another issue that has to be considered
patients presenting immediately after catheter removal, rang- is the approach: transvaginal, transvesical, or transabdominal.
ing from 4 to 6 weeks after surgery (7). In the early postoper- O ften, the approach is the one that the surgeon is most experi-
ative period, there may also be associated ileus and abdominal enced in performing. Advantages of the transvaginal approach
pain due to intraperitoneal urine extravasation. VVFs due to are less blood loss, shorter hospital stay, avoidance of a la-
pelvic irradiation usually have a delayed presentation, devel- parotomy, and thus decreased morbidity. M any reserve the
oping many months or years posttreatment due to progressive transabdominal approach for those patients requiring con-
obliterative endarteritis causing tissue ischemia and necrosis. comitant intra-abdominal surgery (ureteral reimplantation,
The key to diagnosis of a VVF is a high suspicion. O ften, a augmentation cystoplasty) or those patients with a narrow and
complete history and physical examination expose the pathol- deep vagina causing poor exposure to the VVF. H owever,
ogy. In the case of less obvious fistula, a dye test is utilized to Dupont and Raz reported that nearly all VVFs can be accessed
more clearly visualize the passage of fluid through the fistula. In and repaired transvaginally (3).
its simplest form, a saline and dye (indigo carmine or methylene
blue) mixture is instilled into the bladder via a Foley catheter
while inspecting the vagina for leakage or staining of a previ-
ously placed tampon. The failure to identify any discoloration
ALTERNATIVE THERAPY
of the tampon may indicate a small fistula or ureterovaginal fis- Upon diagnosis, a trial of conservative therapy is started de-
tula. The second level of testing requires reinsertion of a vaginal pending on fistula size. Conservative therapy consists of pro-
gauze or tampon followed by administration of 5 mg indigo longed bladder drainage with a Foley catheter, anticholinergic
carmine intravenously to determine whether the source is agents to prevent bladder spasms, antibiotics, and estrogen if
ureteral. Dye from a ureterovaginal fistula may be present on the patient is postmenopausal. Successful closure of a VVF via
the first gauze inspection prior to intravenous (IV) indigo conservative therapy can be expected only in those 3 mm in
carmine if there is vesicoureteral reflux, which can be deter- diameter or less.
mined with a voiding cystourethrogram (VCUG). An alterna- O ther adjunctive minimally invasive treatments include at-
tive to IV dye injection is oral phenazopyridine hydrochloride, tempts to destroy the epithelial lining of the VVF with fulgu-
but it requires several hours of lead time before examination. ration (using electrocautery or laser) and use of occlusive
All patients should have an IV pyelogram (IVP) for upper- substances. Since the late 1980s, glue materials have been used
tract evaluation. Abnormalities to look for include extravasa- to treat a variety of fistulas. There are two main types of glues
tion into the vagina or peritoneal cavity or a displaced or used to treat VVF: fibrin, which is a biologic product, and syn-
partially obstructed ureter. In patients with VVF, up to 25% thetic cyanoacrylic glue. Fibrin glue has the longest reported
will have hydroureteronephrosis, with 10% having a con- follow-up.
comitant ureterovaginal fistula (6). In patients with ureteral There have been a few small series reported on the use of
pathology, a retrograde pyelogram is warranted to evaluate fibrin glue to treat VVF that demonstrate a good success rate.
for ureterovaginal fistula if the IVP is not definitive. Schneider et al. reported on six cases using endoscopic tech-
Cystoscopy is performed to localize and evaluate the VVF, niques and found a 66% closure rate using glue compared
which often has surrounding edematous mucosa. The size and with 88% success with a traditional repair (11). Although it
number of VVFs, their location in relation to the ureteral ori- may involve more than one injection to treat the fistula, fibrin
fices, any lesions such as foreign bodies (i.e., sutures), tumors, glue promotes healing, is biodegradable, and has been used
and tissue quality must be noted. If there is a history of malig- successfully in a large variety of urologic fistulas, including
nancy, biopsy of the VVF is indicated to rule out recurrent tu- those caused by irradiation.
mor. Vaginoscopy is performed simultaneous with cystoscopy Synthetic cyanoacrylic glue is a relatively newer product in
to assess the vaginal aspect of the fistula. If IVP and retrograde occlusion therapy of fistulas. It polymerizes in 90 seconds
pyelograms are inconclusive, then a fistulogram may be per- once injected and can be used without difficulty in a wet envi-
formed transvaginally. ronment such as the bladder; this, together with its antimicro-
A urodynamic study is recommended to look for other fac- bial properties, makes it an attractive option for the treatment
tors that may contribute to the urinary incontinence and may of VVF. The best results are achieved in long fistulas 1 cm in
require surgical correction (augmentation cystoplasty, inconti- diameter. Application can be performed both endovaginally
nence surgery) with the VVF repair simultaneously. Bladder and endoscopically, with the Foley catheter removal between
compliance, capacity, and leak point pressure should be as- 48 hours to 3 weeks depending on the size of the fistula.
sessed if possible. Generally, follow-up cystography is performed in 1 to 3
months.
The benefits of using occlusion therapy to treat VVFs in-
INDICATIO NS FO R SURGERY clude the ability to treat the fistula earlier rather than expect-
ing the patient to live with the distressing symptoms of the
The issue of how long to wait before attempting surgical repair fistula for up to 3 months while awaiting definitive surgery.
of a VVF has long been debated. By tradition, VVF repair is Additionally, there is very low morbidity associated with using
delayed 3 to 6 months to allow inflammation to resolve. In occlusion therapy; there have been no reported complications
from occlusion therapy treatment of VVF, other than the occa-

sional necessity of removing excess glue endoscopically.
Importantly, it does not preclude other forms of treatment if it
is unsuccessful. Although occlusion therapy appears to be safe
and efficacious in selected, small VVFs, more longer-term and
randomized studies are needed to evaluate its durability.
SURGICAL TECHNIQ UE
Transvag inal Ap p ro ach
The patient is placed in the dorsolithotomy position. If a nar-
row vagina is present or the VVF site is high lying, a
Schuchardt posterolateral relaxing incision at the 4 o’clock
position of the vaginal introitus and distal vaginal wall may be
performed to improve exposure. A suprapubic catheter may
be placed with a Lowsley retractor, and a urethral Foley
catheter is placed. The labia minora are sutured to the inner
thigh and a weighted vaginal speculum placed. The VVF is di-
lated to place an 8Fr Foley catheter. Applying gentle traction
to the catheter aids in exposure and dissection of the VVF.
After submucosal injection of a vasopressin mixture (10 U
per 100 mL normal saline), lidocaine with 1% epinephrine, or
saline to elevate the anterior vaginal mucosa, the VVF is cir- FIGURE 20.2 The vaginal mucosa is dissected away from the
cumferentially incised. A posteriorly based inverted U-shaped perivesical fascia. (M odified from Raz S, Bregg KJ, N itti VW, et al.
incision is made with the apex continuous with the VVF inci- Transvaginal repair of vesicovaginal fistula using a peritoneal flap.
sion (Fig. 20.1). If the VVF is situated deep in the vaginal J Urol 1993;150:56–59.)
vault, an anteriorly based U-shaped incision is utilized. The
vaginal mucosa is dissected away from the perivesical fascia to
form vaginal flaps anterior and posterior to the VVF (Fig. 20.2). enlarges the defect and risks injury to the intramural ureter.
Unless nonviable, the fistulous tract is not excised as excision Left intact, the fistula tract also provides strength to the VVF
closure, helping decrease the risk of VVF repair disruption due
to bladder spasms.
The fistula is closed in two nonoverlapping, perpendicular
layers to prevent fistula recurrence. The first layer closes the
fistula with interrupted 4-0 polyglycolic acid sutures, incorpo-
rating the vaginal wall overlying the VVF, the fistula tract, and
the partial thickness of the bladder wall (Fig. 20.3). The sec-
ond layer, using 2-0 polyglycolic acid sutures, imbricates the
perivesical fascia and the deeper musculature of the bladder
over the first layer in a tension-free fashion. The repair is
checked for leaks by instilling indigo carmine into the bladder.
The vaginal wall is advanced over the VVF repair and closed
with an interlocking, running 2-0 polyglycolic acid suture. A
Betadine-soaked vaginal pack is placed.
If there is any concern about the repair, an interposing
layer may be placed between the vaginal wall and bladder. The
most common options are the M artius labial fat pad and the
peritoneal flap. Alternative tissues include labial, vaginal wall,
gluteal, and gracilis muscle flaps.
The M artius labial fat pad provides neovascularity and
lymphatic drainage, fills dead space, and enhances granulation
tissue formation. The flap is harvested by making a vertical in-
cision on the labium majus; the underlying fibrofatty tissue is
mobilized. The anterior portion of the graft is tied off (sacri-
ficing the blood supply from the external pudendal artery),
leaving the fibrofatty pad supplied by its posterior blood
source: the posterior labial artery from the internal pudendal
FIGURE 20.1 The apex of the vaginal inverted-U incision is continu-
ous with the circumferential fistula incision. (M odified from Raz S, artery. A tunnel is developed from the vaginal incision to the
Bregg KJ, N itti VW, et al. Transvaginal repair of vesicovaginal fistula labium majus; the labial fat pad is transferred through the
using a peritoneal flap. J Urol 1993;150:56–59.) tunnel to cover the VVF repair and secured in place with
FIGURE 20.3 Closure of the first layer, including the fistulous tract FIGURE 20.5 Closure of the labial and vaginal wall incisions.
and partial-thickness bladder wall. (M odified from Raz S, Bregg KJ,
N itti VW, et al. Transvaginal repair of vesicovaginal fistula using a
peritoneal flap. J Urol 1993;150:56–59.)
Another effective method is peritoneal interposition as de-
scribed by Dupont and Raz for routine use in fistula repair
interrupted 3-0 polyglycolic acid sutures (Fig. 20.4). The tun- (3). With further posterior dissection of the anterior vaginal
nel must be sufficiently sized to prevent constriction of the fat wall from the bladder, the glistening surface of the peri-
pad’s blood supply. The labial incision is closed with a 1⁄4-in. toneum in the anterior cul-de-sac is exposed. Without enter-
Penrose drain in place unless the graft bed is dry (Fig. 20.5). ing the intraperitoneal space, the peritoneum is mobilized
from the posterior bladder wall to bring it down into the
vagina and suture it over the VVF repair site (Fig. 20.6). The
peritoneal flap has a 96% success rate when used in trans-
vaginal VVF repair (4).
The vaginal pack is removed on postoperative day 1. The
patient is given perioperative antibiotics and anticholinergics
to prevent bladder spasms. Two weeks postoperatively the
urethral catheter and suprapubic tube are removed if the
FIGURE 20.6 Interposition of the peritoneum between the bladder

and vagina. (M odified from Raz S, Bregg KJ, N itti VW, et al.
FIGURE 20.4 Using a right-angle clamp, the M artius flap is passed Transvaginal repair of vesicovaginal fistula using a peritoneal flap.
from the labial incision to the vaginal incision. J Urol 1993;150:56–59.)
cystogram reveals no persistent fistula or extravasation. If a

fistula is still present, bladder drainage continues for another
2 to 3 weeks and the cystogram repeated at that time.
Transab d o minal (Int rap e rit o ne al)

Ap p ro ach
The patient is placed in a low lithotomy position. Cystoscopy
is performed to visualize and cannulate the VVF with a 5FR
to 6Fr ureteral catheter or guide wire. If unable to pass the
guide wire through the VVF transvesically, it is passed from
the vaginal side into the bladder, grasped cystoscopically, and
brought out through the urethra.
A midline infraumbilical incision is made; the rectus muscle
is split midline to enter the pelvis. The bladder is opened with a
midline vertical cystotomy between two stay sutures (Fig. 20.7).
The VVF is identified with the guide wire exiting its opening
into the bladder. The urethral end of the guide wire is pulled
into the cystotomy incision. The VVF’s position in relation to
the ureteral orifices is noted and the ureters are cannulated
with stents, if necessary. If there is any difficulty identifying
the orifices due to local inflammation, IV indigo carmine may
be administered.
Entering the peritoneal cavity, the dissection along the pos-
terior bladder wall is carried out until the guide wire travers-
FIGURE 20.8 After dissecting between the bladder and vaginal, both
ing the VVF is palpated, indicating the junction between the defects are closed in two layers.
vagina and bladder. With a sponge stick or endoanal sizer in
the vagina to help delineate the vagina, the bladder is carefully
dissected away from the vagina. Wide mobilization of the
bladder and vagina to allow tension-free closure of each side VVF, allowing for tension-free closure (Fig. 20.8). Using inter-
of the VVF is critical. The dissection bisects the fistula tract rupted 3-0 polyglycolic acid sutures, the vaginal defect is
without excising the tract extending 1.5 to 2.0 cm beyond the closed in two nonoverlapping layers. The bladder defect is
also closed in two nonoverlapping layers with running 4-0
polyglycolic acid and 3-0 interrupted sutures.
After the bladder and vaginal fistulous defects are closed,
attention is turned to developing an omental pedicle flap to in-
terpose between the bladder and vagina. Evans et al. recom-
mended routine use of an interposition flap during
intra-abdominal VVF repair, noting a success rate of 100%
with a flap versus 63% to 67% without a flap (5). N ot only
does the interposition flap add an extra layer to the VVF re-
pair to prevent recurrence, but it also increases lymphatic
drainage and decreases the risk of infected fluid collection.
Alternatives to omentum include lateral pelvic peritoneum,
pericolic or mesenteric fat, and free bladder mucosal graft.
The omentum is identified, and an omental flap based on
the more reliable right gastroepiploic artery is developed
(Fig. 20.9). The flap is brought down to the pelvis and placed
between the bladder and vagina, covering the fistula repair
(Fig. 20.10). The graft is secured in place with interrupted 3-0
polyglycolic acid sutures.
With the VVF repair completed, a suprapubic catheter and
urethral Foley catheter are placed with 5-mL balloon inflation
each. In patients with prolonged large fistula, the bladder ca-
pacity is reduced due to the constant drainage. Therefore, the
placement of two fully inflated balloons in combination with
irritation from the incisions may lead to intensification of
bladder spasms. The vertical bladder incision is closed in two
layers with 2-0 polyglycolic acid sutures. A closed pelvic drain
FIGURE 20.7 The bladder is opened in the midline without extend- is also placed. Postoperative care is similar to that after trans-
ing the cystotomy to the fistula. vaginal VVF repair.
FIGURE 20.11 Cystotomy extended down to the fistula site.
FIGURE 20.9 Development of an omental pedical flap based on the

right gastroepiploic artery.
FIGURE 20.12 Circumscribing incision around the fistula.
FIGURE 20.10 Placement of the distal end of the omental graft pos-
terior to the detrusor covering the repairs.
An alternative to the above intra-abdominal technique is the

standard O ’Conor technique. The bladder is bivalved posteri-
orly from the dome to the level of the VVF. Then, the VVF is
excised entirely (Figs. 20.11 through 20.13). After further dis-
section of the bladder from the vagina, the vaginal defect is
closed in two nonopposing layers with interrupted absorbable FIGURE 20.13 Sharp excision of the fistula tract.
FIGURE 20.14 Relation of the cystotomy to the vaginal closure.
sutures (Fig. 20.14). An interposition flap is tacked over the

vaginal closure and the bladder is closed. The first technique is
slightly more difficult in that the fistula is approached posteri-
orly and transected between the bladder and vagina. H owever,
the advantages are that the smaller cystotomy is separated
from the repair. FIGURE 20.15 Transvesical development of the plane between the
bladder and vaginal walls.
with a higher morbidity risk and longer recovery time for the
Transve sical (Ext rap e rit o ne al) Ap p ro ach patient. Also, the area of the fistula may be difficult to dissect
The advantage of this approach is that one can avoid entering out without performing a long cystotomy. With the develop-
the peritoneal cavity. Through a midline infraumbilical inci- ment of minimally invasive surgical techniques, the laparo-
sion, the bladder is identified and opened with a midline verti- scope has been applied to the repair of the VVF. Its limitations
cal incision. The VVF is located and the ureteral orifices are have centered mostly around dissection of adhesions and
cannulated with stents. The fistulous opening is circumscribed fibrosis around the fistula and application of sutures in a
tension-free manner. The development of robot-assisted la-
carefully with a scalpel, incising only the thickness of the blad-
paroscopy has offset many of the challenges faced in the surgi-
der mucosa and staying out of the vagina. This is performed to
cal repair of the VVF.
leave the fistula tract intact, along with a 2- to 3-mm ring of
The potential benefits offered by laparoscopic and robotic
bladder mucosa. With sharp dissection directed radially away
repair of these fistulas include shorter recovery time, reduced
from the VVF for 1 to 2 cm, the bladder is mobilized away
morbidity, less blood loss, better cosmesis, and better visualiza-
from the vagina (Fig. 20.15). To help with exposure, a Foley
tion of the fistula area, reducing the need for extensive dissec-
catheter may be placed transvesically in the VVF for upward
tion around the fistula. The surgeon is also able to perform
traction.
With interrupted 3-0 polyglycolic acid sutures, the fistula other concomitant procedures. As the operation is traditionally
and vagina are closed together. N ext, the bladder muscle is performed using a transperitoneal approach, it is easily
closed perpendicular to the fistula and vaginal closure, also amenable to laparoscopic techniques. The first complete trans-
with 3-0 polyglycolic acid sutures. Finally, the bladder mucosa abdominal laparoscopic repair of a VVF and robotic repair of a
is closed with running 4-0 polyglycolic acid sutures. A supra- VVF were performed in 1994 and 2005, respectively. Evidence
pubic cystotomy catheter and a urethral Foley catheter are for the efficacy and safety of this approach is based a small
placed, and the bladder is closed in two layers with 2-0 poly- series of nonrandomized reports and case reports. In Sotello’s
glycolic acid sutures. Postoperative care is similar to that series, 14 out of 15 patients were cured using the laparoscopic
previously described. approach at a mean follow-up of 26 months (12).
The technical advances afforded by the laparoscopic tech-
nique include the need for a minimal cystotomy, often in a
reverse tennis racquet fashion with minimal bladder mobiliza-
Lap aro sco p ic and Ro b o t -Assist e d Re p air tion and magnified anatomy such that it is easier to see the
o f Ve sico vag inal Fist ulas margins of the fistula. Robotic assistance has improved the fa-
tigue factor of the surgeon and has allowed improvement in
The decision to repair a VVF using a transabdominal ap- applying the tension-free sutures to the bladder and vagina. It
proach is controversial. H igh VVFs and those that lie close to also improves the surgeon’s depth perception.
the ureteric orifices, or those with failed vaginal repair, may be Either a four- or five-port system is used via a transabdominal
better served by using a transabdominal approach because of approach. The fistula may be catheterized to reduce loss of
its higher success rate. This approach is, however, associated pneumoperitoneum, and the bladder is catheterized after careful
Chap t e r 21: Ente rove sical and Re ctoure thral Fistulas 137
localization of the fistula using vaginoscopy and cystoscopy. If in preparation for a second procedure. For recurrent fistulas
the fistula is close to the ureteric orifices, the ureters are can- complicated by prior pelvic irradiation, a conservative approach
nulated also, to allow easier localization. M inimal cystotomy is wise, waiting 6 to 12 months before attempting repair.
is performed around the fistula, and the fistula is repaired in Frequency, urgency, and urge incontinence in the early preopera-
the usual fashion. Tissue interpositioning can also be applied, tive period are treated symptomatically with anticholinergic
usually using omentum. Average operation times run around therapy. These, however, are expected due to bladder decompen-
140 to 233 minutes, with an average length of stay of approx- sation and trigonal/suture line irritation. Residual incontinence
imately 4 days. The Foley catheter is removed on days 10 to must be evaluated with physical examination and fluoroscopic
14, preceded by cystography. urodynamics. Occult or de novo stress urinary incontinence oc-
Laparoscopic and robotic techniques can be applied safely curring in 10% to 12% of patients requires separate treatment
and effectively in the treatment of supratrigonal and large after recovery from the VVF repair. Ureteral obstruction, pro-
VVFs. This technique offers many potential benefits to the pa- longed ileus, and bowel obstruction are uncommon.
tient; however, there remains a paucity of randomized studies
to quantitate its true effectiveness. It is also an evolving area,
with the potential for further advances in surgical technique.
Re sult s
A review of the VVF series from the last two decades demon-
strates the success rate of transvaginal and transabdominal
O UTCO MES repairs to be 92.5% to 96% and 85% to 100% , respectively
(1,2,4,8). Therefore, when the appropriate approach is selected
Co mp licat io ns based on the etiology, location, concomitant pathologies, and
surgeon experience, excellent results can be expected in the
Clearly, the most problematic complication is recurrent or per- great majority of patients. H owever, in those who have failed
sistent fistula. The catheter is replaced for several weeks and the multiple repairs due to severe tissue compromise secondary to
cystogram repeated. If the fistula fails to resolve or improve, radiation or who have developed the end-stage detrusor, diver-
then endoscopic evaluation—vesical and vaginal—is performed sion may be the only alternative.
References
1. Blaivas JG, Heritz DM, Romanzi LJ. Early versus late repair of vesicovaginal 7. H arkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterec-
fistulas: vaginal and abdominal approaches. J Urol 1995;153:1110–1113. tomy. O bstet G ynecol 1998;92:113–118.
2. Blandy JP, Badenoch DF, Fowler CG, et al. Early repair of iatrogenic injury to 8. M ondet F, Chartier-Kastler EJ, Conort P, et al. Anatomic and functional
the ureter or bladder after gynecological surgery. J Urol 1991;146:761–765. results of transperitoneal–transvesical vesicovaginal fistula repair. Urology
3. Dupont M C, Raz S. Vaginal approach to vesicovaginal fistula repair. 2001;58:882–886.
Urology 1996;48:7–9. 9. Tancer M L. O bservations on prevention and management of vesicovaginal
4. Eilber KS, Rosenblum N , Rodriguez LV, et al. 10-Year experience of trans- fistula after total hysterectomy. Surg G ynecol O bstet 1992;175:501–506.
vaginal vesicovaginal fistula repair utilizing a peritoneal flap. J Urol 2002; 10. Z acharin RF. A history of obstetric vesicovaginal fistula. A ust N Z J Surg
167[Suppl]:202 (abst 814). 2000;70:851–854.
5. Evans DH , M adjar S, Politano VA, et al. Interposition flaps in transab- 11. Schneider JA, Patel VJ, H ertel E. Closure of vesico-vaginal fistulas from the
dominal vesicovaginal fistula repairs: are they really necessary? Urology urologic viewpoint with reference to endoscopic fibrin glue technique.
2001;57:670–674. Z entralbl G ynak ol 1992;114:70.
6. Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistulas: a 12. Sotello R, M ariano M B, Garcia-Segui A, et al. Laparoscopic repair of vesi-
summary of 25 years of experience. J Urol 1980;123:370–374. covaginal fistula. J Urol 2005;173:1615–1618.
CHAPTER 21 ■ ENTERO VESICAL AND

RECTO URETHRAL FISTULAS
KENNETH W. ANGERMEIER, AARO N J. MILBANK, AND ERIC A. KLEIN
An enterovesical fistula is an extra-anatomic, epithelialized

connection between the intestines and the bladder. This chap- ENTERO VESICAL FISTULAS
ter will describe the etiology, evaluation, and management of
enterovesical fistulas and the less common rectourethral/ In unselected series, the most common etiology of enterovesi-
rectovesical fistulas. The last half-century has seen a dramatic cal fistulas is diverticulitis. In seven series of patients with en-
change in the management of enterovesical fistulas with a terovesical fistulas, the etiology was diverticulitis in 53%
reduction in morbidity and mortality. (range, 39% to 77% ). M oreover, it has been reported that
TA B LE 2 1 . 1 is pneumaturia, reported in 50% to 85% of patients, although

some series report irritative voiding symptoms in as many as
SPECIFIC CAUSES OF VESICOEN TERIC 71% to 93% . Fecaluria is reported in 21% to 68% of patients
FISTULAS with enterovesical fistulas and tends to be more common with
IN FLAMMATORY diverticular and malignant fistulas. O ther symptoms include
Diverticulitis
hematuria, abdominal pain, diarrhea, urinary retention, per-
ineal pain, hematochezia, and fever. Urine in the stool is rarely
Crohn disease
reported with enterovesical fistulas; these fistulas tend to be
Ulcerative colitis
unidirectional, with flow from the high-pressure intestinal
Appendiceal/pelvic abscess tract to the low-pressure urinary tract.
M eckel diverticulum Physical signs of enterovesical fistulas are subtle or absent.
Tuberculosis Abdominal tenderness and a palpable mass may be reported
Actinomycosis in as many as 35% and 27% of patients, respectively, and are
Bladder malakoplakia not specific. In patients with rectal disease, a rectal mass or rec-
Colonic duplication tal tenderness may be present. Rarely, an enterovesical fistula
may present as epididymitis. In general, physical findings are
N EOPLASTIC most commonly seen in patients with Crohn disease.
Carcinoma of sigmoid colon and rectum Urinalysis discloses pyuria, and cultures are positive in
Lymphomas 80% to 100% of cases of enterovesical fistula. Escherichia
AIDS-related lymphomas coli is the most commonly identified organism, and approxi-
Carcinoma of cervix mately one-third to two-thirds of cultures show polymicrobial
Leiomyosarcoma of bladder growth.
The diagnosis of an enterovesical fistula is clinical, and in
TRAUMATIC some instances, despite numerous radiographic studies, the
Gunshot wounds first objective demonstration of the fistula is at laparotomy.
Penetrating injuries N onetheless, numerous studies have been described to aid in
Pelvic fractures the diagnosis and/or localization of fistulas. Functional studies
Transurethral or open prostatectomy
include the charcoal test, administration of visible dyes (meth-
ylene blue, indigo carmine), and the Bourne test, in which
Vesical formalinization
urine voided after a barium enema is radiographed for the
Pelvic external beam radiation
presence of barium. The charcoal test involves the ingestion of
Prostatic brachytherapy nonabsorbable charcoal followed by the observation of char-
Cryoablation of the prostate coaluria. Although these tests have been reported to have sen-
Transurethral microwave thermotherapy sitivities of 80% to 100% , they are rarely performed because
they provide no localizing anatomic information, and the in-
PELVIC
formation they do provide is usually evident from the patient’s
Gynecologic cancer history.
Foreign body
Cystoscopy is the most common abnormal investigation in
AIDS, acquired immunodeficiency syndrome. patients with enterovesical fistulas, although direct observa-
tion of a fistula is relatively unlikely. Approximately 90% of
cystoscopies show at least indirect evidence of the fistula,
most commonly bullous edema, and in 33% to 46% of cysto-
10% of surgically treated cases of diverticulitis are associated scopies the fistulous opening is identified.
with a colovesical fistula. There is a significant male predomi- Barium enema has been a commonly utilized study in the
nance, a finding that has been attributed to a “ protective bar- evaluation of enterovesical fistulas, with some series reporting
rier” provided by the uterus and broad ligament (16). 100% abnormal studies and fistula identification in as many
O ther common causes of enterovesical fistula are pelvic as 16% to 63% of patients. Colonoscopy rarely demonstrates
malignancy (21% ) and Crohn disease (15% ). Crohn disease a fistulous tract, but the study is important in the evaluation
patients tend to present at a younger age than those patients of potentially malignant fistulas.
with diverticular or malignant etiologies. Radiation injury is Computerized tomography (CT) has supplanted most of
an infrequent cause of enterovesical fistulas. M ost enterovesi- the older imaging studies in the evaluation of suspected en-
cal fistulas following pelvic radiotherapy are secondary to terovesical fistulas. Although the fistula tract may be identi-
recurrent disease. The etiologies of enterovesical fistulas are fied in some cases, indirect evidence of the fistula, including
listed in Table 21.1. air in the bladder, focal bladder and bowel wall thickening,
and closely apposed bowel and bladder, may be present in
85% to 100% of cases. CT also provides important informa-
Diag no sis tion in the evaluation of patients with Crohn disease and col-
orectal carcinoma. CT cystography in our institution has
Although enterovesical fistulas are almost always secondary replaced many other studies, including standard cystography,
to extravesical pathology, the presenting symptoms are in gen- intravenous pyelography (IVP), and magnetic resonance imag-
eral urinary in nature. The most common presenting symptom ing (M RI).
an anastomosis is performed suturing normal bowel to normal

Ind icat io ns fo r Surg e ry bowel without tension and with adequate blood supply. Patients
with Crohn disease often have multiple fistulas not involving
Given the symptomatic nature of enterovesical fistulas and
the urinary tract and require multiple resections or stricturo-
their association with recurrent urinary tract infections and
plasties. With diverticular disease, the fistula may often be
sepsis, most fistulas should be addressed surgically. O ver the
“ pinched off” from the bladder with curettage of the fistula
course of the past 30 years, a one-stage operation has become
tract. For malignant fistulas, the requisite oncological proce-
the favored procedure because of reports of fewer complica-
dure is performed and the malignant fistula tract is excised.
tions and lower mortality. It has been demonstrated that a
Partial cystectomy may be required for large or malignant fistu-
one-stage procedure may be safely performed in the setting of
las; radical cystectomy is in general not required.
an abscess or purulent peritonitis provided that the inflamma-
Closure of small bladder fistulas is not essential. Large de-
tory focus can be removed and the bowel anastomosis can be
fects should be closed in two layers using absorbable sutures.
“ quarantined from any inflammatory nest” (16). In general,
In the setting of ureteral involvement, ureteroneocystostomy
diverticular disease is particularly well suited to one-stage pro-
may be required. Ideally, an omental flap should be interposed
cedures because the fistulous process is either chronic or, if
between the anastomosed bowel and the bladder. When an
acute, controllable with antibiotics.
omental flap is not constructable, a peritoneal flap may be
A two-stage procedure should be considered in patients
used. Suprapubic catheters and drainage of the extraperi-
who have an obstructed bowel, have residual significant intra-
toneal space are optional. In general, a urethral catheter is
abdominal inflammation, are significantly ill, and in whom a
maintained until 1 week after surgery. Complete healing of the
healthy anastomosis is unlikely (due to poor blood supply or
bladder defect may be confirmed with a cystogram prior to
tension at the anastomosis). The two stages (for colovesical
removal of the catheter. The aforementioned procedure has
fistulas) may consist of resection with the H artmann pouch
also been performed laparoscopically with good results.
and end colostomy followed by reanastomosis or resection,
anastomosis, and transverse colostomy followed by reversal of
the colostomy. Fistulas secondary to radiation injury in gen- O ut co me s
eral require multiple staged repairs and, frequently, permanent
bladder and bowel diversion (10). Co mp licat io ns
M ajor complications of operative repair of enterovesical fistu-
Alt e rnat ive The rap y las include death (0% to 5% ), myocardial infarction (2% to
6% ), anastomotic leak (0% to 5% ), enterocutaneous fistula
N onoperative management may be considered in patients who (0% to 1% ), wound infection (0% to 21% ), wound dehis-
are extremely debilitated. There are a few reports of sponta- cence (0% to 2% ), pulmonary embolus (0% to 1% ), deep
neous closure of fistulas with medical management. This vein thrombosis (0% to 1% ), prolonged ileus (0% to 5% ),
spontaneous resolution has been reported with traumatic fis- and urine leak (0% to 3% ) (4,11,15,16). O ne of the largest
tulas and in a subset of fistulas secondary to Crohn disease. surgical series (104 patients) reported a 6.4% overall compli-
Placement of bowel stents and endoscopic clipping of the cation rate with no operative mortality (9). Significantly
colonic terminus of the fistula have also been reported for pa- greater morbidity is observed in series focusing on radiation-
tients who are too ill to undergo open surgical procedures. induced and malignant fistulas (6,10).
Experimental evidence suggests that enterovesical fistulas, when
chronic, are physiologically well tolerated (5). Amin et al. fol- Re sult s
lowed a cohort of four patients with diverticular colovesical The results of the one-stage procedure for enterovesical fistu-
fistulas who refused surgery; with 3 to 14 years of follow-up, las are very much dependent upon the etiology of the fistula.
there were no significant complications (1). Fistula recurrence following colonic resection in patients with
diverticular fistulas is virtually nonexistent (16). Following
surgical intervention for Crohn disease with enterovesical fis-
Surg ical Te chniq ue tulas, recurrent enterovesical fistulas are observed in 0% to
13% of patients (4,11). In a surgical series of 13 patients with
O ne -St ag e Surg e ry malignant fistulas, 2 (15% ) patients developed recurrent fistu-
O n the day prior to the operation, a mechanical bowel prepa- las (6). In a surgical series of 13 patients with radiation-
ration is administered and the patient is maintained on a clear induced fistulas, 5 (39% ) failed to resolve or recurred (10). It
liquid diet. Gram-negative and anaerobic coverage is provided should be noted that seven of these operations were diversions
by administering a third-generation cephalosporin (ceftizoxime) or isolations; of the six patients who underwent resections,
and metronidazole 1 hour prior to the surgical procedure. only one developed a recurrent fistula.
M ost fistulas are best approached via a midline incision ex-
tending from the pubic ramus to the umbilicus (Fig. 21.1). This
incision may be extended cranially as needed. Some authors pre- RECTO URETHRAL FISTULAS
fer an infraumbilical transverse incision. The peritoneal cavity is
entered and adhesiolysis is performed. The point of the fistula is Rectourethral fistulas are rare clinical entities. The most com-
identified. The remainder of the procedure is determined by the mon cause is iatrogenesis, usually incurred during prostatic or
disease causing the fistula and intraoperative findings. In the rectal surgery or following radiation. O ther etiologies include
setting of diverticular fistulas, the diseased colon is resected and congenital, infectious, and neoplastic fistulas.
FIGURE 21.1 M anagement of an enterovesical fistula

using bowel resection and restitution with primary blad-
der closure.
urinary sphincter, supravesical diversion is a valid consid-

Diag no sis eration if placement of an artificial urinary sphincter is not
feasible.
Diagnosis of a rectourethral fistula is usually straightforward
2. Presence of urethral stricture or vesical neck contracture.
and suggested by the medical history. Preoperatively, ante-
Coexisting urethral disease may be present in patients with
grade and retrograde studies of the urinary tract, cystoscopy,
rectourethral fistulas, in particular iatrogenic fistulas (sur-
proctoscopy, and, if indicated, anal manometry are per-
gical or radiation-induced). Distal obstruction will com-
formed to delineate the site and extent of the fistula as well
promise a technically adequate repair and should be
as rule out distal obstruction or sphincteric incompetence. If
treated prior to or at the time of fistula repair.
there is clinical suspicion of disease recurrence, a biopsy
3. Status of adjacent tissue. Pelvic radiation induces both
should be performed.
delayed endothelial cell damage and damage to the con-
nective tissue stroma of blood vessels (12). This arteritis
may result in atrophy, fibrosis, and necrosis. As a result,
Ind icat io ns fo r Surg e ry radiation-induced fistulas in general require more exten-
sive repairs involving interposition of omentum or muscle
M any different approaches have been proposed for the man- flaps, have higher failure rates, and on occasion require
agement of rectourethral fistulas. It is imperative to individu- permanent diversion.
alize management. There are five key factors that must be 4. Size and location of the fistula. Whereas small distal fistu-
considered prior to determining the ideal approach: las may be effectively repaired via a transanal approach,
large fistulas often require the greater exposure provided
1. Sphincteric function. In the setting of anal sphincteric in- by transsphincteric, transperineal, or abdominoperineal
competence, complex anal sphincter-sparing procedures approaches. M oreover, large defects may require the inter-
should be deferred and consideration given to permanent position of vascularized tissue (omentum or muscle flaps).
fecal diversion. Similarly, in the setting of failure of the 5. O verall condition and life ex pectancy of the patient.
Surg ical The rap y

Initial treatment of iatrogenic fistulas in general consists of
colostomy, prolonged urinary drainage with a suprapubic
catheter, and broad-spectrum antibiotics, although some au-
thors have advocated the selective use of elemental or par-
enteral nutrition in lieu of bowel diversion (3). Approximately
25% of nonradiated iatrogenic fistulas will resolve with con-
servative management (2). For those fistulas that do not close,
numerous surgical repairs have been proposed (2). In appropri-
ate candidates, our preferred surgical approach is either
transanal or posterior transanosphincteric (York–M ason) (14).
Transperineal repairs allow for formal tissue interposition and
are useful for large or complex fistulas. Abdominoperineal re-
pair allows for a colonic pull-through if necessary and also for
the interposition of omentum or a gracilis or rectus abdominis
muscle flap. It is limited, however, by an increased risk of fecal
incontinence and the morbidity of an abdominal operation.
The anterior transanorectal approach (sphincter divided) and
the Kraske laterosacral (sphincter not divided) approach both
provide excellent exposure of the fistula; however, the former
may be associated with erectile dysfunction if the plane of dis-
section strays from the midline, and the latter procedure risks
fecal incontinence associated with denervation.
Surg ical Te chniq ue FIGURE 21.2 Through the anal canal, an ellipse of rectal mucosa is
removed. A full-thickness U-shaped flap of rectal wall is elevated above
Transanal Ap p ro ach the fistula. The full-thickness flap of rectal wall is brought down over
the fistula and sutured in two layers to the rectal wall. (From Tiptaft RC,
The procedure is performed in the prone jackknife position. A M otson RW, et al. Fistulae involving rectum and urethra: the place of
speculum is introduced into the anus and the fistula is ex- Parks’ operations. Br J Urol 1983; 55:711–715, with permission.)
posed. Two alternative procedures may be performed: the fis-
tula may be circumscribed with mobilization of the rectal
mucosa in a circumferential fashion; the fistula is excised and The rectum is closed in two layers. The posterior rectal wall
the underlying rectal wall muscle and mucosa are closed sepa- and anal mucosa are then reapproximated. Finally, using
rately. Alternatively, the mucosal dissection may be limited to the previously placed marking sutures, the anal sphincter is
the rectal wall lateral and distal to the fistula. The proximal reapproximated in layers. Drainage of the presacral space is
rectal wall is then mobilized for 4 cm, thereby creating a full- optional. A Foley catheter is placed and maintained for 2 to
thickness U-shaped flap that is pulled down over the fistula 3 weeks, at which point the absence of a leak is confirmed
and sutured to the edge of the rectal mucosa (Fig. 21.2). A radiographically.
catheter is maintained for 2 to 3 weeks. The main limitation of
this approach is the limited exposure, and it is best suited for
small distal fistulas. O ut co me s
Yo rk–Maso n Ap p ro ach Co mp licat io ns
The York–M ason procedure is performed in a prone jackknife Specific complications include recurrent fistula formation, uri-
position with the buttocks taped laterally (14) (Fig. 21.3). A nary and/or fecal incontinence, and erectile dysfunction.
midline incision is made from the sacrococcygeal articulation
to the anal verge. Prior to dividing the muscular layers of the Re sult s
posterior anus, matching sutures are placed on either side of Based upon literature reports, the York–M ason approach has
the intended incision so as to allow for subsequent precise become the favored repair for rectourethral fistulas not
reapproximation. Each layer is marked separately and then di- amenable to a transanal approach. There have been two rela-
vided. O nce the sphincter is divided, the mucosa of the poste- tively large series reported recently. Fengler and Abcarian per-
rior anus and the entire posterior rectal wall are divided in formed eight York–M ason repairs for rectourethral fistulas
midline, thereby providing excellent exposure of the fistula. with no recurrences and no fecal incontinence (3). Fecal diver-
The fistula is then entirely excised and any inflammatory tis- sion was performed in three of the eight patients. Stephenson
sue is removed. The plane between the anterior rectal wall and and M iddleton reported on 16 York–M ason repairs for rec-
the urethra/bladder may then be dissected to allow sufficient tourinary fistulas (rectovesical in 8, rectourethral in 7), with 1
mobility for closure of the rectal defect. The urethra (or bladder) recurrence and no fecal incontinence (14). The one recurrence
is closed with absorbable sutures in either one or two layers. was treated successfully with a second York–M ason procedure.
FIGURE 21.3 Posterior sagittal, transanorectal (York–Mason)

approach for repair of rectourinary fistulas. The patient
is placed in the prone jackknife position with tape used to
displace the buttocks laterally. After division of the poste-
rior anus and rectum, the fistula is easily identified with
ample room for excision and repair. (From Stephenson
RA, M iddleton RG. Repair of rectourinary fistulas using a
posterior sagittal transanal transrectal (modified York–Mason)
approach: an update. J Urol 1996;155:1989–1991, with
permission.)
In this series, four patients with urinary incontinence prior to into high lithotomy position. A very careful and meticulous
the repair subsequently underwent artificial urinary sphincter dissection is then conducted in the plane between the rectum
placement; no patients developed urinary incontinence as a re- and the prostate and bladder to the level of the peritoneal re-
sult of the repair. A diverting colostomy was used in nine of flection. The plane of dissection typically starts superior to the
the patients. anal sphincter and then is carried down onto the rectum.
Development of the space between the urinary tract and rec-
tum can be quite difficult, as it is often performed in the setting
of radiotherapy or previous attempts at fistula repair. O nce
Surg ical Re co nst ruct io n fo r Larg e o r
completed, the urinary tract defect is closed primarily when
Co mp le x Fist ulas feasible or patched with a buccal mucosa graft. In the setting of
an associated membranous urethral stricture, a urethrotomy
Pre se rvat io n o f Urinary o r Bo w e l Funct io n incision is created from the level of the fistula through the stric-
Based upon the presurgical evaluation, some patients with a ture into the proximal bulbous urethra. Buccal mucosa is then
rectourethral fistula are candidates for surgical restoration of grafted into the resulting urethrotomy defect, with distal graft
only one system. The most common setting would be a patient coverage using the corpus spongiosum and proximal buttress-
with anorectal dysfunction or sphincteric incompetence who ing with a gracilis muscle flap (17). The rectum is then closed
is a candidate for permanent colostomy and urinary tract re- and a gracilis muscle is rotated into the space between the rec-
construction. Urinary reconstruction is optimized by concomi- tum and urinary tract and anchored to the peritoneal reflec-
tant proctectomy. A small urethral fistula may be closed tion. Lateral sutures are also placed between the gracilis and
primarily, followed by omental mobilization to the pelvis for the levators to ensure that its position is maintained with com-
coverage of the area. Some fistulas too large for primary clo- plete coverage of the reconstruction. Primary closure of the
sure have been managed with omental or gracilis transposition urethral and rectal defects with gracilis interposition was suc-
alone (7); however, we have preferred to close the urethral de- cessful in 13 of 15 (87% ) patients in two studies (13,18). In
fect with a buccal mucosa graft in this setting as this seems to 2004 Zinman and colleagues reported excellent results using a
lead to decreased urinary extravasation and more rapid heal- transperineal approach for repair of complex rectourethral fis-
ing overall. The buccal graft is buttressed with omentum or a tulas with buccal mucosa graft closure of the urethra, primary
gracilis muscle flap for optimal take. closure of the rectum, and gracilis interposition (17). We have
used a similar technique in over 20 patients to date with only
Pre se rvat io n o f Urinary and Bo w e l Funct io n 1 failure of fistula closure thus far. It would seem to be most
In patients who are candidates for attempted preservation of useful when the rectum and perirectal tissues are preserved
both urinary and bowel function, a transperineal procedure is well enough to allow adequate healing with primary rectal clo-
our preferred technique and begins with placing the patient sure, as opposed to situations requiring resection of a severely
Chap t e r 22: Ve sical Trauma and He morrhag e 143
diseased rectum. In these cases, we have successfully used an provides an excellent host bed for the buccal mucosa graft
abdominoperineal approach in patients in whom the rectum when omentum is not available, or if there is insufficient room
was deemed to be too extensively damaged by radiotherapy to in the pelvis to accommodate the omentum. This approach al-
allow a reliable primary closure, due to either severe proctitis lows repair of large fistulas, restores fecal and urinary continu-
or extensive tissue loss (8). In these cases, proctectomy and ity, and eliminates a severely diseased rectum. Potentially
buccal graft closure of the urethral defect were done initially in difficult aspects of this procedure include the morbidity of an
the prone jackknife position, and the patient was then placed abdominal operation and the need to reposition the patient
supine for the remainder of the procedure. Turnbull–Cutait from the prone to the supine position during the case. A minor
staged coloanal pull-through is then carried out via an ab- potential complication that we have encountered in two pa-
dominoperineal approach. We have found that simple rotation tients is the occurrence of minor rectal ectropion or prolapse
of the sigmoid mesentery anteriorly during the pull-through that may require simple outpatient excision at a later date.
References
1. Amin M , N allinger R, et al. Conservative treatment of selected patients 10. Levenback C, Gershenson DM , et al. Enterovesical fistula following radio-
with colovesical fistula due to diverticulitis. Surg G ynecol O bstet therapy for gynecologic cancer. G ynecol O ncol 1994;52:296–300.
1984;159:442–444. 11. M cN amara M J, Fazio VW, et al. Surgical treatment of enterovesical fistu-
2. Elmajian DA. Surgical approaches to repair of rectourinary fistulas. A UA las in Crohn’s disease. D is Colon R ectum 1990;33:271–276.
Update Series 2000;19(6):41–48. 12. M undy AR. Pelvic surgery after radiotherapy. Br J Urol 1997;80[Suppl
3. Fengler SA, Abcarian H . The York M ason approach to repair of iatrogenic 1]:66–68.
rectourinary fistulae. A m J Surg 1997;173:213–217. 13. N yam DC, Pemberton JH . M anagement of iatrogenic rectourethral fistula.
4. Greenstein AJ, Sachar DB, et al. Course of enterovesical fistulas in Crohn’s D is Colon R ectum 1999;42:994–999.
disease. A m J Surg 1984;147:788–792. 14. Stephenson RA, M iddleton RG. Repair of rectourinary fistulas using a pos-
5. H eiskell CA, Vjiki GT, et al. A study of experimental colovesical fistula. terior sagittal transanal transrectal (modified York–M ason) approach: an
A m J Surg 1975;129(3):316–318. update. J Urol 1996;155:1989–1991.
6. H olmes SA, Christmas TJ, et al. M anagement of colovesical fistulae associ- 15. Vasilevsky CA, Belliveau P, et al. Fistulas complicating diverticulitis. Int J
ated with pelvic malignancy. Br J Surg 1992;79:432–434. Colorectal D is 1998;13(2):57–60.
7. Jordan GH , Lynch DF, et al. M ajor rectal complications following intersti- 16. Woods RJ, Lavery IC, et al. Internal fistulas in diverticular disease. D is
tial implantation of 125-iodine for carcinoma of the prostate. J Urol Colon R ectum 1988;31:591–596.
1985;134:1212–1214. 17. Z inman L. The management of the complex recto-urethral fistula. BJU Int
8. Lane BR, Stein DE, et al. M anagement of radiotherapy induced rec- 2004;94:1212–1213.
tourethral fistula. J Urol 2006;175:1382–1387. 18. Z mora O , Potenti FM , et al. Gracilis muscle transposition for iatrogenic
9. King RM , Beart RW Jr, et al. Colovesical and rectovesical fistulas. A rch rectourethral fistula. A nn Surg 2003;237:483–487.
Surg 1982;117:680–683.
CHAPTER 22 ■ VESICAL TRAUMA AND

HEMO RRHAGE
KAMAL S. PO HAR AND RO BERT R. BAHNSO N
bladder rupture (3). Concomitant bladder rupture is found in

VESICAL TRAUMA 10% to 29% of patients who present with rupture of the
posterior urethra, and this is the most common injury to the
Vesical injury can occur as a result of blunt or penetrating genitourinary tract associated with bladder rupture (1,3). The
trauma to the lower abdomen and pelvis. It is more com- mortality rate in patients with bladder rupture ranges from
monly associated with blunt trauma such as that sustained 11% to 44% and is mainly attributable to other associated
from motor vehicle accidents, falls, blows, and during con- organ injuries.
tact sports. Penetrating trauma resulting in vesical injury oc- Bladder injury occurs as three predominant types: contu-
curs from gunshot wounds and knife wounds. Bladder sion with only intramural injury and extraperitoneal or in-
injuries can also be iatrogenic from transurethral surgery, gy- traperitoneal bladder rupture. The exact incidence of bladder
necologic procedures, laparoscopy, and other intra-abdominal contusion is not known as it is often a diagnosis of exclusion.
surgery. Bladder injury, in particular bladder rupture, is asso- It is a partial-thickness tear of the bladder mucosa with ecchy-
ciated with pelvic fractures in 75% to 83% of patients (1). mosis of the bladder wall. It is often associated with a
H owever, only 5% to 10% of patients with pelvic fractures “ teardrop” -shaped bladder, which occurs as a result of a com-
will have associated bladder rupture (2,3). There is also a pressive pelvic hematoma from a pelvic fracture (4). It is usu-
high incidence of injuries to other organs in patients with ally self-limiting and rarely requires treatment.
Traumatic extraperitoneal ruptures usually are associated

with pelvic fractures (89% to 100% ). Previously, the mecha-
nism of injury was believed to be a direct perforation by a
bony fragment or a disruption of the pelvic girdle. It is now
generally agreed that the pelvic fracture is likely coincidental
and that the bladder rupture is most often due to a direct burst
injury or the shearing force of the deforming pelvic ring (5).
These ruptures usually are associated with fractures of the an-
terior pubic arch, and they may occur from a direct laceration
of the bladder by the bony fragments of the osseous pelvis.
The anterolateral aspect of the bladder typically is perforated
by bony spicules. Forceful disruption of the bony pelvis and/or
the puboprostatic ligaments also tears the wall of the bladder.
The degree of bladder injury is directly related to the severity
of the fracture.
Some cases may occur by a mechanism similar to intraperi-
toneal bladder rupture, which is a combination of trauma and
bladder overdistention. The classic cystographic finding is
contrast extravasation around the base of the bladder con-
fined to the perivesical space; flame-shaped areas of contrast
extravasation are noted adjacent to the bladder. The bladder
may assume a teardrop shape from compression by a pelvic
hematoma. Starburst, flame-shape, and featherlike patterns FIGURE 22.1 In intraperitoneal rupture of the bladder, free contrast
also are described. Classic intraperitoneal bladder ruptures are within the peritoneal cavity outlines bowel loops.
described as large horizontal tears in the dome of the bladder.
The dome is the least supported area and the only portion of
the adult bladder covered by peritoneum. The mechanism of
injury is a sudden large increase in intravesical pressure in a
full bladder. When full, the bladder’s muscle fibers are widely
separated and the entire bladder wall is relatively thin, offer-
ing relatively little resistance to perforation from sudden large
changes in intravesical pressure.
Diag no sis
Patients with bladder injury usually complain of lower ab-
dominal pain and tenderness. Such an injury should be sus-
pected in any patient with a pelvic fracture. M ost patients
with bladder trauma, including those with bladder contu-
sions, will have gross or microscopic hematuria. Patients
with contusion alone are usually able to void, whereas those
with a ruptured bladder are often unable to void sponta-
neously. Acidosis with prerenal azotemia and elevated blood
urea nitrogen is sometimes noticeable when there is a delay
in diagnosis (6).
Presence of blood at the urethral meatus mandates per-
forming a retrograde urethrogram. This is performed to rule
out urethral injury before catheterization or instrumentation.
If the retrograde urethrogram is normal, a urethral catheter is
placed and a cystogram is obtained by plain film radiography
(static), fluoroscopy (dynamic), or CT scan. The cystogram is
usually normal in the presence of a bladder contusion.
Intraperitoneal rupture results in ill-defined spillage of con- FIGURE 22.2 In extraperitoneal rupture of the bladder, contrast fills
trast into the peritoneum (Fig. 22.1). The extravasated contrast the pelvic cavity around the bladder.
may outline loops of bowel or accumulate in the paracolic
gutters, beneath the diaphragm, or over the bladder, in an
hourglass pattern. Extraperitoneal rupture is seen as streak- the perivesical space) or complex (extravasation into the scro-
like extravasation of contrast confined to the pelvis on retro- tum, retroperitoneum, abdominal wall, etc.). Displacement of
grade cystogram (Fig. 22.2). Corriere and Sandler (7) further the bladder by a pelvic hematoma can result in a teardrop-
distinguished extraperitoneal ruptures as simple (confined to shaped bladder on cystogram (7).
A B
FIGURE 22.3 A CT cystogram showing evidence of intraperi-

toneal rupture of the bladder with extravasation around the (A)
bladder (arrow ), (B) paracolic space (solid arrow s), and (C) ab-
C dominal viscera (solid arrow s).
The most sensitive means of evaluating for the presence of simultaneously evaluate the bladder would obviate the need
bladder injury has traditionally been a cystogram performed for an additional plain-film cystogram. H owever, during rou-
by fluoroscopy. This is performed by obtaining a scout radi- tine abdominopelvic CT scan, the bladder may not be ade-
ograph followed by instilling at least 250 to 400 cc of water- quately distended to allow evaluation for rupture. The results
soluble contrast (Cystografin) in the bladder under gravity of CT cystography improved as studies demonstrated im-
to ensure adequate distention and visualization of possible proved sensitivity when the bladder was filled in a retrograde
areas of rupture (1,6). O ne of the principal reasons for false- fashion with large volumes of contrast (250 to 500 cc) (8).
negative cystograms is instillation of an inadequate amount Intraperitoneal bladder rupture can be distinguished from
of contrast in the bladder. Static anteroposterior, oblique, or extraperitoneal rupture on CT scan. Presence of contrast
lateral films are obtained with the bladder full, and a around the bladder (Fig. 22.3A), in the paracolic gutters on ei-
washout film is obtained after drainage of the contrast mate- ther side (Fig. 22.3B), and around abdominal viscera such as
rial from the bladder. These additional films are useful in the liver (Fig. 22.3C) indicates intraperitoneal rupture. In the
evaluating patients with posterior wall ruptures, which may case of extraperitoneal rupture, contrast extravasation is usually
be obscured in the anteroposterior view by a contrast-filled seen around the bladder, in the presacral space (Fig. 22.4A), and
bladder. The drainage film also helps detect residual extrava- in the retroperitoneum anterior to the great vessels (Fig. 22.4B).
sation. In children the bladder is filled with contrast accord- Bladder contusions may be seen on CT scan as intramural
ing to the formula, Bladder capacity 60 cc (30 cc age hematomas. The recently reported improved accuracy of CT
in years). scan has resulted in CT being considered equivalent to plain-
Although it is preferable to perform the study under fluo- film cystography in diagnosing bladder ruptures. The accu-
roscopy, if clinical circumstances do not permit, a static cys- racy of CT cystography may be significantly improved if
togram is satisfacory with portable equipment at the bedside. retrograde bladder filling are performed with an adequate
Recently, examination of a contrast-filled bladder during amount of contrast.
computerized tomography (CT) scan has been used as a Intraoperatively, bladder rupture can be diagnosed by ex-
method of assessing injury. This is particularly applicable in travasation of saline, sterile milk, methylene blue, or indigo
patients who first undergo abdominal CT scans to rule out carmine, which is instilled in the bladder through a Foley
suspected visceral injuries. In these situations, the ability to catheter.
FIGURE 22.4 Extraperitoneal rupture showing contrast in the

(A) presacral space (curved arrow ), prevesical space (open
arrow ), and (B) retroperitoneum (solid arrow ). B, bladder.
performed. Approximately 85% of the time, the laceration is

Ind icat io ns fo r Surg e ry sealed and the catheter is removed for a voiding trial. M ost
extraperitoneal ruptures will heal within 3 weeks of catheter
1. Intraperitoneal bladder rupture
drainage. M ost, if not all, intraperitoneal bladder ruptures re-
2. Bladder rupture or perforation sustained during another
quire surgical exploration. These injuries do not heal with
surgical procedure
prolonged catheterization alone.
3. Extraperitoneal bladder rupture in the presence of other
Injuries occurring during other procedures such as laparo-
intra-abdominal injuries requiring surgical intervention
scopic surgery may be repaired laparoscopically.
4. Extraperitoneal bladder rupture with the bladder being in-
adequately drained by urethral catheter drainage
Int rap e rit o ne al Blad d e r Rup t ure
Alternative treatments of bladder trauma are predominantly Intraperitoneal bladder rupture requires immediate surgical
Foley catheter drainage, which is indicated in patients with repair. The abdomen is opened through a vertical lower mid-
bladder contusions and extraperitoneal extravasation. M ost line incision, which affords better exposure and is extendable
extraperitoneal ruptures can be managed safely with simple in the event a laparotomy is required. The rupture, which is
catheter drainage (i.e., urethral or suprapubic). The catheter usually located horizontally on the dome of the bladder, is
is placed to drain for 7 to 10 days and a cystogram is identified. In some situations, this may require instillation of
saline or colored dye in the bladder through a previously demonstrated that these injuries can be managed nonopera-
placed urethral catheter. Combined intra- and extraperitoneal tively (1,7). Corriere and Sandler successfully managed 41 pa-
rupture may coexist, and it is recommended that the opening tients with extraperitoneal bladder rupture by prolonged
in the bladder wall be extended to allow better visualization of urethral catheterization alone. All patients healed the bladder
the interior and bladder neck. Extraperitoneal tears can be injury spontaneously without complications (7). Since then,
closed from inside the bladder in two layers using running other studies have duplicated these results.
absorbable suture (3-0 chromic or polyglycolic/polyglactin acid). Isolated extraperitoneal rupture can be treated by simple
The intraperitoneal rupture(s) are closed in at least two layers urethral catheter drainage. O nce urethral injury has been
using running 3-0 chromic or polyglycolic/polyglactin acid su- ruled out by means of a retrograde urethrogram, a urethral
ture. The mucosa, muscle, and peritoneum are all closed in sep- catheter is placed. The catheter is left in place for 7 to 14 days.
arate layers. The bladder is filled with saline after completion Repeat cystograms are performed at the end of this period. If
of the closure to evaluate for leaks. If any leaks are detected, no extravasation is observed, the catheter can be removed. If
they can be closed using interrupted figure-of-eight sutures. any contrast extravasation is evident on the cystogram, catheter
In some situations, bony spicules that have penetrated the drainage is continued. Cystograms are repeated at weekly in-
bladder wall may need to be removed before closure of the tervals until no extravasation is demonstrable. A majority of
bladder. In cases of penetrating trauma or erosion of the blad- extraperitoneal ruptures treated in this manner will heal by
der wall by pelvic abscess, nonviable tissue must be debrided 2 weeks, and almost all will show healing within 3 weeks.
and the edges of the perforation freshened prior to closure. In Severe bleeding with clots or sepsis should prompt surgical
these cases, the tissue may be extremely friable, and a single- exploration even in cases of extraperitoneal rupture. If patients
layer closure may need to be performed. The ureteral orifices are undergoing laparotomy for other intra-abdominal injuries,
should be identified and observed to ensure normal efflux of it is reasonable to repair extraperitoneal ruptures surgically.
urine. This may be done after administration of IV indigo
carmine to facilitate visualization. If efflux of urine is not seen,
proximal ureteral obstruction, especially by fractured bony O ut co me s
fragments, should be ruled out. This can be done by perform-
ing a retrograde or intravenous pyelogram on the operating Co mp licat io ns
table. Some patients may notice persistent urgency and increased fre-
In addition to a urethral catheter, a suprapubic catheter is quency of micturition after repair of bladder ruptures. These
placed through a separate cystotomy to drain the bladder. symptoms are usually temporary and tend to subside with
Care must be taken not to disturb the pelvic hematoma that is time. Vesical neck injuries increase the risk of subsequent in-
invariably present. Disruption of the pelvic hematoma may continence, and attention should be paid to careful repair of
give rise to significant bleeding. This can be controlled by these injuries. Infection of pelvic hematomas can result in ab-
packing the area with Gelfoam, Surgicel, or laparotomy tapes. scess formation requiring prolonged drainage and antibiotic
The abdomen can be temporarily closed with the packing in treatment. This can be prevented to some extent by taking
place for about 24 hours; the packing is removed at the time care to avoid disrupting the hematoma intraoperatively.
of re-exploration. In extreme cases, angiographic embolization Unrecognized injury to adjacent structures can lead to subse-
of the pelvic vessels may be necessary. quent vesicovaginal or vesicoenteric fistula formation.
A 0.5-in. Penrose drain is placed adjacent to the bladder O therwise, this complication is uncommon.
and left in place for 48 hours. In some cases, if the pelvic Complications such as clot retention and pseudodiverticu-
hematoma has not been disturbed and the bladder closure is lum formation are seen in fewer than 10% of patients treated
truly watertight, drains can be omitted altogether. The abdom- with catheter drainage alone for extraperitoneal rupture
inal fascia and skin are closed in the usual fashion. (1,11). Significant sepsis, delayed healing, formation of blad-
Iatrogenic bladder injury, if suspected to have occurred der calculi, and vesicocutaneous fistula formation have been
during other operative procedures, should be documented by noted to occur in patients treated with urethral or suprapubic
instilling methylene blue or indigo carmine in the bladder and catheter drainage for extraperitoneal rupture (12). These pa-
noting any extravasation. The rupture or tear can be closed tients most often had poorly functioning catheters or did not
primarily in two or three layers using absorbable suture, as in receive prophylactic antibiotics. H ence, it is important to en-
other cases of rupture. Bladder perforations sustained during sure that urethral catheters are functioning adequately when
laparoscopic procedures can be diagnosed by noting disten- used in these situations. Using a larger catheter and consider-
tion of the urethral catheter drainage bag with gas (9). These ing surgical intervention in 24 to 48 hours if the catheter is
injuries can be repaired as described previously by laparotomy not functioning will reduce complications. Prophylactic anti-
or even laparoscopically (10). biotics with gram-negative coverage, when administered for
Intravenous antibiotics are continued until hospital dis- the duration of catheterization, will help prevent urinary tract
charge, and the pelvic drain is removed within 48 to 72 hours of infections.
the procedure. When the follow-up cystogram confirms bladder
healing, the urethral catheter is removed and a voiding trial is Re sult s
initiated by clamping the suprapubic catheter. The suprapubic O pen repair with adequate closure of the rupture is almost
catheter is removed when spontaneous voiding has returned. uniformly successful in all patients treated in this manner, and
74% to 87% of patients managed with urethral catheter
Ext rap e rit o ne al Blad d e r Rup t ure drainage for extraperitoneal rupture will show evidence of
Until the 1970s, extraperitoneal bladder rupture was managed healing by 10 to 14 days (1,12). The remainder will heal with
as an intraperitoneal rupture. Since then several studies have an additional 7 to 10 days of catheter drainage.
TA B LE 2 2 . 1
ETIOLOGIC AGEN TS FOR HEMORRHAGIC CYSTITIS
Infectious causes N oninfectious causes
Viral: BK virus, adenovirus, JC virus, influenza virus Amyloidosis

Bacterial: Escherichia coli, Staphylococcus saprophyticus, Radiation
Proteus m irabilis, Klebsiella
Fungal: Candida albicans, A spergillus fum igatus, Chemicals: anilines and toluidines, pesticides (chlordimeform),
Cryptococcus neoform ans, Torulopsis glabrata ether, gentian violet, spermicidal suppositories, turpentine
Parasitic: Schistosom a haem atobium , Drugs: penicillins (carbenicillin, penicillin G, K, ticarcillin,
Echinococcus granulosus methicillin, piperacillin), methenamine mandelate, danazol
Chemotherapeutic agents: busulfan, thiotepa,
cyclophosphamide, isophosphamide
protective agents such as N -acetyl-cysteine (M ucomyst) or 2-

VESICAL HEMO RRHAGE mercaptoethane sulfonate (mesna) can reduce the incidence of
this complication. Systemic administration of M ucomyst can
Significant bleeding from the bladder in the absence of trauma decrease the antineoplastic effect of cyclophosphamide and
is usually associated with hemorrhagic cystitis. This can result may exacerbate the hemorrhage seen with busulfan.
from a variety of infectious and noninfectious etiologies.
Possible etiologic factors for hemorrhagic cystitis are listed in
Table 22.1. Infection-related hemorrhagic cystitis is usually
treatable by addressing the underlying cause. Tre at me nt o f He mo rrhag ic Cyst it is
Radiation therapy to the prostate, bladder, or other pelvic
organs can result in hemorrhagic cystitis. Initially, there is mu- A practical algorithm for the management of hemorrhagic cys-
cosal edema with submucosal hemorrhage. Chronically, radia- titis is outlined in Fig. 22.5. M ild hematuria can be managed
tion causes obliterative endarteritis with subsequent urothelial by vigorous hydration.
ischemia. Various measures, such as steroids, vitamin E, and M oderate hematuria can be treated with continuous saline
trypsin, have proved futile in treating radiation-induced cysti- irrigation through a Foley catheter after all clots have been
tis, which can manifest many years after exposure. Coating evacuated. In some situations, such as with radiation cystitis,
the bladder mucosa with synthetic agents such as pentosan irrigation with cold saline for 24 to 48 hours may prove more
polysulfate sodium has some beneficial effect (13). H yperbaric effective. If hematuria persists, continuous bladder irrigation
oxygen therapy has also proved effective (14). with 1% alum (potassium or ammonium aluminum sulfate) is
Urothelial malignancies can also cause significant bleeding, helpful. The alum acts as an astringent and precipitates the
which can be controlled by transurethral resection of tumor surface proteins. Aluminum levels must be monitored, partic-
and fulguration with electrocautery in most cases. In patients ularly in patients with renal insufficiency. Severe acidosis
with metastatic or unresectable bladder tumors and severe and encephalopathy can occur in such patients as a result
hematuria, local radiation can be used to palliate the symp- of high aluminum levels. Periodic intravesical instillation of
toms. In some cases, cystectomy or urinary diversion by prostaglandins (PGE2 , PGF2 ) and PGF2 analogs (carbo-
means of percutaneous nephrostomy or conduit urinary diver- prost) have also proved effective. They decrease the inflamma-
sion may be the only viable option. tory response and reduce the hemorrhage. They can be used
A wide range of drugs and industrial toxins can also give prophylactically or therapeutically. Prostaglandin E2 has been
rise to hemorrhagic cystitis. Conservative treatment with ade- used in a dose of 0.75 mg in 200 cc of normal saline instilled
quate hydration, bladder irrigation, and discontinuation of for 4 hours. The effective dose of PGF2 has been 1.4 mg in
the causative agent will suffice as treatment for most cases. 200 cc of normal saline. Carboprost has been used in a dose of
Chemotherapeutic agents are a major cause of hemor- 0.8 mg per dL diluted in normal saline and instilled for 1 hour
rhagic cystitis. Busulfan, alkylating agents such as cyclophos- at 6-hour intervals; good results occurred in 62% of patients,
phamide and isophosphamide, and thiotepa are commonly according to one study (16). Instillation of silver nitrate (0.5%
associated with hemorrhagic cystitis. The incidence ranges to 1.0% solution) for short periods of time followed by saline
from 2% to 40% , and significant mortality rates have also irrigation of the bladder to remove residual silver nitrate is
been reported (15). H emorrhagic cystitis is dose-dependent also an effective technique.
and related to the route of administration of the chemothera- Persistent severe hemorrhage that has not subsided despite
peutic agent (higher with IV administration). It is more severe the above-mentioned measures can be treated with intravesi-
in dehydrated patients. Acrolein, which is a liver metabolite of cal instillation of carbolic acid (phenol) or 1% formalin.
cyclophosphamide, is the principal inciting agent and acts by This requires general anesthesia. Phenol is instilled in a dose of
direct contact with the bladder mucosa. H istological changes 30 cc of a 100% solution mixed with an equal volume of
that occur in the bladder are similar to those seen with radia- glycine for 1 minute. This is washed out with 95% ethanol
tion and include edema, ulceration, neovascularization, hemor- (60 cc) and saline to prevent methemoglobinemia. It is neces-
rhage, and necrosis. Prophylactic hydration and the use of sary to rule out vesicoureteral reflux by performing a voiding
FIGURE 22.5 Algorithm for treatment of hemorrhagic cystitis.
cystourethrogram before using formalin as it can cause fibro- In recalcitrant cases, use of medical antishock trousers and
sis and scarring of the ureters and renal pelvis. If need be, the cryotherapy has been reported (17). Embolization of the hy-
ureters can be occluded with Fogarty balloon catheters to pre- pogastric arteries with autologous clot, Gelfoam, coils, or
vent reflux while formalin is instilled. Fifty milliliters of 1% ethanol can also be resorted to in such cases. This may result
formalin (0.37% formaldehyde) diluted with saline should be in temporary gluteal claudication. O pen ligation of the hy-
instilled for 4 to 10 minutes. This should then be washed out pogastric artery can also be performed. Supravesical urinary
with saline and the saline irrigation continued for 24 hours. diversion by means of percutaneous nephrostomy tubes or
The external genitalia are covered with towels or Vaseline to ileal or sigmoid conduit urinary diversion with or without cys-
prevent irritation. tectomy remains a final but viable option.
References
1. Cass AS, Luxenberg M . Features of 164 bladder ruptures. J Urol 10. Parra RO . Laparoscopic repair of intraperitoneal bladder perforation.
1987;138:743. J Urol 1994;151:1003–1005.
2. Bodner DR, Selzman AA, Spirnak JP. Evaluation and treatment of bladder 11. Cass AS. Diagnostic studies in bladder rupture: indications and techniques.
rupture. Sem in Urol 1995;13:62. Urol Clin N orth A m 1989;16:267.
3. Cass AS. Diagnostic studies in bladder rupture: indications and techniques. 12. Kotkin L, Koch M O . M orbidity associated with non-operative manage-
Urol Clin N orth A m 1989;16:267. ment of extraperitoneal bladder injuries. J Traum a 1995;38:895.
4. Sandler CM . Bladder trauma. In: Pollack H M , ed. Clinical urography. 13. Parsons CL. Successful management of radiation cystitis with sodium pen-
Philadelphia: WB Saunders, 1990:1505–1521. tosanpolysulfate. J Urol 1986;136:813.
5. Carroll PR, M cAninch JW. M ajor bladder trauma: mechanisms of injury 14. N orkool DM , H ampson N B, Gibbons RP, et al. H yperbaric oxygen ther-
and a unified method of diagnosis and repair. J Urol 1984;132:254. apy for radiation induced hemorrhagic cystitis. J Urol 1993;150:332.
6. Peters PC. Intraperitoneal rupture of the bladder. Urol Clin N orth A m 15. Krane DM . H emorrhagic cystitis. A UA Update 1992;11;lesson 31.
1989;16:279. 16. Ippoliti C, Przepiorka D, M ehra R, et al. Intravesicular carboprost for the
7. Corriere JN , Sandler CM . M echanisms of injury, patterns of extravasation treatment of hemorrhagic cystitis after marrow transplantation. Urology
and management of extraperitoneal bladder rupture due to blunt trauma. 1995;46:811.
J Urol 1988;139:43. 17. deVries CR, Freiha FS. H emorrhagic cystitis: a review. J Urol 1990;143:1.
8. Lis LE, Cohen AJ. CT cystography in the evaluation of bladder trauma.
J Com put A ssist Tom ogr 1990;14:386.
9. Schanbacher PD, Rossi LJ, Salem M R, et al. Detection of urinary bladder
perforation during laparoscopy by distension of the collection bag with
carbon dioxide. A nesthesiology 1994;80:680–681.
CHAPTER 23 ■ INTERSTITIAL CYSTITIS/
PAINFUL BLADDER SYNDRO ME
MICHAEL S. INGBER AND KENNETH M. PETERS
Interstitial cystitis/painful bladder syndrome (IC/PBS) is a patients have been clinically diagnosed with urinary tract
chronic, unrelenting condition with considerable morbidity. infections despite negative cultures. O ther misdiagnoses in-
The symptoms were first described in the early 20th century, clude endometriosis, fibroids, or other pelvic disorders, and
and IC/PBS continues to be one of the most commonly missed some have even undergone surgery for them (4). A full dietary
diagnoses in urology (1). While the etiology of IC/PBS has not and fluid history is useful, as certain foods and drinks may ex-
been clearly identified, much is now known about its charac- acerbate IC/PBS symptoms (5). A voiding diary provides ob-
teristics and natural history. The presentation may be variable; jective evidence of daytime and nighttime frequency, and pain
however, the more common symptoms are urinary frequency, symptoms can be recorded with this as well. Sequential void-
urgency, and pelvic pain. Until recently, IC/PBS has been con- ing diaries and symptom questionnaires allow one to deter-
sidered a disease predominantly affecting women; however, mine the impact of various treatments for IC/PBS.
more men are now being diagnosed with this disease. M en A physical examination that includes a thorough pelvic and
presenting with symptoms of genital or perineal pain, fre- neurological examination should be performed. The female
quency, or dysuria are often labeled as having chronic, abacte- pelvic examination should include evaluation for tenderness
rial prostatitis; in fact, many of them suffer from IC/PBS. of the anterior vaginal wall and levator muscles, the ability to
contract and relax the pelvic floor muscles, and the degree of
pelvic relaxation. Urethral fullness, tenderness, or expression
of pus may suggest a urethral diverticulum requiring further
DIAGNO SIS workup. A rectal examination can rule out any rectal abnor-
malities or masses, and in men the prostate should be palpated
Before one can diagnose IC/PBS, causes that can mimic the for nodules or tenderness.
disease must be ruled out. These include bacterial cystitis, A urinalysis, urine culture, and cytology should be per-
overactive bladder, endometriosis, bladder cancer, and urethral formed to exclude active infection or evidence of carcinoma
diverticulum. Defining IC/PBS has been extremely controver- in situ. Sterile pyuria should prompt staining for acid-fast
sial, and to date there remains considerable disagreement bacilli to rule out genitourinary tuberculosis. If microscopic or
among experts. In 1987 and 1988 the N ational Institute of gross hematuria is present, a workup including CT urography,
Diabetes and Digestive and Kidney Diseases (N IDDK) devel- cystoscopy, and urine cytology is required in order to evaluate
oped a research definition for IC/PBS in order to provide ho- for bladder cancer or stone disease.
mogenous groups of patients that may be compared to one In patients with urinary urgency, frequency, or inconti-
another in clinical studies (2). H owever, experts in female nence, a trial of anticholinergics may cause symptoms to sub-
urology and urogynecology have found this definition to be far side. H owever, if symptoms persist, or if pelvic pain or severe
too restrictive, as the majority of patients with IC/PBS were dysuria is present, a cystoscopic evaluation is warranted.
being excluded. According to the International Continence Interstitial cystitis was first described as a distinct ulcer seen
Society, IC/PBS should be suspected in anyone with symptoms on cystoscopic examination. This lesion is typically red,
of suprapubic pain related to bladder filling, accompanied by raised, and friable and can be seen during cystoscopy without
urinary frequency and urgency, in the absence of urinary in- hydrodistention. The lesion is difficult to distinguish from car-
fection or other pathology (3). The European Society for the cinoma in situ, and a biopsy with cauterization of the lesion is
Study of IC/PBS (ESSIC) has developed specific diagnostic cri- warranted. O nly 15% to 20% of patients diagnosed with
teria that are based on a combination of urinary symptoms IC/PBS have an ulcer in their bladder. They are typically older
and bladder findings during cystoscopic evaluation. and have more severe bladder-associated pain and a smaller
Symptoms of IC/PBS are extremely variable and may preanesthetic bladder capacity.
sent as mild irritative symptoms to severe symptoms refrac- In patients in whom a diagnosis of IC/PBS is highly sus-
tory to all standard therapies. Treating the disease early often pected, cystoscopy with hydrodistention under anesthesia may
leads to rapid improvement in symptoms; thus, recognizing reveal petechial hemorrhages and glomerulations, which are
IC/PBS early so that therapy can be initiated is extremely im- found in over 90% of women with the syndrome. H owever,
portant. the presence of petechial hemorrhages alone is not diagnostic,
The diagnosis of IC/PBS begins with a complete history. as they can also be seen in normal men and women (6). A
O nset of symptoms may be days, weeks, or even months. O ften computerized cystometrogram may also be performed to look
150
Chap t e r 23: Inte rstitial Cystitis/ Painful Blad d e r Synd rome 151
for uninhibited contractions and to determine the functional pain, patients who are refractory to standard therapies would
bladder capacity. Some investigators have suggested the use of be candidates for nerve stimulation.
the potassium sensitivity test (PST) to diagnose IC/PBS (7).
The PST is based on the hypothesis that there is increased
epithelial permeability in the bladder of IC patients. H owever,
a significant false-positive rate exists, and many patients will ALTERNATIVE THERAPY
eventually be diagnosed with a normal bladder (8).
Additionally, 17% of women with IC/PBS may have a nega- Establishing a diagnosis of IC/PBS in itself is usually therapeu-
tive test (9). For these reasons, PST should be used only as an tic and alleviates patient frustrations. A multimodality ap-
adjunct during evaluation and diagnosis. proach along with patient education is the most effective
means of treating IC/PBS. Behavioral therapies must be
stressed, such as fluid management, pelvic floor physical ther-
apy, dietary restrictions, and relaxation therapy (13). M any
INDICATIO NS FO R SURGERY patients suffer from pelvic floor spasm, which causes pelvic
pain, dyspareunia, and urinary hesitancy. Treatment by a ther-
Any patient with unexplained urinary urgency, frequency, and apist knowledgeable in myofascial release techniques may be
pelvic pain is a candidate for an operative hydrodistention, of benefit (14). O nce behavioral therapy is optimized, oral
which may be not only diagnostic but also therapeutic. medication is a reasonable first-line treatment for IC/PBS.
Patients with ulcerative disease may benefit from ablation of At the present time, the only oral therapy approved by
the ulcers with cautery or laser (10). the U.S. Food and Drug Administration (FDA) for IC/PBS
Radical surgery for IC/PBS is rarely indicated and should is pentosan polysulfate sodium (Elmiron, O rtho-M cN eil
be used as a last resort. M agnetic resonance imaging (M RI) of Pharmaceuticals), a glycosaminoglycan that binds tightly to
the pelvis may demonstrate a thickened, end-stage bladder the bladder mucosa. Pentosan polysulfate should be consid-
that may be amenable to radical surgery (Fig. 23.1). Patients ered a first-line therapy for IC/PBS; however, because it may
who undergo bladder augmentation or continent diversion require several months before any clinical improvement is
need to be willing and able to perform clean intermittent seen, it should not be used as a single agent for the treat-
catheterization. Additionally, patients must accept that fre- ment of IC/PBS. H ydroxyzine has antihistaminic and an-
quency symptoms may improve but that pain may persist. tianxiety properties and affects mast-cell degranulation,
Diverting the urine without removing the diseased bladder is which may play a role in symptoms of IC/PBS (15).
not always sufficient to relieve the symptoms of IC/PBS. H owever, neither pentosan polysulfate nor hydroxyzine
Therefore, any diversion procedure for pain should be accom- showed high response rates in recent clinical trials (15).
panied by cystectomy (11). Finally, neuromodulation has been M uscle relaxants such as diazepam or low-dose baclofen
effective in treating refractory urinary urgency and frequency may be useful in women with accompanying pelvic floor
(12). Because IC/PBS is a syndrome of urgency, frequency, and spasm, although to date no major studies have been per-
formed on these medicines. Tricyclic antidepressants such as
amitriptyline or imipramine may improve symptoms due
to their anticholinergic and antipain effects (16). Finally,
chronic pain is recognized as a legitimate complaint and
should be treated aggressively. Various narcotics and anti-
inflammatories can be tried, along with nerve blocks or im-
plantable pain pumps, to treat the severe pain that can be
associated with IC/PBS. Cyclosporine has been used in some
clinical trials, but results are inconclusive.
Intravesical therapies have been a mainstay in treatment
for many years. Dimethyl sulfoxide (DM SO ) is the only FDA-
approved intravesical therapy for this disease. DM SO is a
product derived from paper pulp and is mainly used as an in-
dustrial solvent. It is given in the office setting as a 50% solu-
tion in 50 mL of sterile saline. Patients rarely have side-effects,
although they may complain of transient urethral pain or irri-
tation after the first instillation, or a garliclike odor from their
mouth. If effective, symptoms may resolve for months to even
years (17).
Bacille Calmette-Guérin (BCG) is prepared from an attenu-
ated strain of bovine tuberculosis bacillus, Mycobacterium bovis,
and is given intravesically as a 50-mg dose in 50 mL saline so-
lution. While traditionally used for treating carcinoma in situ
FIGURE 23.1 M RI scan of pelvis of 28-year-old woman with end-stage
of the bladder or low-stage urothelial carcinoma, it appeared
interstitial cystitis demonstrating a small, thickened, contracted bladder. to show promise as an intravesical agent in treating IC/PBS. In
(Courtesy of Raymond Rackley, Cleveland Clinic Foundation.) a randomized placebo-controlled clinical trial, 21% of patients
responded to BCG, compared to 12% of placebo. H owever, suggestive of interstitial cystitis. Patients having the ulcerative
the difference was not statistically significant (p 0.062), and form will have distinct inflammatory lesions on cystoscopy
therefore this should not be offered as first-line therapy. called H unner ulcers, and with hydrodistention deep cracks in
O ther second-line agents that have been used include cap- their bladder at the site of ulcers may occur (1) (Fig. 23.3).
saicin, heparin, sodium oxychlorosene, and silver nitrate.
End o sco p ic Re se ct io n o r
SURGICAL TECHNIQ UE
Fulg urat io n o f Ulce rs
Blad d e r Hyd ro d ist e nt io n Approximately 15% of IC/PBS patients comprise the ulcera-
tive subset, and they generally have worse pain and frequency
A complete cystoscopy is performed to assess the urethra and symptoms. A resectoscope with loop electrocautery can be
bladder for any masses, stones, or diverticulae (Fig. 23.2). used to resect these lesions and cauterize the base (18).
After careful inspection, the bladder is filled by gravity drainage Alternatively, the involved areas can be cauterized with a
under anesthesia at 100 cm H 2 O pressure to its capacity. Bugbee electrode, ball electrode, or neodymium:YAG laser.
Upward pressure with a finger along each side of the urethra is The laser is set at 15 W with a firing duration of 1 to 3 sec-
often needed to maximally distend the bladder to prevent onds. The laser fiber is maintained in constant motion over
leakage around the cystoscope. The bladder is distended until the target, and the procedure is completed when the ulcer is
no further water will run into the bladder, and this is allowed completely blanched (10).
to dwell for 2 minutes. The bladder is drained and the volume
measured. The procedure is then repeated a second time.
A normal bladder will accommodate up to (or over) 1 L
under a general anesthetic. O n the other hand, the bladder of
Aug me nt at io n Cyst o p last y
a patient with the ulcerative form of IC/PBS will be less com-
Simple augmentation of the bladder should only be performed
pliant, often stretching to 350 mL. Typically with IC/PBS
if one has an operative bladder capacity with hydrodistention
there is terminal hematuria noted when the bladder is drained.
of 300 cc. The bladder is isolated and a posterior-based U-
Upon reinspecting the bladder, the vast majority of patients
shaped incision is created on the anterior bladder (Fig. 23.4).
will have glomerulations seen in all sectors of the bladder,
A 30-cm segment of distal ileum is isolated in the standard
fashion and opened along its antimesenteric border. The ileal
segment is folded to create a nonperistaltic ileal patch. This is
secured to the anterior bladder with running absorbable su-
ture, effectively increasing the functional capacity of the blad-
der. Patients undergoing an augmentation must understand
that their pelvic pain symptoms may not resolve from aug-
mentation alone. Additionally, because the detrusor is incised,
the emptying mechanism of the bladder is altered, and pa-
tients may need to perform intermittent straight catheteriza-
tion to effectively empty their bladder.
Part ial Cyst e ct o my and

Sub st it ut io n Cyst o p last y
Supratrigonal cystectomy with enterocystoplasty is preferred
over simple augmentation cystoplasty because most of the dis-
eased bladder is removed (19) (Fig. 23.5). This technique
should be reserved for patients with small bladder capacity
found on hydrodistention under an anesthetic ( 300 mL).
Patients with a primary pain complaint are not good candi-
dates for supratrigonal cystectomy, particularly if the pain is
urethral in nature. In addition, patients should be able to per-
form intermittent straight catheterization and bladder irriga-
tion in case of poor emptying or mucus formation.
The patient is placed in a supine position and a Foley
FIGURE 23.2 H ydrodistention is carried out with the irrigation bag
hung 100 cm above the level of the bladder. Bladder capacity is reached catheter is placed sterilely in the bladder. The peritoneal cavity is
when irrigant flow stops. During filling, the bladder mucosa is typically entered through a vertical midline incision, and an appropriate
normal-appearing. After 2 minutes of distention, the bladder is drained segment of either large or small bowel with a mesentery long
and the capacity is measured. At the termination of bladder emptying, enough to reach down to the bladder is selected. The preferred
the irrigant fluid is often blood-tinged or grossly hemorrhagic in pa-
tients with interstitial cystitis (IC). Repeat cystoscopy will demonstrate
bowel segments are the cecum, sigmoid colon, or ileum. The
diffuse glomerulations in all sectors of the bladder consistent with IC. bladder is filled via the Foley catheter and divided using a
Repeat hydrodistention is performed to maximally distend the bladder. clamshell technique, exposing the trigone. Ureteral catheters are
A B
C D
FIGURE 23.3 A: N ormal appearance of the bladder urothelium before hydrodistention in a patient with
symptoms consistent with interstitial cystitis. B: Same patient following hydrodistention. The urothelium is ab-
normal, revealing minimal to moderate glomerulation. C: Cystoscopic appearance of a patient with moderate
glomerulations and submucosal hemorrhage. D: H unner ulcer with marked hemorrhage surrounding the ulcer.
This patient was successfully treated with neodymium:YAG laser ablation therapy.
placed before resection of the bladder to avoid injury to the

ureters. Using electrocautery, a supratrigonal cystectomy is per- To t al Cyst e ct o my w it h O rt ho t o p ic
formed, resecting all but a 1- to 2-cm cuff of bladder that in- Ne o b lad d e r o r Urinary Dive rsio n
cludes the trigone and bladder neck. Placing Allis clamps on the
edges of the remaining bladder controls hemostasis. The vesi- A total cystectomy has the benefit of removing the entire dis-
coenteric anastomosis is completed using a single-layer running eased bladder and may be the treatment of choice for the pa-
closure of 3-0 Vicryl suture. A 22Fr Foley catheter is placed tient with an “ end-stage” bladder. The choice of performing a
through the bowel segment and used as a suprapubic tube. Both continent versus incontinent diversion is based mainly on pa-
tubes are kept to dependent drainage for 21 days, when a cys- tient preference. If a patient has significant urethral symp-
togram is performed to ensure the integrity of the anastomosis. toms, an orthotopic neobladder may not be the preferred
The patient is then started on intermittent catheterization. conduit. The benefits of continent diversions are obvious;
FIGURE 23.4 Ileal augmentation cystoplasty. A: A posterior-based

U-shaped incision is created on the anterior bladder. B: Completion of
the posterior-based bladder flap. C: A 30-cm segment of the distal ileum
is isolated and divided along the antimesenteric border. D: The ileal seg-
ment is then folded and the posterior surface is closed completely with
a running absorbable suture. The anterior segment is partially closed.
E: Completed ileal bladder anastomosis.
however, there have been reports of IC/PBS developing in the M inneapolis, M N ) is approved by the FDA for urinary ur-
continent bowel segments. An informed and motivated patient gency, frequency, urge incontinence, and idiopathic urinary re-
would be the best candidate for a continent diversion. The tention. Preoperatively, the efficacy of sacral nerve stimulation
techniques of cystectomy and urinary diversion, including is determined by a test performed prior to placing a perma-
complications, are described elsewhere. nent generator. If patients experience at least a 50% improve-
ment in their symptoms and desire a permanent implant, an
implantable generator can be placed permanently in a subcu-
Sacral Ne rve St imulat io n taneous pocket in the upper buttocks. Patients have an exter-
nal programmer to control the degree and frequency of
Chronic inflammation in a pelvic organ may lead to nerve stimulation.
upregulation to the spinal cord, affecting all pelvic struc- InterStim therapy has evolved since its approval in the
tures. Sacral nerve modulation (InterStim, M edtronic, Inc, United States in 1997. Initially, a percutaneous lead was
B
A
FIGURE 23.5 Technique of subtotal cystectomy and substitution cystoplasty. A: The bladder is being bi-
valved with electrocautery. B: View of the bladder with both ureteral orifices cannulated with ureteral
catheters to avoid injury to ureters during bladder resection. C: Completion of subtotal cystectomy with only
a small cuff of bladder remaining, which consists of the urethra, bladder neck, and trigone. D: Completed
anastomosis of the bowel onto the bladder cuff. A Foley catheter (not shown) and a suprapubic tube are
placed to ensure adequate drainage during the immediate postoperative period.
placed in the sacral foramen under local anesthetic in the response. The most significant advance with InterStim therapy
office, and the lead was taped to the skin. The patient was dis- is the introduction of a tined permanent quadripolar lead, al-
charged to home with an external stimulating box, and the lowing for percutaneous placement of the permanent lead for
lead was stimulated for 3 to 5 days while voiding diaries were the test period. The most common procedure for InterStim
kept. The lead was then removed, and patients responding to therapy is a “ staged implant.”
the test were candidates for a permanent implant that was per-
formed in the operating room under a general anesthetic. The
permanent implant was relatively complicated because it re- St ag e d Imp lant
quired exposing the periosteum of the sacrum, dissecting the
foramen, and securing the permanent lead to the bone after The patient is given broad-spectrum antibiotic coverage,
testing for muscle response. This lead was then connected to lightly sedated, and placed in the prone position on the oper-
an implantable pulse generator placed in a subcutaneous ating room table. The lower back and buttocks are prepped
pocket under the upper buttocks. and draped. Fluoroscopy is used to mark the midline of the
Several problems were identified with the percutaneous sacrum and the inferior border of the sacral iliac junction.
testing/implant technique. These included migration of the This intersection corresponds to the area of the S3 foramen. A
percutaneous lead resulting in an inadequate test period, un- mark is made 2 cm lateral and superior to this intersection, the
comfortable sensory response when the permanent lead was area is infiltrated with lidocaine, and the foramen needle is ad-
placed under a general anesthetic, the morbid nature of plac- vanced at a 60-degree angle into the S3 foramen with fluoro-
ing the permanent lead, and the inability to duplicate place- scopic guidance (Fig. 23.6). Current is applied to the needle,
ment of the permanent lead in the identical location of and the motor and sensory response is assessed. An ideal mo-
the temporary percutaneous lead, resulting in a poor clinical tor response is good levator ani contraction in the form of
Foramen
needle 1 cm 9 cm
S3 foramen
Coccyx FIGURE 23.6 Insertion of a foramen needle through

the S3 foramen in preparation for testing the motor
Sacral plexus and sensory responses.
anal bellows, sacral flattening, and minimal dorsiflexion of and the needle is removed. The lead introducer is advanced
the greater toe from stimulation of the S3 portion of the me- over the guide wire, through the dorsolumbar fascia and the
dial plantar nerve. The patient should be alert enough intraop- foramen, and below the bone plate. The trocar is removed,
eratively to report a gentle tapping or pulsating sensation in and the permanent quadripolar lead is advanced through the
the rectal, vaginal, or perineal region. If the stimulation is lead introducer (Fig. 23.7). Fluoroscopy is used to confirm
painful, the lead should be readjusted in the operating room. that all four stimulation points lie beneath the sacral bone
To confirm S3 placement, a needle is always passed into the plate. The patient remains awake and sensory, and motor re-
foramen superior to the first. Stimulation of this lead results in sponses are assessed with stimulation of each electrode. After
leg rotation consistent with S2 placement, and this ensures S3 confirming good lead placement, the lead introducer is re-
placement of the first electrode. N ext, a small skin nick is moved under fluoroscopy, deploying the tines to secure the
made alongside the needle, through the dermis of the skin. A lead. A site on the ipsilateral upper buttocks is chosen where
directional guide wire is passed through the foramen needle, a future permanent generator will be placed if the patient
Tined
lead
Lead
Facial
dilator sheath
FIGURE 23.7 Stage I implant. Advancement of perma-

nent tined lead through the lead introducer parallel to
the nerve (see inset). M otor and sensory response tested
and lead introducer removed, deploying the tines and
securing the lead.
Temporary
extension
lead
External
generator
Generator
FIGURE 23.8 Stage I implant. The lead is tunneled to a small, subcu-

taneous pocket on the ipsilateral side. The lead is then connected to a
temporary extension lead, which is tunneled to the contralateral side
and externalized. The external generator is then connected to the ex-
tension lead. The patient is discharged to home, and sacral nerve stim-
ulation is tested over a 14- to 21-day period. Voiding logs and pain FIGURE 23.9 Stage II implant. Patients not responding to the ther-
scores are maintained, and the program is changed as needed to max- apy have the lead removed. Responders have the extension lead re-
imize the clinical response. moved, the ipsilateral subcutaneous pocket extended, and the
generator placed. The generator is then programmed to the settings
that gave a good clinical response during the test phase.
responds to therapy. A small (2-cm) transverse incision is
made and a subcutaneous pocket created. The proximal end
of the lead is then tunneled to this pocket using the lead intro-
ducer. The permanent lead is then connected to a temporary Pud e nd al Ne uro mo d ulat io n
extension wire, and the distal end of the wire is tunneled to the
contralateral upper buttocks and externalized (Fig. 23.8). Stimulation of the pudendal nerve, as with sacral nerve stimu-
O ne of four electrodes is chosen for initial outpatient stim- lation, affects the sacral nerve roots of S2, S3, and S4.
ulation, and the patient is discharged wearing the standard ex- M ultiple studies have shown inhibition of the micturition re-
ternal generator for 2 weeks. The permanent lead allows for flex with afferent pudendal stimulation, which also results in
four different points of stimulation along the nerve. Variables an increase in bladder capacity, and a decrease in uninhibited
such as rate, pulse width, and voltage can be adjusted by the bladder contractions (20,21). Devices used to stimulate the
patient with guidance from the clinician over the phone. The pudendal nerve include InterStim and the BIO N device
patient monitors voids per day, voided volume, urge scores, (Advanced Bionics, Valencia, CA). At the present time, how-
incontinence episodes, and pelvic pain during the 2-week test ever, neither of these nerve stimulation devices is FDA-
period. Responders are considered those with at least a 50% approved for use at the pudendal nerve. N evertheless, some
improvement in symptoms and the desire for a permanent im- studies have shown promise in using the pudendal nerve as a
plant based on improvement in quality of life. N onresponders site of stimulation in patients with urinary urgency, frequency,
have the leads removed, and responders have a permanent and pelvic pain (22). The electrode is implanted along the
generator placed. Permanent generator placement in the course of the pudendal nerve toward Alcock’s canal, at the
staged technique involves extending the incision and subcuta- level of the ischial spine. Intraoperative monitoring of EM G is
neous pocket in the ipsilateral buttocks, removing the tempo- used to confirm pudendal nerve stimulation. The exact tech-
rary extension lead, and connecting the permanent generator nique is described elsewhere.
(Fig. 23.9). At the end of the procedure, the generator is pro- In a recent single-blind crossover trial, patients had both
grammed to the settings to which the patient responded dur- sacral and pudendal tined leads placed. Each was stimulated
ing the test stimulation so that there is no interruption in in random order. In responders ( 50% improvement in their
therapy. symptoms), the “ better” lead was chosen by the patient (Fig.
Currently, a smaller generator is available that may be eas- 23.10). Pudendal lead placement took a mean of 19.6 minutes
ier to implant and more comfortable for patients. Battery life compared to 27.4 minutes for sacral leads (p 0.039). O f 22
on this smaller device is 4 years, compared to 8 years for the patients involved in the study, 17 (77% ) had a permanent gen-
larger generator. Regardless, patients must be aware that they erator placed. The mean Interstitial Cystitis Symptom Index
will require replacement of their generator later in life. score decreased from 14.3 preoperatively to 10.7 at 6 months
postoperatively in the sacral nerve stimulation group (p

0.03) and decreased from 15.7 to 8.6 in the pudendal group
(p 0.009). The decrease in the Interstitial Cystitis Problem
Index was statistically significant only for the pudendal group,
with a decrease from 12.9 to 7.5 at 6 months (p 0.002).
Average preoperative frequency was 24.07 per 24 hours for
both groups. At 6 months, the mean total 24-hour voids de-
creased to 13.94 in the sacral group (p 0.001) and to 12.84
in the pudendal group (p 0.001). M ean voided volume in-
creased from the preoperative value of 81.8 mL to 152.8 mL
in the sacral group (p 0.001) and to 158.0 in the pudendal
group (p 0.001). O f patients having a permanent generator
placed, the majority (77% ) chose to have the pudendal lead
permanently implanted (22). N evertheless, further studies
with larger numbers are needed to determine if pudendal
nerve stimulation is as effective or better at reducing urgency,
frequency and pain symptoms than sacral stimulation.
Po st e rio r Tib ial Ne rve St imulat io n

The tibial nerve arises from L4 through S3 and is a branch of
FIGURE 23.10 Postoperative photograph showing both sacral and the sciatic nerve. As with sacral and pudendal stimulation, it is
pudendal leads in place. The pudendal lead was chosen by the major- possible to stimulate the posterior tibial nerve and modulate
ity of patients in a randomized, single-blind crossover study. the innervation to the bladder, urinary sphincter, and pelvic
60°
FIGURE 23.11 N euromodulation of the posterior tibial nerve. A 34-gauge acupuncturelike needle is
inserted approximately 3 to 4 cm deep to the tibial nerve for stimulation.
floor (23,24) (Fig. 23.11). The technique stimulates the posterior TA B LE 2 3 . 2

tibial nerve with a 34-gauge needle placed bilaterally at SP-6.
The needles are placed approximately 4 cm deep at a 30- COMPLICATION S OF MAJOR BLADDER
degree angle cephalad. An adhesive grounding electrode is ap- RECON STRUCTIVE SURGERY
plied on each side near the medial calcaneus. Stimulation of EARLY
the posterior tibial nerve is done by an amplitude of 0.5 to
10.0 mA, with a fixed pulse width (200 s) and frequency (20 Ileus
H z). Stimulation is applied for 30 minutes. The stimulation Intraperitoneal abscess
needs to be done on a weekly basis for 12 weeks, after which Upper-tract obstruction
an attempt to wean treatments to once a month is tried. Thromboembolic events
Unfortunately, there are no sham studies done on posterior Pneumonia
tibial nerve stimulation for voiding dysfunction, so its use re- Wound infection
mains in question.
Cardiac events
Difficulty with catheterization
Cyt o lysis LATE
Bladder denervation procedures have been reported in the Persistence of interstitial cystitis symptoms
treatment of patients with intractable bladder pain and uri- Upper-tract deterioration
nary frequency and urgency (25). Division of the posterior Urolithiasis
sacral roots, posterior rhizotomy, or division of the inferior M etabolic abnormalities
vesical neurovascular pedicle may result in temporary im- Spontaneous rupture of bowel conduit
provement in urinary frequency, urgency, and pain. Difficulty with catheterization
Ingelmann-Sundberg described a more selective denervation in Ureteral stenosis
which a transvaginal approach is used to resect the inferior
Ureteral reflux
hypogastric plexus, dividing both the sympathetic and
N eoplasia
parasympathetic fibers (25). Candidates for the transvaginal
denervation are selected by first performing a subtrigonal in- Bladder neck contracture
jection of bupivacaine, which, if successful, results in signifi- Urinary incontinence
cant relief of their irritative symptoms. H owever, with the Pyelonephritis/urinary tract infection
advent of more oral therapies, along with neuromodulation,
denervation is mainly mentioned in this section for its histori-
cal significance.
and repair are warranted to prevent peritonitis from urine
leakage in the peritoneal cavity.
O UTCO MES Early and late complications secondary to major bladder
reconstruction are listed in Table 23.2. Persistence of IC/PBS
symptoms is probably the most common and disheartening
Co mp licat io ns outcome for both the patient and surgeon.
The major risk of selective denervation cytolysis is ureteral
Complications of hydrodistention with or without fulguration
injury during the vaginal dissection and is avoidable by plac-
are listed in Table 23.1. The most serious complication is blad-
ing ureteral catheters.
der rupture, which should be considered if there is resumption
N o serious, irreversible, adverse events have been reported
of fluid inflow after maximally distending the bladder, return
with sacral nerve stimulation. Complications associated with
of significantly less fluid than what was instilled upon bladder
InterStim are listed in Table 23.3. Reoperation occurs in ap-
drainage, or severe suprapubic or abdominal pain or disten-
proximately 25% of patients undergoing sacral nerve implan-
tion. If a bladder rupture is suspected, an immediate cys-
tation. Causes for reoperation include sensory discomfort,
togram should be performed. If the rupture is extraperitoneal,
prolonged Foley catheter drainage is usually all that is needed
to allow the rupture to heal spontaneously. If intraperitoneal TA B LE 2 3 . 3
leakage of contrast is seen, however, immediate exploration
COMPLICATION S OF IN TERSTIM
N EUROMODULATION THERAPY
TA B LE 2 3 . 1
Pain at generator site
COMPLICATION S OF BLADDER HYDRODISTEN TION Infection
AN D FULGURATION OF ULCERS
Lead migration
Gross hematuria Transient electric shock
Bladder rupture of perforation Pain at lead site
Urinary tract infection Change in bowel function
Exacerbation of bladder symptoms Device malfunction
Bowel perforation Change in menstrual cycle
lead migration, device failure, pocket revision, and infection. not need to be removed prior to placing the generator, and the
Infection of the device requiring explantation occurs infre- settings that worked on the temporary generator can be pro-
quently, in 5% of patients in a recent review of a large series grammed into the permanent implanted neurostimulator so
(26). Perioperative, broad-spectrum antibiotic coverage dur- that there is no interruption in therapy. Twenty-six patients
ing implantation of the lead and generator should be adminis- with refractory IC/PBS who had failed six previous treatments
tered to decrease the rate of infection. for their disease were implanted with a permanent generator.
With a mean follow-up of 5.6 months, 96% of patients said
they would undergo the implant again and would recommend
Re sult s the therapy to a friend. Significant improvements were seen in
the number of day voids (47% ) and nocturia (60% ). The ma-
Symptoms of IC/PBS may worsen for 2 to 3 weeks after a hy- jority of patients reported at least a 50% improvement in fre-
drodistention. Approximately 40% to 50% of IC/PBS patients quency (72% ), urgency (68% ), pelvic pain (71% ), pelvic
undergoing a hydrodistention will have prolonged symptom pressure (67% ), quality of life (76% ), incontinence (69% ),
improvement. If symptoms improve significantly for at least 4 and vaginal pain (60% ). N o patients showed a 50% wors-
to 6 months, repeat bladder hydrodistention may be indicated. ening in any symptom. The overall reoperation rate was
Fulguration of H unner ulcers improves symptoms in over 11.5% (3 of 26). An objective measurement of pain improve-
80% of patients undergoing this therapy. The improvement in ment was reported. Twenty IC/PBS patients with pelvic pain
pain is usually seen in the first 2 to 3 days and may be long- had a permanent implant placed with a median follow-up of
lasting. For those who relapse, repeat fulguration of ulcers 272 days. Seventeen of 20 (85% ) used chronic narcotics prior
usually yields a similar response. to implant. N ineteen of 20 (95% ) reported moderate or
The more aggressive, open surgical approaches have shown marked improvement in pain after implantation of a perma-
good results in carefully selected patients. Relief of symptoms nent generator. M orphine dose equivalents (M DEs) decreased
in patients undergoing reconstructive surgery ranges between from 86 mg per day to 56 mg per day (34% ) (p 0.015) after
60% and 90% . Patients with ulcerative disease have been reimplant, and 24% stopped all narcotics.
ported to have better results. Although a significant percentage In a recent prospective study, patients with symptoms of
of this highly select group of patients who undergo cystectomy IC/PBS refractory to more conservative treatments were fol-
will experience significant relief, there are reports of patients lowed after having InterStim implanted. At 14 months follow-
having persistent pelvic pain despite having no pelvic organs. up, mean voided volume increased from 111 mL to 264 mL,
Recently, we reviewed our experience with sacral nerve mean daytime frequency decreased from 17.1 to 8.7, and
modulation for refractory IC/PBS (27). When a traditional test mean nighttime voids decreased from 4.5 to 1.1. Additionally,
was performed with a temporary lead, we had a test-to- pain and symptom scores, measured using the Interstitial
implant rate of 52% versus a 94% test-to-implant rate in the Cystitis Symptom and Problem Indices, all improved. O verall,
staged approach. The benefit of the staged test is that the per- 16 of 17 patients who underwent permanent implantation
manent lead is more programmable and can be tested for an (94% ) had improvement in all parameters at their most recent
extended period of time. If a response is found, the lead does postoperative visit (28).
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10. Rofeim O , H om D, Freid RM , et al. Use of the neodymium:YAG laser for pudendal nerve afferents. N eurourol Urodynam 1986;5:381–389.
interstitial cystitis: a prospective study. J Urol 2001;166:134–136. 22. Peters KM , Feber KM , Bennett RC. A prospective, single-blind, random-
11. N eulander EZ , Rivera I, Eisenbrown N , et al. Simple cystectomy in patients ized crossover trial of sacral vs pudendal nerve stimulation for interstitial
requiring urinary diversion. J Urol 2000;164(4):1169–1172. cystitis. BJU Int 2007;100(4):835–839.
23. Van Balken M , Vandoninck V, Gisolf K, et al. Posterior tibial nerve stimu- 26. H ijaz A, Vasavada SP, Daneshgari F, et al. Complications and trou-
lation as neuromodulative treatment of lower urinary tract dysfunction. J bleshooting of two-stage sacral neuromodulation therapy: a single-institu-
Urol 2001;166:914–982. tion experience. Urology 2006;68(3):533–537.
24. Vandoninck V, van Balken M , Finazzi A, et al. Posterior tibial nerve stimu- 27. Peters KM , Carey JM , Karstardt DB. Sacral neuromodulation for the treat-
lation in the treatment of urge incontinence. N eurourol Urodynam 2003; ment of refractary interstitial cystitis: outcomes based on technique. Int
22:17–23. Urogynecol J 2003;14:223–228.
25. Ingelmann-Sundberg A. Partial bladder denervation in the treatment of in- 28. Comiter CV. Sacral neuromodulation for the symptomatic treatment of re-
terstitial cystitis in women. In: H anno PM , Staskin DR, Krane RJ, et al., fractory interstitial cystitis: a prospective study. J Urol 2003;169(4):
eds. Interstitial cystitis. London: Springer-Verlag, 1990:189. 1369–1373.
SECTIO N III ■ PRO STATE
RANDALL RO WLAND
CHAPTER 24 ■ ANATO MY O F THE PRO STATE

SAM D. GRAHAM, JR.
The normal prostate is a firm, elastic organ located immedi- The urethra runs completely through the prostate, al-
ately below the bladder and resting on the superior layer of though the path is angled approximately 45 degrees at the
the urogenital diaphragm to which it is firmly attached. The verumontanum. The verumontanum represents the terminal
normal adult prostate is approximately 4 cm in length and end of the ejaculatory ducts as they course through the
4 to 5 cm in width. It is traversed throughout its length by the prostate from the seminal vesicles/vas deferens (Fig. 24.1).
urethra and ejaculatory ducts entering at the base and termi- The opening in the apex of the verumontanum is known as the
nating in the posterior prostatic urethra. prostatic utricle. In addition, there are a series of ductal open-
In the past the prostate has been divided into three to seven ings directly into the prostatic urethra from the prostatic
lobes. M ost commonly, these segments are the two lateral glands. The urethra exits the prostate at the apex, and
lobes, a median lobe, a posterior lobe, and an anterior lobe. although the anatomical drawings traditionally show the apex
With the advent of ultrasound, the anatomy is now defined as a directly on the pelvic floor, dissections during radical prostate-
transition zone comprised of periurethral glands and a periph- ctomies show that there is approximately a 1-cm gap from the
eral zone or true prostate. Anatomically, no true lobar anatomy apex to the pelvic floor.
exists, and the prostate has been shown to have the two con-
centric areas seen on ultrasound. The peripheral zone is mostly
posteriorly located and is comprised of long, branched glands
from which most carcinomas are thought to arrive. The central VASCULAR ANATO MY
zone is comprised of submucosal glanduloductal units and
short glands from which prostatic hypertrophy is thought to The prostatic blood supply comes predominantly from the in-
arise. Scattered throughout the prostate are smooth muscle ternal iliac artery and is a series of lateral pedicles, the most
fibers that are thought to be involved in ejaculation. prominent and constant of which is the pedicle at the base of
The prostate has a tough capsule of fibrous tissue and mus- the prostate (superior prostatic artery). Additional branches
cular elements that completely envelops the prostate and is may also exist, usually at the apex of the prostate (Fig. 24.2).
densely adherent to it. This capsule is actually aglandular pro- The superior prostatic artery enters just below the bladder
static tissue that is connected to the acini and inseparable from neck and forms two branches, one to the capsule and the other
the parenchyma. This is surrounded by a periprostatic fascia. to the urethra. As patients age, the latter becomes more
There are significant fascial investments around the prominent with prostatic enlargement (2). O ther sites of ori-
prostate. The endopelvic fascia is a continuation of the en- gin for the prostatic artery are the internal pudendal, the supe-
doabdominal fascia. In the pelvis, there are three parts of this rior vesical, or the obturator artery.
fascial plane (1). The parietal layer covers the muscles lining The past 20 years have emphasized the “ nerve-sparing”
the pelvic wall (piriformis and obturatorius internus) and con- technique for both prostatectomy and cystectomy. This opera-
tinues superiorly to connect with the transversalis and iliop- tion is actually a neurovascular-sparing technique that in-
soas fascias. All somatic nerves except for the obturator nerve volves separating the neurovascular bundle from the prostate.
are beneath this fascial layer. A thickening of this fascia ex- The neurovascular bundle can be located along the posterior
tending from the pubis to the ischial spine is known as the ar- lateral prostate at the base of the prostate beneath the anterior
cus tendineus. The second portion of the endopelvic fascia layer of Denonvilliers fascia. M ore distally, the neurovascular
(diaphragmatic portion) covers the two muscles on each side bundle crosses the apex of the prostate and enters the pelvic
of the pelvis that make up the pelvis diaphragm (coccygeus diaphragm posterolaterally to the membranous urethra.
and levator ani). A third (visceral) portion of the endopelvic The venous drainage of the prostate is via the anterior ve-
fascia is continuous with the diaphragmatic fascia and extends nous plexus (Santorini), which is found on the anterior and
upon the pelvic organs for a variable distance, blending into lateral prostate. This plexus receives blood from the dorsal
their fibrous coats. Anteriorly, the endopelvic fascia coalesces vein of the penis and empties into the hypogastric vein.
into the medial puboprostatic ligaments connecting the pubis
to the prostatic capsule. The lateral puboprostatic ligaments
extend from the superior diaphragmatic layer of the en-
dopelvic fascia to the prostate. LYMPHATIC ANATO MY
Posteriorly, the prostate is invested by the two layers of
Denonvilliers fascia, which embryologically is derived from The lymphatic drainage of the prostate is predominantly along
the peritoneum. The posterior layer exists as the rectal fascia, the path of the prostatic artery, with the primary nodal drop
while the anterior layer fuses laterally to the endopelvic and site being the obturator nodes. O ther potential sites of nodal
periprostatic fascia. metastases include the external iliac and presacral nodes.
163
164 Se ct io n III: Prostate
FIGURE 24.1 Relationship of the prostate and the sem-

inal vesicles.
A B
FIGURE 24.2 Vascular anatomy of the prostate. A: Arterial anatomy. B: Venous anatomy.
skin of the perineum, the superficial (Camper) fascia and the

NEURO ANATO MY deep (Colle) fascia. The latter is attached to the ischiopubic
rami and the border of the urogenital diaphragm and is con-
The prostate has sympathetic, parasympathetic, and somatic
tinuous with the Scarpa fascia. The most superficial pelvic
innervation. The sympathetic innervation is from L1 and L2
musculature includes the ischiocavernosus, the bulbocaver-
via the superior hypogastric plexus. The parasympathetic and
nosus, the superficial transverse perineal muscles, and the
somatic innervation is from S2,3,4 via the inferior hypogastric
external anal sphincter (Fig. 24.4). These muscles are united in
plexus and pudendal nerves, respectively.
the midline as a central tendon (perineal body) and function as
a single muscle. This central tendon is attached to the bulb of
CO NTIGUO US STRUCTURES the rectum by fibrous bands of muscle known as the rectus
urethralis (3). Beneath this layer of muscles is the deep per-
The prostate is inferior to the bladder and anterior to the rec- ineal compartment that is predominantly the urogenital dia-
tum (Fig. 24.3). The perineal anatomy is a complex of muscles phragm, which is attached to the inferior rami of the ischia
and tendons that comprise the pelvic floor, beginning from the and pubis.
Chap t e r 24: Anatomy of the Prostate 165
Plexus of santorini
Vesical
plexus
Rectal wall
Pudendal Prostatic capsule

plexus
Anterior and
posterior layers of
Denonvilliers fascia
FIGURE 24.3 Relation of prostate to surround-

Urogenital diaphragm ing structures.
Scrotal
nerves
Scrotal artery
Ischiocavernosus
muscle
Perineal artery
Adductor
Superficial transverse magnus muscle
perineal muscle
Pudendal nerve Perineal nerve
Levator ani
muscle
Gluteus
maximus
muscle
Inferior rectal artery Inferior
rectal nerve
FIGURE 24.4 Pelvic nerves and musculature.
References
1. H ealey JE. A synopsis of clinical anatom y. Philadelphia: WB Saunders, 3. Weyrauch H M . Surgery of the prostate. Philadelphia: WB Saunders, 1959.
1969.
2. Brendler H . Prostatic hypertrophy and perineal surgery. In: Glenn JF, ed.
Urologic surgery. H agerstown, M D: H arper & Row, 1975.
CHAPTER 25 ■ SURGERY FO R BENIGN
PRO STATIC HYPERTRO PHY
BRIAN R. MATLAGA AND JAMES E. LINGEMAN
The prevalence of benign prostatic hypertrophy (BPH ) is an

age-dependent phenomenon; by 60 years of age its prevalence DIAGNO SIS
is 50% , and by age 85 it has been reported to be as high as
90% (1). The natural history of BPH is generally considered The AUA guidelines on the management of BPH explicitly
to be one of progression, with mild symptoms becoming in- define the appropriate evaluation of patients with LUTS, and
creasingly more bothersome over time. It has been reported the following recommendations are based on the meta-
that among 50-year-old men the lifetime incidence of surgical analytic data presented in these guidelines (Table 25.1) (3). A
or medical intervention for BPH may be as high as 35% (1). validated questionnaire, such as the AUA Symptom Index or
Wasson et al. found that in a 3-year, multicenter, randomized the International Prostate Symptom Score (IPSS), will better
controlled trial comparing men with moderate symptoms of quantify the effect of patients’ LUTS on their quality of life.
BPH treated by either watchful waiting or transurethral resec- All patients should undergo a screening urinalysis, and
tion of the prostate (TURP), 24% of men in the watchful wait- serum prostate specific antigen (PSA) should be measured as a
ing arm underwent surgical intervention (2). screening for prostate cancer. Urinary flow-rate measures and
A century ago, open suprapubic prostatectomy was consid- quantification of postvoid residual urine may provide addi-
ered the standard treatment of men with severe symptoms of tional data, particularly for those patients with a complex
BPH requiring removal of the adenoma. Subsequently TURP medical history or those undergoing surgical therapy. A cys-
was developed and became the first significant “ minimally toscopy or transrectal ultrasound is not mandatory before a
invasive surgical procedure.” M ore recently, a number of surgical treatment, but both can provide valuable information
alternative surgical therapies have been introduced to treat for preoperative planning.
men with BPH , most prominently the laser-based therapies.
The American Urologic Association (AUA) convened a clinical
guidelines panel that, following a meta-analysis of the pub- INDICATIO NS FO R SURGERY
lished literature, determined that for patients with significant
lower-urinary-tract symptoms (LUTS) due to BPH , surgical There are certain absolute indications for surgical treatment of
intervention is an appropriate treatment and that selection of BPH (Table 25.2). Typically, however, the management of
the surgical modality should be based upon the surgeon’s patients depends on the degree of inconvenience they experi-
experience, the patient’s individual prostatic anatomy, and ence from their LUTS. The AUA clinical guidelines on BPH rec-
medical comorbidities (Fig. 25.1). ommend that men who experience nonbothersome symptoms
FIGURE 25.1 Treatment options for patients with BPH ,

as plotted with regards to increasing invasiveness and
increasing efficacy.
166
Chap t e r 25: Surg e ry for Be nig n Prostatic Hyp e rtrop hy 167
TA B LE 2 5 . 1 TA B LE 2 5 . 3
IN ITIAL EVALUATION OF MEN WITH LUTS TREATMEN T OPTION S FOR PATIEN TS
WITH SYMPTOMS OF BPH
• AUA Symptom Index Q uestionnaire
• M edical history • Watchful waiting
• O ther causes of voiding dysfunction • M edical therapy
• M edical comorbidities • Alpha-adrenergic blockers
• Physical examination • 5 alpha reductase inhibitors
• Digital rectal examination • Combination therapy
• Laboratory studies • M inimally invasive therapies
• Urinalysis • Transurethral microwave treatment
• Serum PSA • Transurethral needle ablation
• Diagnostic studies • Surgical therapies
• Urinary flow rate • Transurethral resection of the prostate (TURP)
• Postvoid residual urine volume • Transurethral incision of the prostate (TUIP)
• Cystoscopy • H olmium laser enucleation of the prostate (H oLEP)
• Transrectal ultrasound for prostate volume • Laser ablation: holmium:YAG or potassium titanyl
phosphate (KTP)
• O pen prostatectomy: suprapubic or retropubic
TA B LE 2 5 . 2
hypothesis that the symptoms of BPH are potentiated by the
IN DICATION S FOR TREATMEN T OF BPH alpha-adrenergic–mediated contraction of prostatic smooth
muscle. Five alpha reductase inhibitors block the conversion
• Refractory urinary retention
of testosterone to dihydrotestosterone, which can reduce
• Persistent gross hematuria
prostate size and BPH symptoms. Both therapies have been
• Bladder calculi studied extensively, and they may be most appropriately used
• Recurrent urinary tract infections for patients who experience mild inconvenience related to the
• Renal insufficiency symptoms of BPH .
• M oderate or severe LUTS
Minimally Invasive The rap y

These therapies typically are available for the treatment of
of BPH should not be managed surgically. Patients with bother-
patients with symptomatically bothersome BPH . M any of
some symptoms should undergo treatment, and the physician
these minimally invasive treatments rely on the administration
should review the benefits and risks of all approaches and
of high temperatures to produce coagulation necrosis of the
interventions with the patient.
prostate tissue. Ultimately, the goal of such hyperthermic
treatment is to enlarge the prostatic fossa, similar to a surgical
ALTERNATIVE THERAPY debulking but without the morbidity of surgery. Transurethral
microwave thermotherapy (TUM T) is likely more effective
There are a number of alternative therapies besides surgery for than medical therapy in reducing patients’ LUTS, but it is
BPH (Table 25.3). likely less effective than surgical therapy.
Transurethral needle ablation (TUN A) also affects prostate
tissue by a thermal mechanism, but with this intervention heat
Wat chful Wait ing is delivered via radiofrequency energy. A TUN A procedure
involves cystoscopically placing two needles directly into the
Some patients experience certain mild symptoms related to
prostate by piercing the urethra and then administering
BPH . For such patients, the risks may outweigh the benefits
radiofrequency energy that heats the prostate tissue to 100°C.
they may achieve from the therapy. With watchful waiting,
As with microwave therapy devices, TUN A induces a coagula-
patients are monitored by their urologist but do not receive
tive necrosis effect. The efficacy of TUN A is comparable to
any active treatment. Such patients are examined on a regular
that of microwave thermotherapy.
basis to monitor for progression of symptoms, when a more
active intervention can be discussed.
Surg ical Te chniq ue s
Me d ical The rap y Transure t hral Incisio n o f t he Pro st at e (TUIP) and
There are two main medical therapies for patients with Transure t hral Re se ct io n o f t he Pro st at e (TURP)
symptoms of BPH : alpha-adrenergic blockers and 5 alpha re- The patient is placed in a dorsal lithotomy position, with the
ductase inhibitors. These therapies can be administered alone thighs abducted to allow manipulation of the resectoscope.
or in combination. Alpha blocker therapy is based on the After sterile preparation and draping is completed, the patient’s
urethra is calibrated using van Buren sounds up to 30Fr. It is position, and proceeding from the bladder neck to a point just
only necessary to calibrate the anterior urethra; excessive proximal to the verumontanum. Resection should be carried
manipulation of the prostatic urethra may result in bleeding, down to the fibers of the bladder neck and prostatic capsule.
which can make visualization difficult. Proper calibration is es- The left lobe of the prostate can be resected in a similar fash-
sential to reduce the risk of subsequent urethral stricture caused ion. The surgeon should take care not to resect too deeply and
by the resectoscope manipulation. A 26Fr or 28Fr resectoscope perforate the capsule, as well as not to resect beyond (distal
is then inserted into the urethra. A 3% glycine or sorbitol solu- to) the verumontanum.
tion is used for irrigation, at gravity pressure. Cutting and Following complete resection of the lateral lobes, the ante-
coagulation currents should be adjusted to the appropriate lev- rior tissue of the prostate should be inspected. If obstructing
els for the electrical generator used for the case. tissue is present at this location, it may be resected. The Ellik
If the prostate volume is small (20 g or less), the lateral evacuator can then be used to remove the resected tissue frag-
lobes of the prostate are not coapting, and there is a high ments, which may be sent for pathologic analysis. The prosta-
bladder neck or median bar present, it may be appropriate to tic fossa should be reinspected, as oftentimes open blood
proceed with a transurethral incision of the prostate (TUIP). vessels may become more apparent following Ellik evacua-
The bladder should be filled via the continuous-flow resecto- tion. H emostasis should be ensured, and a three-way Foley
scope, and with a TUIP-type electrocautery knife, incisions catheter should be placed. Continuous bladder irrigation with
should be created at the 5:00 and 7:00 positions. The inci- saline is generally necessary overnight; if bleeding persists, the
sions should be deepened until the capsule of the prostate is Foley catheter may be placed on traction.
reached, and they should also be extended to just proximal to
the verumontanum. Ho lmium Lase r Enucle at io n
If the prostate is 20 g, or if there is a median lobe or the o f t he Pro st at e (Ho LEP)
lateral lobes are coapting, a TURP is the more appropriate The patient is positioned as for a TURP. A 26Fr or 28Fr resecto-
procedure to perform (Table 25.4). TURP is performed with scope is then inserted into the urethra. The inner sheath of the
an electrocautery loop and glycine or sorbitol irrigation. resectoscope should be specially configured with a purpose-
H owever, bipolar TURP devices have been developed that per- built laser bridge or laser-stabilizing catheter to minimize
mit the resection of prostate tissue in a saline irrigant. A pro- vibration of the laser fiber during the procedure. The 550-µm
cedural difference between the two approaches is that when end-fire laser fiber is placed through the laser bridge or laser-
the bipolar device is used, the speed with which the loop is stabilizing catheter. N ormal saline irrigant is used during the
withdrawn through the tissue should be much slower than procedure, and the resectoscope should be configured to
with the standard TURP electrocautery loop. If there is a continuous gravity flow.
median lobe present, resection should initially begin with this O nce the resectoscope has been passed via the urethra into
structure. In a stepwise fashion, the lobe is resected with the the bladder, the ureteral orifices should be identified. The veru-
electrocautery loop. Resection of the median lobe is complete montanum and the external urinary sphincter should be iden-
when bladder neck fibers are visualized. Particularly during tified and their location confirmed. If there is a significantly
the resection of the median lobe, care should be taken to not enlarged median lobe, it is often most expeditious to enucleate
involve the ureteral orifices in the resection. this structure first, as this maneuver will provide more room to
Following complete resection of the median lobe of the accomplish the lateral lobe dissection (Table 25.5). To enucle-
prostate, attention can be turned to resection of the lateral ate the median lobe, the holmium laser should be set at an en-
lobes. First, the right lobe is resected, starting at the 7:00 ergy of 2 J and a frequency of 50 H z. Two sulci will be
TA B LE 2 5 . 4
TA B LE 2 5 . 5
TRAN SURETHRAL IN CISION OR
RESECTION OF THE PROSTATE HOLMIUM LASER EN UCLEATION
OF PROSTATE
• Assessment of prostate
• If median lobe present:
• TUIP if:
• Create grooves in 5:00 and 7:00 positions
• Prostate volume 20 cc, high bladder neck, no lateral
lobe hypertrophy • Carry down to surgical capsule
• Incisions at 5:00 position, from bladder neck to • Join grooves just proximal to verumontanum
verumontanum • Enucleate median lobe in retrograde fashion
• Deepen to level of prostate capsule • Lateral lobe dissection begins just lateral to verumontanum
• TURP if: • Develop plane under lateral lobe, on floor of capsule
• Prostate volume 20 cc, coapting lateral lobes, • Dissection moves anteriorly, proceeding from apex to
median lobe bladder neck
• Resect median lobe, if present, first • M ake incision at 12:00 position
• If no median lobe, create groove in 6:00 position • Join anterior and lateral dissections
• Resect to bladder neck and capsular fibers • Divide remaining mucosal attachments
• Resect lateral lobes in stepwise fashion, from bladder • O nce both lobes are completely enucleated, morcellation
neck to verumontanum can proceed
• Resect anterior tissue if present • Take care to always keep morcellator tip in view
FIGURE 25.2 Cartoon representation of the architecture of the

prostate and bladder neck. Dashed lines represent the 5:00 and 7:00
grooves. FIGURE 25.4 The 7:00 incision is subsequently developed, which
isolates the median lobe.
visualized, one at the 5:00 position and the other at the 7:00 Following enucleation of the median lobe, attention can be
position (Fig. 25.2). Beginning at the level of the bladder neck turned to the lateral lobes. If a median lobe was not present,
in the 5:00 position, a groove is cut with the laser along the sul- an incision should be created at the 6:00 position, and this
cus, from the bladder neck to a point proximal to the verumon- midline groove should extend from the bladder neck to a
tanum (Fig. 25.3). This groove is deepened to the level of the point just proximal to the verumontanum (Fig. 25.5).
surgical capsule. As the groove is developed, it should be un- Dissection of the right lobe is initiated by incising the mucosa
dermined and widened to permit the separation of the right lat- lateral to the verumontanum in a transverse fashion, thereby
eral lobe and median lobe. O nce accomplished, the process exposing the adenoma near the apex. O nce the initial plane is
should be repeated at the 7:00 position (Fig. 25.4). The final developed under the right lobe, dissection should proceed
step in the enucleation of the median lobe can then be initiated proximally toward the bladder neck, freeing the lateral lobe
at a point just prior to the verumontanum. The laser fiber is from the capsular floor by moving the laser fiber in a trans-
moved in a transverse fashion between the apical extent of the verse, side-to-side motion; simultaneously, the beak of the
5:00 and 7:00 grooves. As the distal portion of the median lobe resectoscope can advance this effort by applying upward trac-
begins to separate away from the capsule, the beak of the resection on the adenoma. Care should be taken not to maneuver
toscope should be used as a leverage point to assist in lifting the the resectoscope into the adenoma, which will disorient the
median lobe upward. The capsule will begin to slope anteriorly surgeon and lose the plane of enucleation.
toward the bladder neck; careful attention to this anatomy is At some point, it will become apparent that the lateral
important, as it will prevent inadvertent undermining of the attachments of the lobe impede dissection. At this point, the
trigone. O nce the dissection has reached the level of the bladder surgeon should detach the lateralmost aspect of the right lobe,
neck, the most proximal attachments of the median lobe can be near the apex. During the apical dissection, the laser frequency
divided and the entire median lobe pushed into the bladder. should be changed to 40 H z to prevent thermal injury of the
FIGURE 25.3 The 5:00 incision is created with the end-fire holmium FIGURE 25.5 When no median lobe is present, a groove is created in
laser fiber. the 6:00 position.
urinary sphincter. The surgeon should continue to dissect in which is a set of hollow reciprocating blades attached to a
this plane, staying between the apical tissue of the right lobe handle apparatus, can be used for this portion of the proce-
and the capsule by rotating the resectoscope in a clockwise di- dure. Under direct visualization, the tip of the morcellator is
rection. The lateral dissection should proceed anteriorly, and inserted into the bladder and guided beneath a portion of
the lateral wall of the right lobe will be freed from the surgical adenoma. O nce a portion of adenoma is engaged by the mor-
capsule by proceeding proximally along the already defined cellator, it is important to keep the tip of the morcellator an-
plane. At this point, the surgeon should be rotating the resecto- teriorly within the bladder and within the visual field at all
scope in alternating clockwise and counterclockwise direc- times. The morcellator shaft should be moved in and out of
tions, which causes the tip of the laser fiber to proceed in a the working channel in small increments and rotated at times
smooth arc back and forth within the established plane. The to optimize engagement of tissue. When the remaining tissue
dissection should be continued until difficulty is encountered pieces are small, the surgeon should engage them with suction
with exposure of the plane proximally. alone and pull them into the prostatic fossa, where morcella-
Attention should then be turned to the 12:00 region of the tion can be done safely by pinning the tissue against the cap-
prostatic fossa, where the midline groove between the lateral sule. If difficulty is encountered in engaging these smaller
lobes is located. The resectoscope is turned 180 degrees to pieces, an alligator forceps can be used to facilitate their re-
allow the laser fiber to be positioned at the 12:00 position. moval. Lastly, an Ellik evacuator is utilized to remove any
The laser frequency should be readjusted to 50 H z. Beginning remaining pieces of adenoma or clot. A 20Fr, three-way Foley
at the bladder neck and proceeding distally, a groove is cut catheter is placed at the conclusion of the case with the aid of
along this anterior position and should span from the bladder a catheter guide, and continuous bladder irrigation can be
neck to the level of the verumontanum. The surgeon should used if necessary.
occasionally reconfirm the location of the verumontanum by
looking toward the floor to ensure that the groove is not Lase r Ab lat io n o f t he Pro st at e : Ho lmium (Ho :YAG)
extended too far distally. O nce the groove is created, it is again and Po t assium Tit anyl Pho sp hat e (KTP)
widened and deepened to the level of the surgical capsule Laser ablation of the prostate employs laser energy to vapor-
along its entire extent. The right lobe should then be enucle- ize prostate tissue through the generation of temperatures
ated from the anterior aspect of the capsule by angling the tip 100°C. There are two lasers that are commonly used to ab-
of the laser fiber between the adenoma and the capsule. late the prostate: the KTP laser and the H o:YAG laser. The
Capsular definition is often much easier at the bladder neck, KTP laser is an 80-W system that generates laser energy at a
so dissection should begin at that point. The attachments be- wavelength of 532 nm. The laser energy of the KTP laser is
tween the anterior portion of the lobe and the capsule are preferentially absorbed by the hemoglobin pigment. The
taken down sequentially until the lateral extent of the lobe is H o:YAG laser is a 100-W system that generates laser energy at
reached. It is crucial at this stage to identify the extent of the a wavelength of 2,140 nm. The holmium laser energy is pref-
remaining lateral attachments near the apex of the lobe. O nce erentially absorbed by water. Despite the different inherent at-
the junction between the planes is defined, usually by a tributes of the laser energy sources, the fundamental
mucosal strip or bridge, it is cut by the laser to join the planes. techniques of laser ablation are the same for both laser types.
Laser settings are 2 J and 20 H z during division of the mucosal O ne of the inherent limitations of all laser approaches is that
strip. The surgeon can then continue the dissection proximally, laser energy will desiccate the prostate tissue, ultimately im-
at 2 J and 50 H z, to free the lateral extent of the lobe. pairing the tissue ablation as the procedure proceeds. With
At this point, the right lobe will be held only by attach- smaller glands, this may not be a meaningful issue; however,
ments at the bladder neck level. By following this plane fur- with larger glands, tissue desiccation will impede the ablation
ther laterally, any remaining attachments in this area can be procedure.
freed. Finally, one should proceed under the lobe and finish A side-firing laser fiber is used, with a 26Fr or 28Fr
dividing attachments at the floor of the capsule and the poste- continuous-flow resectoscope configured with a laser bridge.
rior bladder neck. The lobe can then be pushed into the blad- Saline is the irrigation of choice. The resectoscope is passed
der by leveraging upward with the beak of the resectoscope. into the bladder, and the locations of the ureteral orifices and
With complete enucleation of the right lobe, attention should verumontanum are confirmed. Laser ablation is a near contact
be turned to the left lobe, which is enucleated as previously procedure, meaning that the laser fiber should be maintained
described. 1 to 2 mm away from the prostate tissue. The aiming beam
O nce all lobes have been dissected free and pushed into the and the side-markings of the fiber should be identified. If a
bladder, the capsular surface is then inspected carefully, and median lobe is present, this structure should be addressed
any bleeding sites should be addressed by defocusing the laser first. The laser fiber is placed in close approximation to the
(positioning the tip of the fiber 2 to 3 mm away from the sur- median lobe tissue, and a rotating lateral motion of the laser
face). A dry fossa is essential before beginning morcellation to fiber is performed while activating the laser energy. The tissue
optimize visualization and minimize the risk of bladder injury. should be vaporized in layers, with a sagittal motion of the
If any residual portions of adenoma remain along the surface fiber, taking care to not vaporize the trigone or ureteral ori-
of the capsule, these can be easily vaporized or enucleated fice. If a median lobe is not present, the laser should be posi-
with the laser. tioned at the bladder neck in the 7:00 position, and the tissue
The final aspect of H oLEP is to remove the enucleated ade- should be ablated with a lateral sweeping motion until the
noma by morcellation. The inner sheath of the resectoscope, fibers of the bladder neck are visualized (Table 25.6). A
along with the laser fiber and stabilizing catheter, is removed, groove should then be extended from the bladder neck to a
and the rigid offset nephroscope is then inserted into the outer point just proximal to the verumontanum. The groove should
resectoscope sheath. A commercially available morcellator, be deepened until capsular fibers are seen. A similar groove
TA B LE 2 5 . 6
LASER ABLATION OF THE PROSTATE
• Troughs created at the 5:00 and 7:00 positions

• Direct ablation of lateral lobes
• Carried to depth of capsular fibers
• Tissue ablation moves anteriorly, proceeding from bladder
neck to apex
• To coagulate bleeding vessels, laser is defocused
2 to 3 mm away from tissue surface
should be created in the 5:00 position, and then the tissue

between the grooves should be ablated.
Returning to the 5:00 position, the tissue from this location
up to the 1:00 position should then be ablated with a slow, FIGURE 25.6 Incision of mucosa over the adenoma.
continuous sweeping motion. Again, the laser should be main-
tained near the tissue but not buried into the tissue. O nce the
lobe is ablated, the contralateral lobe from the 7:00 position of Retzius is entered, perivesical fat identified, and a self-
to the 11:00 position should be ablated in the same fashion. retaining retractor positioned. The bladder should be identi-
Bleeding vessels, most commonly encountered at the 5:00 and fied and cleaned of the perivesical fatty tissue. The bladder
7:00 positions, can be coagulated by defocusing the laser 2 to should be filled to capacity by gravity. Stay sutures should be
3 mm away from the tissue. Following ablation of the prostate positioned in the detrusor just to the left and right of midline,
tissue and assurance of hemostasis, a Foley catheter should be and a vertical incision in the bladder should then be created
placed. In general, bleeding is not significant, and continuous with electrocautery.
bladder irrigation should not be required. After opening the bladder, the intravesical component of
the prostate should be identified. The ureteral orifices should
Sup rap ub ic Pro st at e ct o my be located, and to facilitate identification as the procedure
The patient is placed in a supine position, and the lower progresses they may be cannulated with 5Fr feeding tubes. To
abdomen and genitalia are prepared and draped as a surgical begin the enucleation process, an incision in the posterior
field. A Foley catheter is placed on the surgical field and aspect of the intravesical component of the prostate is made
secured into position. The initial approach is through a low with electrocautery (Fig. 25.6). Care should be taken to ensure
midline incision, and the fascia should be opened from the that the incision is safely away from the ureteral orifices and
umbilicus to the symphysis pubica (Table 25.7). The space trigonal region. The capsule should be sharply freed from the
adenoma, and the surgeon’s finger can then be used to develop
the space between the adenoma and the capsule (Fig. 25.7). By
TA B LE 2 5 . 7 moving the finger in a lateral arc, this plane is extended down
OPEN SURGICAL PROSTATECTOMY to the apical aspect of the prostate. O nce the adenoma is com-
pletely freed from its attachments by this blunt dissection tech-
• Low midline incision nique, it may be removed from the surgical field (Fig. 25.8).
• Suprapubic The prostatic fascia should be packed with sponges and
• Cystotomy created pressure held for 5 minutes to aid in hemostasis. Absorbable
• Ureteral orifices identified sutures, of a 2-0 size, should be placed in a figure-of-eight
• Incision at posterior aspect of intravesical component
of prostate
• Adenoma freed from capsule with blunt digital dissection
• Following complete removal of adenoma, bleeding
vessels controlled
• Sutures at 5:00 and 7:00 positions
• Foley catheter and suprapubic tube, in addition to
perivesical drain
• Retropubic
• Ligation of superficial prostate capsular vessels
• Transverse incision in midcapsule
• Adenoma bluntly dissected away from capsule and
extracted through capsulotomy
• H emostasis ensured, sutures placed at 5:00 and 7:00
positions
• Foley catheter and periprostatic drain placed
FIGURE 25.7 Digital enucleation of the adenoma.
FIGURE 25.10 Foley catheter snug at the bladder neck: prevesical

drain and suprapubic tube.
FIGURE 25.8 View of the empty prostatic fossa. and the Foley catheter may be of help in maintaining patent
drainage and minimizing blood clot formation.
Re t ro p ub ic Pro st at e ct o my
The patient is placed in a supine position, and the lower
abdomen and genitalia are prepared and draped as a surgical
field. A Foley catheter is placed on the surgical field and
secured into position. The initial approach is through a low
midline incision, and the fascia should be opened from the
umbilicus to the symphysis pubica. The space of Retzius is
entered, perivesical fat identified, and a self-retaining retractor
positioned. The fatty tissue overlying the bladder and prosta-
tic capsule should be cleared.
At the midportion of the prostatic capsule, two 0 chromic
sutures should be placed proximally and distally, to ligate the
superficial blood vessels (Fig. 25.11). With electrocautery, an
incision is created transversely between these two sutures
FIGURE 25.9 H emostatic suture ligatures at the 5:00 and 7:00

positions.
fashion at the 5:00 and 7:00 positions to control any blood

vessels, which are commonly encountered at these locations
(Fig. 25.9). A 22Fr Foley catheter, with a 30-cc balloon,
should be placed transurethrally (Fig. 25.10).
The bladder should be closed in two layers with running
3-0 and 2-0 monofilament absorbable suture. A suprapubic
tube should be placed through the dome of the bladder, and
the bladder closed around this tube in a pursestring fashion. A
Penrose or Blake closed suction drain is then placed in the
space of Retzius. The fascia is then reapproximated with no. 1
braided absorbable suture, and the skin is reapproximated
with staples. The drains are sutured into place with 0 silk FIGURE 25.11 Ligation and division of periprostatic veins over the
suture. A continuous bladder setup using the suprapubic tube prostatic capsule anteriorly.
FIGURE 25.14 Figure-of-eight sutures are applied at the vesicle neck

FIGURE 25.12 Transfixion sutures placed on the capsule anteriorly at the 5:00 and 7:00 positions to secure hemostasis.
with an incision made transversely in the prostatic capsule.
FIGURE 25.15 Closure of the incision of the prostate capsule anteri-

orly with interrupted chromic sutures.
FIGURE 25.13 Continuing the dissection of the prostate of the ade-
noma from the prostatic capsule using M etzenbaum scissors.
TREATMENT O UTCO MES

(Fig. 25.12). A plane of dissection between the adenoma and The ultimate assessment of the efficacy of a surgical treatment
the capsule should be bluntly created on either side of this infor BPH is a measure of its treatment outcome. The AUA
cision (Fig. 25.13). The adenoma is progressively freed of its Clinical Guidelines Panel on BPH assessed the literature on
anterior, lateral, and posterior attachments with digital dissec- surgical therapies in order to define the treatment outcomes for
tion. Following complete mobilization of the adenoma, its particular interventions (3). TURP is considered by many to be
attachment to the membranous urethra can be sharply divided the gold standard surgical therapy for men requiring surgical
and the adenoma retrieved through the capsular incision; 2-0 treatment of BPH . H owever, all surgical therapies have been
chromic sutures should be placed in the 5:00 and 7:00 posi- reported to significantly improve patients’ AUA Symptom
tions for hemostasis (Fig. 25.14). A 22Fr Foley catheter with a Index; in fact, the greatest magnitude of improvement among
30-cc balloon is placed, and the prostatic capsule is closed patients undergoing surgical treatments was observed in
with 2-0 chromic sutures (Fig. 25.15). A closed suction drain those undergoing H oLEP (3). Similarly, all surgical therapies
is placed in the space of Retzius; the fascia should be reap- produced significant improvements in peak urinary flow rates;
proximated with no. 1 braided absorbable suture, and the it was not possible to distinguish among the different therapies
skin should be reapproximated with staples. based on this outcome measure. Q uality-of-life data, a measure
TA B LE 2 5 . 8
PSA CHAN GES FOLLOWIN G BPH TREATMEN TS
TREATMEN T MEAN MEAN PERCEN TAGE MEAN TISSUE

(N UMBER OF PREOPERATIVE POSTOPERATIVE DECREASE RESECTED
STUDY PATIEN TS) PSA (N G/ DL) PSA (N G/ DL) IN PSA (GRAMS)
Kuo, 2003 H oLEPa (48) 9.5 0.6 91.7 121

Kim, 2004 H oLEPa (10) 6.2 0.9 85.5 118
O zden, 2003 O pen/TURPb (32) 14.8 3.7 74.2 N /A
M arks, 1996 O pen/TURPb (82) 4.6 0.7 71.3 35
Aus, 1996 TURPb (190) 6.0 1.9 69.7 33.5
Stamey, 1987 O pen (7) 24.1 1.0 95.6 88.9
Stamey, 1987 TURPb (73) 7.9 1.3 83.5 29
Te, 2006 PVPc (139) 3.5 2.9 17 N /A
aH oLEP, holmium laser enucleation of the prostate.
b TURP, transurethral resection of the prostate.
cPVP, photoselective vaporization of the prostate.
that is perhaps most important to the patient being treated, the ureteral orifice may be close to the bladder neck and can be
demonstrate equivalent improvements among all surgical inadvertently ablated or resected. Should the ureteral orifice be
technologies. All prostate interventions will have an effect on injured, an attempt should be made to stent the ureter at the
serum PSA. The more complete a debulking of the prostate, conclusion of the procedure. Stricture formation is the most
the greater the fall in PSA the patient should experience concerning sequelae of this complication. The bladder neck
(Table 25.8) (4–10). may also be undermined, which can complicate the placement
of a catheter at the conclusion of the procedure. In severe cases,
the bladder and prostatic urethra can become completely dis-
CO MPLICATIO NS sociated. If the bladder neck is identified as being undermined,
a Foley catheter should be placed with a catheter guide, or
End o sco p ic Surg e ry alternatively over a wire, to ensure proper placement.
Transient urinary incontinence or urinary retention may
O ne of the more common intraoperative complications for occur following an endoscopic prostate resection or ablation.
patients undergoing endoscopic surgical treatment of BPH is These symptoms generally resolve in the weeks following the
bleeding. Due to the continuous irrigation flow, it can often be procedure. Permanent incontinence or retention following
difficult to estimate the magnitude of bleeding. When bleeding these procedures is exceedingly rare. All patients who undergo
is appreciated, though, a systematic inspection of the prostatic any of these previously described procedures will experience
fossa will permit identification of the source, which can then retrograde ejaculation and should be forewarned of this even-
be fulgurated with cautery or coagulated with laser. If bleed- tuality. Patients who are suffering from urinary retention prior
ing is refractory to these maneuvers, a Foley catheter placed to an intervention for BPH are at increased risk for postopera-
on traction may be helpful. tive complications (11).
O veraggressive resection may result in perforation of the
prostatic capsule. Sequelae of this event may include extravasa-
tion of fluid into the retroperitoneum as well as electrolyte de- O p e n Surg e ry
rangements. When a capsular perforation is encountered,
it should be assessed. In the case of a small perforation, the Severe bleeding following open prostatectomy has been
procedure should be completed expeditiously. If a large perfora- recorded to occur in up to 35% of patients; blood transfusion
tion is identified, however, the procedure should be terminated. rates are similarly high. Urinary clot retention has been
In the case of a retroperitoneal fluid collection, conservative reported to occur following open prostatectomy procedures.
management (catheter drainage and furosemide) is a reasonable Urinary leakage from the cystotomy is not uncommon follow-
approach, as the collections generally reabsorb spontaneously. If ing catheter removal, and it generally resolves within 1 to
the perforation is extensive, however, transurethral resection 2 days. Transient urge urinary incontinence occurs following
(TUR) syndrome may occur, a condition brought about by in- open surgical prostatectomy, usually due to bladder instabil-
travascular absorption of hypotonic irrigating solutions, which ity, but this generally resolves within several weeks of surgery.
ultimately induces a dilutional hyponatremia. H ypertension, Total incontinence is rare. Retrograde ejaculation occurs in
mental confusion, and nausea and vomiting are all associated all patients undergoing adenomectomy, but other effects on
with this syndrome. TUR syndrome can be managed by diuresis sexual function are rare. Postoperative bladder neck contrac-
and repletion with normal saline intravenous fluid or, in extreme ture may occur in up to 8% of patients undergoing open
circumstances, hypertonic (3% ) saline in 100-cc boluses. prostatectomy; its etiology is unclear. Treatment of the blad-
Structures in the vicinity of the prostate may be injured in der neck contracture may require dilation or even incision of
the course of endoscopic surgical treatment. In some patients, the bladder neck.
Chap t e r 26: Prostatic Imag ing and Bio p sy 175
References
1. O esterling JE. Benign prostatic hyperplasia: a review of its histogenesis and 7. M arks LS, Dorey FJ, Rhodes T, et al. Serum prostate specific antigen levels
natural history. Prostate Suppl 1996;6:67–73. after transurethral resection of prostate: a longitudinal characterization in
2. Wasson JH , Reda DJ, Bruskewitz RC, et al. A comparison of transurethral men with benign prostatic hyperplasia. J Urol 1996;156:1035–1039.
surgery with watchful waiting for moderate symptoms of benign prostatic 8. Aus G, Bergdahl S, Frosing R, et al. Reference range of prostate-specific
hyperplasia. The Veterans Affairs Cooperative Study Group on antigen after transurethral resection of the prostate. Urology 1996;47:
Transurethral Resection of the Prostate. N Engl J M ed 1995;332:75–79. 529–531.
3. Roehrborn CG, Bartsch G, Kirby R, et al. Guidelines for the diagnosis and 9. Stamey TA, Yang N , H ay AR, et al. Prostate-specific antigen as a serum
treatment of benign prostatic hyperplasia: a comparative, international marker for adenocarcinoma of the prostate. N Engl J M ed 1987;317:
overview. Urology 2001;58:642–650. 909–916.
4. Kuo RL, Kim SC, Lingeman JE, et al. H olmium laser enucleation of 10. Te AE, M alloy TR, Stein BS, et al. Impact of prostate-specific antigen level
prostate (H oLEP): the M ethodist H ospital experience with 75 gram enu- and prostate volume as predictors of efficacy in photoselective vaporiza-
cleations. J Urol 2003;170:149–152. tion prostatectomy: analysis and results of an ongoing prospective multi-
5. Kim SC, Tinmouth WW, Kuo RL, et al. Simultaneous holmium laser centre study at 3 years. BJU Int 2006;97:1229–1233.
enucleation of prostate and upper-tract endourologic stone procedures. 11. Pickard R, Emberton M , N eal DE. The management of men with acute uri-
J Endourol 2004;18:971–975. nary retention. N ational Prostatectomy Audit Steering Group. Br J Urol
6. O zden C, Inal G, Adsan O , et al. Detection of prostate cancer and changes 1998;81:712–720.
in prostate-specific antigen (PSA) six months after surgery for benign
prostatic hyperplasia in patients with elevated PSA. Urol Int 2003;71:
150–153.
CHAPTER 26 ■ PRO STATIC IMAGING

AND BIO PSY
FRANCES M. MARTIN, WILLIAM T. CO NNER, AND RANDALL G. RO WLAND
Adenocarcinoma of the prostate (PC) is the most common levels may fluctuate, and the decision for biopsy should not be
cancer of men in the United States and Europe. Concomitant based solely on one value alone. In-office screening should
development of prostatic-specific antigen (PSA) assays and also include a digital rectal examination and a complete his-
transrectal ultrasound (TRUS) provided the tools for diagno- tory and physical examination.
sis of PC at an earlier, and presumably more curable, stage. Increased PSA velocity 0.75 ng per mL per year is an indi-
The transvaginal ultrasound probe was adapted to transrectal cation for careful surveillance and possible biopsy. A value of
use, and the spring-loaded Biopty gun with a disposable 0.75 ng per mL per year requires three PSA values over a 2-
18-gauge needle was invented to permit ultrasound-guided year period to be statistically valid (2). PSA levels increase with
biopsies (USBs) with TRUS guidance. PSA, TRUS, and USB age. The formula for calculating the “ age-adjusted normal” is
are now the standard methods for diagnosis of PC. TRUS is age minus 20 divided by 10. Thus, a 50-year-old man would
an adjunct for staging PC, while PSA is the most sensitive have an age-adjusted normal of 3.0 ng per mL, while the value
method of evaluating response to therapy. TRUS is currently for a 70-year-old man would be 5.0 ng per mL. There is con-
the most common method to image the prostate for initial troversy concerning the use of the age- adjusted values, al-
staging, biopsy, and anatomical assessment. Ultrasound is though it seems clear that this technique improves the
also useful in evaluating brachytherapy and cryotherapy. sensitivity for cancer detection in men below age 60 (3). It is
Studies using three-dimensional (3-D) TRUS may show im- unclear if PSA velocity, PSA density, or free-to-total PSA values
proved detection of tumor and extraglandular extension (1). provide a significantly better screening test for prostate cancer.
Additional imaging modalities may change future manage- Additional markers and proteomics profiling, including
ment and detection. prostate-specific membrane antigen (PSM A), prostate stem cell
antigen (PSCA), and hepsin, are being evaluated and may
provide improved screening for prostate cancer (4). Currently,
SCREENING AND DIAGNO SIS PSA is the most widely used marker for screening and biopsy
indication.
Screening PSA tests are in general performed between ages 50 Both benign and malignant prostatic cells produce PSA.
and 75, starting 5 years earlier in African American and high- Infection, trauma, and ejaculation are some of the benign
risk men. Values up to 4 ng per mL are considered acceptable conditions that may cause a PSA elevation. After excluding
in men younger than age 60, although some laboratories other causes for an increased PSA, TRUS and USB are
consider values 2.6 ng per mL moderately elevated. PSA scheduled.
tant organisms. Single-dose regimens were evaluated to reduce

INDICATIO NS FO R SURGERY this risk and support single-dose prophylaxis against infective
complications (5). Patients with artificial heart valves, total
The most common reasons for TRUS and USB are an elevated joint prostheses, or implanted devices are routinely treated
screening PSA or an abnormal digital rectal exam (DRE). Prior using standard American H eart Association guidelines. Some
to the mid-1980s, PC was usually suspected because of an ab- American urologists use cleansing rectal enemas, although
normal DRE. Biopsies were typically performed under spinal there is some controversy concerning their need (6).
or general anesthesia using a digitally guided transperineal ap- Some patients require monitored anesthesia care. These
proach. With the development of PSA and TRUS with USB, the include those with anal stenosis, excessive apprehension, or
procedure became simpler, safer, more precise, and more eco- serious cardiac arrhythmias and patients without a rectum.
nomical. O ral sedatives and analgesics may be given, provided the
O ther indications for TRUS and USB are a suspicious patient has a driver to take him home.
prostatic nodule, asymmetry of the prostate, active surveil- Initial vital signs are monitored, including blood pressure
lance, and, rarely, unexplained metastatic malignancy. TRUS and heart rate. The patient is placed in the left lateral recum-
without USB is used for evaluation of ejaculatory duct cysts, bent (decubitis) position on the table in the US suite. The
prostatic stones, unexplained urinary tract infection (UTI), operator sits at a comfortable level beside the table and again
and suspected prostatic abscess. Prostatic biopsy without explains the procedure as it is being performed. A gentle, thor-
TRUS is on occasion performed for very ill patients with ough rectal examination is performed, noting significant
highly suspicious prostate glands, for whom the procedure is external hemorrhoids, anal sphincter diameter and tone, and
performed at the bedside. Confirmation of the diagnosis lesions in the rectum. Examination of the prostate includes
allows prompt hormonal ablation, often with improvement in specific notes concerning size, texture, tenderness, borders,
hematuria or pain. An Iowa Trumpet (©V. M ueller, M cGraw fixation or mobility of the apex, symmetry, location of the
Park, Illinois) allows access for the digitally guided transrectal midline sulcus, and the seminal vesicles. Any prostatic nodules
biopsy while protecting the finger of the operator. or abnormal areas are noted.
We use a B& K M edical (Wilmington, M A) US system with
either a 7.0- or 7.5-M H z endorectal probe. For the rare
instances of TRUS for patients without a rectum, a 3.5- or
ALTERNATIVE THERAPY 4.0-M H z probe is used. The TRUS probe has been prepared in
advance by decontamination with glutaraldehyde solution or
N ot everyone who has an elevated PSA or abnormal DRE heated 35% peroxyacetic acid solution (STERIS) sterilization.
should have a prostatic biopsy. Patients should be counseled A finger cot is placed snugly over the inflation port and
concerning the risks and benefits of both the biopsy and possi- inflated to exclude air bubbles, which interfere with the US
ble treatment. Thus, an 85-year-old man with Alzheimer’s image. Finally, a condom containing about 15 cc of US gel is
disease and no significant urinary symptoms who has an ill- placed over the rectal end of the probe. The US gel reduces
advised PSA test with a result of 8 ng per mL should not have artifacts during TRUS. The probe is lubricated and gently in-
a biopsy unless there is an unusual reason. H e should have serted into the rectum. Lidocaine gel (1% ) may be used, if the
another PSA in 6 months. If there is no significant change, patient is not allergic, to provide topical analgesia to the rectal
PSA testing should be stopped. wall. Inflation of the finger cot with 25 to 40 mL of water
General medical evaluation should detect anticoagulation, produces an acoustic window, which allows better definition
medications, significant cardiovascular disease, diabetes melli- of the rectal wall and prostate.
tus, and excessive apprehension. Any of these factors may Local anesthesia has become a frequent adjunct to TRUS
require a change of plans for USB. O f importance, an interac- and USB (7). Periprostatic nerves can be blocked by injecting
tive discussion with the patient should take place regarding 5 to 10 cc of 1% lidocaine without epinephrine just lateral to
the recommendations for or against a biopsy in light of all the junction of the seminal vesicle and prostate on each side
findings and overall health status. (Fig. 26.1). After guiding a 22-gauge, 7-in. spinal needle
(Becton/Dickinson, Franklin Lakes, NJ) to the correct spot with
US, and aspirating to be sure a vein has not been entered, the
anesthetic is slowly injected. The area of injection expands and
SURGICAL TECHNIQ UE produces a hypoechoic image that confirms the proper location
of the drug. Local anesthesia allows multiple biopsies to be
Anticoagulation must be stopped before USB. Consultation taken with little discomfort for most patients. As with all proce-
with the patient’s physician or cardiologist will determine if it dures with conscious patients, each event must be announced in
is safe to stop oral anticoagulation 5 to 10 days in advance, advance. Lidocaine causes the same stinging sensation in the
depending upong the medication. If not, he is changed to a periprostatic area that occurs with dental or other local injec-
form of heparin, which is stopped for 6 to 12 hours before the tions. Neutralizing the lidocaine solution with alkali can prevent
biopsy. Gross hematuria and clot retention that requires a this, but the shelf life of the drug is significantly reduced.
Foley catheter are more common in this group. The prostate is then imaged in transverse and longitudinal
Antibiotics are commonly given before and after the biopsy. planes, noting areas of abnormal echogenicity, cysts, calcifica-
Regimens vary, but the usual protocol in the United States tions, indistinct borders, lesions of the seminal vesicles or
includes a full dose of a fluoroquinolone before the biopsy. ejaculatory ducts, and other abnormalities. Tiny corpora amy-
Previously, routine use of antibiotics for several days after lacea are easily visible and usually define the border of the tran-
biopsy was standard. Prolonged prophylaxis can lead to resis- sitional and peripheral zones. Bladder US can be performed if
Chap t e r 26: Prostatic Imag ing and Bio p sy 177
FIGURE 26.1 Prostate ultrasound. Dotted line indicates

path of biopsy needle on sagittal view.
desired but is best accomplished as a suprapubic exam with a decrease the additional urethral bleeding. Bleeding usually
3.5- to 4-M H z probe. stops without treatment within 24 hours.
Prostatic volume is calculated using the greatest transverse, After all biopsies are obtained and carefully labeled, the US
anterior–posterior, and longitudinal dimensions. M ost modern probe is removed. A useful technique to control rectal bleed-
TRUS machines have computer programs for computing the ing is to roll a hand towel into a tight roll about 6 in. long and
volume. One formula for calculating the volume of a prostate 3 in. in diameter and then have the patient sit with the towel
ellipse by US is as follows: height multiplied by width multi- between his ischial tuberosities for 10 minutes. This places
plied by length multiplied by 0.52. Images are recorded to pressure on the perineum, compressing the prostate against
show anatomy of the prostate and seminal vesicles, abnormal- the symphysis pubis. Blood pressure and heart rate are again
ities, and prostatic volume. Digital recording of the procedure recorded. The patient sits on the table for about 10 minutes,
is possible. The volume of suspicious hypoechoic lesions is then voids. The urine usually contains blood, especially if TZ
measured and recorded. The classical appearance of a prostate biopsies have been obtained.
tumor is hypoechoic, but some cancers can appear isoechoic or When the patient is stable and voiding well, he is given his
hyperechoic. The TRUS procedure takes several minutes, postbiopsy instructions and allowed to leave, with a return
enough time for the lidocaine to anesthetize the periprostatic appointment for 1 to 2 weeks depending upon the response
nerves. time of the pathology department.
Biopsies are obtained with a sharp, disposable, spring- Instructions include the following:
loaded 18-gauge needle, which produces a 17-mm specimen
with little crush artifact. Several such needles are available. 1. Expect blood with urination and bowel movements for 1
Some are completely disposable devices, whereas others use a to 7 days.
permanent biopsy gun and disposable needles. M ost brands 2. Expect blood with ejaculate for up to 6 weeks.
of needles have a slightly abraded tip that makes them 3. Take medications as prescribed.
echogenic and easier to see. We currently use either a Bard 4. Report temperature over 101°, passage of clots after
M agnum Biopty N eedle Gun with a disposable needle or a 24 hours, persistent rectal bleeding, difficulty with urina-
M icrovasive Topnotch disposable gun and needle. The device tion, pain, or any other symptom that concerns him.
is fired before the biopsy to familiarize the patient with the 5. Return for discussion of the biopsy as scheduled.
sound. 6. Resume all other medications, with special instructions for
We routinely obtain 12 biopsies: lateral and medial at each anticoagulants.
base, lateral and medial at the midgland on each side, and 2 7. Resume preoperative activities after 24 hours, avoiding
biopsies at each apex, as described by Gore et al. (8) and heavy lifting or strenuous activity for 72 hours.
others. Patients who need a second biopsy because of a high
suspicion of cancer will have 12 to 20 biopsies, including
specimens from the transition zones (TZ s) and far lateral
peripheral zone. “ Saturation” biopsy under anesthesia obtains O UTCO MES
up to 45 cores of tissue, although this technique is reserved for
the patient who has had multiple negative biopsies and still Co mp licat io ns
has a suspicious PSA or rectal exam (9). The great value of
TRUS is to be able to precisely sample specific areas of the H ematuria, hematochezia, and hematospermia are expected,
prostate. Anesthetizing the urethra with lidocaine reduces the as mentioned above. Excessive bleeding requires evaluation
additional urethral pain with TZ biopsies but does not and appropriate treatment. Rarely, patients require admission
for bladder irrigation for urinary bleeding. Patients who are ating for lymphatic involvement and nodal staging, but it is
on anticoagulants on occasion require cystoscopy with fulgu- based upon size criteria. It is less sensitive for bony involve-
ration of bleeding vessels. Rectal bleeding is usually minor and ment than magnetic resonance (M R) or bone scan.
self-limited. If rectal bleeding is persistent or causes the hema-
tocrit to fall, proctoscopic examination is indicated. The urol-
ogist, a general surgeon, or a gastroenterologist, depending
upon the time of occurrence and the training of the physician,
Mag ne t ic Re so nance Imag ing (MRI)
may perform this. Arterial or venous bleeding may be
Use of M RI to detect prostate cancer and locally advanced
controlled with direct suture ligation or injection of epineph-
disease has provided mixed results. It provides improved
rine around the vessel. H ematospermia requires reassurance
anatomic visualization with better soft tissue resolution. The
only. Urinary retention usually resolves unless the patient has
use of the endorectal coil may improve the specificity of
bladder outlet obstruction, but it may require temporary
M RI for detection of cancer and extraprostatic extension.
catheterization.
Prostatitis, hemorrhage, and benign hyperplasia can mimic
Bacteriuria and bacteremia are fairly common but usually
cancer on M RI. Studies suggest that it may be more valuable
asymptomatic and resolve without further complications (10).
to detect local recurrence after prostatectomy (11). N ewer
Persistant rectal pain or fever 101.5ºF may signal prostatic
advances, including magnetic resonance spectroscopic imag-
abscess or early sepsis. Isolated reports of perirectal abscess,
ing (M RSI), may improve evaluation of tumor size, location,
septic shock, disseminated intravascular coagulation, and os-
and extent (12). M RSI displays relative concentrations of
teomyelitis are in the literature. Seeding of the biopsy tract
citrate, choline, and creatinine, which are typically higher in
with implantation of cancer is a theoretical complication
cancer cells. Criteria for diagnosing prostate cancer are based
that has been rarely reported. The biopsy technique does not
upon choline-citrate ratios. Some authors state that combined
interfere with radical prostatectomy, external radiation, or
M RI/M RSI can help stratify patients’ risk by assessing the
brachytherapy.
aggressiveness of the tumor biology (12).
ADDITIO NAL IMAGING

MO DALITIES FO R EVALUATIO N Po sit ro n Emissio n To mo g rap hy (PET)
O F THE PRO STATE Although PET scans have been useful in evaluating metastatic
disease, the use of 18 F-FDG tracer is not helpful in diagnosing
Co mp ut e rize d To mo g rap hy (CT) or imaging localized prostate cancer. This tracer has con-
founding uptake in prostate cancer cells and benign prostatic
The contrast resolution of CT is ineffective in distinguishing hyperplasia (13). N umerous additional tracers are under in-
the prostate from cancers or surrounding organs. Its use in vestigation and may prove more useful in diagnosing prostate
prostate cancer detection is limited. CT can be useful in evalu- cancer.
References
1. Garg S, Fortling B, Chadwick D, et al. Staging of prostate cancer using 8. Gore JL, Shariat SF, M iles BJ, et al. O ptimal combinations of systematic
3-dimensional transrectal ultrasound images: a pilot study. J Urol 1999; sextant and laterally directed biopsies for the detection of prostate cancer.
162:1318–1321. J Urol 2001;165:1554–1559.
2. Potter SR, Carter H B. The role of prostate-specific antigen velocity in 9. Stewart CS, Leibovich BC, Waver AL, et al. Prostate cancer diagnosis us-
prostate cancer early detection. Curr Urol R ep 2000;1:15–19. ing a saturation needle biopsy technique after previous negative sextant
3. Polascik TJ, O esterling JE, Partin AW. Prostate specific antigen: a decade of biopsies. J Urol 2001;166:86–91.
discovery—what have we learned and where are we going. J Urol 1999; 10. Lindert KA, Kabalin JN , Terris M K. Bacteremia and bacteriuria after
162:293–306. transrectal ultrasound guided prostate biopsy. J Urol 2000;164:76–80.
4. Bradford TJ, Tomlins BA, Wang X, et al. M olecular markers of prostate 11. Sella T, Schwartz LH , Swindle PW, et al. Suspected local recurrence after
cancer. Urol O ncol: Sem in O riginal Invest 2006;24(6):528–551. radical prostatectomy: endorectal coil M R imaging. R adiology 2004;
5. Aron M , Rajeev TP, Gupta N P. Antibiotic prophylaxis for transrectal 231:379–385.
needle biopsy of the prostate: a randomized controlled study. BJU Int 12. H ricak H . M R imaging and M R spectroscopic imaging in the pre-
2000;85(6):682–685. treatment evaluation of prostate cancer. Br J R adiol 2005;78:S103–S111.
6. Terris M K. Letter to the Editor. J Urol 2002;167:2145–2146. 13. H ofer C, Laubenbacher C, Block T, et al. Fluorine-18-fluorodeoxyglucose
7. Pareek G, Armenkadas N A, Fracchia JA. Periprostatic nerve blockade for positron emission tomography is useless for the detection of local recur-
transrectal ultrasound guided biopsy of the prostate: a randomized, rence after radical prostatectomy. Eur Urol 199;36:31–35.
double-blind, placebo controlled study. J Urol 2001;166:894–897.
CHAPTER 27 ■ PELVIC LYMPHADENECTO MY
MICHELLE L. RAMÍREZ, RAJ S. PRUTHI, JO O N-HA O K, AND RALPH W. DEVERE WHITE
Pelvic lymph nodes are the initial site of the spread of prosta-
tic, bladder, and proximal urethral cancers. Tumors of the PRO STATE CANCER
penis, scrotum, and distal urethra spread primarily to the
inguinal lymph nodes but can involve the pelvic lymph nodes Ind icat io ns fo r Surg e ry
at a later stage. Testicular tumors rarely involve the pelvic
lymph nodes unless there is massive retroperitoneal disease Pelvic lymphadenectomy adds modest operating room time,
(retrograde spread) or a history of orchiopexy or prior pelvic cost, and complication risk to a radical prostatectomy, but
procedures. when performed independently, results in additional anes-
Standard practice had been that all patients undergoing thetic risk and exposure to cardiopulmonary, thromboem-
radical prostatectomy undergo pelvic lymphadenectomy for bolic, and wound complications. Several investigators have
staging. Currently, pelvic lymph node dissection is performed therefore attempted to identify prostate cancer patient groups
only if a patient is at significant risk for metastasis. Preoperative in which pelvic lymphadenectomy can be omitted with an ac-
prostate-specific antigen (PSA), PSA kinetics, biopsy Gleason ceptable risk of understaging. By combining these criteria, pa-
score, and clinical stage define those patients at risk for nodal tients can be grouped as low (2% to 5% ), moderate (20% ),
metastasis. Identifying lymph node involvement is important and high (40% ) risk categories for lymph node metastases (8).
for accurate tumor staging, prognosis, and selection of adju- Patients at highest risk for lymph node metastases include
vant therapy; however, the therapeutic value of lymph node those with a Gleason score equal to or 7 and a PSA equal to
removal for prostate cancer remains controversial. When cys- or 20 ng per mL, a Gleason score equal to or 8 and a
tectomy is indicated for bladder cancer, bilateral pelvic lym- PSA equal to or 10 ng per mL, or a PSA equal to or 50 ng
phadenectomy remains the standard of practice. per mL (Table 27.1). Using a decision analysis, M eng and
TA B LE 2 7 . 1
SELECTION CRITERIA FOR PELVIC LYMPHADEN ECTOMY
% OF ALL % WITH POSITIVE

PROCEDURE CRITERIA PATIEN TS LYMPH N ODES
N o lymphadenectomya PSA 10, Gleason score 7, 50% 2%

and clinical stage T2
Intended retropubic prostatectomy; no PSA 10 or Gleason score 7 50% 2%
laparoscopic pelvic lymphadenectomy, or clinical stage T2c
but open lymphadenectomy may be
performed at the time of prostatectomy
Intended retropubic prostatectomy; laparoscopic PSA 50 or (PSA 20 and 10% 40%
pelvic lymphadenectomy may be considered Gleason score 7) or (PSA 10
and Gleason score 8)
Intended perineal prostatectomy; laparoscopic
pelvic lymphadenectomy may be considered b
PSA, prostate-specific antigen.

a Staging lymphadenectomy does not affect outcome (PSA recurrence at 2 years). From El Galley RES, Keane TE, Petros JA, et al. Evaluation of staging
lymphadenectomy in prostate cancer. Urology 1998;52:663–667, with permission.
b Pelvic lymphadenectomy has not been shown to affect the intermediate outcome. From Salomon L, H oznek A, Lefrere-Belda M A, et al. N ondissection
of the pelvic lymph nodes does not influence the results of perineal radical prostatectomy in selected patients. Eur Urol 2000;37:297–300, with
permission.
M odified from Wolf JS. Indications, technique, and results of laparoscopic pelvic lymphadenectomy. J Endourol 2001;15(4):427–435, with permission.
179
associates have suggested that lymph node dissection is

unwarranted in those with 18% risk for lymph node involve- Surg ical Te chniq ue
ment (7). Application of the selection criteria (Table 27.1) may
The boundaries of the traditional pelvic lymph node dissection
help to decrease the number of what at least some believe are
for prostate cancer include the pelvic sidewall laterally, the par-
unnecessary lymph node dissections.
avesical fascia and peritoneum medially, the genitofemoral
We currently perform pelvic lymph node dissection con-
nerve superiorly, the obturator nerve inferiorly, and the femoral
comitantly with retropubic prostatectomy in those patients
canal distally (Fig. 27.1). Proximally, the dissection is carried
with clinical T2a disease, a PSA equal to or 10 ng per mL,
varying distances up the common iliac artery (Figs. 27.2
and/or those with high-grade tumors (biopsy Gleason score
and 27.3). M any urologists feel that only the obturator nodal
equal to or 7). Due to the stage migration, we feel that per-
packet need be removed, for three reasons:
formance of lymphadenectomy as a separate procedure, that
is, laparoscopically, is not cost-effective. The yield of cancer- 1. The obturator nodes are involved in 87% of cases when
ous nodes for a clinical stage T1c tumor of a Gleason sum 7 lymphatic metastases are found.
and a preoperative PSA 10 ng per mL is well within the 5% 2. The procedure is for staging and not therapy.
to 10% margin of error of a false-negative diagnosis at frozen 3. If radiation therapy is used for local control following
section. Routine pelvic node dissection in such patients is surgery, patients who had an extensive lymphadenectomy
not cost-effective regardless of technique and subjects the have a higher incidence of scrotal or lower-limb edema.
patient to an unnecessary procedure with possible morbidity.
We no longer perform lymph node dissection prior to radia- As prophylaxis against deep venous thrombosis, patients
tion therapy. are administered 7,500 U of subcutaneous heparin in the arm,
FIGURE 27.1 Right lateral pelvic wall. Anatomy of pelvic blood vessels and nerves encountered in a
pelvic lymph node dissection is depicted.
Common iliac node Node of promontory
External iliac nodes

(intermediate chain)
Lateral sacral nodes
(lateral chain)
Internal iliac nodes
(medial chain)
FIGURE 27.2 Incision of fibroareolar tissue
loosely adherent to adventitia of the iliac
artery and vein. This allows a portion of the
areolar tissue to pass lateral to the iliac vessels
into the obturator fossa.
Chap t e r 27: Pe lvic Lymp had e ne ctomy 181
FIGURE 27.3 Boundaries of pelvic lymph node

dissection subdivided into different regions.
“ Limited” dissection removes tissue from the obtu-
rator fossa (region I). “ Extended” template dissec-
tion removes tissue along the major pelvic vessels
(external iliac vein, obturator fossa, and internal il-
iac artery and vein) (regions I and II). The dissection
is carried varying distances up the common iliac
artery and vein (region IV ). (From M attei A,
Fuechsel FG, Bhatta Dhar N , et al. The template of
the primary lymphatic landing sites of the prostate
should be revisited: results of a multimodality map-
ping study. Eur Urol 2008;53(1):118–125, printed
with permission from Elsevier.)
which may reduce lower limb edema (1). The supine or litho- We place the Bookwalter retractor on top of sterile towels,
tomy position may be used, although we recommend the low one on each thigh and one on the abdomen. A bladder blade
lithotomy position. The sacrum is positioned over the table and moist lap sponge are used for lateral retraction on the side
break or a roll to allow for hyperextension of and better vision of the dissection. A malleable retractor and moist lap sponge
into the pelvis. The bladder is emptied using a Foley catheter. are placed on the bladder and used to retract the bladder to-
A midline incision is made from below the umbilicus to the ward the contralateral side. A third blade is placed at the apex
symphysis pubica down through the anterior rectus sheath. of the incision. With these three blades, excellent visibility can
The posterior rectus sheath is incised for 2 to 3 cm above the be obtained.
linea semilunaris to aid in lateral retraction of the wound. An The nodal packet is palpated to detect grossly enlarged
extraperitoneal lymph node dissection is performed. If the lymph nodes. If such nodes are found, they are sent for frozen
peritoneum is entered during this incision, the defect is closed section evaluation following removal. If no enlarged nodes are
with absorbable sutures. palpated, we continue with the lymphadenectomy and prosta-
The transversalis fascia is sharply divided in the midline to tectomy and do not send the lymph nodes for frozen section.
allow lateral dissection superficial to the peritoneum, which The external iliac artery is identified, and dissection of the
helps avoid injury to the inferior epigastric vessels. The iliac lymph node packet is begun over its anteromedial aspect. The
vessels are exposed by bluntly sweeping the peritoneum super- correct plane of dissection is easily found here, and there are
omedially. The vasa deferentia are encountered during this no other structures in this area to be damaged (Fig. 27.4).
maneuver and may be divided. The table is tilted toward the Blunt dissection is performed with a sponge stick, and the suc-
first side for evaluation. If the prostate cancer is confined to tion tip and smooth forceps are used to clean away adipose
one lobe, the dissection is begun on that side. A self-retaining tissue. The dissection is brought proximally to the bifurcation
retractor is applied, with care taken not to injure the inferior of the common iliac vessels and distally to the femoral canal.
epigastric vessels. We use the Bookwalter retractor without The lymph node of Cloquet is the most distal aspect of the dis-
the post, as it can be more quickly applied and the post can in- section. Lymphatic channels into this node and surrounding
terfere with the surgeon. O ther self-retaining retractors may the external iliac vein are meticulously clipped and divided.
be used. We place a right-angle clamp around the lymph node packet
FIGURE 27.4 Correct plane of dissection is

shown.
and ligate it with a 2-0 Vicryl tie. A large right-angle clip is and medial to the artery. It is important to dissect down to the
placed below the tie. As the nodal packet is divided and swept correct fibroalveolar plane just overlying the artery and the
superiorly, an accessory obturator vein may be found medial vein. This will allow for easier and more precise dissection of
to the internal iliac artery and should be ligated (rather than the lymph node packets for the remainder of the procedure.
clipped) and divided to avoid avulsion. Identification of this O ur initial approach is to perform the obturator and hy-
vein is necessary as damage can cause extensive bleeding. pogastric dissection by locating and developing the medial
With gentle lateral retraction of the external iliac vein, the border of the iliac vein, thereby exposing the obturator fossa
lymph node packet is dissected off the pelvic sidewall laterally. posteriorly. Typically the patient is placed in the steep
Although a vein retractor is usually used for this maneuver, we Trendelenburg position and maintained relatively hypov-
use a peanut/Kitner dissector. Identification of the obturator olemic. Consequently, the iliac vein is decompressed and less
nerve is essential to avoid injury as the dissection is carried prone to grasping or sharp injury. With the medial edge of the
into the pelvic fossa. The packet is freed from the obturator external iliac vein identified, the plane between the vein and
nerve and vessels. The obturator vessels are spared if they are the obturator packet can be extended down to the pubic bone
in their usual location below the nerve. If the vessels are above distally. Blunt and sharp dissection, often with the aid of
the nerve or involved with the lymph node packet, it is best to monopolar scissors, bipolar graspers, and the appropriate
ligate and divide them to prevent avulsion and bleeding. This countertraction placed by the assistant or the surgeon’s non-
is especially true near the femoral canal. The superior attach- dominant hand, can be used to facilitate retraction of the vein
ment of the packet is now near the internal iliac artery. laterally and the obturator packet medially. With the dissec-
Previously we used to identify and dissect out the ureter, but, tion completed off the iliac vein, the nodal packet can then be
in most cases, we no longer do this. To ensure the ureter is not dissected off the obturator nerve and vessels posteriorly.
damaged by a clip, the specimen is split over the obturator M onopolar and bipolar cautery can aid in the division of
nerve, and a right-angle clip is placed over either limb of the smaller lymphatic channels, and laparoscopic clips (e.g.,
split packet on each side of the nerve in a cranial-to-caudal H emolock clips) can be used to ligate larger lymphatic chan-
fashion so that the ureter cannot accidentally be included in nels, pedicles, and vein branches as necessary. The pubic bone
the clip. Additional loose attachments to the proximal hy- and anterior surface of the obturator nerve and vessels help to
pogastric vessels are clipped and divided. The entire packet is mark the distal margin of the nodal packet. With the obtura-
sent to pathology as the two portions divided over the obturator packet freed and divided distally, it is peeled back in the
tor nerve. The obturator fossa is irrigated with sterile saline. It cephalad direction to the level of the hypogastric artery while
had been our routine to leave a gauze sponge in the fossa for keeping the obturator nerve, medial border of the external il-
hemostasis; however, we now do this only for minimal oozing. iac vein, and the medial umbilical ligament in clear view. The
The same dissection is then performed on the contralateral medial umbilical ligament should be retracted medially to
side to complete the lymph node dissection. We place one or achieve proper exposure for the hypogastric dissection.
two Jackson–Pratt drains in the pelvis postoperatively. If an extended dissection is to be performed, we begin
above and along the external iliac artery. Again, it is vital to
dissect down to the correct fibroalveolar plane over the artery,
Lap aro sco p ic and Ro b o t ic Ap p ro ach beginning the dissection distally. While avoiding the circumflex
vein distally, all tissue between the external iliac vein and
In recent years laparoscopic and robotic approaches have be- artery, as well as lymphatic tissue out to the psoas muscle and
come increasingly utilized in the surgical treatment of prostate genitofemoral nerve laterally, is included. With this packet di-
and bladder cancers. Accordingly, the ability to perform an vided distally, this lymph tissue is teased and dissected in the
adequate laparoscopic pelvic lymphadenectomy is necessary, cephalad direction with blunt and sharp dissection, occasion-
particularly at the time of the primary laparoscopic procedure. ally with the use of monopolar and bipolar cautery. Unlike the
Changes in port placement are not necessary, and the same external iliac vein, it is quite rare to encounter aberrant
instrumentation and setup can be used as is required for the pri- branches off of the artery, and this dissection is readily per-
mary surgical procedure. Instrumentation used includes broad formed proximally up to and along the common iliac vessels.
graspers in the nondominant hand and cautery scissors in the O ne needs to remain aware during the common iliac dissection
dominant hand. Typically, we utilize nontraumatic graspers such that the ureter will be crossing over the common iliac vessels. If
as Hunter graspers in laparoscopic cases or fenestrated bipolar desired, a para-aortic dissection is achievable laparoscopically
forceps in robotic cases. The surgical assistant also should be or robotically. If this dissection is anticipated, it may be neces-
available with nontraumatic graspers and a suction irrigator. sary to place the laparoscopic or robotic ports approximately
When the lymphadenectomy is performed following a 2 cm superior or cephalad than typically positioned.
laparoscopic or robotic prostatectomy or cystectomy, the pos- With the lymph node dissection complete, the lymph node
terior peritoneum has already been incised and the retroperi- specimen can be extracted through the 10- to 12-mm port or
toneal space exposed. If the lymph node dissection is to be preferably placed in an impermeable sack and extracted.
performed initially, the posterior peritoneum should be incised
in a cephalad-caudad direction just lateral to the medial
umbilical ligament on each side. This will expose the Limit e d Ve rsus Ext e nd e d Lymp h
retroperitoneal space and relevant landmarks. No d e Disse ct io n
The primary surgical step is to identify and expose the exter-
nal iliac artery and vein by blunt dissection (e.g., with the closed Though there is individual variability in lymphatic drainage,
scissor tips by the surgeon or with the suction irrigator by the the principal location for prostate cancer lies in the pelvis,
assistant). The vein can be located lying immediately posterior along the external and internal iliacs and in the obturator
fossa. Limited dissection involves only the obturator region continues along the lateral border of the medial umbilical liga-
bounded by the external iliac artery and the obturator nerve, ment and bladder. Large lymphatic channels are clipped and
whereas extended dissection involves all three regions divided, and gentle traction is applied to pull lymphatic tissue
(Fig. 27.3). Extended dissection results in the resection of ap- from the sidewall. Posteriorly, the dissection continues deep to
proximately two-thirds of all primary prostatic landing sites, the obturator nodal packet to the internal iliac vessels. This
compared to only one-third with a limited dissection (6). In packet is dissected along the obturator nerve as formerly de-
low-risk patients, up to 7% of positive lymph nodes may be scribed until the nerve passes posterior to the iliac vein, that is,
missed with limited lymph node dissection, while as high as the border of the lateral dissection.
20% may be missed in intermediate- and high-risk patients
(1). M apping studies have also demonstrated a considerable
amount of drainage to nodes along the common iliacs, in the BLADDER CANCER
presacral/pararectal regions, and along the aorta and vena
cava as high as the origin of the inferior mesenteric artery. Ind icat io ns fo r Surg e ry
Using an extended template that includes the nodes along the
common iliac arteries up to the ureteric crossing may remove There are compelling data that regional lymphadenectomy
approximately 75% of prostate primary lymphatic landing during radical cystectomy can prolong survival in patients with
sites (6). The risk-benefit ratio may not justify a complete dis- locally advanced bladder cancer and should be considered the
section up to the inferior mesenteric artery. standard of care. M ost urologists perform a standard bilateral
While controversy exists on the extent of lymph node dis- pelvic lymphadenectomy (to include lymphatics as far lateral
section, evidence suggests that extended dissection improves as the genitofemoral nerve) based on Skinner’s early 1980s
the accuracy of surgical staging and prognosis, given that the data that such a dissection can improve 5-year survival by up
percentage of positive lymph nodes predicts for disease pro- to 36% (11), which suggests that lymphadenectomy may have
gression. Data from a few retrospective analyses with long- some curative potential in bladder cancer patients with limited
term follow-up reveal that extended lymph node dissection nodal disease. Survival rates have been shown to be similar
may reduce the risk of disease progression and disease-specific (55% ) in those with minimal pelvic lymph node involvement
mortality (4). Joslyn and Konety examined the Surveillance, (N 1) and those without pelvic lymph node involvement if the
Epidemiology and End Results (SEER) database on 1,923 primary cancer is organ-confined (pT0 to pT3a). Recently, a
patients and detected an association between the extent of prospective, multi-institutional trial randomized 270 patients
lymphadenectomy and prostate cancer-specific mortality at to receive neoadjuvant chemotherapy followed by radical cys-
10 years after controlling for other variables (4). Patients un- tectomy or radical cystectomy alone (2). Twenty-four patients
dergoing excision of at least four lymph nodes (node-positive forewent lymphadenectomy, 98 underwent a limited lymph
and node-negative patients) or more than ten nodes (only node dissection (obturator nodes only), and 146 underwent a
node-negative patients) had a lower risk of death than did standard lymph node dissection. The 5-year survival rates for
those who did not undergo lymphadenectomy. The extended the three groups were 33% , 46% , and 60% , respectively.
dissection may result in the removal of unidentified metastatic The presence of positive lymph nodes in bladder cancer has
disease, explaining the potential therapeutic benefits in pa- therapeutic implications. If detected, some urologists forego
tients with not only positive but also negative nodes. surgery and treat with systemic therapy, whereas others favor
In contrast, several high-powered studies do not show any debulking the tumor with cystectomy followed by postoperative
survival advantage, and complication rates have been reportedly chemotherapy. If we find grossly enlarged lymph nodes with
higher in those undergoing extended dissection versus limited histological evidence of metastasis, our decision to proceed with
dissection. In fact, the probability of complications may increase cystectomy is influenced by whether the patient received neoad-
in direct proportion to the number of lymph nodes removed and juvant chemotherapy, the bulk of local disease, and preopera-
needs to be taken into account when the benefits associated with tive discussion with the patient. H owever, if the lymph nodes
more extensive dissection are considered. A multi-institutional, are grossly normal, we proceed with the radical cystectomy
randomized clinical trial is needed to determine the value of without sending the nodes for frozen section evaluation.
extending the boundaries of pelvic lymphadenectomy.
At this time, we do not routinely perform an extended dis-
section for prostate cancer; however, if indicated, it is carried Surg ical Te chniq ue
out as described previously while extending the boundaries to
the internal iliac vessels, bladder wall, and pelvic sidewall. The dissection is similar to the one described previously for
Lymphatic tissue is cleared from the pubis to the bifurcation prostate cancer with some differences. The incision is carried
of the common iliac vessels. The lateral dissection proceeds to just above the umbilicus and down to the pubic bone. We
along the external iliac vessels lateral to the circumflex vein palpate the pelvic lymph nodes while remaining extraperi-
and medial to the genitofemoral nerve as described previously. toneal. If no grossly enlarged nodes are palpable, the dissec-
As the dissection is carried cephalad along the anterior border tion becomes intraperitoneal and is performed after the
of the common iliac artery, any psoas branches are clipped and cystectomy is completed, rendering the operation easier and
divided. As with the dissection for bladder cancer, the vas def- quicker. The peritoneum is entered in midline, and inspection
erens is located over the medial umbilical ligament as it enters is performed of the intra-abdominal organs for signs of metas-
the internal inguinal ring and is divided. This allows exposure tases. If none are found, dissection is continued by mobilizing
of the medial umbilical ligament, which is then traced back to the cecum and ascending colon. The peritoneum is incised
the internal iliac artery. The medial border of dissection begins along the white line of Toldt and the right colon is rolled
with the ureter as it crosses the common iliac artery and medially. The right ureter is identified and freed superiorly
and inferiorly. Inferiorly, this leads to the bifurcation of the il- is lengthened approximately 1 hour without a significant in-
iac vessels. In freeing the peritoneum, we routinely divide the crease in complications (5).
vas deferens. O n the left, the peritoneum is incised lateral to M apping studies have attempted to identify a pattern of
the sigmoid colon, and it is reflected medially. The left ureter is anatomic distribution of metastatic lymph nodes and to
identified and freed as on the right. M obilization is aided by demonstrate an increase in the number of positive nodes out-
dividing the vas deferens. side the boundaries of the standard dissection as the patho-
A self-retaining retractor may be placed as described logic stage increases. Up to a third of patients with positive
above. The bowel can easily be retracted into the upper ab- common iliac nodes will have metastases to the presacral re-
domen, as it has been mobilized. The node dissection begins gion, which lies outside the standard template. Results from a
over either common iliac artery just proximal to the bifurca- prospective, multinational study of 290 patients with pT1G3-
tion. It is carried down the hypogastric artery to the superior T4 disease revealed positive lymph nodes in 81 patients
vesical artery, which is identified and divided. The remainder (27.9% ). For analysis, three anatomic regions were identified:
of the lymph node dissection is similar to that for prostate (I) below the bifurcation of the common iliacs, (II) between
cancer. Based on data demonstrating that excising and submit- the aortic and common iliac bifurcation, and (III) between
ting lymph nodes from each site separately increases the the inferior mesenteric artery and aortic bifurcation.
lymph node yield and improves nodal status assessment (13), Approximately 14% had positive nodes confined to either
we routinely send lymph nodes from different sites separately level I or level II. There were no skip lesions identified in level
as opposed to en bloc with the bladder specimen. III. If level I disease was present, 57% had level II positive
nodes and 31% at level III. The authors concluded that if only
the obturator nodes were removed in the 81 patients, then
Limit e d Ve rsus Ext e nd e d Lymp h 74.1% of the positive nodes would be left behind, potentially
No d e Disse ct io n compromising survival.
Variation in reported 5-year survival rates (5% to 30% )
There is no accepted standard for either the optimal number in lymph-node–positive bladder cancer treated with radical
of lymph nodes to be removed or the surgical limits of lymph cystectomy and pelvic lymph node dissection may be partly
node dissection. The most common dissection includes the explained by the extent of the lymph node dissection.
bifurcation of the common iliac, external and internal iliacs, Retrospective studies suggest that recurrence-free and cancer-
and the obturator lymph nodes, and generally yields 10 to 14 specific survival depend on the extent of local and regional
nodes. Further extending the dissection to the bifurcation of disease and maximizing its removal. In the late 1990s, Poulsen
the aorta, presacral, and presciatic nodes can yield 40 nodes and associates demonstrated that extending the limits of pelvic
from 13 separate nodal packets (Fig. 27.5). The surgical time lymph node dissection from the common iliac bifurcation to
the bifurcation of the aorta, along with removal of the
perivesical fat containing paravesical lymph nodes, improves
the recurrence-free survival rate following radical cystectomy
for bladder cancer confined to the bladder wall (pT3a) (85%
for pT3a versus 64% for those with pT3b) (10). M oreover,
H err et al. reported a 92% survival rate in patients with
pT2N 0 disease with the removal of at least nine lymph nodes,
compared to 53% survival in those who underwent less exten-
sive dissections. Significant differences in mortality were also
found among patients with pT3N 0 and pT4N 0 disease using
the same threshold of nine lymph nodes. In those with nodal
disease, a survival benefit was noted with the removal of 11
nodes (3). Similarly, Stein et al. determined that 15 lymph
nodes was the cutoff point associated with a significant bene-
fit in 5- and 10-year recurrence-free survival. They also calcu-
lated the lymph node density (ratio of positive lymph nodes to
total lymph nodes) and found a density of 20% to be associ-
ated with decreasing recurrence-free survival (12).
While the extent of lymphadenectomy necessarily remains
debatable and a randomized, prospective trial is needed to de-
termine which dissection should be employed, what is not in
question is that a pelvic lymph node dissection is the standard
of care.
FIGURE 27.5 Total of 13 separate nodal packets: left paraaortic (1),
right paracaval (2), right common iliac (3), left common iliac (4), right
external iliac (5), left external iliac (6), right lymph node of Cloquet O UTCO MES
(7), left lymph node of Cloquet (8), right obturator/hypogastric (9),
left obturator/hypogastric (10), right presciatic (11), left presciatic Although pelvic lymph node dissection is usually a relatively
(12), presacral (13). (From Stein JP, Penson DF, Cai J, et al. Radical
cystectomy with extended lymphadenectomy: evaluating separate short procedure with little morbidity, it has potential for sig-
package versus en bloc submission for node positive bladder cancer. nificant complications. These can be divided into intra- and
J Urol 2007;177(3):876–882, with permission.) postoperative (early and late) complications (Table 27.2). Paul
TA B LE 2 7 . 2 avoid ureteral injury, identified or not. If there is any concern

for ureteral injury, the ureter must be dissected out and fully
COMPLICATION S OF PELVIC visualized.
LYMPHADEN ECTOMY Postoperative complications include those related and un-
IN TRAOPERATIVE COMPLICATION S related to the wound. Wound infections and dehiscence are
uncommon. Seroma and hematoma formation are more com-
Vascular injury mon and may require drainage and local wound care.
Ureteral injury Prolonged lymph drainage and lymphocele formation may
O bturator nerve injury occur in 3% to 12% of patients. Prolonged drainage is treated
by instilling autologous blood or Betadine solution through
POSTOPERATIVE COMPLICATION S the preexisting drains as sclerosing agents. If Jackson–Pratt or
similar drains are used, tissue will eventually grow into the
Wound-R elated drains. This has occurred twice in our experience, and in both
H ematoma cases a general anesthetic was required for drain removal.
Seroma Although it has been reported that the use of subcutaneous
Wound infection heparin increases the incidence of prolonged lymph drainage,
Wound dehiscence this has not been our experience. O ur rate of prolonged lymph
drainage and/or symptomatic lymphocele formation is 3% .
N on–Wound-R elated Treatment of symptomatic lymphoceles varies from percuta-
Pulmonary atelectasis neous drainage under radiological guidance and sclerotherapy
Pneumonia to laparoscopic or open marsupialization into the peritoneal
M yocardial infarction cavity. Although some lymphatic drainage is expected, careful
Congestive cardiac failure dissection and meticulous ligation of lymphatic channels help
minimize the risk of prolonged drainage.
Prolonged lymph drainage
Any patient with prolonged or excessive lymph drainage
Lymphocele formation must be evaluated for a urinary leak. This may be done by
Deep venous thrombosis/pulmonary embolism sending a sample of the fluid for creatinine testing.
Epididymo-orchitis Thrombophlebitis and deep venous thrombosis are recog-
Urinary tract infection nized complications of pelvic lymph node dissection. Although
Prolonged ileus the studies are conflicting, most have shown that some method
Urinary retention of anticoagulation, low-dose heparin, or pneumatic compres-
sion stockings are beneficial in reducing the risk of these
Chronic lymphedema
complications. We routinely administer subcutaneous heparin
preoperatively and every 8 to 12 hours postoperatively as well
as use pneumatic compression stockings until the patient is
discharged.
and associates (9) reported an 8.6% incidence of intraoperative Chronic lymphedema of the lower extremities and external
complications, an 8.7% immediate postoperative wound com- genitalia may occur, and this may be worsened by radiother-
plication incidence, and an additional 31.4% immediate apy. Although extended dissections have been reported to
non–wound-related complication rate (3). They also reviewed result in improved survival rates in retrospective studies, they
the complication rates reported in multiple studies. These may be associated with increased incidence of lymphedema.
ranged from 4% to 53% with a mean rate of 26.6% (3). The modified pelvic lymph node dissection has been a reliable
Intraoperative complications can be minimized by familiarity way of preventing chronic lymphedema.
with the pelvic anatomy and careful dissection to identify vul-
nerable structures. The most common vascular injury is to the
accessory obturator vein. Care should be taken not to avulse
the obturator vessels as they enter the pelvic foramina because ALTERNATIVE THERAPY
they will retract caudally and ligation will be difficult. If this
occurs, bone wax can be used. Significant injuries to the exter- Pelvic lymph node dissection is currently the only definitive
nal iliac vessels require repair, sometimes with the aid of a vas- means of evaluating lymph node status. Enlarged lymph nodes
cular surgeon. Transection or avulsion of the obturator nerve suspicious for metastases may be identified by ultrasound,
leads to difficulties with adduction of the ipsilateral leg and is cross-sectional imaging with thin-cut computerized tomogra-
usually irreparable. Splitting the nodal packet as described phy (CT) scans, magnetic resonance imaging (M RI), and pedal
reduces the chance of inadvertent nerve injury. lymphangiography, all of which have low sensitivity. Unless
Ureteral injuries are uncommon and require repair when bulky disease is seen on a CT scan (1 cm), a tissue sample
encountered. A problem with ureteral injuries is that they are (e.g., by CT-guided needle aspiration core biopsy) is required
not always identified at the time of surgery. These are often for validation of a suspicious scan finding. Drawbacks with
the result of a clip inadvertently being placed across the ureter. biopsy include size limitation, random sampling error, disrup-
Therefore, as we now dissect out the lymph node packet, we tion of nodal architecture, low cellular yield, and need for an
no longer specifically look for the ureter. H owever, we always expert cytopathologist. While CT scans are routinely done
place a clip on the upper end of the nodal packet after splitting prior to a cystectomy, we very rarely employ them prior to a
it over the obturator nerve in a cranial-to-caudal direction to radical prostatectomy.
The use of PSA alone is not a good predictor of pathological may offer improvement in detection of nodal metastases over
stage, as there can be significant overlap between the two conventional imaging and are only indicated in high-risk pa-
variables. Costly alternatives such as radioisotopic metabolic tients. M ethods to improve specificity, such as fusion of ac-
imaging using positron emission tomography scans and tumor- quired images with three-dimensionally reconstructed M RI,
directed imaging by labeled antibody scans (111In-capromab are currently being investigated.
pendetide, the ProstaScint scan, Cytogen Corp., Princeton, N J)
References
1. Bader P, Burkhard FC, M arkwalder R, et al. Is a limited lymph node 8. Partin AW, Kattan M W, Subong EN , et al. Combination of prostate-
dissection an adequate staging procedure for prostate cancer? J Urol specific antigen, clinical stage, and Gleason score to predict pathological
2002;168(2):514–518; discussion 518. stage of localized prostate cancer. A multi-institutional update. JA M A
2. Grossman H B, N atale RB, Tangen CM , et al. N eoadjuvant chemotherapy 1997;277(18):1445–1451.
plus cystectomy compared with cystectomy alone for locally advanced 9. Paul DB, Loening SA, N arayana AS, et al. M orbidity from pelvic lym-
bladder cancer. N Engl J M ed 2003;349(9):859–866. phadenectomy in staging carcinoma of the prostate. J Urol 1983;
3. H err H W, Bochner BH , Dalbagni G, et al. Impact of the number of lymph 129(6):1141–1144.
nodes retrieved on outcome in patients with muscle invasive bladder 10. Poulsen AL, H orn T, Steven K. Radical cystectomy: extending the limits of
cancer. J Urol 2002;167(3):1295–1298. pelvic lymph node dissection improves survival for patients with bladder
4. Joslyn SA, Konety BR. Impact of extent of lymphadenectomy on survival cancer confined to the bladder wall. J Urol 1998;160(6, Pt 1):2015–2019;
after radical prostatectomy for prostate cancer. Urology 2006;68(1): discussion 2020.
121–125. 11. Skinner DG. M anagement of invasive bladder cancer: a meticulous pelvic
5. Leissner J, Ghoneim M A, Abol-Enein H , et al. Extended radical lym- node dissection can make a difference. J Urol 1982;128(1):34–36.
phadenectomy in patients with urothelial bladder cancer: results of a 12. Stein JP, Cai J, Groshen S, et al. Risk factors for patients with pelvic
prospective multicenter study. J Urol 2004;171(1):139–144. lymph node metastases following radical cystectomy with en bloc pelvic
6. M attei A, Fuechsel FG, Bhatta Dhar N , et al. The template of the primary lymphadenectomy: concept of lymph node density. J Urol 2003;170(1):
lymphatic landing sites of the prostate should be revisited: results of a mul- 35–41.
timodality mapping study. Eur Urol 2008;53(1):118–125. 13. Stein JP, Penson DF, Cai J, et al. Radical cystectomy with extended lym-
7. M eng M V, Carroll PR. When is pelvic lymph node dissection necessary phadenectomy: evaluating separate package versus en bloc submission for
before radical prostatectomy? A decision analysis. J Urol 2000;164(4): node positive bladder cancer. J Urol 2007;177(3):876–881; discussion
1235–1240. 881–882.
CHAPTER 28 ■ O PEN RADICAL RETRO PUBIC

PRO STATECTO MY
MISO P HAN AND WILLIAM J. CATALO NA
O ver the past two decades, the management of patients with

clinically localized prostate cancer has changed dramatically. INDICATIO NS FO R SURGERY
Widespread screening with serum prostate-specific antigen
(PSA) and digital rectal examination has allowed much earlier Radical prostatectomy is indicated for men with a life
detection of prostate cancer (1, 2). M odification of the surgi- expectancy of at least ten years, a completely resectable and
cal technique of radical retropubic prostatectomy has allowed biologically significant tumor, and no comorbidity that might
better hemostasis, improved visualization during dissection, make the operation unacceptably risky. Actuarial life tables
and facilitated preservation of neurovascular bundles supply- can project the life expectancy of US men, and with appropri-
ing the corpora cavernosa (3). As a result, radical prostatec- ate adjustment for comorbidities, life expectancy can be
tomy can be performed with a high cure rate while preserving estimated for the individual patient.
urinary and erectile function in the majority of patients. Thus, After confirming the likelihood of a sufficiently long life
radical prostatectomy has become the most commonly expectancy, the next step in patient selection is to identify
performed treatment for clinically localized prostate cancer, those with potentially curable disease. Radical prostatectomy
with abundant long-term data confirming its efficacy. In this provides the best chance for cure for men whose tumor is
chapter, we discuss the technique, outcomes, and complica- confined to the prostate gland. N omograms predicting the
tions of anatomic radical retropubic prostatectomy using the pathologic stage based on preoperative clinical and pathologic
senior author’s surgical series, now including 5,000 parameters have been widely used to identify patients who are
anatomic radical retropubic prostatectomies as an example. likely to benefit from the surgical resection and those who are
Chap t e r 28: O p e n Rad ical Re trop ub ic Prostate ctomy 187
not (4). Alternatively, nomograms predicting recurrence-free There are nine key steps in performing anatomic nerve-
survival probabilities following treatment also are sometimes sparing radical prostatectomy:
useful for patients (5,6). 1. A limited pelvic lymphadenectomy
2. Incision of the endopelvic fascia and the puboprostatic
ligaments
ALTERNATIVE THERAPY 3. Proximal and distal suture ligation, and transection of the
dorsal venous complex
Alternatives to radical retropubic prostatectomy include 4. Placement of hemostatic sutures in the neurovascular
watchful waiting/expectant management, hormonal manipu- bundles and the prostatic pedicles
lation, brachytherapy, external beam radiation therapy, and 5. Dissection of the prostate from the neurovascular bundles
other alternative surgical approaches such as radical perineal 6. Vascular control and transection of the prostatic pedicles
prostatectomy and laparoscopic radical prostatectomy with or 7. Transection and reconstruction of the bladder neck
without robotic assistance. 8. Dissection of the seminal vesicles and ampullary portions
of the vasa deferentia
9. Performance of the vesicourethral anastomosis
These steps are described in detail below with correspond-
SURGICAL TECHNIQ UE ing illustrations.
Before the operation, a first-generation cephalosporin (or
appropriate substitute, if the patient is allergic to
cephalosporins) antibiotic is given intravenously. After a general 1. A Limit e d Pe lvic Lymp had e ne ct o my
endotracheal or regional anesthesia is administered, thigh-high
elastic hose are placed on the patient. Sequential compression A superficial midline (or transverse) lower abdominal incision
devices and prophylactic low-dose heparin are used only in (usually between 4 and 5 in. in length, depending upon the
patients with increased risk for thromboembolic complications. patient’s body habitus) is made with a scalpel. The linea alba
The patient is positioned with his legs on spreader bars, and the is incised and the space of Retzius is entered. Anatomic radical
operating table is dorsiflexed with the break just above the retropubic prostatectomy performed in the extraperitoneal
patient’s anterosuperior iliac spine (Fig. 28.1). The abdomen space is arguably less invasive than laparoscopic and robotic
and genitalia are appropriately prepared and draped. prostatectomy, in which a transperitoneal approach is fre-
quently used. By avoiding any entry into the peritoneal cavity,
anatomic radical retropubic prostatectomy can be performed
while minimizing the risk of injury to bowel, major vascular
structures, and other adjacent organs. In addition, the cos-
metic results are not significantly different between a single,
limited infraumbilical incision for anatomic radical retropubic
prostatectomy and multiple laparoscopic port site incisions
and an incision for prostate removal during laparoscopic or
robotic prostatectomy.
Taking care to avoid disrupting the lymphatic tissue lat-
eral to the external iliac vein and to avoid compression of the
vein itself, a Balfour retractor is placed. A modified pelvic
lymphadenectomy is performed, removing only the lymph
nodes medial to the external iliac vein. Care is taken during
A
the lymphadenectomy to preserve any accessory arterial
branches to the corpora cavernosa that arise from the distal
external iliac or obturator arteries. The obturator nerve is
identified and preserved. In most incidences, the patient
elects to have the prostate gland removed, even if there are
pelvic lymph node metastases; otherwise, the excised lymph
node packet is sent for frozen section examination. If the
patient elects not to have the prostate removed and there are
lymph node metastases, frozen section examination of the
lymph nodes is performed. If frozen sections reveal metasta-
tic cancer, the operation is terminated. Lymphadenectomy is
optional in patients who are at low risk for pelvic lymph
node metastases by virtue of a low Gleason grade, low PSA,
and low biopsy tumor volume.
B
After completing the lymphadenectomy, the adipose and
FIGURE 28.1 A and B: Positioning of the patient. Legs are separated areolar tissues are swept gently from the anterior surface of
on spreader bars. The operating table is flexed with the break just
above the patient’s anterosuperior iliac spine. (From M H an, WJ
the prostate and the endopelvic fascia to expose the pubopro-
Catalona. Anatomic nerve-sparing radical retropubic prostatectomy. static ligaments. Care is taken to avoid injury to the perforat-
Chapter 29, 2005; 514–527, with permission.) ing branches of the Santorini plexus that pierce the
FIGURE 28.2 The endopelvic fascia is incised in the groove between

the levator ani muscles and the lateral border of the prostate. (From FIGURE 28.4 The dorsal venous complex is suture-ligated with a 2-0
H an, Catalona. Anatomic nerve-sparing radical retropubic prostatec- chromic catgut suture on a CT-1 needle. (From H an, Catalona.
tomy. Urol O ncol 2005; 516–525, with permission.) Anatomic nerve-sparing radical retropubic prostatectomy. Urol O ncol
2005; 516–525, with permission.)
endopelvic fascia between the puboprostatic ligaments and injuring the dorsal venous complex, care is taken not to divide
pass cephalad on the anterior surface of the prostate gland the puboprostatic ligaments too medially or too far under the
and bladder. pubic symphysis.
2. Incisio n o f t he End o p e lvic Fascia and 3. Sut ure Lig at io n and Transe ct io n o f t he
t he Pub o p ro st at ic Lig ame nt s Do rsal Ve no us Co mp le x
The endopelvic fascia is incised in the groove between the After the puboprostatic ligaments have been divided, the lat-
levator ani muscles and the lateral border of the prostate eral surfaces of the urethra are palpated. The groove between
(Fig. 28.2). Inside the endopelvic fascia, the lateral surface of the anterior surface of the urethra and the dorsal venous
the prostate is covered by a smooth, glistening membrane complex is developed with a pinching motion of the left index
overlying the lateral portion of the Santorini plexus. Strands finger and thumb. The plane between the urethra and the
of the levator ani muscles are gently dissected off the prostate dorsal venous complex is then developed gently, first with a
to the level of the urogenital diaphragm. O ften, venous tribu- large right-angle clamp. This facilitates tight ligation of the
taries pass from the levator ani muscles to the prostate just dorsal venous complex. After the dorsal venous complex has
lateral to the puboprostatic ligaments. These vessels are cauter- been ligated, it is also suture-ligated in a slightly more caudal site
ized, secured with hemostatic clips, or ligated laterally; then with a 2-0 chromic catgut suture on a CT-1 needle (Fig. 28.4). A
they are clamped medially with a delicate snub-nose right- suture ligature is also placed in the anterior surface of the
angle clamp. After the vein is transected sharply, its medial por- prostate to reduce the back-bleeding from the Santorini plexus
tion is ligated. When the endopelvic fascia has been opened (Fig. 28.5).
from the base to the apex of the prostate, the superficial branch The right-angle clamp is then passed behind the dorsal
of the Santorini plexus is gently retracted medially, and the venous complex, and the jaws of the clamp are spread. The dor-
puboprostatic ligaments are placed on stretch and partially sal venous complex is transected with electrocautery or a
divided close to the pubic symphysis (Fig. 28.3). To avoid
FIGURE 28.5 To reduce back-bleeding from the Santorini plexus, the

FIGURE 28.3 The puboprostatic ligaments are placed on stretch and cephalad aspect of the dorsal venous complex is suture–ligated. (From
incised. (From H an, Catalona. Anatomic nerve-sparing radical retrop- H an, Catalona. Anatomic nerve-sparing radical retropubic prostatec-
ubic prostatectomy. Urol O ncol 2005;516–525, with permission.) tomy. Urol O ncol 2005;516–525, with permission.)
FIGURE 28.8 The anterior wall of the urethra is incised with a scalpel
without dissecting around the lateral or posterior surfaces of the ure-
thra. (From H an, Catalona. Anatomic nerve-sparing radical retropubic
FIGURE 28.6 The dorsal venous complex is transected with a right- prostatectomy. Urol O ncol 2005;516–525, with permission.)
angle clamp jaws spread behind the complex. (From H an, Catalona.
Anatomic nerve-sparing radical retropubic prostatectomy. Urol
O ncol 2005;516–525, with permission.)
Fibromuscular bands tethering the apex of the prostate
to the pelvic floor are incised using sharp dissection (Fig. 28.9).
The rectourethralis muscle is incised, exposing the prerectal fat.
scalpel (Fig. 28.6). Back-bleeding from the dorsal venous
complex is controlled with figure-of-eight 3-0 sutures. It is
important to obtain good hemostasis at this time to allow the
apical dissection of the prostate to be performed in a relatively
4. Place me nt o f “Pro p hylact ic”
bloodless field. If the dorsal venous complex ligature slips off, He mo st at ic Sut ure s in t he Ne uro vascular
the complex is oversewn using a 3-0 chromic catgut suture on a Bund le s and Pro st at ic Pe d icle s
5/8-circle needle. The goal in oversewing the complex is to pass
the suture just through the lateral borders of the complex itself To reduce bleeding during the dissection of the neurovascular
in its anterior, middle, and posterior aspects. Wide, imprecisely bundles and prostatic pedicles in a manner similar to that
placed sutures may damage the neurovascular bundles. achieved with the pneumoperitoneum during laparoscopic
The anterior surface of the urethra is palpated between surgery, “ prophylactic” hemostatic figure-of-eight suture liga-
the neurovascular bundles. The circumurethral sphincter tures of 4-0 plain catgut are placed in the neurovascular bundles
muscle and the anterior wall of the urethra are incised with lateral to the prostate. Similarly, 3-0 suture ligatures are placed
a scalpel just distal to the apex of the prostate without in the prostatic pedicles. After these sutures have been placed on
dissecting around the lateral or posterior surfaces of the ure- both sides of the prostate, sharp, energy-free dissection can be
thra (Figs. 28.7 and 28.8). The incision should not be carried used to dissect the neurovascular bundles from the prostate. The
too far laterally, or it may injure the neurovascular bundles. prophylactic hemostatic sutures are tied “ softly” to avoid crush-
The urethral catheter is exposed and carefully hooked with ing the nerve fibers in the neurovascular bundles, and the plain
a delicate right-angle clamp. Gentle traction on the clamp in a catgut sutures are quickly absorbed. This technique minimizes
cephalad direction exposes the posterior urethral wall. The or avoids the use of hemostatic clips and sutures that may per-
catheter is divided and placed on gentle cephalad traction, manently entrap the neurovascular bundles.
and the posterior urethral wall is sharply transected.
FIGURE 28.9 The apical pedicles of the prostate may require suture
ligation. Fibromuscular bands tethering the apex of the prostate to
FIGURE 28.7 The circumurethral external sphincter muscle fibers are the pelvic floor are incised using sharp dissection. The prostate gland is
incised to expose the urethra. (From H an, Catalona. Anatomic nerve- dissected from neurovascular bundles. (From H an, Catalona.
sparing radical retropubic prostatectomy. Urol O ncol 2005;516–525, Anatomic nerve-sparing radical retropubic prostatectomy. Urol O ncol
with permission.) 2005;516–525, with permission.)
5. Se p arat io n o f t he Pro st at e fro m t he

Ne uro vascular Bund le s
The lateral pelvic fascia is incised from the apex of the prostate
to the base. A delicate right-angle clamp may be used to elevate
the lateral pelvic fascia from the underlying veins on the surface
of the prostate. Recent studies suggest that high, anterior re-
lease of the neurovascular bundles is associated with improved
potency rates. This maneuver must be performed carefully in
patients with high-grade and high-volume disease and is some-
times difficult to perform in patients with periprostatic fibrosis
or inflammatory changes. Small perforating bleeders not con-
trolled by the prophylactic hemostatic sutures may be secured FIGURE 28.11 The prostate base pedicle is ligated or hemoclipped
with hemoclips, ties, or ligatures to ensure adequate hemostasis. laterally, taking care to place the tie medial to the neurovascular bun-
The plane between the prostate and the neurovascular bundles dle. (From H an, Catalona. Anatomic nerve-sparing radical retropubic
prostatectomy. Urol O ncol 2005;516–525, with permission.)
is developed using sharp and blunt dissection, allowing the
prostate to assume a more anterior position in the pelvis.
(Fig. 28.11). The pedicle is divided close to the prostate. This
The lateral aspect of the prostate is then dissected from the
dissection is performed on both sides to a point cephalad to
neurovascular bundles, allowing the bundles to retract later-
the seminal vesicles. Care is taken when dissecting near the
ally. In a case of extensive fibrosis, the dissection is performed
seminal vesicles to avoid injuring the neurovascular bundles
only sharply to avoid tearing into the rectum with blunt
that are situated just lateral to the seminal vesicles. The semi-
dissection. The dissection is carried cephalad until the portion
nal vesicles are freed from the bladder base using sharp and
of the Denonvilliers fascia covering the ampullary portions of
blunt dissection, and a large right-angle clamp may be used to
the vasa deferentia and the seminal vesicles is exposed
further develop this plane. Two hemostatic sutures of 3-0
(Fig. 28.10). The Denonvilliers fascia is incised with the
chromic catgut are placed in the lateral bladder pedicles
cautery. The M etzenbaum scissors are then used to develop
cephalad to the seminal vesicles, one just lateral to the
the proper plane of dissection for the prostatic vascular pedi-
prostate and another just medial to the neurovascular bundles.
cles. If there is continued bleeding from the periurethral tis-
The lateral bladder neck fibers are then partially incised with
sues and apical pedicles of the prostate, hemostatic sutures
the cautery but not through their entire thickness.
should be placed at this juncture to avoid continued blood
loss during the remainder of the procedure.
7. Transe ct io n and Re co nst ruct io n o f t he
6. Vascular Co nt ro l and Transe ct io n Blad d e r Ne ck
o f Pro st at ic Pe d icle s The anterior bladder neck is transected with electrocautery
in the natural groove between the bladder and the prostate.
The prostatic pedicles are divided by inserting the right-angle
The bladder neck opening is enlarged with scissors, and the
clamp medial to them, with the tip of the clamp directed
catheter is pulled through and used as a tractor on the prostate
almost parallel to the lateral surface of the prostate. The
(Fig. 28.12). The posterior bladder neck is incised with the
prostatic pedicle is ligated or hemoclipped laterally, taking
care to place the tie or clip medial to the neurovascular bundle
FIGURE 28.10 The dissection is carried cephalad until the portion of

the Denonvilliers fascia covering the ampullary portions of the vasa FIGURE 28.12 The anterior bladder neck is transected in the natural
deferentia and the seminal vesicles is exposed. The Denonvilliers fas- groove between the bladder and the prostate. The bladder neck open-
cia is incised with cautery to expose vascular pedicles at prostate ing is enlarged with scissors. The ureteral orifices are identified.
base. (From H an, Catalona. Anatomic nerve-sparing radical retropu- (From H an, Catalona. Anatomic nerve-sparing radical retropubic
bic prostatectomy. Urol O ncol 2005;516–525, with permission.) prostatectomy. Urol O ncol 2005;516–525, with permission.)
cautery. The muscular attachments between the bladder and

prostate are divided using electrocautery and/or hemostatic
clips for hemostasis.
8. Disse ct io n o f Se minal Ve sicle s and

Amp ullary Po rt io ns o f t he Vasa
De fe re nt ia
The seminal vesicles are dissected first along their lateral
edges, carrying the plane of dissection medially. M any small
perforating arteries enter the lateral and terminal portions of
the seminal vesicles. These are secured with small hemoclips. FIGURE 28.14 Perineal pressure is applied with a sponge forceps to
The ampullae are freed, using sharp and blunt dissection, and better expose the cut end of the urethra. (From H an, Catalona.
then are clipped and transected. After the seminal vesicles Anatomic nerve-sparing radical retropubic prostatectomy. Urol O ncol
2005;516–525, with permission.)
have been dissected to their tips and the hemoclips placed, the
surgical specimen is removed. At this point, the pelvis is care-
fully inspected for hemostasis. Small bleeders on the neurovas-
cular bundles may require 4-0 absorbable suture ligatures. It is
important not to use the cautery for hemostasis on the neu-
rovascular bundles, to avoid cautery injury to the cavernosal
nerves. Suture ligatures of 3-0 or 4-0 absorbable material are
placed in the “ pockets” of the seminal vesicle pedicles on the
medial aspects of the neurovascular bundles to ensure good
hemostasis in this difficult-to-visualize region.
9. Ve sico ure t hral Anast o mo sis

Reconstruction of the bladder neck begins by placing a contin-
uous running everting suture of 3-0 chromic catgut that
encompasses bladder mucosa and underlying muscle for a
distance of nearly the entire anastomotic circumference FIGURE 28.15 Double-armed 2-0 chromic catgut sutures are used
for the vesicourethral anastomosis. (From H an, Catalona. Anatomic
(Fig. 28.13). The bladder neck is then reconstructed in a tennis nerve-sparing radical retropubic prostatectomy. Urol O ncol 2005;
racket fashion, with the handle of the racket directed posteri- 516–525, with permission.)
orly. The bladder neck closure is accomplished with a contin-
uous 2-0 chromic catgut suture. Care should be taken to avoid
compromising the ureteral orifices. The bladder neck is closed
to better expose the cut end of the urethra (Fig. 28.14), double-
to a size of approximately 22Fr to 24Fr. Closing the bladder
armed 2-0 chromic catgut sutures are used for the vesi-
neck to a smaller caliber may lead to postoperative vesi-
courethral anastomosis (Fig. 28.15). A 5/8-circle needle is used
courethral anastomotic stricture.
to place the sutures in the urethra from inside to outside, avoid-
An 18Fr catheter is passed through the urethra. While an
ing placing the suture into the neurovascular bundles. The tip of
assistant exerts pressure on the perineum with a sponge forceps
the catheter is grasped and brought out of the wound to expose
the posterior lip of the cut end of the urethra. The posterior
sutures are similarly placed. The anterior sutures are placed at
the 10 o’clock and 2 o’clock positions, and the posterior sutures
are placed at the 5 o’clock and 7 o’clock positions. In addition,
a stronger 2-0 monocryl suture is placed at the 6 o’clock posi-
tion to secure the most posterior aspect of the reconstructed
bladder neck to the urethral stump. The other ends of the su-
tures containing an 1/2 circle taper point needle are placed in
the corresponding positions of the bladder neck from inside to
outside. These sutures encompass mucosa and muscle and exit
at the edge of the mucosa. The catheter tip is placed in the blad-
der, and the bladder neck is guided gently toward the cut end of
the urethra. The anastomotic sutures are tied carefully under di-
rect vision. The bladder is then irrigated free of clots, and a sin-
FIGURE 28.13 A continuous running mucosa-everting suture of 3-0 gle suction drain is placed in the pelvis and brought out the
chromic catgut is placed for a distance of nearly the entire anasto-
motic circumference. (From H an, Catalona. Anatomic nerve-sparing lower end of the wound. The incision is closed with no. 1 loop
radical retropubic prostatectomy. Urol O ncol 2005;516–525, with M axon running sutures on the fascia, 2-0 chromic catgut suture
permission.) on the subcutaneous tissue, and a 4-0 monofilament absorbable
subcuticular suture on the skin. The skin incision is covered anatomic radical retropubic prostatectomy between 1983 and
with Steri-Strips. 2003, including those with adverse prognostic features. Cancer
progression was defined as detectable serum PSA ( 0.2 ng per
mL), local recurrence, or distant metastases. With a mean fol-
Po st o p e rat ive Care low-up of 65 months (range, 0–233), actuarial ten-year cancer
progression-free survival probability was 68% . Actuarial ten-
Patients are ambulated with assistance once or twice on the year cancer-specific and overall survival rates were 97% and
day of surgery, 5 times on the first postoperative day, and 83% , respectively. Other large radical prostatectomy series have
7 times on the second postoperative day. A clear liquid diet is reported similar excellent results (9,10). Similar long-term onco-
given on the night of surgery, advancing to a regular diet as logical outcome results are not yet available in laparoscopic or
tolerated on the following days. A suction drain and dressing robotic prostatectomy series.
are removed, and the patient is usually discharged from the
hospital on the second postoperative day. Intravenous antibi-
otics are discontinued after the suction drain is removed. For
analgesia, ketorolac (30 to 60 mg) is given intravenously every Urinary Co nt ine nce O ut co me
6 hours for the first 48 hours. It may be supplemented with
The overall urinary continence outcome following nerve-
acetaminophen or sparingly with morphine, as needed.
sparing radical retropubic prostatectomy was excellent in the
Although some claim a quicker recovery following laparo-
current series. M ore than 93% of men achieved complete
scopic surgery compared to anatomic radical retropubic
urinary continence, defined as requiring no protection for
prostatectomy, a recent study has shown similar low narcotic
daily activities (11). The return of urinary continence was
usage and patient-reported pain scores regardless of which
strongly associated with the age of the patient. For example,
approach was used (7). Therefore, the same clinical care path-
95% of men younger than age 50 were continent following
way, without a significant difference in length of hospital stay,
surgery. In contrast, 86% of men above age 70 were continent
can be applied to patients treated by either open radical
postoperatively. O nly four men (0.2% ) eventually required
prostatectomy or laparoscopic/robot-assisted radical prostate-
an artificial urinary sphincter placement for stress urinary
ctomy. M ost patients are discharged from the hospital on the
incontinence. The relative long-term functional outcomes of
second or third postoperative day following anatomic radical
laparoscopic and robotic prostatectomy methods are yet
retropubic prostatectomy.
unknown.
Antibiotic ointment is applied to the urethral meatus
around the catheter 4 to 6 times a day until catheter removal.
The catheter may be removed on the seventh, tenth, or four-
teenth postoperative day, depending upon the perceived Ere ct ile Funct io n O ut co me
amount of tension on the vesicourethral anastomosis. A
cystogram is not performed before removing the catheter There are several possible goals of the nerve-sparing aspect
unless an anastomotic leak is suspected. The catheter should of radical retropubic prostatectomy. Patients with intact
not be removed before 7 days, as 10% to 15% of men may libido and erectile potency want to maintain their current
experience urinary retention from edema and require quality of erections or erections sufficient for penetration
recatheterization. An oral fluoroquinolone antibiotic is given with the help of oral medication, such as phosphodiesterase
1 day before and 1 week following the catheter removal. Daily type 5 inhibitors. O thers with poor-quality erections preop-
Kegel exercises are performed in four sets of ten, before the eratively might accept erections that at least offer some
surgery and following the catheter removal until continence rigidity to provide sensory satisfaction for both sexual part-
returns. A protective pad or diaper is used until complete ners. The erectile potency in the current series was defined
urinary control is achieved. The first postoperative serum PSA as an ability to maintain erections strong enough for pene-
level is measured 1 month after the operation. tration with or without the help of oral phosphodiesterase
inhibitors.
The return of erectile potency following radical retropubic
prostatectomy was strongly associated with the age of the
O UTCO MES patient, preoperative potency status, nerve-sparing status
(bilateral versus partial sparing), and the era of surgery (1980s
Cance r Co nt ro l O ut co me versus 1990s) (11). M ore than 75% of men younger than age
60 regained potency following bilateral nerve-sparing radical
The most important objective of radical prostatectomy is can- retropubic prostatectomy. In the modern era, 95% of men
cer control. A rising serum PSA level is usually the earliest ev- below age 50 recovered potency following surgery. Between
idence of recurrence or progression following prostatectomy. 62% and 72% of men in their 60s became potent following
Because follow-up data are not sufficiently mature to effec- bilateral nerve-sparing surgery. Finally, there was a significant
tively evaluate cancer-specific survival trends, biochemical- improvement in recovery of potency in men treated in the
recurrence-(detectable serum PSA)–free survival has been used 1990s compared to those treated in the 1980s, even after cor-
frequently as a surrogate in evaluating treatment efficacy in recting for the age and nerve-sparing status. In the most favor-
radical retropubic prostatectomy series. able candidates in whom preoperative potency is normal and
Analyses of the senior author’s series recently have been bilateral nerve-sparing surgery can be performed, approxi-
reported (8). They include almost 3,500 men who underwent mately 95% in their 40s, 85% in their 50s, 75% in their 60s,
and 50% in their 70s will recover erections sufficient for pen- associated with radical prostatectomy included infection, lym-
etration and intercourse with or without the aid of phospho- phocele formation, neurologic deficit, and cardiovascular
diesterase type 5 inhibitors. events.
The senior author now strongly encourages patients to Anastomotic stricture can be initially managed with a
begin an erectile dysfunction rehabilitation program begin- gentle, serial dilation. Alternatively, a careful internal
ning 1 month postoperatively, using intracavernosal injections urethrotomy can be performed. For a long and persistent stric-
of Tri-M ix two to three times per week. This regimen provides ture, a transurethral resection of the scar tissue cephalad to
excellent rigid erections with well-oxygenated arterial blood the external sphincter may be necessary. Care should be taken
and also provides the patient with a method to return to a to avoid cutting too deeply in the posterior direction to avoid
relatively normal sex life soon after surgery. Patients may tran- creating a fistula with the rectum. After resection, triamci-
sition to oral phosphodiesterase inhibitor therapy when spon- nolone can be injected via a cystoscopic approach to prevent
taneous erections begin to return. inflammatory response and subsequent, recurrent scar forma-
tion. Usually, an interval of self-catheter dilation of the anas-
tomosis is required.
Inadvertent injury to the obturator nerve can occur during
CO MPLICATIO NS the pelvic lymphadenectomy. When a tension-free primary
nerve repair is not feasible, nerve grafting can be performed
With careful selection of patients and performance of neces- utilizing either the sural nerve or the lateral antebrachial cuta-
sary cardiovascular evaluation, perioperative mortality can be neous nerve. H owever, even without a nerve repair, conserva-
largely avoided. There was no intraoperative or immediate tive management with physical therapy can compensate for
postoperative mortality in the current series. the deficit, and many patients do not exhibit significant thigh
The overall complication rate of radical prostatectomy was adductor deficit following the injury.
9% in the current series (12). Initially, the complications oc- An injury to the ureter can occur inadvertently during the
curred more commonly in older men, but the overall compli- transection of the bladder neck or the dissection of the lateral
cation rate gradually decreased with the surgeon’s experience. prostate pedicles. When recognized, a simple mobilization of
The most common complications of anatomic nerve-sparing the distal ureter and ureteroneocystostomy should be per-
radical retropubic prostatectomy included anastomotic stric- formed. The reimplanted ureter should be cannulated using a
ture (bladder neck contracture), thromboembolic complica- 5Fr or 8Fr pediatric feeding tube to prevent the urinary
tions (deep vein thrombosis and pulmonary embolism), and obstruction due to the edema at the reimplantation site.
postoperative inguinal hernia. In the current series, the rate of Usually, a rectal injury can be repaired primarily using a
anastomotic stricture decreased from 8% in the 1980s to 1% multiple-layer closure. H owever, a diverting colostomy should
after 1990. Similarly, a marked decrease in thromboembolic be strongly considered in men with a large rectal defect, a his-
events was observed, with the rate decreasing from 3% to tory of pelvic radiotherapy, or long-term preoperative steroid
1% during the past 20 years. O ther rare complications ( 1% ) therapy.
References
1. Catalona WJ, Smith DS, Ratliff TL, et al. M easurement of prostate-specific 8. Roehl KA, H an M , Ramos CG, et al. Cancer progression and survival rates
antigen in serum as a screening test for prostate cancer. N Engl J M ed following anatomical radical retropubic prostatectomy in 3,478 consecu-
1991;324(17):1156–1161. tive patients: long-term results. J Urol 2004;172(3):910–914.
2. H an M , Partin AW, Piantadosi S, et al. Era specific biochemical recurrence- 9. H ull GW, Rabbani F, Abbas F, et al. Cancer control with radical prostatec-
free survival following radical prostatectomy for clinically localized tomy alone in 1,000 consecutive patients. J Urol 2002;167(2, Pt 1):
prostate cancer. J Urol 2001;166(2):416–419. 528–534.
3. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight 10. H an M , Partin AW, Pound CR, et al. Long-term biochemical disease-free
into etiology and prevention. J Urol 1982;128(3):492–497. and cancer-specific survival following anatomic radical retropubic prosta-
4. M akarov DV, Trock BJ, H umphreys EB, et al. Updated nomogram to tectomy. The 15-year Johns H opkins experience. Urol Clin N orth A m
predict pathologic stage of prostate cancer given prostate-specific antigen 2001;28(3):555–565.
level, clinical stage, and biopsy Gleason score (Partin tables) based on cases 11. Catalona W, Roehl KA, Antenor JA. Potency, continence, complications,
from 2000 to 2005. Urology 2007;69(6):1095–1101. and survival analysis in 3,032 consecutive radical retropubic prostatec-
5. Stephenson AJ, Scardino PT, Eastham JA, et al. Preoperative nomogram tomies. J Urol 2002;167[Suppl 4]:625.
predicting the 10-year probability of prostate cancer recurrence after radi- 12. Kundu SD, Roehl KA, Eggener SE, et al. Potency, continence and compli-
cal prostatectomy. J N atl Cancer Inst 2006;98(10):715–717. cations in 3,477 consecutive radical retropubic prostatectomies. J Urol
6. H an M , Partin AW, Z ahurak M , et al. Biochemical (prostate specific anti- 2004;172(6, Pt 1 of 2):2227–2231.
gen) recurrence probability following radical prostatectomy for clinically
localized prostate cancer. J Urol 2003;169(2):517–523.
7. Webster TM , H errell SD, Chang SS, et al. Robotic assisted laparoscpic rad-
ical prostatectomy versus retropubic radical prostatectomy: a prospective
assessment of postoperative pain. J Urol 2005;174:912.
CHAPTER 29 ■ RADICAL PERINEAL
PRO STATECTO MY
SAM D. GRAHAM, JR., JEFFREY C. LO U, AND THO MAS E. KEANE
Radical perineal prostatectomy, first performed in 1869 by imaging (M RI), computerized tomography (CT) scan, and
Buchler and popularized in the United States by Young in pelvic M RI, have been shown to have limited usefulness. The
1903, remained the primary surgical approach to carcinoma new generation of MRI scanners and ProstaScint scanning using
of the prostate into the mid-1970s. With the recognition of the fusion technology with CT or M RI have the potential to im-
importance of assessing pelvic lymph nodes preoperatively prove prostate cancer staging. Radionuclide bone scans are
and the advantage that retropubic prostatectomy offered with useful in assessing advanced bone disease but generally are not
the concomitant pelvic node dissection, perineal prostatec- positive in patients with PSAs below 20 and no other sign of
tomy declined in popularity for the treatment of prostate can- advanced disease.
cer. The perineal approach, however, saw a resurgence in the For the past 20 years we have prospectively provided data
1990s for several reasons: (a) the trend toward minimally in- that has been applied to an algorithm for the preoperative as-
vasive surgery with a focus on reducing the morbidity and sessment of patients with prostate cancer developed through
therefore hospital stay of patients, (b) the advent of laparo- data on over 400 patients who had undergone pelvic node dis-
scopic surgery for lymph node assessment, (c) the introduction section. The current algorithm includes patients with a Gleason
of prostate-specific antigen (PSA) for screening for prostate sum of 7, providing that the predominant pattern is 3, a low-
cancer with reduction in the numbers of patients with node- volume cancer (T1b-c, T2a), and PSA of 10 ng per mL.
positive disease, (d) algorithms that may predict patients at Patients meeting all of these criteria have a 5% chance of
high risk for positive lymph nodes, and (e) increased recogni- positive lymph nodes, and therefore we do not routinely per-
tion of similar results compared to all other methods of radi- form pelvic lymph node dissections (1). Patients exceeding any
cal prostatectomy. The procedure is also associated with one of the above criteria are considered to be in the high-risk
reduced blood loss and low morbidity, and it can be modified group and have undergone pelvic lymph node dissections.
to incorporate the neurovascular sparing techniques for Using this method of assessment, our overall PSA recurrence
preservation of potency. rate from 1986 to 1993 was 24% . This compares favorably to
other series of retropubic prostatectomies from that time in
which all patients had a node dissection; in those series PSA
DIAGNO SIS recurrence rates were between 24% and 28% (2–5).
All patients who are potential candidates for radical perineal

prostatectomy should undergo appropriate preoperative stag- INDICATIO NS FO R SURGERY
ing to ensure that they are operable candidates; preopera-
tive imaging is rarely required in low- to intermediate-risk Patients who are candidates for radical prostatectomy must
patients. M ethods of differentiating local versus advanced dis- have clinically organ-confined prostate cancer (T1-2). O ther
ease include digital rectal examination, transrectal ultrasonog- factors that need to be taken into consideration are the pa-
raphy, radionuclide bone scan, assessment of pelvic lymph tient’s life expectancy, other comorbidities, or any other fac-
nodes, and pathologic indicators of progression such as tors that may affect the patient’s choice. We generally do not
Gleason sum and other markers. offer a radical prostatectomy to patients who have a 10-year
PSA screening has made a significant impact on the preop- expectancy. O ver the age of 70, we offer a radical prostatec-
erative stage of patients with prostate cancer. Patients present- tomy only in selected cases where we feel that the benefits
ing for surgery are generally younger, healthier, and more that can be obtained from radical prostatectomy outweigh the
likely to have organ-confined prostate cancer than the popula- potential risks, particularly when compared to alternative
tion treated only a decade earlier, and in many ways this therapies.
attributes to the large increase in the number of radical prosta-
tectomies done in the United States in the past decade.
Digital rectal examination has a limited role in the clinical ALTERNATIVE THERAPY
staging of prostate cancer. It is primarily used to crudely esti-
mate the volume of the cancer. Transrectal ultrasonography is Alternatives to perineal prostatectomy include retropubic and
another modality that also has limitations in assessing local laparoscopic or robot-assisted laparoscopic prostatectomies.
disease, but combined with digital rectal examination it at least The retropubic approach allows simultaneous node dissection
gives some gross assessment of the likelihood of extracapsular and removal of larger prostate glands, though the length of
disease. Other modalities, such as transrectal magnetic resonance hospitalization and immediate postoperative morbidity are
194
Chap t e r 29: Rad ical Pe rine al Prostate ctomy 195
higher in our institution. The robotically assisted laparoscopic Prior to putting the patient in position, the legs are wrapped
approach allows some improvement in visualization com- with ACE bandages.
pared to the retropubic or laparoscopic surgeries due to the Five instruments are significant in assisting the surgeon for
magnification and three-dimensional visualization, but it has this operation. These include the Lowsley curved tractor, the
yet to show any significant advantages in terms of operative Young straight prostatic tractor, a H alogen head lamp, a har-
morbidity, length of stay, or reduction in long-term morbidity. monic scalpel, and an O mni-Tract miniwishbone retractor
There are few if any large comparisons with radical perineal system. The curved Lowsley tractor is used to bring the prostate
prostatectomy, although results to date indicate that no signif- up into the perineum to allow dissection against the prostate
icant differences exist. while mobilizing the rectum from the prostate. The straight
Alternatives to radical prostatectomy include observation, Young tractor is used to manipulate the prostate laterally as
hormonal deprivation, and radiation therapy. We do not con- well as cephalad and caudad after the membranous urethra
sider either observation or hormonal deprivation to be cura- has been divided. The H alogen head lamp is important be-
tive; these are good options only for patients with less than a cause it allows the surgeon to aim a strong light into the oper-
5-year life expectancy, patients who are 70 years old with a ative field, which may be too deep and narrow for standard
well-differentiated cancer, and patients who are at high risk operating lights to adequately illuminate the structures. The
for surgery and refuse radiation. Radiation therapy, however, harmonic scalpel allows coagulation and closure of vessels
may be definitive and has a 5- to 10-year survival rate equiva- without transmission of electrical current, thereby reducing
lent to that of surgery. The recurrence rates with radiation the risks to the neurovascular bundles. The O mni-Tract mini-
therapy are bimodal, with initial recurrences within 1 to 2 years wishbone allows virtually unlimited retraction in any direc-
of treatment and a delayed peak at 5 to 7 years after treat- tion. We have developed a posterior weighted speculum that is
ment. If the patient is young with a 15-year or longer outlook, compatible with the O mni-Tract (Fig. 29.2).
we feel that our results would favor radical prostatectomy. It should be noted that in manipulating the prostate within
the pelvis, the pelvis should be viewed as a cone with the apex
of the cone being the incision (Fig. 29.3). To achieve better vi-
SURGICAL TECHNIQ UE sualization, it is sometimes necessary to actually push the
The patient is placed in an exaggerated lithotomy position

(Fig. 29.1). It is important that the patient’s perineum be par-
allel to the floor because this directly affects exposure. We use
a standard operating room table with seven folded sheets un-
der the patient’s sacrum supporting the patient’s entire weight.
Shoulder braces are not recommended, and if a patient tends
to slide off the sheets, we will place the table in a slight reverse
Trendelenburg position. The patient’s legs are stabilized using
candy cane or Allen stirrups, again taking precautions to pre-
vent stretching the hamstring or causing pressure on the legs.
FIGURE 29.1 Positioning of the patient requires the perineum to be

parallel to the floor. The sacrum supports the patient’s weight, and the
legs are positioned with no traction on the hamstrings. N o shoulder FIGURE 29.2 Posterior weighted speculum can be articulated to
braces are indicated. adapt to each patient’s anatomy.
prostate further into the pelvis. Also note that traction is not
placed directly on the bulb or membranous urethra, as this
will decrease the likelihood of restoration of potency and po-
tentially affect the patient’s continence postoperatively.
The incision is made from the ischial tuberosity crossing
the midline at the juncture between the squamous epithelium
and the mucocutaneous border of the rectum (Fig. 29.4). The
incision extends posteriorly to a line equal to the posterior
portion of the anus. Using sharp dissection and electrocautery,
the ischiorectal fossae are entered, and using blunt dissection
the central perineal tendon is identified and transected with
electrocautery. At this point, we employ the Belt approach,
dissecting down to the white fascia of the rectum and proceeding
subsphincterically (Fig. 29.5). A transsphincteric or supra-
sphincteric approach is also an option. Using predominantly
blunt dissection with an index finger in the rectum, the rectal
sphincter and levator ani can be dissected free of the rectum
with minimal bleeding (Fig. 29.6). The blades from the mini-
FIGURE 29.3 The bony pelvis is a cone with the apex at the incision. wishbone retractor are then used to retract these muscles ante-
Better visualization can be obtained in many cases by actually pushing
the prostate deeper into the pelvis. riorly and laterally. With tension on these muscles and tension
on the rectum, the rectourethralis is identified and divided,
allowing the surgeon to dissect the rectum free of the apex of
the prostate (Fig. 29.7).
In patients who are undergoing nerve-sparing surgery, the
dissection is carried down to approximately 1.5 to 2.0 cm from
the apex, at which point the external layer of the Denonvilliers
fascia is divided and dissection is carried between the two lay-
ers of the Denonvilliers fascia (Fig. 29.8). Care is taken not to
FIGURE 29.4 An inverted U-shaped incision is made

in the perineum extending from ischial tuberosity to
ischial tuberosity.
FIGURE 29.5 The dissection is carried along the rectal fascia, sparing FIGURE 29.7 Dissection of the rectum from the prostate after division
the anal sphincter. of the rectourethralis is facilitated with the surgeon’s finger in the rectum.
FIGURE 29.8 An incision into the posterior layer of the Denonvilliers

fascia allows the dissection to continue between the two layers. For a
nerve-sparing technique, this incision is made transversely 1 to 2 cm
FIGURE 29.6 The Levator ani and the anal sphincter are retracted to proximal to the apex of the prostate, avoiding carrying the incision
expose the rectourethralis. into the neurovascular bundles.
FIGURE 29.11 Using the wings of the distal posterior layer of the
Denonvilliers fascia to aid in dissection, the inferior branch from the
neurovascular is isolated and divided.
FIGURE 29.9 Anatomic view of the neurovascular bundles from the
posterior view of the prostate. The vessels course along the lateral and
posterior prostate and cross the apex to enter the urogenital di-
aphragm posterior to the membranous urethra.
A right-angled clamp is placed around the membranous
urethra and generally meets little resistance if one stays poste-
rior to the endopelvic fascia (Fig. 29.12). The Lowsley tractor
damage the neurovascular bundles that course along the latis removed and the membranous urethra divided. The Young
eral posterior prostate on either side (Fig. 29.9). tractor is then placed into the bladder through the prostatic
The distal portion of the Denonvilliers fascia is then incised urethra, and the endopelvic fascia is divided with the har-
in the midline with scissors, and the tag is used to facilitate monic scalpel.
dissection of the neurovascular bundle from the prostate (Fig. The anterior prostate is dissected free of the bladder. It
29.10); the inferior pedicle, if present, is then ligated and di- should be noted that there are generally two small arteries that
vided (Fig. 29.11). If the dissection is in any way impaired by enter the prostate along the anterior bladder at 10 and 2 o’clock
fibrosis such that there is a potential for prostatic tissue to be positions that should be cauterized and divided. The groove
left behind, the neurovascular bundle is sacrificed on that side. between the prostate and bladder is identified, and the
It should be noted during this dissection that the neurovas- prostate and bladder can be separated with either sharp or
cular bundle actually courses across the posterior surface of blunt dissection. If the plane between the prostate and bladder
the prostate at the apex and enters the urogenital diaphragm is not easily developed, the dissection should be performed
just posterior to the membranous urethra. This proximity is sharply and biopsies taken of the bladder neck to ensure that
important in that the vesicourethral anastomosis may incor- there is no invasion of the bladder neck by the cancer. In pa-
porate the neurovascular bundle if the surgeon is not precise tients who have had prior transurethral resections of the
with the placement of sutures in the posterior urethra. The re- prostate, palpation of the blades of the Young tractor can be
traction of the neurovascular bundle on either side thereby ex- used to identify the bladder neck.
poses the proximal membranous urethra. In most cases, there is insignificant bleeding from the dor-
sal venous complex in the endopelvic fascia. H owever, if there
should be communicating veins, they may be suture-ligated
using 3-0 Vicryl. The prostate is dissected from the bladder
anteriorly to posteriorly to the 5 and 7 o’clock positions, re-
spectively, on the patient’s left and right, and the bladder neck
is divided over the Young tractor and the Young tractor re-
moved; a stay suture may be inserted in the bladder neck at
this point (Fig. 29.13). The bladder is evacuated of any urine,
and the posterior bladder neck is divided with the harmonic
scalpel. The prostate is then dissected free from the posterior
bladder. A plane is entered after dividing the posterior bladder
neck, which is anterior to the seminal vesicles and the ampulla
of the vas but posterior to the bladder. The superior pedicles
lie in the lateral aspect of this plane and can be divided at this
point.
Attention is then directed to the posterior surface of the
prostate. The rectum is swept free of the neurovascular bun-
FIGURE 29.10 Incision of the distal posterior layer of the dles, which also allows identification of the superior pedicles
Denonvilliers fascia in the midline. This is best done w ithout electro- of the prostate as well as the seminal structures. The superior
cautery if a nerve-sparing technique is planned. pedicles can be divided with the harmonic scalpel at this point,
FIGURE 29.12 Division of the membranous urethra at the

apex of the prostate.
The anastomosis is performed using 3-0 Vicryl simple sutures

and an RB-1 controlled-release needle (Fig. 29.15). The anas-
tomosis is performed around a 22Fr, 5-cc Foley catheter, and
generally seven to eight sutures are used. Care should be taken
that small portions of the membranous urethra are incorpo-
rated in the anastomosis such that the continence mechanism
is left undisturbed as well as the neurovascular bundles, which
contribute to potency.
The rectum is then inspected, a Foley balloon inflated, and a
Penrose drain placed through the left ischiorectal fossa and a
separate stab incision. The incision is closed with a 3-0 chromic
gut closure. O ne suture is placed to reapproximate the central
tendon, and the remainder of the sutures are used to close the
skin in a horizontal mattress (Fig. 29.16).
Postoperatively, patients have a very low requirement for
pain medication. M ost patients either do not require parental
pain medication or are off the parental medications within
12 to 24 hours. Average time to discharge is approximately
24 hours from the time of surgery (Table 29.1). The patient’s
catheter is removed on day 12. The Penrose drain is removed
prior to discharge. O ne of the authors, Tom Keane, discharges
patients and removes the catheter on day 7 (6).
FIGURE 29.13 A Young prostatic tractor is used to manipulate the
prostate and to identify the vesical neck.
if not done earlier. The seminal vesicles are dissected to their

tips with blunt dissection, and the artery from the seminal
vesical is divided by the harmonic scalpel. The vasa deferens
are likewise divided with the harmonic scalpel. Any remaining
fibrolymphatic tissue is then divided, allowing removal of the
prostate.
After ensuring complete hemostasis, the bladder neck is re-
constructed using 3-0 Vicryl on an SH needle beginning poste-
riorly to anteriorly (Fig. 29.14). This direction of the closure,
beginning in the posterior bladder, is done to facilitate the clo-
sure without injury to the ureters and also to take advantage FIGURE 29.14 Reconstruction of the posterior bladder neck is car-
of the anatomic relationship between the bladder neck and the ried from posterior to anterior, leaving an opening of approximately
membranous urethra with a shorter distance being anteriorly. 22Fr.
FIGURE 29.15 Anastomosis of the urethra to the bladder is performed over a 22Fr Foley catheter.
FIGURE 29.16 Closure of the incision.
who are older, obese, and have had prior radiation therapy.
O UTCO MES Potency following nerve-sparing perineal prostatectomy is
dependent upon the patient’s age and preoperative status.
Co mp licat io ns Patients under the age of 60 who are fully potent and have
both neurovascular bundles spared have approximately a
Perioperative complications include hemorrhage, wound in- 50% to 60% potency rate. Patients who are over the age of 60
fection, cardiovascular complications, and rectal injury. The have a reduced rate of potency, and we have not yet had a pa-
instance of rectal injury is 1% with current techniques and tient over the age of 70 who has spontaneously regained his
antibiotics, preoperative bowel preparation (two Fleet ene- potency. Patients who are having difficulties with potency prior
mas, the night before and morning of surgery), or GoLytely to surgery and patients in whom the neurovascular bundles
and antibiotics. The rectal injury is closed primarily in two could not be spared will likely be impotent. We generally ad-
layers without the need to perform a diverting colostomy. vocate early use of pharmacotherapy or other means of assis-
Wound infection rates are 1% , and cardiovascular compli- tance in these patients.
cations are approximately 1% to 2% . The average blood loss
in these patients is approximately 300 to 400 cc, and our
transfusion rate is 1% . Re sult s
Long-term complications include incontinence and impo-
tence. Incontinence requiring intervention such as pads, Following radical prostatectomy, recurrence can be measured
clamps, or inflatable devices occurs in 2.8% of patients. We using PSA, which is exquisitely sensitive. Any patient who
have found that incontinence generally occurs in patients undergoes a radical prostatectomy can expect his PSA to fall
TA B LE 2 9 . 1
POST OP ORDERS
Lab
• CBC, Basic M etabolic Panel in AM
Interventions/Treatments
• Vital signs q 4h
• I & O q shift
• Urinary catheter to bedside bag
• Leg bag at bedside upon admission to unit. Post O p day 1, staff nurse to begin leg bag teaching.
Ensure that catheter remains secure at all times using catheter holder (Cath Secure)
• Dressing Changes prn
• Ace wraps to lower extremities until patient ambulatory
Activity
• Dangle at bedside evening of surgery, may get out of bed to chair
• Starting post op day 1, out of bed to chair for meals and ambulate in hall
Diet
• Clear liquids immediately post op, regular diet as tolerated
IV Fluids
• RL at 125cc/hr
• convert to heparin lock in AM
M edications
• Cefazolin 1 gram IV q 8h 4 doses
• Gentamicin 80mg IV q 8h 3 doses
• M orphine Sulphate 2–4 mg IV q 3h prn severe pain
• Percocet 5/325 q 3h prn pain
Respiratory
• Incentive Spirometry q 2h while awake
Patient and Family Teaching
• Review discharge instructions with patient and family on day of surgery and reinforce daily
• Instruct patient on leg bag usage, catheter care, and diet
below detectable levels. Failure to do so generally means that every patient. Based upon PSA, we can now predict disease re-
the patient has significant residual disease, either locally or currence earlier, allowing assessment of the outcome of radical
distantly. Another group of patients will have an initial drop prostatectomy within 5 years as opposed to the older data,
of their PSA to undetectable levels and then a return to mea- which required a 7- to 10-year follow-up (3).
surable levels. These patients may have local and/or distant re- Using a clinical care pathway, we have seen better pain
currence of their disease, or possibly residual malignancy. control, earlier ambulation, quicker short-term recovery, and
Patients who develop recurrence based upon PSA will gener- earlier discharge than in patients undergoing radical retropu-
ally manifest a clinical progression within 18 months. bic prostatectomy in the same institution. This has been con-
Additionally, if the PSA is going to rise, it will do so within firmed in other studies and will lead to a lower cost of care
2 years in 90% of patients and within 4 years in virtually (2,7).
References
1. El Galley RE, Keane TE, Petros JA, et al. Evaluation of staging lym- 5. Sullivan LD, Weir M J, Kinahan JF, et al. A comparison of the relative mer-
phadenectomy in prostate cancer. Urology 1998;52:663–667. its of radical perineal and retropubic prostatectomy. BJU Int 2000;85:
2. H arris M J. Radical perineal prostatectomy: cost efficient, outcome effec- 95–100.
tive, minimally invasive prostate cancer management. Eur Urol 2003;44: 6. Bong GW, Ritenour CW, O sunkova AO , et al. Evaluation of modern
303–308; discussion 308. pathological criteria for positive margins in radical prostatectomy speci-
3. Iselin CE, Robertson JE, Paulson DF. Radical perineal prostatectomy: on- mens and their use for predicting biochemical recurrence. BJU Int 2008.
cological outcome during a 20 year period. J Urol 1999;161:163–168. 7. Weizer AZ , Silverstein AD, Young M D, et al. Prospective evaluation of pain
4. Lance RS, Freiderichs PA, Kane C, et al. A comparison of radical retropu- medication requirements and recovery after radical perineal prostatectomy.
bic with perineal prostatectomy for localized prostate cancer within the Urology 2003;62:693–697.
Uniform Armed Services Urology Research Group. BJU Int 2001;87:
61–65.
CHAPTER 30 ■ BRACHYTHERAPY FO R LO CALIZED
PRO STATE CANCER
JO HN A. FO RTNEY, A. JASO N ZAULS, AND DAVID T. MARSHALL
The term brachytherapy describes the process of placing a ra-

dioactive source directly inside or in close proximity to the DIAGNO SIS
intended target. The use of brachytherapy in prostate cancer
was first reported by Pasteau in 1913 (1), and various tech- The diagnosis and risk-stratification of prostate cancer is via
niques have been explored since. Retropubic implantation of 12 to 16 core prostate biopsies following an elevated PSA or
radioactive sources was used initially until the introduction abnormal digital rectal exam. Patients with high risk of semi-
of the transrectal ultrasound probe (TRUS) in the early nal vesicle involvement, such as those with clinical stage T2a
1980s (2). With significant advancements in ultrasound tech- or perineural invasion seen on prostate biopsy, should un-
nology, ultrasound-guided transperineal prostate brachy- dergo TRUS-guided biopsy of the seminal vesicles. Pelvic lym-
therapy is now the accepted technique used for prostate phadenectomy is not commonly performed for patients with
brachytherapy and has experienced substantial growth over low-risk disease. Patients with high risk of lymph node in-
the last 15 years. volvement (patients with seminal vesicle involvement, Gleason
Brachytherapy offers several advantages over radical score 7, PSA 20) may benefit from laparoscopic pelvic
prostatectomy, including patient convenience, no surgical inci- lymph node dissection as nodal involvement changes treatment
sion, decreased anesthesia requirement, minimal blood loss, recommendations.
rapid recovery, and less risk of incontinence. Brachytherapy
also offers advantages over external beam radiation ther-
apy (EBRT). Proper brachytherapy technique can lead to
decreased radiation dose to surrounding structures, thereby
limiting normal tissue morbidity. Evidence continues to accu-
When considering brachytherapy as monotherapy for prostate
mulate stressing the importance of dose escalation in
cancer, it is critical to carefully select patients with low-risk
prostate cancer. In order to deliver an acceptable dose via
disease. A number of tools have been developed to aid the physi-
EBRT, patients must undergo several weeks of treatment,
cian when making this selection, including the Partin tables
whereas brachytherapy can be completed in one outpatient
(3) and the Roach formulas (4,5). These tools can help esti-
procedure. Finally, the position of the prostate and
mate the risk of extraprostatic extension, seminal vesicle inva-
surrounding critical organs may be difficult to reproduce
sion, and pelvic lymph node involvement. Recommendations
daily during a protracted course of treatment, which may
have been made regarding classification of patients into
lead to an increased dose to normal tissues or a decreased
low-, intermediate-, and high-risk categories as illustrated in
dose to the prostate.
Table 30.1. Low-risk prostate cancer can be summarized as
Three isotopes (125 I, 103 Pd, and 131 Cs) are now available
PSA 10, Gleason score 7, and clinical stage T2b. O ther
for low-dose-rate (LDR) brachytherapy. The majority of the
risk factors, such as PSA velocity, PSA doubling time, presence
radiation dose is delivered over 2 to 10 months, depending
of perineural invasion or lymphovascular space invasion, and
on which isotope is used. The timing and severity of acute
side effects have been described regarding the different
sources; however, no convincing evidence is available to rec-
TA B LE 3 0 . 1
ommend one source over another. H igh-dose-rate (H DR)
brachytherapy has been increasingly utilized as well. PATIEN T SELECTION FACTORS
Catheters are placed within the prostate as described below
for LDR needles, and a dosimetric plan is developed with CT Monotherapy Combination Therapy
imaging and computer planning. An iridium-192 source can (Low Risk) (Intermediate to High Risk)
then be moved in and out of each catheter remotely via a ro- N odule N one or small Large or multiple
botic device. The time the radioactive source spends in each Gleason score 2–6 7–10
catheter and at each dwell position within each catheter can PSAa 10 ng/mL 10 ng/mL
be manipulated via computer control to achieve a conformal
Clinical stage T2b T2b
radiotherapy plan. H DR brachytherapy typically requires a
short hospital stay and two to ten treatments over a 2- to aPSA, prostate-specific antigen.
5-day period.
202
Chap t e r 30: Brachythe rap y for Localize d Prostate Cance r 203
number of cores positive on biopsy, should be considered TA B LE 3 0 . 3

when stratifying patients and choosing appropriate treatment
modalities. TYPICALLY PRESCRIBED MIN IMUM PERIPHERAL
Clinical outcomes for prostate brachytherapy alone in the DOSES FOR 125 I AN D 103 PD
setting of intermediate- or high-risk disease have been conflict- 125 Ia 103 Pdb 131 Csc
ing. Furthermore, there is a growing body of evidence sup-
porting the use of dose-escalated EBRT or combined androgen M onotherapy 145–160 Gy 125 Gy 115 Gy
deprivation therapy and EBRT in this setting. Brachytherapy Combined therapyd 100–110 Gy 90–100 Gy 85 Gy
is often used in this situation in combination with EBRT to
aRivard
augment dose escalation, but it is not generally recommended M J, Butler WM , Devlin PM , et al. American Brachytherapy
as monotherapy for intermediate- or high-risk patients. Society recommends no change for prostate permanent implant dose
prescriptions using iodine-125 or palladium-103. Brachytherapy
2007;6(1):34–37; Kao J, Stone N N , Lavaf A, et al. (125)I monother-
apy using D90 implant doses of 180 Gy or greater. Int J R adiat
ALTERNATIVE THERAPY O ncol Biol Phys 2008;70(1):96–101.
b Rivard M J, Butler WM , Devlin PM , et al. American Brachytherapy
Society recommends no change for prostate permanent implant dose
Prostate brachytherapy is an ideal treatment for men with prescriptions using iodine-125 or palladium-103. Brachytherapy
localized, low-risk prostate cancer, but alternatives exist and 2007;6(1):34–37.
cBice WS, Prestidge BR, Kurtzman SM , et al. Recommendations for
may be more appropriate in certain situations. M en with high
permanent prostate brachytherapy with (131)Cs: a consensus report
International Prostate Symptom Scores (IPSS), large prostate from the Cesium Advisory Group. Brachytherapy 2008;7(4):290–296.
volume, or history of previous transurethral resection of the d In addition to 40- to 50-Gy external beam radiation therapy.
prostate (TURP) may tolerate EBRT or prostatectomy better

than brachytherapy while achieving a similar therapeutic out-
come. H igh IPSS before treatment predicts significant risk of
severe lower urinary tract symptoms (LUTS) and acute uri- hour) as another option. H owever, no conclusive clinical evi-
nary obstruction following brachytherapy (6). Similarly, large dence proving this theory has yet been made available, and
prostates have been shown to be at increased risk for urinary one clinical trial has shown equivalence between 125 I and
retention (7), although the absolute risk may still be low de- 103 Pd regarding PSA control at 3 years (11). The current rec-
pending on the technique used (8). Patients with a history of ommended doses for the three isotopes in monotherapy and in
prior TURP may be at increased risk for significant toxicity, combination with external beam therapy are shown in
including incontinence, if brachytherapy is used (9,10). Table 30.3. The selection of 103 Pd or 131 Cs may be most ap-
propriate in the setting of combination therapy as EBRT may
be initiated sooner in the treatment paradigm after prostate
SURGICAL TECHNIQ UE brachytherapy due to earlier resolution of urinary symptoms
following brachytherapy.
Se le ct io n o f Iso t o p e
As noted above, three isotopes (125 I, 103 Pd, and 131 Cs) are cur- Tre at me nt Planning
rently being used for LDR prostate brachytherapy. Each deliv-
ers radiation to a volume of tissue within millimeters of each Prostate brachytherapy has evolved significantly over the
source; however, they differ in initial activity, dose rate, and years, and two methods now predominate: preplanned im-
half-life, as illustrated in Table 30.2. Some investigators plant as popularized by the Seattle Prostate Institute and intra-
believe 103 Pd may be more effective than 125 I at eradicating operative planning as described by Stock and Stone at M ount
more rapidly proliferating tumors due to higher initial activity Sinai School of M edicine (M SSM ) in N ew York.
(20 to 25 cGy per hour and 7 to 10 cGy per hour, respectively).
This belief has been propagated by convincing mathematical Pre p lanning Ap p ro ach
models and has led to the emergence of 131 Cs (32 cGy per With this approach pioneered in Seattle (12), the patient is
placed in the dorsal lithotomy position (Figs. 30.1 and 30.2)
and an imaging study is performed using transrectal ultrasound
1 to 2 weeks before the implant. This image data set is imported
TA B LE 3 0 . 2 into the brachytherapy planning software and utilized to
CHARACTERISTICS OF THE MOST COMMON LY develop an optimized plan. The number of seeds ordered for
USED PERMAN EN T SOURCES the procedure is then determined from this preplan. The patient
returns to the operating room (OR) on the day of the operation
125 I 103 Pd 131 Cs and is placed in position as he was on the day of planning. It is
critically important that the patient is repositioned as accurately
H alf-life 60 days 17 days 9.7 days as possible. Seeds are then placed within the prostate using
Initial dose rate 8 cGy/hr 20 cGy/hr 32 cGy/hr needles preloaded with seeds or strands of connected seeds ac-
Average energy 28.5 keV 20.8 keV 30.4 keV cording to the previously developed plan. Seeds may also be
90% delivered 204 days 58 days 33 days placed with a gun-type applicator, such as the M ick applicator
(M ick Radio-N uclear Instruments, M ount Vernon, N Y),
FIGURE 30.1 Schematic of the closed, ultrasound-guided

implantation technique.
FIGURE 30.2 Patient prepared for surgery in the dorsal lithotomy

position.
based on the planning study completed earlier. With the pre- FIGURE 30.3 CT images obtained to estimate prostate volume to
planned approach, the M ick applicator allows the practitioner determine activity and number of seeds to order.
to make minor adjustments to more accurately reproduce the
preplanning study.
Re al-Time Int rao p e rat ive Planning Ap p ro ach and 30.6) is then developed based on a prostate volume-
With this approach developed by Stock and Stone at M SSM to-activity nomogram developed at M SSM . N eedles are
(13), no preplanning study is acquired; however, the prostate placed in the periphery of the prostate at approximately 1-cm
volume is measured via a computerized tomography (CT), intervals (Figs. 30.7 and 30.8). O nce the needles are placed,
magnetic resonance imaging (M RI), or TRUS study (Fig. 30.3) images are reacquired to account for changes in size, shape,
at some point prior to the day of the implant in order to deter- and position of the prostate that occurs with the trauma of
mine how many seeds to order for the procedure. This can be needle placement. Longitudinal views on the TRUS are used to
the volume determined at TRUS for biopsy. The patient is then observe placement of the seeds into the prostate according
brought to the O R and placed in the dorsal lithotomy posi- to the intraoperative plan. Seeds are most often placed using the
tion. TRUS (Fig. 30.4) is utilized to localize the bladder, M ick applicator. Typically 75% of the required activity is
prostate, and anterior rectal wall in three-dimensional space, placed in the periphery of the gland, while 25% is placed in
and these data are recorded in the intraoperative treatment the interior of the gland. Then needles are placed in the central
planning software. An initial intraoperative plan (Figs. 30.5 portion of the gland and the M ick applicator is then used to
from initial placement) can be actively detected in the intraop-

erative treatment planning software and therefore corrected
with subsequent seed deposition. Disadvantages include
longer procedure duration and M ick applicator utilization,
which some practitioners may find unwieldy. Although the
M ick applicator requires significant operator skill, in prac-
ticed hands this applicator allows precise placement of indi-
vidual seeds and significant flexibility. Some investigators
have noted seed migration when seeds are placed individually
in the prostate and surrounding tissues and have therefore
argued for the use of stranded seeds. In fact, seeds have been
observed to move significant distances and even to the lungs
or other remote locations. When compared to stranded or
linked seeds, single seed placement has been documented to
result in increased overall seed migration (14,15). H owever,
this has not been definitively shown to affect overall dosimet-
ric outcome or toxicity (16–18).
FIGURE 30.4 Transrectal ultrasound probe in ratcheting cradle/
stepper. Hyb rid Ap p ro ach w it h Re al-Time Planning
and Linke d Se e d s
A novel technique has been developed and is currently being
place the remaining 25% of the required activity in the gland pursued at a few institutions in an attempt to combine the ad-
according to the intraoperative plan. The majority of the inner vantages of real-time intraoperative planning and linked seeds
seeds are placed at the apex and base of the gland in order to (19). This technique is very similar to the intraoperative tech-
“ cap” the prostate. Using modern treatment planning soft- nique described above; however, stranded seeds are formed in
ware and TRUS, the actual seed location can be documented the O R at the time of implant and in response to real-time
as the seeds are placed and the intraoperative plan can better treatment planning. As before, an imaging study is obtained
reflect reality, allowing for dosimetric inadequacies to be de- approximately 2 weeks before the date of implant to deter-
tected and corrected during the procedure. mine the prostate volume, and an appropriate number and ac-
This approach offers many advantages over the previously tivity of seeds are ordered according to nomograms developed
described technique as well as some disadvantages. The most at M SSM . O n the day of implant the patient is placed in the
significant advantage offered by this technique is that intraop- dorsal lithotomy position and TRUS is utilized to build a
erative planning allows for real-time optimization of the plan three-dimensional model of the prostate, bladder, and anterior
as each seed placed in the prostate is accounted for in the plan- rectal wall within the treatment planning system. An initial in-
ning software and the resultant isodose lines are generated. traoperative plan (Figs. 30.5 and 30.6) is then developed by
Three variables unaccounted for with the previous technique the radiation oncologist while the urologist places needles in
(changes in prostate size and shape with needle placement, the periphery of the prostate at approximately 1-cm intervals
needle deviation from planned position, and seed movement (Figs. 30.7 and 30.8). O nce the needles are placed, images are
FIGURE 30.5
Treatment planning
transverse and axial
images of the
prostate showing
preliminary isodose
lines for a 103 Pd im-
plant (prescription
dose 100 Gy).
FIGURE 30.6 Dose-volume histogram

for 103 Pd implant depicting percentage
of prescribed dose to the prostate,
rectum, and urethra (prescription
dose 100 Gy).
FIGURE 30.7 O perator implanting linked seeds at surgery.
FIGURE 30.8 Sagittal ultrasound image of implant needle in the

reacquired and the plan reoptimized. Longitudinal views of prostate preparing to place seed.
each individual needle are used to calculate the distance each
needle traverses through the prostate. A push-button delivery
system (Q uickLink, C. R. Bard, Inc., Covington, GA) is then
used to construct links (Fig. 30.9) of the appropriate number
of seeds for the length measured along the longitudinal path of
each needle in the prostate. Each strand can be customized ac-
FIGURE 30.9 Custom-constructed linked seeds. N ote asymmetrical
cording to the number of seeds needed and the overall length seed pattern that can be constructed in the operating room according
of the needle path in the prostate via custom-sized linkers. The to the real-time plan.
linked seeds are then transferred to the prostate via the appro-
priate needle in a manner similar to that used with a preloaded
needle in a preplanned approach (Figs. 30.7 and 30.10). The of the remaining required activity. O nce the plan has been
process is then repeated until all peripheral seeds have been approved, the remaining interior links of seeds are constructed
placed. The inner needles are then placed (usually five to and placed within the prostate as described previously.
seven). The plan is then reoptimized to determine placement Preliminary data regarding this hybrid planning approach
intraoperative antibiotics and a short course of postoperative

antibiotics. Intraprostatic edema and bleeding may lead to uri-
nary retention in approximately 5% to 25% of patients. Large
prostate volume and an elevated pretreatment IPSS predict an
increased risk of urinary retention, and some studies have
shown that a short course of androgen deprivation may re-
duce this risk (8).
Urinary irritation may develop within 1 to 2 months after
125 I implantation and within 1 to 2 weeks with 103 Pd or 131 Cs.
These symptoms can be monitored and prospectively recorded

through utilization of IPSS evaluation at each subsequent
follow-up. The majority of men undergoing prostate brachy-
therapy will experience urinary symptoms such as increased
frequency, dysuria, nocturia, and weakened stream, which can
be treated symptomatically with alpha blockers and antimus-
carinics. M ost men will return to their baseline function at 1
to 2 years. Proctitis may also occur in approximately 15% of
men and manifest as mild hematochezia typically 1 to 2 years
after treatment. These symptoms can often be managed con-
servatively by avoiding constipation and in severe cases with
FIGURE 30.10 Ultrasound image of linked seeds in prostate after argon-plasma coagulation.
implantation. Late complications associated with prostate brachytherapy
include incontinence, erectile dysfunction, and the remote possi-
bilities of severe rectal injury or secondary malignancies involv-
reveal similar quality of dosimetry and O R times as compared ing the bladder or rectum. The risk of developing incontinence
to the traditional gun method (20). is limited except for men who have undergone a previous TURP
or require TURP for obstruction after brachytherapy (10).
Patients with a history of prior TURP have an approximate
Po st imp lant Cyst o sco p y 20% risk of developing stress incontinence, and a post-
brachytherapy TURP portends an even higher risk unless the
Following prostate seed implantation, flexible cystoscopy is TURP is of very limited volume. Erectile function will likely
performed to verify an intact urethra and bladder wall and to decrease in 20% to 30% of men 2 to 3 years after brachyther-
account for any misplaced seeds. At the end of the procedure, apy. The risk of severe rectal injury is remote but does occur
C-arm radiography may also be performed to verify seed posi- in 1% of patients and can require permanent colostomy.
tion and to document the presence or absence of loose seeds in Finally, EBRT has been associated with an absolute 1% in-
the bladder. crease in secondary malignancies of the rectum or bladder as
compared to patients undergoing prostatectomy alone (22).
Theoretically, prostate brachytherapy would carry a similar
Po st imp lant Do sime t ry risk; however, this remains unproven.
Postimplant dosimetry should be obtained at a consistent in-

terval following prostate seed implant; however, the most ap- Re sult s
propriate interval is yet to be determined. M any institutions
have patients return at 1 month following the implant for CT Defining and subsequently reporting low-risk prostate cancer
imaging. This image data set can then be imported into the outcomes has been the subject of much debate. Unlike with
treatment planning system, allowing for determination of prostatectomy, PSA levels rarely become undetectable follow-
dosimetric end points. Using this study, seed count should be ing radiation therapy. Therefore, the American Society for
verified, and isodose curves at 50% , 80% , 90% , 100% , Therapeutic Radiology and Oncology Consensus Panel issued a
150% , and 200% of the prescribed dose should be displayed consensus statement in 1997 defining biochemical failure fol-
on axial images of the prostate, urethra, bladder, and rectal lowing radiation therapy for prostate cancer as three consecutive
wall. The D90 or minimum dose delivered to 90% of the increases in PSA value. Furthermore, the date of failure has been
prostate as well as rectal and urethral doses should be defined as the midpoint between the postirradiation nadir PSA
recorded (21). and the first of the three consecutive rises (23). These recom-
mendations were subsequently revised in 2006 and defined as a
PSA rise of 2 ng per mL or more above the nadir PSA with no
O UTCO MES backdating (24).
Prostate cancer outcomes have been actively studied fol-
Co mp licat io ns lowing brachytherapy, and long-term outcomes have now
been published confirming the utility of this procedure in the
Immediate symptoms following brachytherapy are related to setting of low-risk prostate cancer. Table 30.4 summarizes four
needle placement and include edema, bleeding, pain, and in- series reporting ≥10-year outcomes following brachytherapy
fection. The risk of infection can be minimized with the use of as the sole intervention for localized prostate cancer. Freedom
TA B LE 3 0 . 4 from PSA failure at 10 years is approximately 90% and com-

pares favorably with outcomes obtained from other therapeu-
LON G-TERM (>10 YEARS) BIOCHEMICAL (PSA) tic options such as EBRT and prostatectomy. Table 30.5
OUTCOMES FOR LOW-RISK DISEASE: summarizes three series that combined brachytherapy and
BRACHYTHERAPY ON LY
EBRT for intermediate- to high-risk prostate cancer. Long-
Actuarial Median term outcomes reveal that freedom from PSA failure at a min-
Study N time (yr) follow-up (mo) FFPFa (%) imum of 5 years is 75% for intermediate-risk patients and
60% for high-risk patients. Relatively early data (median
Stone et al. 146 10 72 91 follow-up of 50 months) from M SSM show promising results
(25) using brachytherapy combined with EBRT and 9 months of
Potters et al. 481 12 82 88 hormonal therapy, with 86% PSA control at 5 years for high-
(26)b risk patients.
Grimm et al. 125 10 81 87
(27)
M artin et al. 273 12 60 90
(28)
aFFPF, freedom from PSA failure.
b Four percent received EBRT and 23% hormonal therapy for down-
sizing.
TA B LE 3 0 . 5
BIOCHEMICAL (PSA) OUTCOMES FOR IN TERMEDIATE- TO HIGH-RISK DISEASE:
BRACHYTHERAPY COMBIN ED WITH EXTERN AL BEAM AN D/ OR HORMON AL
THERAPY
Study N Actuarial time (yr) Median follow-up (mo) FFPFa (%)
Stock et al. (29) 5 50

H igh-risk 132 86
Potters et al. (26) 12 82
Intermediate-risk 554 76
H igh-risk 418 62
Sylvester et al. (30) 15 113
Intermediate-risk 50 80
H igh-risk 114 68
aFFPF, freedom from PSA failure.
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Panel. Consensus statement: guidelines for PSA following radiation ther- survival in clinical stage T1-T3 prostate cancer following combined exter-
apy. Int J R adiat O ncol Biol Phys 1997;37(5):1035–1041. nal beam radiotherapy and brachytherapy; Seattle experience. Int J R adiat
24. Roach M III, H anks G, Thames J, et al. Defining biochemical failure fol- O ncol Biol Phys 2007;67(1):57–64.
lowing radiotherapy with or without hormonal therapy in men with clini-
SECTIO N IV ■ URETHRA
E. ANN GO RMLEY
CHAPTER 31 ■ ANATO MY O F THE URETHRA

E. ANN GO RMLEY
abundant longitudinal and circular elastic fibers and contains

FEMALE URETHRA a prominent venous system. The mucosa and submucosa act
as a washer producing a seal that contributes to urethral clo-
Gro ss/ Micro sco p ic sure pressure (1). These tissues are estrogen-dependent, and in
hypoestrogenic states thinning of the tissue may result in in-
The female urethra extends from the bladder neck to the continence (2). The smooth muscle layer consists of a thick
external urethral meatus and varies in length from 3 to 5 cm. sheet of longitudinally oriented fibers and a thin outer layer of
The urethra is a fibromuscular tube composed of a mucosal circular fibers. These muscles are continuous with the bladder
lining, a submucosal layer, and a muscle layer. Proximally the neck proximally and terminate distally in the subcutaneous
transitional cell mucosa is continuous with the bladder epithe- tissue surrounding the external urethral meatus. Colleselli and
lium. Distally the mucosa is nonkeratinized stratified squa- others have shown in the cranial and most of the middle third
mous epithelium (Fig. 31.1). The submucosa consists of of the urethra that there are three smooth muscle layers, in-
cluding outer and inner longitudinal layers and a middle
transverse layer (3). The density of urethral circular smooth
muscle is lower in older women, which may account for the
change in urethral closure pressure that is seen with increasing
age (4).
In the distal two thirds of the urethra a layer of striated
muscle, the rhabdosphincter, surrounds the smooth muscle
layer, on the ventral and lateral aspects making an omegalike-
shaped sphincter. The rhabdosphincter is composed of delicate
Type I (slow-twitch) fibers and consists of three distinct mus-
cles. Proximally the muscle forms a ring (sphincter urethrae)
that encircles the urethra. Distally the muscle (compressor ure-
thrae) fans out laterally along the curve of the inferior border
of the pubic rami to compress the urethra against the anterior
vaginal wall. At the vestibule the muscle completely surrounds
the urethra and vagina to form a urethrovaginal sphincter
(Fig. 31.2) (5). The three muscles work together to provide
FIGURE 31.1 The female urethra.
FIGURE 31.2 Striated urogenital sphincter mus-

cle seen from below after removal of the perineal
membrane and pubic bones. US, urethral sphinc-
ter; UV S, urethrovaginal sphincter; CU, compres-
sor urethrae; B, bladder; IR , ischiopubic ramus;
T V , transverse vaginae muscle; SM , smooth mus-
cle; U, urethra; V , vagina; V W , vaginal wall.
(From O elrich TM . The striated urogenital
sphincter muscle in the female. A nat R ec 1983;
205:223, with permission.)
211
212 Se ct io n IV: Ure thra
Inne rvat io n
The smooth muscle of the urethra is innervated by parasym-
pathetic nerves. The predominant sympathetic receptors are
alpha-adrenergic (8). These receptors are responsible for ure-
thral smooth muscle contraction and possibly engorgement of
the submucosal vasculature to create a watertight seal of the
urethral mucosa (9). The striated muscle fibers of the external
intrinsic sphincter receive innervation from the pudendal and
pelvic somatic nerves (10). Both somatic and autonomic nerves
to the urethra travel on the lateral walls of the vagina near the
urethra. Various authors have advised against dissection in
this area during transvaginal surgery to prevent development
of stress urinary incontinence due to intrinsic sphincter dys-
function (11).
Lymp hat ics

FIGURE 31.3 Location of various structures along the urethra. N ote The lymphatic drainage of the proximal urethra is to the deep
the three parts of the rhabdosphincter. (Copyright University of pelvic nodes. The drainage of the distal portion of the urethra
M ichigan, 1989, with permission.) is to the inguinal nodes.
constant urethral tone (Fig. 31.3) (6). N ormally the striated

Co nt ig uo us St ruct ure s
sphincter plays a minimal role in resisting abdominal pressure.
H owever, preservation of the rhabdosphincter is necessary for A “ hammock” of vaginal tissue supports the urethra (12). The
continence after creation of a female neobladder (3). urethral supports, also termed pubourethral ligaments, in-
Paired periurethral (Skene) glands drain on either side of clude fascial and muscular attachments to the arcus tendineus
the midline just posterior to the urethral meatus. There are fasciae pelvis and levator ani muscles. These supports are only
also numerous small periurethral mucous glands that open present in the distal third of the urethra and fix the urethra to
into small recesses in the mucosa. the pubic bone. The pubovesical muscle is a separate structure
that is an extension of the smooth muscle of the bladder,
which extends from the detrusor muscle to the arcus tendineus
Vascular Anat o my fasciae pelvis and pubic bone (Fig. 31.4) (13).
Posteriorly the urethra is intimately related to the anterior
The arterial supply to the female urethra is from the urethral surface of the vagina. The periurethral fascia is located imme-
artery, a branch of the internal pudendal artery, which in turn diately beneath the vaginal epithelium and is seen as the glis-
is a branch of the internal iliac artery (7). The venous drainage tening white layer that surrounds the urethra when an incision
is via the pelvic venous plexus. is made in the anterior wall of the vagina. The fascia extends
FIGURE 31.4 Cross section of the urethra (U), vagina

(V ), arcus tendineus fasciae pelvis (AT FP), and superior
fascia of levator ani (SFL A ) just below the vesical neck
(drawn from cadaver dissection). Pubovesical muscles
(PV M ) lie anterior to urethra and anterior and superior to
paraurethral vascular plexus (PV P). The urethral supports
(Usu) (the pubourethral ligaments) attach the vagina and
vaginal surface of the urethra to the levator ani muscles
(M A t, muscular attachment) and to the superior fascia of
the levator ani (Fat, fascial attachment). R , rectum; R P,
rectal pillar; V M, vaginal wall muscularis. (From DeLancey
JO L. The pubovesical ligament, a separate structure from
the urethral supports. N eurol Urodynam 1989;8:53,
with permission.)
Chap t e r 31: Anatomy of the Ure thra 213
FIGURE 31.5 View of the anterior vaginal fascial sup-

port, which is found beneath the vaginal wall (shown re-
tracted). The periurethral fascia, which forms the vaginal
layer of the urethropelvic ligaments, is continuous with
the pubocervical fascia proximally.
from the meatus to the bladder neck and laterally to where it

fuses with the endopelvic fascia at the pubic bone (Fig 31.5).
MALE URETHRA
Gro ss/ Micro sco p ic
The posterior urethra is the portion of the urethra extending
from the bladder neck through the prostate and through the
urogenital diaphragm. It is divided into the prostatic urethra
and the membranous urethra, which traverses the urogenital
diaphragm just prior to entering the corpora spongiosa. The
anterior urethra runs from the urogenital diaphragm to the tip
of the glans penis and may be further divided into the bulbous
urethra extending from the root of the penis to the conver-
gence of the corpora cavernosa and the pendulous or penile
urethra that traverses the pendulous portion of the penis.
There is a dilation of the urethra in the area of the glans penis
called the fossa navicularis (Fig. 31.6).
A number of ducts empty into the lumen of the urethra.
Two to 3 cm distal to the membranous urethra the paired
orifices of the Cowper glands (bulbourethral glands) are noted
on the floor. O n the roof of the pendulous urethra there are
openings for the glands of Littre, or the submucosal urethral
glands, and small recesses termed urethral lacunae. The lacuna
magna is a larger lacuna in the midportion of the anterior
aspect of the fossa navicularis.
The urethral epithelium varies along the length of the
urethra. In the prostatic urethra the cells are transitional,
whereas in the membranous urethra they are stratified colum-
nar. The epithelium of the penile urethra is composed of pseu-
dostratified and columnar cells. In the fossa navicularis, the
epithelium is composed of stratified squamous cells.
Vascular Anat o my
Paired bulbourethral arteries, which arise as the first of three
penile branches of the internal pudendal artery, supply the ure-
thra. The venous drainage is via the emissary veins, which drain FIGURE 31.6 The male urethra and its divisions with associated
to the circumflex branches of the deep dorsal vein of the penis. histology.
Inne rvat io n Co nt ig uo us St ruct ure s

The urethra mucosa is innervated via the urethrobulbar nerve. The membranous urethra is covered by the fibers of the stri-
It is a branch of the nerve to the bulbocavernosus, which is a ated urethral sphincter (rhabdosphincter). Brooks et al. used
branch of the perineal nerve, which is derived from the puden- computer-generated, three-dimensional reconstruction of the
dal nerve. A branch of the bulbocavernosus nerve at the 3 and male pelvis from the visible human data set to show that the
9 o’clock positions penetrates the striated urethral sphincter striated urethral sphincter is circular with abundant posterior
(14). The pudendal nerve, consisting of fibers from the sec- tissue, making it more signet-ring shaped (16). Ventrally and
ond, third, and fourth sacral spinal nerves, is thus both motor laterally, the rhabdosphincter is separated from the membra-
to the urethral sphincter and sensory to the urethra and glans nous urethra by a thin sheath of connective tissue (15).
penis. Anteriorly the sphincter is approximately twice as long as it is
posteriorly. An intrinsic smooth muscle lies between the ure-
thral mucosa and the striated urethral sphincter. This muscle
Lymp hat ics begins above the striated sphincter and then gradually thins
distal to the striated sphincter (16).
The lymphatic drainage of the anterior urethra is into the su- The remainder of the anterior urethra lies within the cor-
perficial and deep inguinal node and ultimately to the external pus spongiosum lying in the ventral groove of the corpora cav-
iliac nodes. The lymphatics of the posterior (the bulbous, ernosa of the penis. The Cowper glands (bulbourethral
membranous, and prostatic) urethra can take three routes: to glands) lie within the urogenital diaphragm posterior and lat-
the external iliac nodes, to the obturator and internal iliac eral to the membranous urethra.
nodes, or to the presacral nodes.
References
1. Raz S, Caine M , Z eigler M . The vascular component in the production of 10. Borirakchanyavat S, Aboseif SR, Carroll PR, et al. Continence mechanism
intraurethral pressure. J Urol 1972;108:93–96. of the isolated female urethra: an anatomical study of the intrapelvic
2. Klutke JJ, Bergman A. N onsurgical management of stress urinary inconti- somatic nerves. J Urol 1997;158:822.
nence. In: O stergard DR, Bent AE, eds. Urogynecology and urodynam ics, 11. Ball TP Jr, Teichman JH M , Sharkey FE, et al. Terminal nerve distribution
4th ed. Baltimore: Williams & Wilkins, 1996:505–516. to the urethra and bladder neck: considerations in the management of
3. Colleselli K, Stenzl A, Eder R, et al. The female urethral sphincter: a mor- stress urinary incontinence. J Urol 1997;158:827.
phological and topographical study. J Urol 1998;160:49–54. 12. DeLancey JO L. Structural support of the urethra as it relates to stress
4. Clobes A, DeLancey JO L, M organ DM . Urethral circular smooth muscle in urinary incontinence: the hammock hypothesis. A m J O bstet G ynecol
young and old women. A m J O bstet G ynecol 2008;198:587.e1-5. 1994;170:1713–1723.
5. O elrich TM . The striated urogenital sphincter muscle in the female. A nat 13. Strohbehn K. N ormal pelvic floor anatomy. O bstet G ynecol Clin N orth
R ec 1983;205:223–232. A m 1998;25:683–705.
6. DeLancey JO L. Functional anatomy of the female pelvis. In: Kursh ED, 14. Shafik A, Doss S. Surgical anatomy of the somatic terminal innervation to
M cGuire EJ, eds. Fem ale urology. Philadelphia: JB Lippincott Co, the anal and urethral sphincters: role in anal and urethral surgery. J Urol
1994:3–16. 1999;161:85–89.
7. Ferner H , Staubesand J, eds, Sobatta atlas of hum an anatom y, 10th ed. 15. Dalpiaz O , M itterberger M , Kerschbaumer A, et al. Anatomical approach
M unich/Baltimore: Urban & Schwartzenberg, 1982. for surgery of the male posterior urethra. BJU International 2008;
8. Ek A. Innervation and receptor functions of the human urethra. Scan J 102:1448–1451.
Urol N ephrol 1997;S45:1–50. 16. Brooks JD, Chao W, Kerr J. M ale pelvic anatomy reconstructed from the
9. H uisman AB. Aspects on the anatomy of the female urethra with special re- visible human data set. J Urol 1998;159:868–872.
lation to urinary incontinence. Contrib G ynecol O bstet 1983;10:1–31.
CHAPTER 32 ■ FEMALE URETHRAL DIVERTICULUM

AHMED M. EL-ZAWAHRY AND ERIC S. RO VNER
Urethral diverticulum (UD) in women represents a challenge lumen, termed the neck or ostium. Complicated UD may ex-
in both diagnosis and reconstruction for the urologist. The ac- tend partially around the urethra to form a “ saddlebag” UD,
tual prevalence of UD is not known, but it is reported to occur or more uncommonly anterior to the urethra (3), or circum-
in 1% to 6% of adult women (1). UD is an epithelialized cav- ferentially around the urethra (4).
ity dissecting within the fascia of the urethropelvic ligament It is generally believed that an adult UD is formed as a re-
(Fig. 32.1) (2). This cavity forms an isolated cystlike ap- sult of infection and obstruction of the periurethral glands.
pendage, usually with a single connection to the urethral These tubuloaveolar glands are anatomically located in the
Chap t e r 32: Fe male Ure thral Dive rticulum 215
Pelvic Urethropelvic Tendinous

sidewall ligament Urethra arc
Vaginal
wall
Diverticulum forms within

the urethropelvic ligament FIGURE 32.1 Diverticulum forms within the ure-
lined by epithelium thropelvic ligament.
distal one-third of the urethra ventral and lateral to the ure- Physical examination should include a careful inspection of
thral lumen. Infection of these glands leads to abscess the anterior vaginal wall. M asses or areas of tenderness
formation and eventual rupture of the abscess back into the should be noted and further examined. Suspected UD should
urethral lumen, resulting in an epithelialized cavity in commu- be carefully differentiated from vaginal prolapse, including
nication with the urethra. cystourethrocele. M ost UD are located ventrally over the mid-
O ften, although not invariably highly symptomatic due to dle and proximal portions of the urethra corresponding to the
the location, the most common coexisting condition is proba- area of the anterior vaginal wall 1 to 3 cm inside the introitus.
bly urinary incontinence, especially stress urinary inconti- During physical examination, the anterior vaginal wall may be
nence (SUI), which may coexist in up to 50% of individuals gently “ stripped” or “ milked” distally in an attempt to ex-
(1). M alignant and benign tumors in UD are quite rare. The press purulent material or urine from within the urethral lu-
most common malignant pathology in UD is adenocarcinoma, men out through the urethral meatus, which strongly suggests
followed by transitional cell and squamous cell carcinomas. the diagnosis of UD.
Calculi within UD may be diagnosed in 4% to 10% of cases Endoscopic examination of the bladder and urethra is per-
and is most likely due to urinary stasis and/or infection. formed in an attempt to visualize the UD ostium (communica-
tion to the urethra) as well as to evaluate for other causes of
the patient’s presenting symptoms. A flexible cystoscope or a
specially designed rigid female cystoscope with a short beak to
DIAGNO SIS maintain the discharge of the irrigation solution immediately
adjacent to the lens is most useful in visualizing the lumen of
The diagnosis of UD can be made with a combination of a thor- the relatively short female urethra. During cystoscopy, simul-
ough history, physical examination, and selected imaging. The taneous gentle compression of the bladder neck and the diver-
symptoms of UD are classically described as the “ three Ds” : ticular sac with an assistant’s finger can express luminal
dysuria, dyspareunia, and dribbling (postvoid). H owever, com- discharge of purulent material during urethroscopy localizing
mon presenting symptoms include irritative lower urinary tract the ostium.
symptoms, pain, and urinary tract infection (UTI), which is re- H igh-quality preoperative imaging is important in the diag-
ported in almost one-third of patients (5). O ther symptoms in- nosis of UD as well as in planning operative therapy. This will
clude a vaginal mass, hematuria, vaginal discharge, obstructive help to provide an accurate reflection of the relevant anatomy
voiding symptoms, and urinary retention. Up to 20% of pa- of the UD and its anatomical relationships. N o single study
tients may be completely asymptomatic and are thus diagnosed can be considered the gold standard for the evaluation of UD.
incidentally on imaging or physical examination. Patients may Furthermore, the availability and quality of individual radio-
often be misdiagnosed and treated for years for a number of un- logical techniques is quite variable across centers. Currently
related conditions, such as interstitial cystitis, recurrent cystitis, available techniques for the evaluation of UD include double-
vulvodynia, endometriosis, and vulvovestibulitis, before the di- balloon positive-pressure urethrography (PPU), voiding cys-
agnosis of UD is made. tourethrography (VCUG), ultrasound (US), and magnetic
have included transurethral and open marsupialization, endo-

scopic unroofing, fulguration, incision and obliteration, and
coagulation (1). O ne noteworthy alternative to excision and
reconstruction is transvaginal marsupialization as described
by Spence and Duckett (7). This approach may reduce opera-
tive time, blood loss, and recurrence rate but is probably only
applicable to UD in very select cases involving the distal one-
third of the urethra due to the risk of sphincteric injury and re-
sulting de novo SUI.
In rare cases, when the UD is highly symptomatic, acutely
infected, and unresponsive to antibiotic therapy, or in cases
when a complete elective excision should be postponed, such
as during pregnancy, a transvaginal incision (diverticulotomy)
can be performed directly into the UD cavity. This will create
a temporary urethrovaginal fistula from the UD ostium
through the UD cavity into the vagina, thus decompressing the
UD. The UD and fistula are subsequently repaired at the time
FIGURE 32.2 Axial T-2 weighted M RI of an unusual anterior urethral of planned elective excision and reconstruction.
diverticulum.
SURGICAL TECHNIQ UE
resonance imaging (M RI) with or without an endoluminal coil
(eM RI). eM RI has several distinct advantages over VCUG; Excision and reconstruction is probably the most common
however, these studies are often complementary (6). We surgical approach to UD in the modern era. The principles of
currently utilize M RI in the evaluation of all patients with the urethral diverticulectomy operation have been well de-
known or suspected UD as the complexity of these lesions is scribed (Table 32.1). There are only a few minor differences
more readily appreciated using this technique (Fig. 32.2). between surgical approaches, including the type of vaginal in-
Urodynamic studies, especially videourodynamics, are utilized cision (inverted “ U” versus inverted “ T” ), whether it is neces-
in patients with urinary incontinence or significant voiding sary to remove the entire mucosalized portion of the UD, and
dysfunction in order to characterize these symptoms, espe- finally, the optimal type of postoperative catheter drainage
cially if surgery is planned. These studies are useful in evaluat- (urethra only versus urethra and suprapubic).
ing the anatomy of the UD, assessing the competence of the Preoperative preparation includes (a) antibiotic adminis-
bladder neck, assessing bladder function, and confirming the tration in patients with recurrent or persistent UTIs; (b) strip-
diagnosis of SUI. ping of the anterior vaginal wall to prevent urinary stasis and
recurrent UTIs; and (c) application of topical estrogen creams
for several weeks prior to surgery in postmenopausal patients
with atrophic vaginitis.
INDICATIO NS FO R SURGERY The patient is placed in the high lithotomy position with all
Symptomatic patients should be offered surgical excision and pressure points well padded. We have found that the use of
reconstruction. Those with concomitant SUI can be considered padded adjustable stirrups for the lower extremities greatly
for a simultaneous anti-incontinence procedure at the time of enhances operative access to the female perineum. A standard
UD excision. vaginal antiseptic preparation is applied. The use of a head-
Asymptomatic patients may not desire surgical excision. light as well as operative magnification (1.5 to 2.0 )
O ther patients may be unwilling or medically unable to un- assists with the dissection and precise reconstruction. A Foley
dergo surgical excision. H owever, the natural history of un- catheter (16Fr) is placed in the urethra. A suprapubic tube may
treated UD is unknown. In such cases, patients should be
counseled that certain carcinomas or other complications such
as stones or urinary incontinence may arise and that close
follow-up is warranted. TA B LE 3 2 . 1
PRIN CIPLES OF TRAN SVAGIN AL URETHRAL
DIVERTICULECTOMY
ALTERNATIVE THERAPY M obilization of a well-vascularized anterior vaginal wall
Patients electing nonoperative management can be treated Preservation of periurethral fascia
with daily low-dose antibacterial preparations and digital Identification and excision of the neck of the UD or ostium
stripping of the anterior vaginal wall following micturition to Removal of the entire UD wall or sac (mucosa)
prevent postvoid dribbling and reduce the risk of UTI due to Watertight closure of the urethra
stasis in the UD. M ultilayered, nonoverlapping closure with absorbable suture
M ost commonly, UD are treated with a complete excision Closure of dead space
and urethral reconstruction. H owever, a variety of other surgi- Preservation or creation of continence
cal interventions for UD have been reported. Approaches
FIGURE 32.3 Incision along the anterior vaginal wall, with the base FIGURE 32.4 A transverse incision is made into the periurethral fas-
of the “ U” at the level of the distal urethra, provides an excellent lat- cia. Proximal and distal layers will be carefully developed without
eral exposure at the midvagina for transvaginal urethral diverticulec- entering the UD. (From Rovner ES. Urethral diverticula. In: Raz S,
tomy. (From Rovner ES. Urethral diverticula. In: Raz S, Rodriguez Rodriguez L, eds. Fem ale urology, 3rd ed. Philadelphia: Elsevier,
L, eds. Fem ale urology, 3rd ed. Philadelphia: Elsevier, 2008: 825–844, 2008: 825–844, with permission.)
with permission.)
be utilized for an additional postoperative urinary drainage if recurrence, close dead space, and avoid urethrovaginal fistula
desired. formation postoperatively. Pseudodiverticula have been de-
A weighted vaginal speculum and Scott retractor with scribed where this layer of tissue is considerably attenuated or
hooks are placed to assist with exposure. An inverted “ U” is even absent (8). In these patients, an interpositional flap, or
marked out along the anterior vaginal wall proximal from the graft such as a pubovaginal sling, may be utilized for recon-
urethral meatus with the limbs extending to the bladder neck struction.
or beyond (Fig. 32.3). The inverted “ U” incision provides ex- Following the completed takedown of the anterior vaginal
cellent exposure laterally at the level of the midvagina and can wall flap, the periurethral fascia is incised transversely (Fig.
be extended proximally as needed for lesions that extend be- 32.4). Proximal and distal layers of periurethral fascia are
yond the bladder neck. N ormal saline can be injected along carefully developed, avoiding entrance into the UD. The UD
the lines of the incision beneath the vaginal wall to facilitate is then grasped and sharply dissected back to its origin on
dissection. A posterolateral episiotomy may be of help in some the urethra within the leaves of the periurethral fascia (Fig.
patients with a narrow introitus, especially in nulliparous 32.5). In many cases it is necessary to open and enter the UD
women. to facilitate dissection from the surrounding tissues, especially
An anterior vaginal wall flap is created by careful dissec- if the patient had a previous recent infection. The ostium
tion in the potential space between the vaginal wall and the or connection to the urethra is identified and the walls of the
periurethral fascia. The use of sufficient countertraction dur- UD are completely excised. Every effort should be made to
ing this portion of the procedure is important in maintaining remove the entire mucosalized surface of the UD in order to
the proper plane of dissection. During the dissection it is im- prevent recurrence. All abnormal tissue in the area of the
portant to preserve the periurethral fascia, maintain an ade- ostium should be removed if possible to ensure that no
quate blood supply to the anterior vaginal wall flap, and avoid mucosal elements of the UD wall remain that could result in
inadvertent entry into the UD. The periurethral fascia forms a postoperative urine leakage and recurrence. Following com-
distinct layer that is usually interposed between the vaginal plete excision of the UD, the urethral catheter is often seen
wall and the UD; however, in some lesions it may be deficient (Fig. 32.6). The urethra can be reconstructed over a Foley
(8). Preservation and later reconstruction of the perirurethral catheter as small as 12Fr without long-term risk of urethral
fascia is of paramount importance in order to prevent UD stricture and should be closed in a watertight fashion with 4-0
FIGURE 32.5 Following mobilization of the anterior and posterior FIGURE 32.7 Closure of the urethra with absorbable suture should
leaves of the periurethral fascia, the urethral diverticulum is dissected be watertight and tension-free. (From Rovner ES. Urethral diverticula.
back to its origin on the urethra within the leaves of the periurethral In: Raz S, Rodriguez L, eds. Fem ale urology, 3rd ed. Philadelphia:
fascia. (From Rovner ES. Urethral diverticula. In: Raz S, Rodriguez L, Elsevier [in press], with permission.)
eds. Fem ale urology, 3rd ed. Philadelphia: Elsevier [in press], with
permission.)
synthetic absorbable suture (Fig. 32.7). The closure should be

tension-free and should include the full thickness of the ure-
thral wall. The periurethral fascial flaps are reapproximated
with 3-0 synthetic absorbable sutures in a perpendicular ori-
entation to the urethral closure line in order to minimize over-
lap and hence the risk of postoperative urethrovaginal fistula
formation (Fig. 32.8). Care is taken to secure the periurethral
fascial flaps in such a way as to close all dead space.
If desired, a fibrofatty labial (M artius) flap can be har-
vested at this point and placed over the periurethral fascia as
an additional layer of closure. Indications for such a flap are
not universally agreed upon. H owever, in patients with poor-
quality tissues or attenuated periurethral fascia, or in whom
significant inflammation is encountered intraoperatively, a
well-vascularized adjuvant flap such as a M artius flap may re-
duce the risk of wound breakdown and subsequent complica-
tions such as urethrovaginal fistula. The anterior vaginal wall
flap is then repositioned and reapproximated with absorbable
suture (Fig. 32.9). This completes a three-layer closure (four
layers if a M artius flap is utilized). An antibiotic impregnated
vaginal pack is placed postoperatively.
The vaginal packing is removed within 6 to 24 hours, and
the patient is discharged home with closed urinary drainage.
Antispasmodics are used liberally to reduce bladder spasms. A
pericatheter VCUG is obtained at 14 to 21 days postopera-
tively. If there is no extravasation, the catheters are removed.
If extravasation is seen, then repeat pericatheter VCUGs are
FIGURE 32.6 Following removal of the entire urethral diverticulum,
performed weekly until resolution is noted. In the vast major-
the Foley catheter is often seen. (From Rovner ES. Urethral divertic-
ula. In: Raz S, Rodriguez L, eds. Fem ale urology, 3rd ed. Philadelphia: ity of cases, extravasation will resolve in several weeks with
Elsevier [in press], with permission.) this type of conservative management.
CO MPLICATIO NS
Postoperative complications can be avoided by careful adher-
ence to the principles of transvaginal urethral diverticulec-
tomy. N evertheless, complications may arise. Large diverticula
( 4 cm) or those associated with a lateral or horseshoe con-
figuration may be associated with a greater likelihood of post-
operative complications (9). Complications include recurrent
diverticulum (1% to 29% ), stress incontinence (1.7% to
16.0% ), urethral stricture (0% to 5% ), and recurrent UTIs
(0% to 31% ) (1).
Intraoperative bleeding can be avoided by maintaining the
proper plane of dissection during takedown of the anterior
vaginal wall flap. If bleeding is encountered, cautery or suture
ligature can be used. Excessive use of cautery should be
avoided as this can lead to flap necrosis and fistula formation.
Urethrovaginal fistula is a devastating but fortunately rare
complication that may result from diverticulectomy. A fistula
can be located either distal or proximal to the sphincteric
mechanism. A distally located fistula is usually not associated
with symptoms other than perhaps a split urinary stream
and/or vaginal voiding. As such a distal urethrovaginal fistula
may not require repair, although some patients may request
repair. Conversely, a proximal fistula located at the bladder
neck or within the proximal half of the urethra in patients
with an incompetent bladder neck will likely result in consid-
FIGURE 32.8 Closure of the periurethral fascia should be perpendic- erable symptomatic urinary leakage. These patients should
ular to the urethral closure line to minimize overlap and the risk of undergo repair with or without the use of an adjuvant tissue
urethrovaginal fistula. (From Rovner ES. Urethral diverticula. In: Raz
S, Rodriguez L, eds. Fem ale urology, 3rd ed. Philadelphia: Elsevier [in
flap such as a M artius flap to provide a well-vascularized ad-
press], with permission.) ditional tissue layer. M eticulous attention to surgical tech-
nique, good hemostasis, avoidance of infection, preservation
of the periurethral fascia, a well-vascularized anterior vaginal
wall flap, and a multilayered closure with nonoverlapping
suture lines should minimize the potential for postoperative
urethrovaginal fistula formation.
Coexisting SUI can be treated at the time of urethral diver-
ticulectomy as noted previously. H owever, de novo SUI may
occur following urethral diverticulectomy. The proximity of
most urethral diverticula to the sphincter mechanism puts the
patient at risk for this complication even with meticulous
attention to surgical technique.
Persistence or recurrence of symptoms following divertic-
ulectomy may occur in some patients. This may be caused by
a new medical problem (e.g., UTI, etc.), a new UD, or alterna-
tively, recurrence of the original lesion. Recurrence of a UD
may be due to incomplete excision of the UD, inadequate clo-
sure of the urethra or residual dead space, or other technical
factors. Ljungqvist et al. found recurrence in 11 out of 68 of
their patients over 26-year follow-up with a 92% overall satis-
faction (10). Repeat urethral diverticulectomy surgery can be
challenging due to altered anatomy, scarring, and the diffi-
culty of identifying the proper anatomic planes.
O UTCO MES
The significance of appropriate preoperative patient counsel-
FIGURE 32.9 Closure of the vaginal wall with reapproximation of the ing regarding surgery and postoperative expectations of cure
anterior vaginal wall flap. This completes a three-layer closure includ-
ing closure of the urethra, periurethral fascia, and vaginal wall. (From
cannot be overemphasized. Individuals with UD have a myr-
Rovner ES. Urethral diverticula. In: Raz S, Rodriguez L, eds. Female iad of symptoms, including pain, UTIs, and urinary dysfunc-
urology, 3rd ed. Philadelphia: Elsevier [in press], with permission.) tion. Although these are often related to the presence of the
UD, sometimes they do not resolve even with a technically tion of the patient’s symptoms or recurrence of the diverticu-
successful surgery. N evertheless, surgical outcome for the UD lum. Successful excision of UD has been reported in 86% to
has generally been good. O utcome can be evaluated by resolu- 100% of patients.
References
1. Rovner ES. Bladder and urethral diverticula. In: Wein AJ, Kavoussi L, 7. Spence H M , Duckett JW Jr. Diverticulum of the female urethra: clinical as-
N ovick A, et al., eds. Cam pbel’s urology, Vol. 9. Philadelphia: Elsevier, pects and presentation of a simple operative technique for cure. J Urol
2007:2361–2390. 1970;104:432–437.
2. Young GPH , Wahle GR, Raz S. Female urethral diverticulum. In: Raz S, ed. 8. Leng WW, M cGuire EJ. M anagement of female urethral diverticula: a new
Fem ale urology. Philadelphia: WB Saunders, 1996:477–489. classification. J Urol 1998;160:1297–1300.
3. Vakili B, Wai C, N ihira M . Anterior urethral diverticulum in the female: 9. Porpiglia F, Destefanis P, Fiori C, et al. Preoperative risk factors for surgery
diagnosis and surgical approach. O bstet G ynecol 2003;102:1179–1183. for urethral diverticula: our experience. Urol Int 2002;69:7–11.
4. Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or circum- 10. Ljungqvist L, Peeker R, Fall M . Female urethral diverticulum: 26-year fol-
ferential urethral diverticulum. J Urol 2003;170:82–86. lowup of a large series. J Urol 2007;177:219–224.
5. Ganabathi K, Leach GE, Z immern PE, et al. Experience with the manage-
ment of urethral diverticulum in 63 women. J Urol 1994;152:1445–1452.
6. Blander DS, Rovner ES, Schnall M D, et al. Endoluminal magnetic reso-
nance imaging in the evaluation of urethral diverticula in women. Urology
2001;57:660–665.
CHAPTER 33 ■ RECO NSTRUCTIO N O F THE

FEMALE URETHRA
JERRY G. BLAIVAS AND RAJVEER S. PURO HIT
Reconstruction of the female urethra is technically challeng- causes include damage from Shirodkar cerclage sutures for
ing, but when done correctly can restore anatomy and func- cervical incompetence in gravid women, complications from
tion in women with a urethrovaginal fistula or urethral operative vaginal delivery, and pressure necrosis from tightly
stricture using a single procedure. Conversely, surgical failure placed Kelly plication sutures over an indwelling catheter. The
necessitates multiple operations with decreasing chances of presence of an indwelling urethral catheter itself can cause
success and may leave patients functionally crippled or in need erosive necrosis, typically in the population of paralyzed or
of a urinary diversion. For this reason, technical proficiency
and a comprehensive preoperative diagnostic examination to
understand the patient’s pathophysiology are mandatory. The TA B LE 3 3 . 1
goal of surgery should be repair of the damaged urethra in
CAUSES OF URETHRAL DAMAGE IN A CASE SERIES
such a way as to allow the patient voluntary, unobstructed, OF 74 WOMEN
and painless micturition.
In the developing world, the most common cause of ure- Urethral diverticulectomy or diverticulum 28
thral damage requiring reconstruction is urethrovaginal fistula Urethral injury from Pereyra procedure 18
resulting from obstetric trauma. Prolonged obstructed labor Anterior colporrhaphy 10
with compression of the fetal head against the symphysis Fistula from other gynecologic surgery 3
pubica may cause pressure necrosis of the urethra and, conse-
Fistula or erosion associated with synthetic material 9
quently, the development of complicated fistulas. Cesarean
Urethral obstruction from previous surgery 3
section performed to relieve this condition also carries a risk
of subsequent fistula formation (1). Where modern obstetric Trauma 3
care is available, urethral damage is commonly the result of O bstetric injury 2
reconstructive surgery for urethral diverticulum but can Ectopic ureter 1
also occur from bladder neck suspensions, anterior colporrha- Primary urethral stricture 1
phy, and, rarely, vaginal hysterectomy (Table 33.1). Total 74
Urethrovaginal fistulas are also caused by erosion of synthetic
From Flisser AJ, Blaivas JG. O utcome of urethral reconstructive
materials placed during pelvic reconstructive surgery or anti- surgery in a series of 74 women. J Urol 2003;169:2246–2249, with
incontinence procedures (2), locally invasive malignancies, permission.
and long-term effects of radiation (3). Less commonly reported
Chap t e r 33: Re construction of the Fe male Ure thra 221
comatose patients. Finally, pelvic trauma can cause laceration reconstruction; however, patients with radiation damage are
of the urethra, usually when accompanied by separation or unique. The poor tissue quality in this subset of patients
fracture of the symphysis pubica (4). makes successful anatomic repair difficult and often results in
functional problems. In this situation, supravesical diversion is
often the more prudent and successful choice. In such patients,
DIAGNO SIS when repair of the fistula is undertaken, it may be wise to use
a vascularized muscular flap as part of the initial procedure
A thorough history and physical examination are critical for and to perform synchronous augmentation cystoplasty in
evaluating a patient suspected of urethral injury. In our expe- patients who have low blade compliance.
rience, pelvic examination will reveal the vast majority of Past teaching suggested that 3 to 6 months of delay was
injuries. If concurrent sphincteric urinary incontinence com- necessary to allow the quality of the local tissue to improve as
plicates the diagnosis, the urethral meatus can be occluded by inflammation and edema subsided; however, we believe that
the examiner’s finger while the patient strains or coughs. If the although pliable tissue must be available and free of infection
anterior vaginal wall is visualized with the assistance of a and inflammation, lengthy delay is not necessary, and under
speculum blade placed into the posterior fornix, urinary leak- the right conditions successful repair can be accomplished
age from the fistula can usually be detected. within days or weeks of the injury.
Cystoscopic examination is essential in the diagnostic in-
vestigation. Cystoscopy enables visualization of the extent of
the pathology as well as the evaluation of both concurrent in- ALTERNATIVE THERAPY
juries or defects and the quality of the surrounding local tissue
that is available for use in a reconstructive procedure. The ad- Alternatives to urethral reconstruction include observation,
dition of methylene blue to the cystoscopic irrigant may be catheterization, or urinary diversion. O ccasionally, women
useful if a fistula is suspected but has not been observed. After may decide against any form of surgical repair or drainage,
the surgeon occludes the urethra with a partially inflated particularly if the fistula does not result in any bothersome
Foley catheter, the vagina is examined for signs of urinary symptoms or if other significant medical problems preclude
leakage. operative intervention. Chronic catheterization is an option if
It is important to recognize that urethral damage alone patients are too sick to undergo surgery, but this is associated
causes neither urinary incontinence nor detrusor instability. In with infections, stones, detrusor spasms, further urethral ero-
patients who have coexisting urologic symptoms, the physi- sions, and the development of squamous cell cancer. In pa-
cian should be suspicious of injury to the proximal urethra tients with radiation-induced urethral damage, a urinary
and/or vesical neck. Videourodynamic examination provides diversion may be the best long-term option, although labial
vital information about the presence of involuntary bladder fat interposition and rectus or gracilis flaps combined with a
contractions, bladder outlet obstruction, ureteral reflex, and buccal graft may be an alternative.
bladder compliance and can also identify concurrent fistulas
or diverticula. A low urinary flow rate can suggest posttrau-
matic stricture. SURGICAL TECHNIQ UE
Radiographic imaging is of great value in patients with
urethral and urovaginal pathology. Abdominal and pelvic CT Regardless of the specific nature of the pathology and the
with intravenous contrast can reveal complicated fistulas precise procedure chosen to correct it, certain general princi-
that are associated with concomitant ureteral pathology. ples should be followed: the operative site should be clearly
Retrograde pyelography should be performed when ureteral exposed and the closure tension-free, in multiple layers, with
injury is suspected and may show ureteral injury despite a local flaps or relaxing incisions used to mobilize the anterior
normal CT scan. vaginal wall. Appropriate postoperative bladder drainage is
also essential and is accomplished through the placement of a
large suprapubic catheter as well as a urethral catheter employed
INDICATIO NS FO R SURGERY as a stent.
It is usually helpful to employ a well-vascularized pedicle
Surgical repair is usually undertaken due to the presence of flap to promote healing and prevent fistula formation; poten-
urethral obstruction, sphincteric urinary incontinence, or as- tial sources of this flap include the labia majora (6) and the
sociated vesicovaginal fistula. We advocate the simultaneous rectus abdominis muscle (7); gracilis myocutaneous (8) or per-
correction of all of the coexisting anatomic and functional ineal artery axial fasciocutaneous (Singapore) flaps (9) may
pathologies that led to the surgery. In patients with sphincteric also be used. Regardless of the specific anatomic findings and
incontinence, we recommend an autologous fascial pubovagi- the choice of vascular supply, the basic procedure is described
nal sling with a supporting labial fat flap interposed between as follows.
the vesical neck and the sling and with the vaginal mucosa With the patient in the dorsal lithotomy position, cys-
closed directly over the fascial sling; however, others have tourethroscopy is performed and the urethral orifices are visu-
alternatively proposed transvaginal bladder neck suspension alized. Inadvertent injury to the ureter when the fistula
in patients with favorable anatomy and incontinence due to extends close to the trigone can be avoided by placing ureteral
urethral hypermobility (5). stents and removing them at the conclusion of the case. A
In our experience, the majority of patients with urethral 14Fr percutaneous suprapubic cystotomy tube is placed under
damage who also have impaired detrusor contractility, low blad- direct visualization unless concurrent abdominal incisions are
der compliance, or detrusor instability improve after urethral planned (such as those used in autologous fascial pubovaginal
FIGURE 33.1 Bladder flap recon-

struction. Tanagho anterior bladder
flap reconstruction can be used in lieu
of vaginal flap reconstruction. (From
Tanagho EA. Bladder neck recon-
struction for total urinary inconti-
nence: 10 years of experience. J Urol
1981;125:321, with permission.)
sling), in which case the placement of the tube is deferred until catgut sutures, which in our experience result in less dysuria
the end of the procedure. A 16Fr urethral Foley catheter is and long-term urethral pain than do longer-acting synthetic
placed and the balloon inflated to secure the catheter in place absorbable sutures. If possible, a second layer of periurethral
at the bladder neck. tissue is closed over the first. The vaginal mucosa is closed us-
Three basic methods are available for urethral repair, de- ing lateral flaps elevated alongside the urethral repair or, alter-
pending on the anatomic defect and the availability of local natively, using an inverted U incision of vaginal mucosa;
tissue for flaps: primary closure, local tissue flaps originating chromic suture is also employed.
from the vaginal wall close to the urethra or from the bladder, If insufficient urethral tissue exists for primary closure, the
or a buccal graft. Small urethral defects can be fixed with a use of a flap is an alternative. Rotation of a U-shaped advance-
tension-free prim ary closure (Fig. 33.1). The urethra is closed m ent flap of the anterior vaginal wall is one option (Fig. 33.2).
over a 16Fr catheter with interrupted 3-0 or 4-0 chromic The cephalad aspect of the anterior vaginal wall is mobilized
FIGURE 33.2 Primary closure. A: The fistula is circumscribed. B: The lateral vaginal wall flaps are
elevated, and the lateral urethral walls are mobilized if possible. C: The urethra is closed primarily with
interrupted sutures of 3-0 chromic catgut. The vaginal wall is closed either primarily or with a U-shaped
flap, depending on the availability of local tissue. (M odified from M attingly RF, Thompson JD. In:
Telinde’s operative gynecology, 6th ed. Philadelphia: JB Lippincott Co, 1985:662.)
FIGURE 33.3 Advancement flap. A: A U-shaped incision is made with the arms of the U extending caudally as
far as the planned urethral meatus. B: The flap is elevated and rotated 180 degrees. The flap is sutured to the
edges of the parallel distal incisions over the catheter to form the new urethra. The vaginal wall is closed either
primarily or with a U-shaped flap, depending on the availability of local tissue. (M odified from M attingly RF,
Thompson JD. In: Telinde’s operative gynecology, 6th ed. Philadelphia: JB Lippincott Co, 1985:660–661.)
with M etzenbaum scissors, advanced, and rotated to form the tube graft incisions. In our experience, gracilis myocutaneous
posterior and lateral walls of the neourethra, using the ure- and rectus pedicle flaps have been necessary in only 2 of over
thral catheter as a guide around which the tissue is sutured. 110 patients.
The harvested site in the vaginal wall can usually be repaired In cases of extensive vaginal scarring and urethral damage,
by closing the lateral and cephalad edges of the wound; how- there may be insufficient vaginal wall for use in the repair. A
ever, pedicle flaps are sometimes necessary if the graft is large. labia m inora pedicle flap (Fig. 33.4) is a potential solution to
A larger vaginal wall flap can be employed as a tube flap this problem. The labia is cut as close as possible to the site of
(Fig. 33.3) in the case of extensive loss of urethral tissue. A the urethral repair and in such a manner as to allow a rota-
rectangular incision is made with wide margins and the vagi- tional patch graft or tube graft of labial mucosa to be em-
nal wall flap is rolled into a tube over the urethral catheter. It ployed as a neourethra that is loosely approximated over the
is best to provide a vascular pedicle flap for successful wound urethral catheter. The graft with underlying vascular supply is
healing, and a pubovaginal sling is usually required if conti- passed beneath the vaginal wall such that the mucosal surface
nence is to be achieved. As with vaginal advancement flaps, forms the inner wall of the reconstructed urethra.
the vaginal wound may be too large for primary closure, and a At the conclusion of the procedure, a Penrose drain is
secondary rotational flap of vaginal wall or labia minora placed in the labial harvest sites if applicable and is removed
can be used to close the principal defect created by the initial usually on postoperative day 1 or 2. The Foley catheter should
outlined previously; however, continence is not as easily

achieved, with success rates of about 50% (6). Accordingly,
we prefer vaginal reconstruction with anti-incontinence
surgery as the preferred management of urethral injury associ-
ated with incontinence rather than employing these alterna-
tives and their associated complications. N onetheless, when
extensive vaginal scarring in conjunction with large fistulas
precludes vaginal flap reconstruction, a bladder flap proce-
dure is an option (Fig. 33.5).
After the edges of the fistula are dissected free from the pubic
rami and the anterior and inferior aspect of the bladder is sepa-
rated from its attachments, a rectangular flap of anterior blad-
der wall is raised and rolled into a tube over a 16Fr catheter.
The distal end of this tube is sutured either to the vaginal por-
tion of the remaining urethra or at the site of the new urethral
meatus. “ Fixation sutures” are used to attach the neourethra/
tubular bladder flap to the pubic periosteum, and a M artius
fat pad is placed beneath the suture lines (6).
While skin grafts have not been widely utilized, buccal mu-
cosal graft have been employed for repair of female urethral
strictures (10,11). We generally use a two-team approach to
harvesting the graft, with the oral cavity prepared and draped
separately and instrument trays also kept separate. A
Steinhauser mucosal retractor is used to improve visualiza-
tion, and the graft harvest site is marked and lidocaine with
epinephrine injected just below the mucosa. The graft is in-
cised and removed sharply, taking care to remain in the fatty
layer superficial to the buccinator muscle. O nce removed, the
graft is defatted and the wound closed primarily. The graft tis-
sue has been used on the dorsal urethra, where it is quilted to
the adventitia of the clitoris and the urethra anastamosed to
this (10). Buccal grafts have also been sutured to the ventral
(vaginal) edge of the urethra after the stricture is incised (11).
An autologous fascial pubovaginal sling can be prepared as
part of the reconstructive procedure (Fig. 33.6) in cases associ-
ated with sphincteric incontinence or fistula where extensive
dissection under the bladder neck puts the patient at risk for
postoperative incontinence. Further, we recommend against
FIGURE 33.4 Tube graft. A: An inverted U-shaped incision is made
in the anterior vaginal wall with the apex of the U at the vesical neck the use of synthetic materials for concurrent incontinence
just proximal to the urethral fistula. The fistula is circumscribed. B: A surgery due to the risk of complications from erosion of the
plane is created in the avascular plane just underneath the vaginal synthetic graft. It is crucial to note that if a pubovaginal sling
epithelium, and the vaginal wall flap is reflected posteriorly. If a pubis to be employed, it is harvested, but no vaginal dissection is
ovaginal sling is to be performed, the dissection into the retropubic
space is completed at this time. C: The urethrovaginal fistula is closed performed to place the sling until after the urethra is repaired;
with interrupted sutures of 3-0 or 4-0 chromic catgut. D: Two parallel vaginal tissue should not be compromised by additional inci-
incisions are made alongside the Foley catheter, and medially based sions until successful repair of the urethra is complete, leaving
flaps are elevated. E: The vaginal and labial wounds are closed. (From the widest variety of possible solutions to the patient’s primary
Blavais JG. Vaginal flap urethral reconstruction. An alternative to the
problem.
bladder flap neurourethra. J Urol 1989;41:542–545, with permission.)
A Pfannenstiel incision is made approximately two finger
breadths above the symphysis pubica. The surface of the rec-
be fixed in a tension-free manner to the anterior abdominal tus fascia is freed from adherent subcutaneous tissue and two
wall to prevent trauma and pressure necrosis of the repair; this parallel horizontal incisions are made in the midline, defining
catheter is usually removed within postoperative days 2 to 5, the 2- to 3-cm width of the rectus fascial strip that will become
before the patient is discharged from the hospital. A voiding the sling. These incisions are extended laterally and superiorly
cystourethrogram should be performed though the suprapubic until approximately 10 cm of fascia is marked by the parallel
catheter about 2 weeks after the procedure. If the patient success- incisions. The fascial strip is then freed from the underlying
fully voids and there is no extravasation, the suprapubic muscle and scar using careful sharp dissection. Each end of the
catheter can be removed; if not, the voiding trial is repeated in sling is then secured with long 2-0 nonabsorbable monofila-
another 2 weeks. N one of our patients has required a catheter ment sutures and a running mattress suture directed across the
for longer than 4 weeks. width of the sling. The sling is then cut free, and the security
Alternatives to vaginal wall flaps include anterior and poste- of the suspension sutures is checked by pulling each suture
rior bladder flaps. Creating a neourethra using these methods is separately with moderate tension created by grasping each end
possible with a comparable degree of success to the procedures of the fascia; it is then placed in a saline bath.
FIGURE 33.5 Labia minora pedicle graft. A: An oval incision in the labia minora mobilizes the labial
tissue and underlying fat. B: The flap is passed through the wall of the labia minora and sutured into
position as a neourethra with the mucosal surface of the labia becoming the interior of the neourethra.
surgeon’s finger displacing the vesical neck medially, a long,

curved (DeBakey) clamp is fed abdominally under the inferior
aspect of the free rectus fascia, against the pubic periosteum,
and is then guided by the surgeon’s abdominal hand onto the
lateral aspect of the vaginal fingertip, thus protecting the blad-
der from injury.
The clamp is then fed through into the vagina, where it is
used to grasp and pull through one of the nonabsorbable sling
sutures into the abdominal wound. The procedure is repeated
on the contralateral side, and the absorbable sutures are
threaded through separate small stab incisions of the inferior
leaf of the rectus fascia. Following this, the rectus fascia is
closed using 0 delayed absorbable monofilament suture, and the
vascular pedicle graft is positioned between the pubovaginal
sling and reconstructed urethra (Fig. 33.7). The vaginal mu-
cosa is then closed, and at the conclusion of the operation the
long ends of the sling are tied together in the midline over the
rectus fascia without any tension at all.
O UTCO MES
Re sult s
A review of published results reveals that successful anatomic
reconstruction has been reported in 67% to 100% of cases,
with emphasis on the need for vascular pedicle flaps to ensure
viability of the repair (5,12). Continence varied from 55% to
93% in patients after a single operation, and resulting urethral
obstruction varied from 2% to 41% ; however, most studies
did not specify the method of evaluating continence. It was
clear that anti-incontinence procedures were in general suc-
cessful and dramatically improved the continence rates, with
FIGURE 33.6 Pubovaginal sling. A: A 2- to 3-cm-wide graft is out- postoperative incontinence in 50% to 84% of patients who
lined with the incision kept parallel to the direction of the fascial underwent anatomic reconstruction only. Table 33.2 summa-
fibers. The incision is extended laterally to the point where the fascia rizes these studies.
divides and passes to the internal and external oblique muscles. B: A
2-0 nonabsorbable running horizontal mattress suture is placed across We have performed 110 urethral reconstructive procedures
the most lateral portion of the graft, and the ends are left long. in women. All but 1 underwent primary or vaginal wall re-
C: Each end of the fascial graft is transected approximately 1 cm pairs, and the 1 Tanagho anterior bladder flap was unsuccess-
lateral to the mattress suture. D: Dissection is begun with ful because of refractory overactive bladder. A M artius flap
M etzenbaum scissors in the avascular plane just beneath the vaginal
epithelium. The tips of the scissors are directed toward the patient’s
was used in all but 4 patients. We did not perform pubovagi-
ipsilateral shoulder. E: The endopelvic fascia is perforated with the in- nal sling routinely until later in the series, and 50% of the
dex finger and the retropubic space is entered. F: A long DeBakey early patients who underwent modified Pereyra procedures
clamp is passed from the abdominal to the vaginal wound lateral to were incontinent; of these, all were subsequently cured or
the urethra. G: The fascial graft is passed around the urethra and improved by a pubovaginal sling. For this reason we are
brought to the abdominal wound on either side. H: The long ends of
the sling are tied together in the midline with no tension. The labial fat strongly in favor of a pubovaginal sling for concurrent anti-
pad is positioned between the sling and the vesical neck. (A–G from incontinence surgery.
Blavais JG. Pubovaginal sling procedure. In: Whitehead ED, ed.
Current operative urology. Philadelphia: JB Lippincott Co, 1990:
93–101, with permission.) Co mp licat io ns
Three patients experienced necrosis of the flap, which in one
The lateral edges of the vaginal incisions are retracted lat- case was associated with the development of sphincteric in-
erally using Allis clamps, and a closed M etzenbaum scissor is continence and in one with overactive bladder. O ne patient
used to dissect bluntly into the retropubic space, keeping the had urinary obstruction from the pubovaginal sling, and one
scissor directed laterally by exerting pressure against the lat- patient had an unrecognized vesicovaginal fistula that was
eral aspect of the underside of the vaginal mucosa. There is successfully repaired transvaginally. All patients who suffered
usually a distinct and abrupt decrease in tissue resistance as from sphincteric incontinence were cured or improved by suc-
the retropubic space is entered. The surgeon then places a cessful reoperation at 1 year follow-up, except for one patient
fingertip into the dissected tract and further mobilizes the who declined surgery. N o patients required intermittent
bladder neck and urethra through blunt dissection. With the catheterization.
FIGURE 33.7 Vascular pedicle graft. A: Incisions in the labia majora expose the underlying fat pad,
which is suture-ligated at its superior margin and mobilized posteriorly. B: The graft is drawn through a
perforation in the vaginal wall. C: A 2-0 chromic catgut suture is used to fix the graft over the recon-
struction. D: The vaginal wall is closed over the reconstruction. If a pubovaginal sling is performed, it is
placed beneath the vaginal wall prior to the closure. (M odified from M attingly RF, Thompson JD. In:
Telinde’s operative gynecology, 6th ed. Philadelphia: JB Lippincott Co, 1985:663.)
Urethral reconstruction in women can be highly compli- surgical procedure employing vaginal flap reconstruction with
cated and requires considerable surgical expertise as well as a a grafted vascular supply and a pubovaginal sling as an anti-
thorough diagnostic workup. In most women successful incontinence measure. Bladder flap techniques can also be
anatomic and functional repair can be achieved with a single used, especially in cases of extensive vaginal scarring.
TA B LE 3 3 . 2
RESULTS OF URETHRAL RECON STRUCTION
Continence Cure/ improved Anatomic repair Obstruction

Reference N umber (%) (%) (%) (%)
Xu, 2008 8 100 100 — 13

Wadie, 2007 13 85 a 92 — 31
M igliari, 2006 (10)b 3 100 100 100 0
Flisser, 2003 74 87 93 — —
Bruce, 2000 (7) 6 83 100 100 0
Taneer, 1993 (12) 34 — 82 82 —
Elkins, 1990 (5) 20 50 55 90 10
M undy, 1989 30 93 — 93 41
Patel, 1980 9 — 78 100 0
M organ, 1978 9 56 89 100 11
Elkins, 1969 6 10 83 67 17
H amlin, 1969 50 80 84 98 12
Gray, 1968 10 50 50 — —
Symmonds, 1968 20 65 90 85 —
aA second adjunctive procedure used.
b Buccal grafts used for repair.
References
1. Danso KA, et al. The epidemiology of genitourinary fistulae in Kumasi, 7. Bruce RG, El-Galley RE, Galloway N T. Use of rectus abdominis muscle
Ghana, 1977–1992. Int Urogynecol J Pelvic Floor D ysfunct 1996;7(3): flap for the treatment of complex and refractory urethrovaginal fistulas.
117–120. J Urol 2000;163(4):1212–1215.
2. Siegel AL. Urethral necrosis and proximal urethro-vaginal fistula resulting 8. Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the blad-
from tension-free vaginal tape. Int Urogynecol J Pelvic Floor D ysfunct der flap neourethra. J Urol 1989;141(3):542–545.
2006;17(6):661–664. 9. Z orn KC, et al. Female neo-urethral reconstruction with a modified neu-
3. Loran O B, Pushkar DO . Treatment of vesicovaginal fistula, simple or com- rovascular pudendal thigh flap (Singapore flap): initial experience. Can
plicated by urethral destruction. Experience apropos of 903 cases. J Urol J Urol 2007;14(1):3449–3454.
(Paris) 1991;97(6):253–259. 10. M igliari R, et al. Dorsal buccal mucosa graft urethroplasty for female
4. Perry M O , H usmann DA. Urethral injuries in female subjects following urethral strictures. J Urol 2006;176(4, Pt 1):1473–1476.
pelvic fractures. J Urol 1992;147(1):139–143. 11. Berglund RK, et al. Buccal mucosa graft urethroplasty for recurrent stric-
5. Elkins TE, et al. Transvaginal mobilization and utilization of the anterior ture of female urethra. Urology 2006;67(5):1069–1071.
bladder wall to repair vesicovaginal fistulas involving the urethra. O bstet 12. Blaivas JG, H eritz DM . Vaginal flap reconstruction of the urethra and vesi-
G ynecol 1992;79(3):455–460. cal neck in women: a report of 49 cases. J Urol 1996;155(3):1014–1017.
6. Elkins TE, DeLancey JO , M cGuire EJ. The use of modified M artius graft
as an adjunctive technique in vesicovaginal and rectovaginal fistula repair.
O bstet G ynecol 1990;75(4):727–733.
CHAPTER 34 ■ SURGICAL MANAGEMENT O F

THE INCO MPETENT BLADDER O UTLET IN THE
PATIENT WITH A NEURO GENIC BLADDER
ALIENO R S. GILCHRIST, GARY E. LEMACK, AND PHILIPPE E. ZIMMERN
Patients with a neurogenic bladder can exhibit one of two Bladder neck closure (BN C) is an uncommon procedure
main abnormalities of the urethra and bladder neck: bladder that has traditionally been reserved as a final alternative for
outlet overactivity, leading to obstruction, and bladder outlet the management of the female patient with neurogenically
underactivity, leading to incontinence. induced intractable incontinence arising from long-term ure-
Detrusor contraction with involuntary contraction of the thral catheter drainage (9,14). It has also been used in the
urethra and/or sphincter, known as detrusor striated sphincter treatment of nonneuropathic conditions such as traumatic
dyssynergia (DSD), is a common pattern of voiding dysfunc- urethral destruction or fistulas that have failed surgical repair.
tion in patients with suprasacral spinal cord lesions. BN C in men is usually reserved for patients with incontinence
Sphincterotomy is the gold standard for treatment of DSD and secondary to neurogenic bladder, recalcitrant urethrocuta-
renders the patient completely and continuously incontinent neous fistula, or trauma who have failed surgical correction or
via endoscopic incision of the external urethral sphincter at artificial sphincter placement. In recent years, salvage prosta-
the 12 o’clock position. Sphincterotomy may also ameliorate tectomy and BN C in the management of recurrent prostate
symptoms of autonomic dysreflexia in patients suffering from cancer after radiation therapy and in the management of
this condition (7). Risks associated with the procedure include severe complications after salvage cryotherapy have been
erectile dysfunction, hemorrhage, and urinary extravasation. reported (5).
Patients are subsequently managed with a condom catheter,
which can lead to skin breakdown and ulceration. Some pa-
tients may require a concurrent bladder neck incision to treat DIAGNO SIS
obstruction, and in many cases a repeat incision may ulti-
mately be required as the efficacy may diminish over time. Preoperative evaluation and patient selection are extremely
Incontinence in the neurogenic population can originate important to the success of BN C. A detailed history should
from sphincteric and bladder neck deficiency in addition to elicit any prior abdominal or pelvic surgeries, including previ-
detrusor overactivity. O utlet insufficiency is frequently neuro- ous reconstructive flaps or grafts. A thorough physical exami-
logic in origin but may also arise from iatrogenic destruction of nation is important to assess for the following: (a) the presence
tissue from long-term urethral catheter use. For patients with of lower-extremity contractures that may limit vaginal access;
sphincteric incompetence, a variety of treatments exists, includ- (b) perineal skin integrity and the presence of decubitus; and
ing injectables, slings, artificial urinary sphincters (Fig. 34.1), (c) a body habitus that may impede successful intermittent
adjustable continence therapy, and bladder neck closure with catheterization. In patients with adequate manual dexterity or
tissue interposition. a reliable caregiver, a catheterizable efferent limb from the
Chap t e r 34: Surg ical Manag e me nt of the Incomp e te nt Blad d e r O utle t in the Patie nt with a Ne urog e nic Blad d e r 229
TA B LE 3 4 . 1
COMPARISON OF APPROACHES TO BLADDER N ECK CLOSURE IN THE FEMALE PATIEN T
FACTOR VAGIN AL CLOSURE ABDOMIN AL CLOSURE
M ultiple prior abdominal procedures Preferred approach Alternate approach

Prior radiation N o prior pelvic radiation H istory of pelvic radiation
Postoperative drainage Suprapubic tube drainage Desires incontinent vesicostomy
or catheterizable bladder drainage
Vascularized interposition M artius flap O mentum; rectus flap; peritoneal flap
Lower-extremity flexibility Adequate Impaired
Perineal skin condition Adequate Decubitus or infected
bladder may be chosen for postoperative drainage. When in- closure, BN C with a continent catheterizable efferent channel,
termittent catheterization is not feasible, postoperative blad- incontinent vesicostomy, or suprapubic tube may represent a
der drainage is achieved via suprapubic tube or incontinent viable option for management.
ileovesicostomy (8). The vaginal approach is favored in the patient without
Evaluation of the upper urinary tract is important, and history of prior radiation who desires suprapubic tube
when upper-tract deterioration is noted, strong consideration drainage. An abdominal approach is preferred for the patient
must be given to supravesical diversion or bladder preserva- with a history of radiation in whom vaginal tissues may be
tion with augmentation cystoplasty to lower intravesical pres- poorly vascularized and in whom omental interposition
sures. A voiding cystogram may assist in detecting bladder between the bladder neck and vagina is desirable. It is also the
diverticula or vesicoureteral reflux. In most cases, reflux approach of choice in the patient who elects a continent effer-
should resolve after regularizing intravesical pressures (in the ent limb (bowel or appendix) or an incontinent ileovesicos-
case of augment), and therefore ureteral reimplantation is typ- tomy, or has failed a prior attempt at vaginal closure of the
ically not recommended unless severe obstruction at the level bladder neck (Table 34.1) (8).
of the ureterovesical junction is noted on preoperative imag-
ing. In the case of urethral fistula or stricture, a retrograde
urethrogram or fistulogram can document the nature and Me n
extent of the patient’s underlying disease.
Cystoscopy with biopsy to exclude bladder malignancy is The role of BN C in men with benign disease resides in the
essential for patients managed long term with indwelling management of refractory urethrocutaneous or urethrorectal
catheters. The extent of urodynamic evaluation is tailored to fistula and in cases of severe neurogenic or postoperative
the type of postoperative bladder management. In patients incontinence (with low outlet resistance) when an artificial
desiring continent, catheterizable access to the bladder, preop- sphincter is not an option. It may also be used in the treatment
erative urodynamic or preferably video-urodynamic evalua- of recalcitrant urethral strictures when reconstruction is
tion of bladder storage parameters such as capacity, impossible or undesired. BN C may be considered in conjunc-
compliance, and detrusor overactivity helps determine the tion with salvage prostatectomy for locally recurrent prostate
need for concomitant augmentation cystoplasty. adenocarcinoma after radiation therapy. Complications
encountered after salvage cryotherapy, such as osteitis pubis,
recurrent gross hematuria, bladder outlet obstruction, urinary
INDICATIO NS FO R SURGERY incontinence, puboprostatic fistula, urethral stricture disease,
and intractable perineal pain, can be managed by prostatec-
tomy with BN C as well.
Wo me n
Patients suffering from neurogenic incontinence often have
intractable leakage from urethral destruction due to the long- ALTERNATIVE THERAPY
term effects of an indwelling urethral catheter. A common
indication is the patient with advanced multiple sclerosis and O ptions for local reconstruction in women with severe incon-
detrusor overactivity resulting in leakage around the catheter tinence or fistula are limited. Though urethral reconstruction
or repeated catheter extrusions. Though control of inconti- with vaginal wall or bowel is an available option, maintaining
nence has been achieved by some using a pubovaginal sling, a urethral outlet that is both patent and continent can prove
many patients with urethral destruction and reduced urethral extremely challenging. Continence following these reconstruc-
length are not suitable candidates for this procedure (2,10). tive procedures may be provided by autologous or synthetic
The indications for bladder neck closure in the nonneurogenic sling materials, injectable bulking agents, an artificial urinary
patient are urethral destruction, severe intrinsic sphincteric sphincter, or bladder neck reconstruction (Young–Dees) (2). In
deficiency that is not amenable to or has failed conventional men with refractory incontinence or fistula, when previously
treatment, and failed urethrovaginal fistula repair. For the irradiated tissue is not present, the artificial urinary sphincter
woman who has failed attempts at urethrovaginal fistula and formal fistula closure are other viable alternatives.
A B
FIGURE 34.1 A: Lateral view cystogram in a severely incontinent woman demonstrating a wide open
and incompetent bladder neck and proximal urethra. B: Intraoperative view of AUS placement at the
bladder neck with a 10 cm cuff and a 61–70 cm H 2 O pressure reservoir in the same patient.
H istorically, supravesical diversion and ureterosigmoidos- case of a small contracted bladder, a curved Lowsley retractor
tomy (nonneurogenic patients) have been advocated for treat- is employed to place a suprapubic tube. The patient is placed
ment of patients with this severity of incontinence. H owever, in deep Trendelenburg position to displace bowel contents,
it is our opinion that BN C should be considered before and the curved retractor is introduced through the urethra and
embarking on these more extensive surgical options. BN C not directed to the anterior abdominal wall 1 to 2 cm above the
only preserves the bladder, but it also preserves the integrity of symphysis pubica. A small suprapubic incision is made over
the ureterovesical junction, thereby protecting the upper the tip of the Lowsley, which can be palpated beneath the
tracts. In addition, BN C is performed through either a vaginal fascia. The tip of the retractor is then pushed out through the
or retropubic approach, avoiding complications associated skin incision, and a 20Fr Foley catheter is grasped between
with open abdominal surgery. the open jaws and delivered back into the bladder. Its intraves-
ical position can be confirmed with cystoscopy or irrigation
with normal saline.
SURGICAL TECHNIQ UE A waterproof surgical ink pen marks the proposed inverted
U-shaped vaginal wall incision. N ormal saline or a dilute solu-
The goals of the procedure are the same for both male and tion of vasopressin 60 U per 100 cm 3 is injected into the peri-
female patients, regardless of the approach utilized. These urethral tissues and anterior vaginal wall to facilitate
goals include wide mobilization of the bladder neck to allow dissection of both the urethra and anterior vaginal flap.
for tension-free closure; multilayer closure of the outlet with- Vasopressin can reduce local bleeding (Fig. 34.1).
out overlapping suture lines, thereby reducing secondary After a circumscribing incision has been made around
fistula formation; interposition of vascularized tissue between the destroyed urethra, a broad-based vaginal flap is elevated
the vesical outlet and urethral stump or vagina; and adequate (Fig. 34.2). This flap not only aids in the exposure of the
postoperative bladder drainage with a large-bore catheter. remainder of the bladder neck dissection, but will also serve as
an advancement flap over the closed vesical outlet and inter-
posed labial fat pad graft. The bladder neck is freed from its
Vag inal Ap p ro ach (Wo me n) lateral and anterior fascial attachments to achieve a tension-
free closure (Fig. 34.3). The anterior mobilization includes de-
The vaginal approach is preferred in the woman who will be taching the bladder neck from the pubic symphysis
managed with suprapubic tube drainage, has no history of attachments with sharp and blunt dissection and entering the
prior radiation, and is not undergoing a concomitant abdomi- retropubic space. M ain concerns during this portion of the
nal procedure. Preoperative preparation includes antibiotics case include bleeding and injury to the bladder. Indigo
to sterilize the urine, vaginal douching, and deep venous carmine is given intravenously to aid in visualizing the ureteral
thrombosis prophylaxis. The patient is placed in high litho- orifices. Remnant urethral edges, when present, may be
tomy position with careful attention to padding of all pressure trimmed before formal closure.
points and extremities. A Lone Star ring retractor (H ouston, The bladder neck is closed in a vertical fashion with
TX) is recommended along with a weighted vaginal speculum absorbable suture (Fig. 34.4). The bladder is then filled
and headlight to provide maximal vaginal exposure. In the through the suprapubic tube to ensure that the closure is
FIGURE 34.4 Primary closure with tension-free anastomosis.

FIGURE 34.2 Elevation of the vaginal flap.
of the internal pudendal artery. The M artius flap is tunneled

beneath the vaginal wall and fixed in place over the bladder
neck closure (Fig. 34.6). The vaginal flap is advanced to close
the vagina (Fig. 34.7). The vagina is packed for 24 hours with
an antibiotic-soaked pack.
Ab d o minal Ap p ro ach (Wo me n)

The patient is placed in low lithotomy position with ad-
justable stirrups to provide continuous access to the vagina.
Alternatively, if lower-extremity contractures prohibit the
lithotomy position, the supine position may be used. A ure-
thral Foley catheter is placed, and an infraumbilical midline
incision is made. This incision not only provides excellent
exposure but also can be extended for omental harvest or use
of bowel for an efferent catheterizable limb. A Pfannenstiel in-
cision may be considered if a chronic suprapubic tube has
been chosen for long-term bladder management. The rectus
muscles are retracted laterally, and the prevesical space
(Retzius) is developed bluntly. The peritoneum is retracted
superiorly, and a self-retaining retractor (Balfour or
Bookwalter) provides exposure of the retropubic space.
FIGURE 34.3 Detachment of the bladder neck. By palpating the Foley catheter balloon, the bladder neck
and urethra are identified. An absorbable figure-of-eight
suture is placed through the distalmost aspect of the deep
dorsal vein over the proximal urethra. Using electrocautery or
watertight. To reduce the likelihood of secondary vesicovagi- sharp dissection, the anterior bladder neck is incised over the
nal fistula, a second horizontal layer of interrupted sutures most distal aspect of the Foley catheter. The lip of the bladder
imbricates the first layer in such a way that the closed bladder neck is grasped with traction sutures or Allis clamps, and the
outlet is elevated to a position high behind the symphysis Foley catheter is identified and delivered into the surgical
pubica (Fig. 34.5). This technique not only avoids a dependent field. After intravenous administration of indigo carmine,
closure but also directs the force of bladder spasms away from ureteral catheters may be placed for safe dissection of the
the vagina. posterior bladder neck (Fig. 34.8). Placing a hand in the
The use of a M artius flap is recommended to reinforce the vagina can help identify and maintain the appropriate plane
bladder neck closure and reduce the risk of fistula. The tech- between the posterior bladder neck and the vaginal wall.
nique relies on a well-vascularized fibrofatty labial pad (from Using electrocautery or sharp dissection, the posterior bladder
the labia majora) that is based posteriorly on a labial branch neck is freed from the anterior vaginal wall. This dissection
FIGURE 34.5 A: Photograph of closure of the bladder neck. B: Lateral view of bladder neck closure.
FIGURE 34.6 A: M artius flap tunneled beneath the labia minora. B: Intraoperative photograph of
M artius flap to close over the bladder neck.
continues until the bladder neck is rolled up and out of its closure is watertight. A well-vascularized interposition tissue
dependent position. The edges of the bladder neck are is placed over the two-layer closure to minimize the risk of
trimmed to allow approximation of healthy tissues, and the fistula.
ureteral catheters are removed. If an incontinent vesicostomy
or catheterizable efferent limb is selected for postoperative
bladder drainage, they may be fashioned at this time. Ap p ro ach in t he Man
O therwise, a large-bore (24Fr) M alecot or Foley suprapubic
tube is placed at the bladder dome. The bladder neck is closed The technique of bladder neck closure in men differs from that
in two layers as described for vaginal closure. The bladder is in women in several distinct ways: (a) lack of direct perineal
then filled through the suprapubic tube to verify that the access to the bladder neck; (b) limited selection of vascularized
of the infraprostatic urethra, though easily performed, is not

desirable for the following reasons:
1. The surgical closure continues to remain in a dependent
position.
2. With the exception of a gracilis or gluteal flap, there is
little opportunity for interposition of a large healthy seg-
ment of vascularized tissue.
3. Prostatic secretions can only drain in a retrograde fashion
into the bladder or, in dyssynergic patients, remain trapped
in the prostatic fossa, leading to high rates of fistulization.
4. Perineal closure does not preserve antegrade ejaculation
and compromises future fertility.
Ab d o minal Clo sure (Me n)

The abdominal approach to bladder neck closure has two
distinct advantages over perineal closure: (a) the bladder neck
can be rotated anteriorly and out of a dependent position and (b)
the choices for vascularized interposition are abundant (omen-
tum, rectus flap, and peritoneal flap). Two techniques have his-
torically been employed for abdominal closure of the bladder
neck in men with benign disease: supraprostatic and infraprosta-
tic closure. Supraprostatic bladder neck closure has been our
FIGURE 34.7 Closure of the vaginal flap. choice as it offers several distinct advantages over infraprostatic
closure. It is technically easier and does not involve deep pelvic
dissection or transection of the dorsal venous complex. It also
interposition tissue; and (c) challenging intraoperative closure allows better mobilization of the bladder neck, resulting in a
and postoperative care due to prostatic anatomy. tension-free closure. Lastly, it provides opportunity for future
fertility as an antegrade flow of ejaculate is preserved.
When BN C is to be performed in conjunction with salvage
Pe rine al Acce ss (Me n) prostatectomy, the extirpative portion of the procedure is
performed first. Description of this portion of the procedure
The perineal approach to BN C, though conceptually and tech- is beyond the scope of this chapter, but those who have pub-
nically feasible, is not considered to be the procedure of choice lished reports in the care of these patients describe it as techni-
in the man. Perineal access to the bladder neck necessitates cally challenging (5). A distinct advantage of this operation,
either a concomitant prostatectomy with its own inherent when compared to salvage prostatectomy with vesicourethral
morbidity or closure of the infraprostatic urethra, a procedure anastamosis, is that it allows for wider excision, particularly
associated with a high rate of spontaneous fistulization. Closure at the apex of the prostate.
A B
FIGURE 34.8 A: O pened bladder with mobilization of the bladder neck. B: Intraoperative photograph
of divided urethral stump and mobilized open bladder neck.
After supine or low lithotomy positioning, the patient is Vascularize d Int e rp o sit io n (Me n)
prepared and a catheter is placed in sterile fashion. An in- Following the BN C, it is highly advisable to interpose vascu-
fraumbilical vertical midline incision is performed, and the larized tissue between the bladder neck and the pelvic outlet to
retropubic space is accessed as described earlier. The bladder reduce the risk of secondary fistula. Choices for interposition
neck is identified, and absorbable sutures are used to ligate the include omentum, a flap of adjacent peritoneum, or a rectus
superficial dorsal venous complex at the prostatovesical junc- flap. We prefer omentum because of its size, reliable blood
tion. The prostate and vesical neck are grasped, and electro- supply, and abundant lymphatic drainage. In patients with a
cautery or sharp dissection is then used to amputate the generous omentum, a tongue may be easily mobilized with
anterior vesical neck from the prostate. O nce the bladder neck only limited dissection. If, however, the patient is extremely
mucosa is entered, the Foley balloon may be deflated and thin or has had radiation or prior intra-abdominal surgery, the
removed to permit visualization of the posterior vesical neck. incision may be extended to mobilize the omentum on a pedi-
Indigo carmine and ureteral catheters are used as previously cle supplied by the right gastroepiploic artery. The right side is
described. The posterior bladder wall is transected and the plane preferred due to its more dependent position in the abdomen
between the bladder and the rectum identified. M obilization and its more generous blood supply. The omentum is posi-
of the posterior bladder neck from the Denonvilliers fascia tioned between the BN C and the pelvic outlet, and it is
and rectum should continue until the vesical outlet has sutured in place with absorbable sutures. When a rectus flap is
reached an anterior, nondependent position. Excessive mobi- selected, it may be mobilized and based on an inferior epigas-
lization should be avoided to prevent injury to the ureters or tric vascular pedicle with careful attention to tie all lateral
vascular pedicles of the bladder. A large-bore M alecot or vascular collaterals. The mobilized rectus flap is then rotated
Foley suprapubic tube is then placed through a separate stab downward and positioned as described above for omentum.
incision. If an alternative bladder drainage method is desired Alternatively, a paravesical peritoneal flap may be interposed;
(incontinent vesicostomy, catheterizable efferent limb), it may however, its vascular supply may not be as reliable as that of
be constructed at this time. omentum or a rectus flap. A suction drain is left in the pelvis
Depending on its size, bladder neck closure can be per- and brought out through a separate stab wound along with
formed by one of two methods. In the patient with a small the suprapubic catheter.
bladder neck, a series of two absorbable pursestring sutures
may be used to invert the outlet similar to the inversion of
an appendiceal stump. For a larger bladder neck, or where Po st o p e rat ive Care
closure is more difficult, the outlet may be closed in two layers
as described above. Placement of a well-vascularized flap Postoperative intravenous antibiotics are used for 3 to 5 days,
of omentum, rectus muscle, or peritoneum in the fossa be- after which patients are placed on daily oral antibiotic sup-
tween the bladder neck closure and prostate is performed to pression. The suction drain is usually left for 1 to 2 days. In
not only facilitate healing but also to help prevent fistulization our experience a nasogastric tube is not usually necessary. The
(Fig. 34.9). suprapubic tube is carefully secured to avoid kinking or dis-
Concomitant prostatectomy may be planned in the case of lodgement. Patients are kept on either oral or rectal anti-
salvage prostatectomy, or it may be indicated in the case of a cholinergic medication (belladonna and opium suppositories)
strictured urethra or prostatorectal fistula that poses a prob- to prevent bladder spasms. A cystogram is obtained at 2 to 3
lem to postoperative prostatic drainage. weeks to document the integrity of bladder neck closure. If
A B
FIGURE 34.9 A: O mental interposition in the man. B: Intraoperative photograph showing omental
wrap over bladder neck closure to prevent secondary vesicourethral fistula.
there is no evidence of leak or fistula, the suprapubic tube may negotiate the tract and pass a flexible wire down to the blad-
be changed or removed if a catheterizable stoma was chosen der. If this procedure fails, the patient may be given a fluid bo-
for bladder drainage. lus and the bladder may be percutaneously accessed under
sonographic guidance. O nce access has been established, the
tract may be dilated and a council catheter passed over the
wire. Inability to catheterize a continent efferent limb may be
O UTCO MES treated similarly, and endoscopic negotiation of the conduit
usually suffices to reestablish access.
Co mp licat io ns
The primary complication of bladder neck closure is postoper- Re sult s
ative fistula. Such a fistula may occur as early as 1 week
postoperatively or as late as 1 year. When a fistula is sus- Though a number of authors have reported their results with
pected, the patient should undergo a cystogram with a BN C, most series have been small, retrospective, and with a
mixture of contrast and methylene blue dye. The site of leak- great deal of variability in technique (3,4,8,11). Consequently,
age (vagina or perineum) should then be assessed both visually long-term outcomes and overall success rates are difficult to
and radiographically. If a small fistula is encountered early in judge. In series where the bladder neck is anteriorly mobilized
the postoperative period, bilateral percutaneous nephros- and appropriate vascularized interposition tissue is utilized,
tomies may be used to divert the urine away from the fistulous long-term continence rates range from 83% to 100% with a
site. Reoperation is a more complex but reliable method of 7% to 8% reoperation rate (4,6,11). In series where these
dealing with postoperative fistula. When the initial procedure principles have not been employed, fistula formation and
was performed from a vaginal or perineal approach, reopera- reoperation rate range from 30% to 46% and 25% to 46% ,
tion should be performed suprapubically to allow extensive respectively (1,3,9). In one series where female multiple sclero-
bladder mobilization and interposition of a large, well- sis patients were treated with vaginal urethral closure and
vascularized omental flap. Supravesical diversion is reserved suprapubic cystostomy, approximately 80% of the patients
for patients in whom all attempts at repair have failed. who were continent (and available for reliable follow-up)
Loss of access to the bladder may also represent a source of remained continent at an average follow-up of 6.5 years
postoperative morbidity. Loss of a suprapubic tube and clo- (range, 2 to 17 years) (3). Upper-tract deterioration has been
sure of its tract is an underreported but not uncommon com- noted in a single series (11% ) and has been causally related
plication. Access may be re-established by using a flexible to the use of continent, catheterizable efferent channels in
cystoscope or ureteroscope and may require fluoroscopy to patients with persistent bladder dysfunction (1).
References
1. Andrews H O , Shah PJR. Surgical management of urethral damage in 7. Perkash I. Transurethral sphincterotomy provides significant relief in auto-
neurogenically impaired female patients with chronic indwelling catheters. nomic dysreflexia in spinal cord injured male patients: long-term followup
Br J Urol 1998;82:820. results. J Urol 2007;177:1026.
2. Chancellor M B, Erhard M B, Kiilholma PJ, et al. Functional urethral 8. Schwartz SL, Kennelly M J, M cGuire EJ, et al. Incontinent ileo-vesicostomy
closure with pubovaginal sling for destroyed female urethra after long-term urinary diversion in the treatment of lower urinary tract dysfunction. J
catheterization. Urology 1994;43(4):499. Urol 1994;152:99.
3. Eckford SB, Kohler-O ckmore J, Feneley RCL. Long-term follow up of 9. Stower M J, M assey JA, Feneley RC. Urethral closure in management of
transvaginal urethral closure and suprapubic cystostomy for urinary incon- urinary incontinence. Urology 1989;34(5):246.
tinence in women with multiple sclerosis. Br J Urol 1994;74:319. 10. Wanatabe T, Rivas DA, Smith R, et al. The effect of urinary reconstruction
4. H ensle TW, Kirsch AJ, Kennedy WA, et al. Bladder closure in association on neurogenically impaired women previously treated with an indwelling
with continent urinary diversion. J Urol 1995;154:883. urethral catheter. J Urol 1996;156:1926.
5. Izawa JI, Ajam K, M cGuire EJ, et al. M ajor surgery to manage definitively 11. Z immern PE, H adley H R, Leach GE, et al. Transvaginal closure of the
severe complications of salvage cryotherapy for prostate cancer. J Urol bladder neck and placement of a suprapubic catheter for destroyed urethra
2000;164:1978. after long term indwelling catheterization. J Urol 1985;134:554.
6. O ’Connor RC, Stapp EC, Donnellan RM , et al. Long-term results of supra-
pubic bladder neck closure for treatment of the devastated outlet. Urology
2005;66(2):311–315.
CHAPTER 35 ■ SURGERY FO R URETHRAL
STRICTURE DISEASE
JACK R. WALTER AND GEO RGE D. WEBSTER
Urethral stricture have been described and managed since an- stricture (8). If one is unable to adequately distend the proxi-
tiquity. Egyptians used reeds to dilate strictures in 1700 B.C ., mal uretha due to near obliteration of the lumen, voiding cys-
documenting the first nonsurgical intervention reported for tourethrography (VCUG) provides additional information.
the management of strictures. Urethral strictures remain a rel- Simultaneous RUG–VCUG is indispensable in the evaluation
evant disease process in present times. Their etiology remains of the obliterative urethral defect that follows pelvic fracture.
trauma, inflammation, or ischemia, with trauma being the Urethral ultrasonography and magnetic resonance imaging
most common cause. Traumatic injuries may result from ex- have also been used in the evaluation of urethral disease but
ternal violence, including blunt trauma to the perineum, pelvic are not as widely available. Uroflowmetry provides insight on
fracture, or penetrating injury with knife or projectile injury. the functional significance of the stricture. Cystourethroscopy
M ore frequently, iatrogenic injury secondary to urethral provides little additional information in the clinic setting as vi-
catheterization and endoscopic surgery create strictures. sualization of the proximal urethra is limited by the stricture.
Inflammatory processes, including gonococcal urethritis or Urethroscopy if performed is primarily used to rule out malig-
lichen sclerosis, can result in stricture formation. Rarely, ure- nancy and complement the radiological findings.
thral strictures can result from malignancy, typically of urethral,
penile, or lymphoid origin. The central process of urethral
stricture pathophysiology is progressive fibrosis of the epithe- INDICATIO NS FO R SURGERY
lium with subsequent involvement of the underlying spongio-
sum. The urethral lumen narrows, leading to a weak urinary The presence of stricture alone does not necessitate surgical
stream and difficulty voiding, culminating in complete obliter- intervention as many wide-caliber strictures are of little con-
ation with urinary retention. Rarely, stricture disease will lead squence. Prior to surgery, strictures should demonstrate outlet
to fistula or abscess formation. obstruction. Stricture location and characteristics dictate ini-
tial management. In most settings dilation or optical urethro-
tomy is acceptable. Such intervention is rarely curative but
DIAGNO SIS usually temporizes the acute event for a variable duration
(11). Indications for open urethroplasty include frequent ure-
The presentation of urethral strictures ranges from insidious thral dilation or complications associated with dilation, in-
to obvious. M en may have stricture disease for many years cluding false passage, diverticulum, fistula, bacteremia,
and never seek evaluation or suspect they have a problem. hemorrhage, and excessive pain. In addition, strictures that
These men are commonly diagnosed when urethral catheters occur in children or long, obliterative strictures justify earlier
are placed for surgery or when their long-standing strictures consideration for open repair.
lead to bladder decompensation. Frequently, strictures present N umerous urethroplasty techniques have been described,
with symptoms of bladder outlet obstruction and irritative and no single technique is appropriate for all strictures. Consider
symptoms, including urgency, frequency, and dysuria. two broad technical groups of urethroplasty: anastomotic and
O ccasionally, patients will present with microscopic or gross substitution repairs. Anastomotic, as the name implies, involves
hematuria. Recurrent urinary tract infection can accompany removal of the diseased urethra and reanastomosis of the
these symptoms. In cases of traumatic stricture, the history healthy ends. Substitution repairs augment or replace the ure-
will include prior urethral instrumentation or an episode of thral lumen with a pedicalized flap or graft performed in single
external injury. or multiple stages. Traditionally, grafts and flaps originated from
M en with newly diagnosed strictures require a thorough genital skin. However, buccal mucosal grafts have emerged as
history and physical examination with special attention to the the preferred urethral substitute in adults due to their favorable
genitalia. Penile length should be noted. The character, color, inherent qualities and consistent availability.
and laxity of penile shaft skin and preputial skin, when pre- The goals of any reconstructive urologic surgery are func-
sent, should be assessed to determine flap and graft availabil- tional and anatomic success. Location, length, and etiology of the
ity. The urethra is palpated to help determine the severity of stricture as well as personal experience determine the appro-
spongiofibrosis. Laboratory evaluation should include urine priate surgical technique. Additional factors, including con-
analysis, urine culture, and assessment of renal function. cominant fistulas, inflammation, and prior repairs, need to be
Conventional radiological studies adequately delineate ure- considered. With these thoughts in mind, excellent function—
thral strictures in most men. Retrograde urethrography (RUG) urethral patency and stable sexual function—and cosmetic
provides the length, location, caliber, and multiplicity of the results are attainable.
236
Chap t e r 35: Surg e ry for Ure thral Stricture Dise ase 237
catheter is fenestrated to promote drainage of the operative

ALTERNATIVE THERAPY site (Fig. 35.1). O ne rarely needs suprapubic catheter drainage
with anterior urethral surgery. If present, it may facilitate
N onsurgical and minimally invasive alternatives exist for man- postoperative urethral stent management, allowing removal of
agement of urethral stricture. N onsurgical options include ex- the urethral catheter without requiring the patient to void.
pectant management and dilation performed by the patient or The type and location of repair determine the length of time
physician. M inimally invasive techniques include optical ure- that catheterization is required. M eatal or glanular repairs
throtomy using cold knife, electrocautery, or laser. In general, require 5 to 7 days, anastomotic repairs require 10 to 14 days,
urethrotomy is contraindicated in the pendulous urethra due to and one-stage graft repairs require 21 days of urinary
the paucity of surrounding spongy tissue, which is necessary drainage. Prior to catheter removal, the anastomotic lines are
for urethral re-epithelialization. M ore recently transurethral assessed for healing with a pericatheter RUG for all urethro-
placement of metallic urethral stents has been utilized. plasties proximal to the fossa navicularis. If there is no ex-
Currently, urethral stenting is discouraged in the pendulous travasation at the repair site, the catheter is removed and the
urethra due to patient discomfort and potential compromise of patient resumes normal voiding. H istory and examination,
erectile function. In the bulbar urethra all of the mentioned op- uroflowmetry, and RUG are performed at 3 and 12 months
tions are available. In terms of cure rates, optical urethrotomy following repair. Subsequently, symptomatic follow-up is indi-
has no advantage over urethral dilation (11). Further, if one cated, and some use periodic uroflow studies.
urethrotomy or dilation fails to cure a patient, then subsequent
procedures are rarely if ever successful (6). With poor success
of repeat internal urethrotomy, the cost-effective strategy is to
move to open surgical repair following one failed endoscopic
St rict ure s o f t he Glanular Ure t hra
treatment (12). Strictures that may be cured by dilation or ure- Strictures in the glanular urethra arise commonly from inflam-
throtomy are usually short ( 1 cm) bulbar strictures, whereas matory conditions, instrumentation, or improper circumci-
longer strictures or those of the pendulous urethra are rarely sion. Simple meatotomy, a glans-based Y–V advancement flap
cured by dilation or urethrotomy. for very distal stenosis, or a ventral shaft skin onlay flap in the
case of stricture involving the entire fossa navicularis may ac-
complish surgical repair. For Y–V advancement, a V-shaped
SURGICAL TECHNIQ UE incision is made on the dorsal aspect of the glans with the
apex terminating at the urethral meatus (Fig. 35.2). A dorsal
Ge ne ral Surg ical Princip le s midline extension of this incision is made into the urethra to
widen the lumen to accept a 22Fr sound. The glans flap can be
Prior to incision, controlled variables should be optimized. elevated using skin hooks and sharp dissection to allow its
The preoperative urine culture must be negative. If the patient mobilization into the most proximal limit of the dorsal ure-
has an indwelling suprapubic tube, broad-spectrum oral antibi- thral incision, where it is anchored with a 4-0 PGA suture.
otics should be provided during the 24 hours prior to surgery. Care must be taken to leave this glans flap with a wide base to
O n-call parenteral antibiotics should be given. Appropriate avoid vascular compromise.
radiological studies must be available in the operative room. M ore extensive strictures of the glanular and distal penile
The surgeon should communicate openly with anesthesia urethra should be managed according to their etiology. If one
about anticipated length of surgery, expected blood loss, and suspects lichen sclerosis (LS), biopsies may be obtained to con-
type of anesthetic required. M ost anterior urethral strictures firm diagnosis and exclude possible malignancy. Strictures as-
can be managed with a spinal anesthetic. If one determines sociated with LS are best repaired with nongenital skin as the
that a buccal mucosal graft will be needed, one should advise penile skin is considered blighted and may eventually develop
anesthesia that general endotracheal anesthesia is necessary. LS. In these cases, the diseased urethra is excised, the buccal
We prefer to position patients in modified lithotomy using mucosa is inlayed, and the urethra is left open. A second stage,
padded Allen stirrups. Exaggerated lithotomy is rarely neces- during which the urethra is then tubularized, occurs 6 to 12
sary and carries a significant risk of neuronal injury and months later after the graft matures, and the adjacent urethra
compartment syndrome, especially with prolonged operative is observed for further development of LS. If extensive stric-
time (1). Staining the urethra with methylene blue assists in ture disease is unrelated to LS, then a flap of skin obtained
identifying the urethral lumen as well as differentiating from the penile shaft allows repair in a single stage. The flap
urethral scar from healthy urothelium. “ Table-fixed” ring may be fashioned as an onlay or as a tube, depending on the
retraction (Bookwalter or O mni) provides ideal exposure extent of the disease (Fig. 35.3).
for bulbar or posterior urethroplasty, while nonfixed ring re-
traction (Lone Star) is optimal for pendulous urethroplasty.
Polyglycolic acid (PGA) suture material has ideal tensile St rict ure s o f t he Pe nd ulo us Ure t hra
strength, absorption rate, and tissue reactivity; and 5-0 is
generally used. Wound drainage when necessary is accom- Pendulous urethral strictures are most often repaired using an
plished with a 7Fr closed-suction drain. Dressings should be onlay flap of penile skin. Although many variations of this
supportive and noncompressive. technique have been described, the laterally based pedicled is-
Postoperative urinary drainage should be effective and land flap originally described by O randi gives excellent results
cause minimal urothelial irriation. For this purpose 12Fr sili- and is technically forgiving. It is in general suitable for repairs
cone urethral catheters function adequately. When surgical re- measuring up to 8 cm (depending on penile length), although
pair in bulbar stricture disease requires a graft or flap, the longer repairs can be performed by harvesting a penile “ J”
FIGURE 35.1 The fenestrated urethral catheter is

optimal following urethroplasty. Either a balloon or
straight catheter may be used, and fenestrations are
made in the catheter shaft in the region of repair. The
fenestrations allow debris and exudate to be washed
away from the site of repair. Bladder irrigation can-
not be performed unless the catheter is inserted all
the way into the bladder so that the most distal fenes-
tration is intravesical.
along the ventral penile raphe through the Buck fascia down
to the strictured segment of urethra. Using skin hooks to ele-
vate the flap and fine scissors for dissection, one skin margin is
mobilized from the corpus cavernosum for 10 to 15 mm, stay-
ing deep to the Buck fascia (Fig. 35.4). With the urethra ade-
quately exposed, a suitable catheter or filiform is placed in the
urethral lumen as a guide and the urethra incised ventrally
along the stricture. This incision is then extended to expose at
least 1 cm of healthy urethra proximal and distal to the stric-
ture. An onlay flap of suitable width to achieve a 24Fr lumen
(in general, 18 to 25 mm) is then outlined on the mobilized
lateral penile shaft skin. The flap length corresponds to the
length of the urethrotomy and is tapered at the proximal and
distal ends. Care must be taken not to incorporate a significant
segment of hair-bearing shaft skin in the repair.
O nce the flap has been outlined, the projected new skin
edges are approximated in the midline to ensure that wound
closure with minimal tension is possible. The lateral aspect of
FIGURE 35.2 Glans flap meatoplasty. the flap is then incised through the subcutaneous connective tis-
sue, leaving the underlying dartos and deeper Buck fascia intact.
With exposure of the correct tissue plane, the lateral penile
flap that has a vertical and a distal circumferential compo- shaft skin will retract with minimal additional dissection. The
nent. A flap width up to 25 mm can be used without compro- medial border of the island flap is then anchored to the lateral
mising penile skin closure. The patient is placed in either the edge of the incised urethra with 5-0 PGA stay sutures. The flap
lithotomy or supine frog-legged position. An incision is made is sutured to the urethra beginning at the distal margin, using a
FIGURE 35.3 Repair of meatal and distal penile

urethral stricture using a pedicled island of distal
penile skin. This procedure allows for reapproxi-
mation of glans tissue around the neourethra,
giving an excellent cosmetic and functional result.
FIGURE 35.4 O nlay urethroplasty of a pendulous

urethral stricture (O randi repair). The stricture is ap-
proached through a ventral penile incision. The outline
of the skin island to be used for onlay is marked once
the stricture has been opened and its length and caliber
determined. The skin island is raised on a subcuta-
neous vascular pedicle, rotated inward, and sutured as
an onlay to augment urethral caliber. Skin closure is in
at least two layers to avoid fistula formation.
running 5-0 PGA suture, incorporating the urothelium in the by stricture length. Strictures under 1 cm in length are best
closure. When the lateral suture line is complete, the free edge managed with excision and anastomotic urethroplasty. The
of the island flap can be rolled over and secured with 5-0 PGA patient is placed in modified lithotomy position. A midline
stay sutures to the contralateral margin, recreating the urethral perineal incision is made and bifurcated posteriorly 2 cm
lumen. A similar running suture line is performed with 5-0 PGA above the anus. The bulbospongiosus muscle is divided in
to complete the onlay repair. Local wound drainage may be ac- the midline, exposing the bulbar urethra. The bulbospongio-
complished with a suction drain placed underneath the vascular sus muscle can frequently be separated from the underlying
pedicle along the length of the flap to obviate hematoma or bulbar urethra with blunt disection if the correct plane is
urinoma formation, which could compromise the flap. identified. By sharply dividing the reflection of the Buck fas-
Wound closure is performed in two layers using 5-0 inter- cia lateral to the urethra as it drapes over the corporal bodies
rupted PGA sutures. Care must be taken when approximating proximal to the crus, one can safely dissect the urethral cir-
the subdermal connective tissue of the skin margins to avoid cumferentially. A space deep to the Buck fascia and between
injury to the flap pedicle. This first layer of closure covers the the separating corporal bodies is entered on each side. This
exposed urethral suture line and minimize the risk of fistula dorsal dissection, separating the urethra from the corporal
formation. Skin closure is performed with a running subcuticu- bodies, is continued sharply until the entire strictured ure-
lar 5-0 PGA suture. The wound is supported with adhesive thra has been circumferentially mobilized. O ne should avoid
strips and covered with a gauze and loosely applied Coband mobilization distal to the suspensory ligament of the penis if
dressing to reduce edema formation. The urethral catheter is possible, as this will increase the risk of chordee and penile
secured to the abdominal wall and remains in place for up to length shortening. Further mobility of the proximal bulbar
3 weeks. If a suction drain is used, it is removed within urethra is obtained by dividing the ventral attachments to
24 hours. The supportive dressing is taken down on postoper- the perineal body.
ative day 2. The patient is allowed to ambulate on postoperative O nce the strictured segment is fully mobilized, the urethra
day 1, and the procedure is usually performed as an outpatient. is divided at the distal extent of the stricture as defined by a
catheter or bougie à boule placed from the meatus. The ure-
thra should be spatulated through the diseased segment defin-
Bulb ar Ure t hral St rict ure Re p air ing the extent of disease. Complete removal of fibrotic tissue
with exposure of healthy proximal and distal urethra is essen-
Anast o mo t ic Ure t hro p last y tial for successful repair, but no 1 cm of urethra should be
Strictures of the bulbar urethra originate most commonly excised. If the urethral ends appose in a tension-free fashion,
from straddle injuries or iatrogenic trauma during en- they are spatulated sharply for 1 cm (Fig. 35.5). Using 5-0
doscopy or catheterization. O ptimal management is dictated interrupted PGA sutures, the dorsal wall of the anastomosis is
FIGURE 35.5 Anastomotic repair of bulbar

urethral stricture that may follow straddle in-
jury. A: The urethra is exposed through a mid-
line perineal incision and the stricture site
identified and excised. B: Following stricture ex-
cision, apposing spatulations of 1 cm are ac-
complished. C: The proximal urethral opening
is spread-fixed to the underlying corporal body,
and spatulated anastomosis is performed with
interrupted sutures. D: The anastomosis is com-
pleted, and additional tension-relieving sutures
A D between urethral adventitia and adjacent corpo-
ral bodies are placed to avoid anastomotic ten-
C sion during erection.
completed while spread-fixing the urethra to the corporal are placed along the exposed dorsal aspect, and the urethra is
bodies. Circumferential partial-thickness anastomotic sutures then incised along the strictured segment in the 12 o’clock (dor-
incorporating the urothelium and some of the corpora spon- sal) position. The incision is extended for 1 cm into healthy ure-
giosum complete the first layer of the repair on the ventral sur- thra proximal and distal to the stricture.
face. A second layer of closure is accomplished using the Confirmation of proximal and distal patency is confirmed
redundant spongiosum. The bulbospongiosus muscle and the endoscopically and by calibration with a 24Fr bougie à boule.
Colle fascia are approximated in the midline with interrupted A suitable skin donor site, selected on the ventral penile shaft
5-0 PGA sutures. Final skin closure is made with interrupted or prepuce, or a buccal mucosa graft is harvested. The graft is
5-0 PGA sutures. The perineum is dressed and bolstered with spread-fixed on a paraffin block and defatted. It is then fenes-
fluff gauze and mesh underwear. The urethral catheter is se- trated with a scalpel and sized and shaped to fit the defect cre-
cured to the abdominal wall to minimize traction and pressure ated by urethral incision. The graft is then anchored in a
on the urethra. spread-fixed fashion to the corporal bodies opposing the dor-
sally incised strictured urethra. The urethra is then rotated
Aug me nt e d Anast o mo t ic Ure t hro p last y back to its normal anatomic position, and the margins of the
Excision of 1 cm of urethra and associated 1-cm spatulated re- urethral incision are sutured to the fixed graft edge and corpo-
pair results in a total of 2 cm of urethral shortening, an ral body using interrupted 5-0 PGA sutures. In this fashion,
amount that can be easily accommodated by the elasticity of the dorsal graft becomes the new urethral roof, augmenting
the mobilized bulbar urethra. As bulbar urethral strictures the urethral caliber at the stricture site. This dorsal approach
extend beyond 1 cm in length, the risk of chordee and short- mitigates blood loss from a ventral bulbar incision and pro-
ening increases if primary anastomotic repairs are performed. vides excellent graft stabilization. O f note, the residual floor
A variety of alternative procedures that avoid penile shortening of the strictured urethra functions as the foundation for the re-
and chordee may be used for strictures that are 1 cm in pair. If the stricture is severe, outcomes may be compromised.
length.
For strictures of up to 2 cm in length, stricture excision and
augmented anastomotic repair is a good option (5). The 2-cm Panure t hral St rict ure o r Faile d
segment of stricture is excised. The urethra is then spatulated Ure t hro p last y
proximally and distally for 1 cm into healthy urethra on the
same side. The anastomosis is then augmented with a graft (or The management of extensive stricture of the anterior urethra
a flap), increasing the lumen and avoiding the need for spatula- involving both the pendulous and bulbar portions can be ex-
tion. This in effect spares an additional 1-cm loss of urethral tremely challenging. These are usually of inflammatory origin
length. In the ventral onlay, spatulation is at the 6 o’clock posi- (often due to lichen sclerosis) and can be up to 20 cm in length.
tion (floor), and the unspatulated dorsal (roof) strips are then Urethral repair in these circumstances is undertaken either by
reapproximated end-to-end after spread-fixation, thereby se- combination repairs using grafts and flaps or, more conserva-
curing the anastomosed urethral roof strip to the overlying cor- tively, by multistaged repairs that may also use perineal inlays
poral body. The anastomosis is not completed circumferentially, of full- or split-thickness skin grafts. O ne must consider the use
resulting in a diamond-shaped ventral urethral defect into of perineal urethrostomy or repeat dilations, as reconstructive
which is laid either a graft of penile skin or buccal mucosa or, results in other locations and situations are not as successful.
alternatively, a diamond-shaped flap of penile skin mobilized
on a pedicle through the scrotum. This repair is called an aug-
mented roof strip anastomotic procedure. It provides the ad- O ne -St ag e Co mb inat io n Ure t hro p last y
vantages of an anastomosis while augmenting the repair to
limit penile shortening to 2 cm, which is usually acceptable O ne-stage combination procedures make use of both a flap
(Fig. 35.6). Alternatively, and our preference, is to perform a repair for the pendulous portion of the urethra and a graft re-
floor strip anastomosis, placing the augmenting graft, typically pair for the bulbar area, with the two procedures being per-
buccal mucosa, on the dorsal aspect, where it is spread-fixed to formed in continuity (7). The patient is placed in the lithotomy
the overlying corporal body. This approach permits superior position for access to the perineum as well as the penile shaft.
spread-fixation of the graft and therefore reduces graft shrink- In uncircumcised men the prepuce can be used as a skin graft
age and enhances graft take because of the reliable apposition donor site, leaving the remaining shaft skin for island pedicle
to the corporal body; it also avoids graft or flap sacculation. flap construction. In the event there is insufficient penile skin,
Consequently, since 1996, we prefer the dorsal onlay in the buccal mucosa may be used for the graft repair of the contigu-
bulbar urethra (3). ous scrotal/bulbar urethra, or buccal mucosa may be preferred
even in cases where penile skin is sufficient. O ne should avoid
O nlay Bulb ar Ure t hro p last y the use of penile skin when lichen sclerosis is present.
As bulbar stricture length increases to 2 cm in length, it is A ventral incision is made over the pendulous urethra, and
rarely possible to complete any type of anastomotic repair this portion of the stricture is repaired using a ventral onlay re-
without causing some penile chordee and tension on the anas- pair in the fashion of O randi, as described earlier. The more
tomosis. In this setting we have found success using a buccal proximal scrotal portion of the stricture is then repaired in con-
mucosal or skin graft onlay applied to the dorsal aspect of the tinuity by a dorsal or ventral onlay. This portion of the repair is
strictured portion of the bulbar urethra (Fig. 35.7). The ure- approached through a separate incision in the perineum for
thral bulb is exposed circumferentially. The distal extent of the exposure of the bulbar urethra. If a dorsal onlay is used, which
stricture is defined with a 20Fr catheter. The urethra is rotated is our preference, the bulbar urethra is circumferentially mobi-
180 degrees to expose its dorsal aspect. Stay sutures of 4-0 silk lized as far distally as the proximal limit of the penile flap
FIGURE 35.6 Augmented roof strip anastomotic repair. A–D: A healthy roof strip of urethra is created
by stricture excision and roof strip reanastomosis. E–G: An appropriately sized and shaped island of
ventral penile skin is mobilized on its vascular pedicle, tucked through the scrotum, and sutured over the
anastomosis, augmenting its caliber (closure is in layers). H–K: This series illustrates the augmented roof
strip anastomotic repair using a fenestrated full-thickness skin graft from the ventral penile shaft rather
than a pedicled island of penile skin.
FIGURE 35.7 The dorsal onlay graft bulbar urethroplasty. A: Exposure of the urethra. B, B1:
Fenestrated graft sutured to the undersurface of the corporal body. Strictured portion of the urethra
either excised or rotated. C: Suture of the opened urethra to dorsal onlay graft. D: Completed repair.
repair, and the urethra is then incised dorsally through the striction, and long recurrent strictures following prior repair, is best
ture, with the distal limit being the visible ventral onlay; the managed by a staged repair. H istorically, such repairs were per-
dorsal onlay graft is then completed as described earlier. H ence, formed as scrotal inlay procedures with the resultant neourethra
the long stricture is repaired by a ventral onlay flap for the pen- being constructed from hair-bearing scrotal skin, which experi-
dulous portion and a dorsal onlay graft for the more proximal ence has proven to be a suboptimal substitute. Variations on
urethra, with the composite repair being completed nose to tail. this theme now inlay fenestrated full-thickness preputial skin,
split-thickness thigh skin, or buccal mucosa alongside the mar-
supialized urethra in the first stage. In the second stage, the
St ag e d Re p air neourethra is formed by tubularization of the graft. Full-thick-
ness skin is superior for this purpose but is not often available in
Extensive anterior urethral stricture disease, in particular full- communities where circumcision is common. If split-thickness
length strictures, strictures complicated by fistula or inflamma- skin is to be used, it is in general harvested from the thigh,
which is easily accessed with a patient in the lithotomy position. moist by periodic application of Bunnell solution until the
The strictured anterior urethra is exposed through a ventral dressing is removed after 5 days. Graft take is in the order of
midline perineal incision that may bifurcate the scrotum, and 95% or greater.
the urethra is then incised along the length of the stricture to The second stage is performed a minimum of 3 months
healthy urethra proximally and distally. This again is confirmed later and in practice usually 6 to 12 months later to allow
by calibrating the urethra with a 24Fr to 28Fr bougie à boule, thorough vascularization of the graft and to allow adjacent
which should pass easily through each ostium. Using a der- stricture disease to declare itself. The proximal and distal ure-
matome set to 20 thousandths of an inch, a split-thickness graft thral openings should again freely calibrate to 28Fr and 24Fr,
is harvested from the thigh and meshed to a ratio of 1.5:1.0. A respectively, prior to second-stage closure. If the ostia have
strip of meshed graft measuring 3 to 5 cm is then inlayed narrowed, revision rather than dilation should be undertaken,
around the marsupialized strictured urethra (Fig. 35.8). usually using a Y–V advancement technique. Second-stage repair
Medially it is sutured to the incised urethral margin and later- is begun by incising the graft circumferentially to a width that
ally to the incised scrotal and perineal skin edges using 5-0 will allow neourethral tubularization to approximately 28Fr.
PGA. This width of graft accounts for the up to 50% shrinkage The tubularization is performed by midline anastomosis with
that may occur with split-thickness skin, resulting in suitable a running 5-0 PGA suture, interlocking every third pass, fol-
graft width for a future neourethra. If buccal mucosa is inlayed lowed by a multilayer wound closure. The urethral is stented
(preferable but not always adequately available), a fenestrated for 20 days.
graft of 2.5 to 3.0 cm in width is usually adequate because it un-
dergoes less contraction. A suprapubic tube is placed for uri-
nary diversion in the postoperative period, and the graft is O UTCO MES
dressed with an Adaptic gauze and a tie-down dressing of ster-
ile cotton fluffs soaked in Bunnell solution. The graft is keep Co mp licat io ns
H ematoma or hemorrhage is in general rare if meticulous at-
tention is paid to hemostasis during the repair. Wound infec-
tion is an uncommon complication that in general presents
with erythema and induration at the incision site.
Flap necrosis is uncommon in experienced hands and is
most often due to technical errors in preparation of skin flaps
or poor flap selection. Flap viability may also be adversely
affected by prior surgery, infection, tissue ischemia, tobacco
usage, and malnutrition. Contraction of 15% to 25% is antic-
ipated for full-thickness skin grafts and must be accounted for
during preparation. Removal of subcutaneous fat and fascia
must be achieved for adequate exposure of the subdermal vas-
cular plexus but should not be so excessive as to convert the
graft to a split-thickness variety. Fenestration of free grafts will
promote drainage of the graft bed, and a well-vascularized
graft bed must be assumed, sometimes requiring redeployment
of spongy tissue. Split-thickness grafts are not advocated for
one-stage urethroplasty because their shrinkage is unpre-
dictable and may be excessive (up to 50% ).
Fistula is in general uncommon in adult urethral surgery
but is on occasion encountered in the setting of underlying in-
fection or vascular compromise. It most commonly occurs fol-
lowing repair of pendulous urethral strictures. Suprapubic
urinary diversion may allow for spontaneous healing of fistu-
las encountered within the first few weeks following urethro-
plasty. Fistulas that fail to close with proximal diversion
generally need reoperation after a minimum of 6 months.
With use of an oversized or poorly supported ventral onlay
flap or graft, in particular in the bulbar urethra, there is on oc-
casion formation of a redundant urethral segment in which
urine may pool, leading to poor urethral emptying and recur-
rent infection. Urethral stones can form as a result of urinary
stasis in the diverticulum or as a result of retained hair on flaps
and grafts. Proper measurement of flaps and grafts to provide
a 26Fr to 28Fr lumen, as well as adequate spread-fixation of
FIGURE 35.8 Staged urethroplasty for full-length stricture disease the onlay, may obviate sacculation. Preoperative epilation and
using meshed split-thickness skin graft. The meshed graft is laid
proper selection of donor sites can prevent the hairy urethra.
alongside the marsupialized urethra so that the neourethra will be
tubularized from the graft rather than from hair-bearing scrotal skin. Penile curvature may result because of inappropriate pro-
Tubularization of the neourethra is delayed for 3 to 6 months. cedure selection in attempting anastomotic repair or long-graft
Chap t e r 36: Surg e ry for Ure thral Trauma Includ ing Ure thral Disrup tion 245
onlay repair to the pendulous urethra distal to the suspensory

ligament. It may also follow excessive urethral excision Re sult s
( 2 cm) when performing anastomotic repair in the bulbar
As understanding of urethral anatomy and tissue transfer tech-
urethra. A downward deflection of the erect penis may also
niques has grown, so too has the effectiveness of urethral recon-
occur. Grafts of nonpenile origin frequently will not have the
struction for stricture disease. Patency rates in excess of 90%
same elasticity as the penis, contributing to curvature.
are reported for anastomotic repairs in bulbar strictures (10).
In experienced hands erectile dysfunction as a result of an-
With regard to substitution repairs, tube grafts fare less well
terior or posterior urethroplasty is rare. Temporary (3 months
than onlay procedures, both of which are best applied to the
or less) impotence occurs in 53% of those who undergo anas-
more proximal portion of the anterior urethra. A discouraging
tomotic urethroplasty and in 33% of those who undergo
constant annual attrition rate of 5% per year has been reported
patch repair. H owever, permanent impotence is unusual: 5%
for substitution urethroplasty at follow-up of 10 years, although
and 0.9% , respectively. Further, Coursey et al. reported that
this is not these authors’ experience (9). For repair of pendulous
erectile dysfunction after anterior urethroplasty is no more
urethral strictures, flaps perform best in terms of patency and
common than in men who undergo circumcision (4). In a
avoidance of penile curvature. Buccal mucosal grafts show
prospective evaluation of the effect of bulbar urethroplasty on
promise and conceptually seem to be superior, but long-term
erectile function using International Index of Erectile Function
data are necessary to define their emerging role in urethral recon-
scores, surgery proved to have an insignificant effect (2).
struction. Certainly the most common cause for stricture recur-
These results can be attributed to judicious scar excision, min-
rence appears to be ongoing fibrosis in the adjacent unmanaged
imal use of electrocautery, and dissection away from the dor-
urethra, in particular that proximal to the repair.
sally based neurovascular structures.
References
1. Anema JG, M orey AF, M cAninch JW, et al. Complications related to the 8. M cCallum RW. The adult male urethra: normal anatomy, pathology and
high lithotomy position during urethral reconstruction. J Urol 2000; method of urethrography. R adiol Clin N orth A m 1979;17:227–244.
164:360–363. 9. M undy AR. The long-term results of skin inlay urethroplasty. Br J Urol
2. Anger JT, Sherman N D, Webster GD. The effect of bulbar urethroplasty on 1995;75:59–61.
erectile function. J Urol 2007;178:1009–1011. 10. Santucci RA, M ario LA, M cAninch JW. Anastomotic urethroplasty for
3. Barbagli G, Selli C, Tosto A, et al. Dorsal free graft urethroplasty. J Urol bulbar urethral stricture: analysis of 168 patients. J Urol 2002;167:
1996;155:123–126. 1715–1719.
4. Coursey JW, M orey AF, M cAninch JW, et al. Erectile function after ante- 11. Steenkamp JW, H eyns CF, deKock M LS. Internal urethrotomy versus dila-
rior urethroplasty. J Urol 2001;166:2273–2276. tion as treatment for male urethral strictures: a prospective, randomized
5. Guralnick M L, Webster GD. The augmented anastomotic urethroplasty: comparison. J Urol 1997;157:98–101.
indications and outcome in 29 patients. J Urol 2001;165:1496–1501. 12. Wright JL, Wessells H , N athens AB, et al. What is the most cost-effective
6. H eyns CF, Steenkamp JW, deDock M LS, et al. Treatment of male urethral treatment for 1 to 2 cm bulbar urethral strictures: societal approach using
strictures: is repeated dilation or internal urethrotomy useful? J Urol decision analysis. Urology 2006;67(5):889–893.
1998;160:356–358.
7. Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bul-
bar urethral stricture. J Urol 1999;161:815–818.
CHAPTER 36 ■ SURGERY FO R URETHRAL

TRAUMA INCLUDING URETHRAL DISRUPTIO N
JACK MCANINCH AND BRYAN B. VO ELZKE
A solid understanding of the etiology, evaluation, and man- cohort of patients will be cured by these temporizing mea-
agement of traumatic urethral injuries is dependent upon the sures; however, the majority will require an invasive surgical
location of urethral trauma. The urethra is divided into ante- repair 3 to 6 months after the initial injury. Early recognition
rior (pendulous and bulbar urethra) and posterior (membra- and diagnosis of urethral injuries are crucial to the successful
nous and prostatic urethra) divisions, which have specific management and prevention of long-term complications.
mechanisms of injury that will influence eventual therapy and This chapter will divide the diagnosis and management of
outcome. Immediate management of anterior and posterior urethral trauma into anterior and posterior injuries to better
urethral trauma predominantly involves temporizing solu- enable the reader to learn how to manage their unique pre-
tions to divert urine away from the urethral injury. A small sentations.
ANTERIO R URETHRAL INJ URIES Diag no sis

The anterior urethra extends distally from the membranous Anterior urethral injuries can present in an immediate or
urethra to the urethral meatus (Fig. 36.1). Contrary to the poste- delayed fashion. A careful history and physical examination
rior urethra, the anterior urethra is encompassed by the corpus should raise suspicion for anterior urethral injury. Straddle
spongiosum, the deep (Buck) fascia, and the superficial (dartos) injuries often present in a delayed fashion with obstructive
fascia along its entire length. The penoscrotal junction divides voiding symptoms and an idiopathic etiology. In a series of
the shorter, proximal bulbar urethra from the longer, distal pen- 78 patients with straddle injuries, 40% presented to the emer-
dulous urethra. The bulbospongiosus muscle ventrally covers gency department in an acute setting, versus 60% of patients
the bulbar urethra and terminates at the penoscrotal junction, who presented 6 months to 10 years after the original injury
prior to the origination of the distal pendulous urethra. The (3). H ematuria, difficulty voiding, penile sleeve hematoma (in-
pendulous urethra closely approximates the corpora cavernosa jury confined to the Buck fascia), and perineal “ butterfly”
during most of its length, with the lumen of the distal pendu- hematoma (injury penetration to the Buck fascia) are common
lous urethra dilating distally to form the fossa navicularis. presenting symptoms in the acute or delayed setting. In addi-
Blunt or penetrating injury can result in anterior urethral tion to a perineal “ butterfly” hematoma, penetration of the
trauma; however, blunt forces predominate along the entire Buck fascia can allow the spread of urine and/or blood to the
urethra. Etiologies include blunt compression or straddle in- scrotum (dartos fascia), anterior abdominal wall (Colles fas-
juries, penile fracture with concomitant urethral disruption, cia), and/or thighs (fascia lata).
constriction rings, iatrogenic trauma (e.g., after Foley All patients with a suspected anterior urethral injury should
catheterization or endoscopic urethral surgery), and penetrat- undergo a retrograde urethrogram prior to an attempt at ure-
ing trauma (e.g., stab or gunshot wounds). Compression of thral catheter placement. Ideally the patient should be placed
the bulbar urethra against the pubic bone (straddle injury) is obliquely at a 30- to 45-degree angle with the bottom leg
the most common anterior urethral injury and occurs after a flexed at 90 degrees and the top leg kept straight (Fig. 36.2). In
direct force to the perineum compresses the relatively immo- the acute setting, associated pelvic fracture may preclude this
bile bulbar urethra against the pubic bone. Additionally, position; therefore, a supine retrograde urethrogram should be
penile constriction rings can damage the anterior urethra sec- employed to answer the simple question of whether or not the
ondary to tissue ischemia. Foley catheterization or endoscopic urethral lumen has been disrupted. Flexible cystoscopy has
urethral surgery can damage the bulbar urethra, resulting in been advocated to aid the diagnosis of urethral trauma; how-
contusion or partial urethral disruption. The true extent of ever, we prefer radiographic imaging when possible.
iatrogenic injuries, along with trauma from constriction rings, The retrograde urethrogram should be performed with undi-
may not become evident until many years after the original luted water-soluble contrast medium [full-strength (60% ) ionic
event (1). Anterior urethra injuries are rarely associated with contrast medium]. A scout film provides initial information on
pelvic fractures but are seen in approximately 20% of penile patient position and the potential presence of a foreign body. A
fractures (2). The close relation of the corpora cavernosa to 12Fr Foley catheter is then placed into the fossa navicularis, and
the pendulous urethra contributes to this association. the balloon is inflated with 2 to 3 mL of sterile water to prevent
FIGURE 36.1 Anatomy of the anterior and posterior

urethra.
repair of all acute anterior urethra injuries is dependent upon

minimal associated inflammation; therefore, surgeons should
consider waiting for delayed, definitive repair when possible.

Alternative options to surgical repair are placement of a ure-
thral or suprapubic catheter to divert urine from the injured
area. Contusions to the anterior urethra should be managed
with a urethral catheter for approximately 2 to 3 weeks fol-
lowed by a retrograde urethrogram. The patient should be
counseled on the possibility of delayed development of a ure-
thral stricture at the site of contusion; however, stricture
development is uncommon.
Percutaneous suprapubic catheter placement should be
considered in patients with penetrating urethral trauma and
hemodynamic instability, multiple associated injuries, or a
long anterior urethra defect. Ultrasound guidance should be
considered in the setting of a nonpalpable bladder or a history
of prior abdominal surgery. If there is an associated pelvic
FIGURE 36.2 Proper positioning for retrograde urethrography. The
patient is placed obliquely at a 45-degree angle with the bottom leg fracture, urologists are urged to speak with orthopedic staff
flexed and the top leg straight. Slight traction on the penis during in- to ensure that future internal or external fixation hardware
jection of contrast helps avoid telescoping of the urethra and allows will not interfere with the planned suprapubic tube location.
more accurate characterization of the injury. If radiographic staging was precluded by the patient’s con-
comitant injuries, then a suprapubic cystogram and retrograde
urethrogram should be done at the earliest opportunity.
catheter dislodgment during the urethrogram. The penis is posi- Broad-spectrum antibiotics are essential to maintain the steril-
tioned laterally on a slight stretch to provide a more descriptive ity of extravasated urine or blood. A voiding cystogram is rec-
study, and 20 to 30 mL of contrast is then injected in a retro- ommended after 3 weeks of urinary diversion. We do not
grade fashion. Dynamic fluoroscopy is ideal; however, in the advocate blind urethral catheter placement in the presence of
setting of acute trauma in the emergency department, static ra- blood at the urethral meatus, pelvic fracture, or perineal
diographs will suffice. The entire anterior urethra can be visual- hematoma if hemodynamic instability precludes a retrograde
ized during a retrograde urethrogram; however, the posterior urethrogram; however, some would argue that one attempt at
urethra is typically excluded by reflex contraction of the exter- urethral catheter placement by an experienced physician or
nal sphincter. If a catheter is present at the time of evaluation, urologist is acceptable.
then a cystogram is recommended to confirm the catheter’s Partial urethral disruptions diagnosed by retrograde ure-
presence in the bladder. After documenting the correct location throgram may be managed via various algorithms. Urinary
of the urethral catheter, a pericatheter retrograde urethrogram diversion with formal repair after a minimum of 3 months to
can delineate possible urethral injury. allow resolution of inflammation and maturation of scar tis-
Anterior urethral injuries are classified into three groups sue is our preference. As mentioned above, one attempt at
based upon radiographic, clinical, or endoscopic findings. urethral catheter placement by experienced medical person-
Contusions appear normal on retrograde urethrogram or as nel is acceptable; however, the possibility of creating a com-
urethral elongation from compression by periurethral plete urethral disruption during this attempt should be
hematoma. Contusions are best appreciated by cystoscopy in considered. If urethral placement is unsuccessful, percuta-
the setting of a “ normal” retrograde urethrogram; however, neous suprapubic tube placement should be performed. The
we are not recommending cystoscopy for all “ normal” ure- preservation of urethral mucosa with partial disruptions
throgram studies with a suspicious clinical history. Partial dis- may be adequate for re-epithelialization and eventual luminal
ruptions appear as extravasated urine on retrograde recanalization; however, if successful, we would recommend
urethrogram with visualization of contrast in the urethra or periodic evaluation with pressure-flow urine studies and
bladder proximal to the injury. Com plete disruptions appear counseling patients regarding the possibility of future stricture
as total extravasation without visualization of contrast in the development.
more proximal urethra or bladder. Endoscopic alignment of the anterior urethra has been de-
scribed in a limited series of 16 men with partial and complete
bulbar straddle injuries (4). With this management, 14 out of
Ind icat io ns fo r Surg e ry 16 patients were successfully managed with endoscopic ure-
thral alignment alone. The 2 failures had a history of a failed
Primary surgical repair of acute anterior urethral injuries attempt at blind urethral catheter placement. The authors
should be avoided, with the exception of a stable patient with a stressed the importance of not advancing the cystoscope past
complete urethral disruption and an open or penetrating injury. the stricture during endoscopic alignment, but rather to only
We also recommend an attempt at anterior urethral repair in pass guide wires through the urethral disruption in an attempt
the setting of emergent surgery for penile fracture. Successful to prevent worsening the degree of urethral injury.

O pen surgical repair is primarily reserved for stable patients
after open or penetrating injury to the anterior urethra. The
patient is placed in either the supine position or lithotomy po-
sition and draped widely to allow exploration of potential
concomitant injuries to the penis, testes, perineum, and rec-
tum. Clean wounds need only minimal debridement followed
by urethral closure with interrupted or running 6-0 polygly-
conate monofilament (polydioxanone, M axon) sutures over a
16Fr catheter. Contaminated wounds require thorough irriga-
tion and debridement of devitalized tissues to ensure reap-
proximation of healthy tissue.
With open or penetrating bulbar urethra injuries, the pa-
tient is placed in the high lithotomy position and a vertical
perineal incision is performed along the raphe. As expected,
only stable patients without injury precluding the high litho-
tomy position should be offered acute surgical intervention.
The urethra is exposed after division of Colles fascia and the
bulbospongiosus muscle. As with elective bulbar urethra stric-
ture surgery, anastomotic urethroplasty should only be con-
sidered for defects 20 mm. Surgeons should avoid acute
repair of bulbar urethra defects longer than 20 mm as more
complex intervention with grafts of flaps will be required. The
most important tenet allowing successful outcome is a ten-
sion-free anastomosis; therefore, mobilization of the distal
urethra is an important step to ensure adequate urethral
length. O nce adequate length is achieved, the urethral ends are
spatulated (Fig. 36.3). The anastomosis is performed with in-
terrupted 5-0 and 6-0 polyglyconate monofilament suture to FIGURE 36.4 Repair of bulbar urethral injuries. Anastomosis is
create a tension-free, watertight closure. The dorsal surface is carried out with a single-layer dorsal closure and a two-layer ventral
closed in one layer with 5-0 interrupted polyglyconate closure using interrupted 5-0 or 6-0 M axon sutures.
monofilament incorporating the urethral mucosa and spon-
giosal adventitia. Since the ventral bulbar urethra is vascular-
the added vascularity from the spongy urethra will provide
ized by the spongy urethra, we advocate ventral closure in
enhanced healing of the anastomosis after two-layer closure.
two layers with interrupted 6-0 polyglyconate monofilament
We strongly recommend that a first-stage marsupialization of
suture (Fig. 36.4). We make no attempt to control bleeding
healthy proximal urethra be considered if tension-free closure
from the spongy urethra during closure, as we theorize that
cannot be achieved or if there is significant wound inflamma-
tion or contamination.
Penile urethral injuries are best exposed via a subcoronal
circumferential incision. Contrary to bulbar urethral injury,
anastomotic repair should not be considered for defects
15 mm, as the risk of penile chordee is higher with penile
anastomotic repairs. In prior editions of this textbook, we have
advocated utilization of a 16Fr silicone Foley catheter; however,
we now use regular latex catheters, if possible. Suppressive an-
tibiotics are given while the catheter is in place to maintain
urine sterility, with a voiding cystogram performed after 2 to
3 weeks. If extravasation is noted, we gently replace the
catheter for an additional period of time with repeat imaging at
the time of urethral catheter removal.
O ut co me s
Co mp licat io ns
The major complications relating to anterior urethral trauma
include urethral stricture formation and infection. If untreated,
FIGURE 36.3 Repair of bulbar urethral injuries. The urethra is mobi- persistent extravasation of infected urine or blood may lead to
lized and spatulated in preparation for a tension-free end-to-end anas- urethral abscess, urethrocutaneous fistula, or urethral divertic-
tomosis. ula. Prolonged urine extravasation into the corpus spongiosum
can also lead to added spongiofibrosis, resulting in a longer urethra include penetrating injuries and iatrogenic injuries sec-
urethral stricture. Consequently, a longer anterior urethral ondary to endoscopic or open prostate surgery.
stricture translates to more complex management with a buc- The clinical and surgical appearance of each form of poste-
cal mucosa graft or fasciocutaneous flap. rior urethral injury will differ. Endoscopic or open prostate
With early urine diversion, a percentage of anterior ure- surgery is associated with continuity strictures and preservation
thral strictures will never progress to functional significance; of the distal external urinary sphincter. As such, these injuries
however, of those that do, early diversion can limit stricture have been termed “ sphincter stenoses” (bladder neck sphinc-
length to allow a wider array of future options. Incontinence ters). In contradistinction, pelvic fractures are associated with
and impotence, although common in posterior urethral in- urethral disruptions to the membranous urethra. These injuries
juries, are uncommon in anterior urethral injuries. Stricture have been termed “pelvic fracture urethral disruption defects”
recurrence after formal anastomotic urethroplasty is most (PFUDDs). Interestingly, a recent report has found that 7 of 10
common in the first 12 months. Stricture recurrence after ure- patients examined at autopsy had urethral disruption after
throplasty is generally short and can be successfully treated in pelvic fracture distal to the external urinary sphincter, disputing
one session with internal urethrotomy. the historical view that these injuries occur at the interface of
the fixed prostatic apex and the less supported membranous
Re sult s urethra (7). Additionally, urodynamic studies have demon-
Anastomotic urethroplasty can be successfully performed in a strated a functional rhabdosphincter at the prostatomembra-
high percentage of patients who sustain a bulbar urethra nous region in many patients after anastomotic posterior
(straddle) injury requiring surgery. The procedure has an over- urethroplasty for PFUDD (5).
all success rate of approximately 95% when performed in a
delayed setting (3). As mentioned previously, patients sustain-
ing open or penetrating injuries associated with minimal in- Diag no sis
flammation are the best candidates for acute repair; otherwise,
urine diversion is recommended with formal repair at a later This section will primarily focus on PFUDD injuries, as these
date. injuries are the most common presentations in the acute
trauma setting. Given the close association of more serious
concomitant injuries with PFUDD, the first goal is resuscita-
PO STERIO R URETHRAL INJ URIES tion of the patient. Suspicious findings after PFUDD mirror
those of anterior urethral injuries, namely, hematuria, blood
The posterior urethra is shorter than the anterior urethra and at the meatus, perineal hematoma, and difficulty voiding.
consists of the membranous and prostatic urethra (Fig. 36.1). Additionally, a high-riding prostate on digital rectal exam
The more proximal prostatic urethra extends from the bladder and specific pelvic fractures are linked with PFUDD. The
neck to the apex of the prostate and is secured to the pubic prostate can appear elevated in position on digital rectal exam
bone by the paired puboprostatic ligaments. During cys- due to displacement from a pelvic hematoma and/or digital
toscopy, the verumontanum marks the most distal aspect of confirmation of the prostate may be indistinguishable from
the prostatic urethra. The proximal urethral sphincter is pre- the pelvic hematoma. Regarding pelvic fractures, displacement
sent within the prostatic urethra and is an extension of of the inferomedial pubic bone and symphysis pubica diasta-
smooth muscle fibers of the trigone and prostatic urethra sis are independently associated with urethral injury (8).
cephalad to the verumontanum. Conversely, the distal ure- Retrograde urethrogram should be performed on all
thral sphincter encompasses smooth muscle fibers caudad to patients suspected of having PFUDD before any attempt at ure-
the verumontanum, including the rhabdosphincter (slow- thral catheter placement (Fig. 36.5). If normal, the catheter
twitch skeletal muscle fibers) (5). In the absence of a func- should be gently advanced into the bladder and a formal
tional distal urethral sphincter, the proximal urethral cystogram should be obtained to assess for bladder perfora-
sphincter can maintain urinary continence in select patients; tion. The technique for retrograde urethrogram was discussed
however, the bladder must be compliant and free from peri- in the section on anterior urethra injuries. A formal cystogram
odic elevations of detrusor pressure (e.g., overactive bladder). can be performed in the emergency department or radiology
The membranous urethra is the least supported portion of the suite. Three radiographic views should be obtained, including
urethra, and injury to the membranous urethra is not uncom- an anterior-posterior scout film, a full-bladder anterior poste-
mon given its location between two relatively fixed points rior film, and a drainage film. False-negative results are
(prostate and bulbar urethra). Since the distal urethral sphinc- strongly correlated with inadequate filling; therefore, passive
ter is located in the membranous urethra, shear injuries lead- filling to discomfort or 350 mL of contrast is recommended.
ing to partial or complete membranous urethral disruption O ther studies to further delineate posterior urethral injuries in-
can result in distal urethral sphincter damage. clude flexible cystoscopy; however, we caution against advanc-
Posterior urethral trauma is almost always associated with ing the cystoscope past the site of injury for fear of worsening
pelvic fracture; conversely, only 10% to 15% of pelvic frac- the injury. Lastly, in a nonacute setting M RI can be useful to
tures are associated with urethral injury. Furthermore, bladder provide more descriptive analysis of complex PFUDD.
injury has also been diagnosed in 10% to 20% of patients Posterior urethral injuries secondary to blunt trauma have
with pelvic fracture and urethral injury (6). Since the blunt historically been classified based upon the Colapinto and
forces required to generate a pelvic fracture are significant, the M cCallum system (9). A recent modification maintains the
associated urethral injuries are highly correlated with serious original three classes of injury; however, this revised system also
injuries (e.g., intra-abdominal and vascular injuries to the includes posterior urethral injuries that extend to the bladder
pelvic vasculature). O ther sources of injury to the posterior neck and blunt anterior urethral injuries (Table 36.1) (10).
A B
FIGURE 36.5 Posterior urethral injuries. A: Type I: stretched urethra

without rupture. N ote the displaced and compressed bladder and frac-
tures of the right symphysis and superior and inferior rami. B: Type II:
complete rupture of the membranous urethra with intact urogenital
diaphragm. N ote the limited extravasation and venous filling. C: Type III:
N ote the pattern of extravasation when the urogenital diaphragm is dis-
rupted, as compared with type II. (From Dixon CM . Diagnosis and acute
management of posterior urethral disruptions. In: M cAninch JW, ed.
Traum atic and reconstructive urology. Philadelphia: WB Saunders,
C 1996:347–355, with permission.)
TA B LE 3 6 . 1
CLASSIFICATION OF BLUN T URETHRAL IN JURIES (9)
Class Description
I Posterior urethra stretched but intact

II Tear of the prostatomembranous urethra above the urogenital diaphragm
III Partial or complete tear of both the anterior and posterior urethra with disruption of the urogenital diaphragm
IV Bladder injury extending into the urethra
IVa Injury of the bladder base with periurethral extravasation simulating posterior urethral injury
V Partial or complete pure anterior urethral injury
Ind icat io ns fo r Surg e ry primary alignment is a lower stricture rate of 56% versus the
97% stricture rate seen with suprapubic catheter placement
Controversy and confusion exist regarding whether primary (11). In addition, urethral strictures after endoscopic align-
alignment or suprapubic diversion is better for acute man- ment can result in shorter stricture length and the possibility
agement of PFUDD. There is no correct answer for this ques- of a less invasive option, such as internal urethrotomy in-
tion, despite what has been written in the literature regarding stead of formal perineal urethroplasty. Despite claims that
the impact of each on eventual incontinence, impotence, and periodic office urethral dilations are trivial to the patient, we
urethral stricture rates. Since each procedure is governed by would disagree with this assertion and counsel the patient
different definitions for successful outcome, neither should for posterior urethroplasty to definitively treat the persistent
be considered the best therapy option. The obvious benefit of stricture.
Impotence and incontinence outcomes in the literature can

be difficult to compare, with multiple reports claiming differ-
ent results after endoscopic alignment and suprapubic tube
with delayed urethroplasty. In experienced centers, inconti-
nence and impotence rates after endoscopic alignment are 4%
and 36% , respectively (11). A suprapubic tube with delayed
urethroplasty in the same study found minimal improvement
in incontinence (2.7% ) but a more significant reduction in im-
potence among those with erections preinjury (18% versus
36% endoscopic alignment).
Given the above findings, we would agree that endoscopic
alignment and suprapubic tube placement are acceptable op-
tions for management of PFUDD; however, in the setting of a
severely injured patient, we favor percutaneous suprapubic
catheter placement. A review of our experience with posterior
urethral disruption after pelvic trauma shows that the average
stricture length was 2.08 cm during posterior urethroplasty
and the delayed posterior urethroplasty was predominantly
amenable to one-stage repair (12). We believe this average
length of stricture is acceptable, especially given that approxi- FIGURE 36.6 A large-caliber Foley catheter is placed in the bladder
dome after inspection for concomitant bladder laceration. With the
mately 33% of the patients in our series had a prior failed at- catheter placed through the superior end of the midline incision,
tempt at treatment (cut-to-the-light approach, urethral bladder neck identification is facilitated at the time of subsequent
dilation, internal urethrotomy, and failed urethroplasty). reconstruction.
Alt e rnat ive The rap y a supine approach will suffice. An infraumbilical incision is
made to allow access to the prevesical space anterior to the
Given the association of PFUDD with bladder injury, we rec- bladder dome. After placing stay sutures around the anticipated
ommend open suprapubic cystostomy to allow repair of asso- cystostomy site, the bladder is opened vertically at the bladder
ciated bladder injuries when present. If the patient is too dome, which will provide ample exposure to examine the blad-
unstable to allow operative exploration, then percutaneous der and urethra for injury. Strict avoidance of dissection into the
suprapubic placement with or without ultrasound guidance is space of Retzius and lateral perivesical space is essential to pre-
appropriate; however, percutaneous placement may be diffi- vent pelvic hemorrhage and contamination. Therefore, in the
cult if there is associated bladder injury. Therefore, we would presence of an associated bladder neck or bladder base injury,
advocate open suprapubic catheter placement after the patient intravescial repair is recommended. An additional benefit of
is stabilized. M ost bladder injuries associated with PFUDD bladder neck repair is that it prevents the laceration from
are extraperitoneal and heal spontaneously with catheter extending into the external urethra sphincter complex.
drainage; however, if surgical management of pelvic fractures Bladder lacerations, if present, should be repaired in two
is planned, we recommend operative repair of the associated layers with a deeper 2-0 polyglactin (Vicyl, Dexon) suture in-
bladder injury to reduce complication rates. corporating the detrusor muscle and a superficial 4-0 chromic
Primary suture repair of PFUDD in the acute setting is as- suture incorporating the bladder mucosa. O pen suprapubic
sociated with elevated impotence and incontinence rates. catheter placement is performed in the bladder dome, and the
Primary suture repair of PFUDD is not recommended for this bladder cystostomy site is fixed in place with a pursestring su-
reason, and also because of the more important risk of hemor- ture (Fig. 36.6). We do not favor M alecot catheters, as they
rhage and contamination associated with evacuation of the have a higher propensity to be accidentally dislodged. Instead,
retropubic hematoma to gain access to the injury site. The we utilize a 20Fr to 24Fr Foley catheter with an inflation
only clinical scenario in which we favor acute repair of balloon. The vesicostomy is closed in two layers with 2-0
PFUDD is in the setting of a class IV injury (Table 36.1). This polyglactin suture. Regarding associated pelvic fractures, we
is because of the risk of bladder neck stenosis from urine ex- recommend communicating with the orthopedic service to
travasation at the bladder neck. We would also recommend ensure that the suprapubic tube skin site does not interfere
repair of rectal and vaginal lacerations in this clinical scenario. with future operative endeavors. We do not use abdominal
Lastly, endoscopic alignment should be considered in the set- drains unless an associated bowel injury is present.
ting of a stable patient with a stable pelvis. Furthermore, we
advocate utilization of fluoroscopy during cystoscopy to aid
alignment in the safest possible manner. O ut co me s
Co mp licat io ns
Surg ical Te chniq ue Complications after treatment of posterior urethral trauma
are directly related to the severity of injury. Acute complica-
For open suprapubic catheter placement, the patient is placed in tions include pelvic hemorrhage and infection or abscess of
the low lithotomy position to allow simultaneous access to the the pelvic hematoma, which can occur after ill-advised retro-
rectum if needed. If orthopedic injuries preclude this positioning, pubic exploration or attempts at pelvic hematoma evacuation.
Delayed complications include incontinence, impotence, and Re sult s

urethral stricture formation. Regarding impotence, recent At our institution, delayed urethroplasty after suprapubic tube
studies have demonstrated that sexual dysfunction is com- is the preferred management algorithm for PFUDD. Posterior
monly associated with pelvic fracture, even in the absence of urethroplasty has been successful for resolution of stricture in
urethral injury (13). Delayed return of potency has been 86% of patients; however, definition of success is improved to
reported after definitive urethroplasty; however, this would 93% if an additional internal urethrotomy is utilized for stric-
depend upon the severity of the initial injury (14). N early all ture recurrence (12). Endoscopic alignment is also an appro-
patients remain continent if their bladder neck continence priate management strategy in the acute setting; however,
mechanism is undamaged; however, they should be counseled urologists should seriously consider formal urethroplasty (or
on the potential negative impact of future transurethral referral to a tertiary care center) if internal urethrotomy or
prostate surgery. urethral dilation is unsuccessful.
References
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and outcomes in 78 patients. J Urol 2004;171(2, Pt 1):722–725. 10. Goldman SM , Sandler CM , Corriere JN Jr., et al. Blunt urethral trauma: a
4. Ying-H ao S, Chuan-Liang X, Xu G, et al. Urethroscopic realignment of unified, anatomical mechanical classification. J Urol 1997;157(1):85–89.
ruptured bulbar urethra. J Urol 2000;164(5):1543–1545. 11. Koraitim M M . Pelvic fracture urethral injuries: evaluation of various meth-
5. Whitson JM , M cAninch JW, Tanagho EA, et al. M echanism of continence ods of management. J Urol 1996;156(4):1288–1291.
after repair of posterior urethral disruption: evidence of rhabdosphincter 12. Cooperberg M R, M cAninch JW, Alsikafi N F, et al. Urethral reconstruction
activity. J Urol 2008;179(3):1035–1039. for traumatic posterior urethral disruption: outcomes of a 25-year experi-
6. Corriere JN Jr., Sandler CM . M echanisms of injury, patterns of extravasa- ence. J Urol 2007;178(5):2006–2010; discussion 10.
tion and management of extraperitoneal bladder rupture due to blunt 13. M etze M , Tiemann AH , Josten C. M ale sexual dysfunction after pelvic
trauma. J Urol 1988;139(1):43–44. fracture. J Traum a 2007;63(2):394–401.
7. M ouraviev VB, Santucci RA. Cadaveric anatomy of pelvic fracture urethral 14. M orey AF, M cAninch JW. Reconstruction of posterior urethral disruption
distraction injury: most injuries are distal to the external urinary sphincter. injuries: outcome analysis in 82 patients. J Urol 1997;157(2):506–510.
J Urol 2005;173(3):869–872.
CHAPTER 37 ■ CARCINO MA O F THE

FEMALE URETHRA
PETER L. STEINBERG AND WILLIAM BIHRLE III
Carcinoma of the female urethra is a histologically heteroge- Primary urethral carcinoma is extremely uncommon, ac-
neous disease; while most cases are squamous cell (55% ) in counting for 1% of adult malignancies. Urologic orthodoxy
origin, transitional cell carcinoma (TCC) and adenocarcinoma holds that urethral carcinoma is the only genitourinary malig-
equally account for between 15% and 20% of new cases. nancy with a higher incidence in women than in men.
M elanoma and clear cell carcinoma represent rare subsets of H owever, findings from the most recent SEER population
disease. Disease developing in urethral diverticuli is, most database suggest that, with an incidence of 1 case per
commonly, adenocarcinoma and often presents at a higher 100,000 women annually, urethral cancer appears to be less
stage than the squamous carcinomas. common in women (1,2). With the exception of adenocarci-
Disease progression occurs by way of local invasion into the noma in the African American population, for which the inci-
muscularis of the urethra followed by extension to local struc- dence in women remains elevated, there is a higher rate of all
tures, including the anterior vaginal wall, vulva, and bladder three subtypes of urethral cancer in men relative to women.
neck. Lymphatic spread is not uncommon; distal urethral dis- Excepting adenocarcinomas, urethral carcinoma is rare in
ease migrates into the superficial and deep inguinal nodes, women under the ago of 60; the incidence of adenocarcinoma
while more proximally based cancers spread preferentially into begins to rise about ten years earlier. Urethral cancer is dis-
the pelvic lymph chain (iliac, obturator, and presacral). tinctly uncommon in the premenopausal population. Its inci-
M etastatic disease, while uncommon at presentation, occurs dence peaks between ages 75 and 84 for TCC and squamous
via hematogenous spread to the liver, lung, bone, and brain. cancer, whereas the incidence of adenocarcinoma appears to
Chap t e r 37: Carcinoma of the Fe male Ure thra 253
TA B LE 3 7 . 1
STAGIN G OF FEMALE URETHRAL CARCIN OMA
Grabstalda TN M b
Tx Primary Tumor Cannot be Assessed

T0 N o Evidence of Primary Tumor
Stage 0 Tis Carcinoma In Situ (CIS)
Ta N oninvasive Papillary, Polypoid, or Verrucous
Stage A T1 Invades Lamina Propria
Stage B T2 Invades Periurethral M uscularis
Stage C1 T3 Invades Anterior Vaginal M uscle or Bladder N eck
Stage C2 Invades Anterior Vaginal M ucosa
Stage C3 T4 Invades adjacent Structures Including Clitoris, Labia, or Pubis
Stage D1 N1 Regional M etastasis to Inguinal Lymph N odes (TN M Single N ode 2 cm)
Stage D2 N2 Regional Metastasis to Pelvic Lymph Nodes (TNM Single Node 2 cm but 5 cm or Multiple 5 cm)
Stage D3 N3 M etastasis to Lymph N odes Above the Aortic Bifurcation (TN M cm N ode)
Stage D4 M1 Distant M etastasis (With Any Primary Tumor)
aFrom Grabstald H . Tumors of the urethra in men and women. Cancer 1973;32:1236, with permission.
b M odifiedfrom Beahrs O H , et al, eds. M anual for staging of cancer, 3rd ed. Philadelphia: JB Lippincott Co, 1988:120, with permission.
remain stable throughout. For reasons that remain conjec- Staging is based upon the tumor-nodes-metastasis (TN M )
tural, the incidence of female urethral carcinoma has dropped system, although many practitioners continue to use the sys-
by 50% over the past 30 years. tem developed by Grabstald noted in Table 37.1.
DIAGNO SIS INDICATIO NS FO R SURGERY

N early all women are symptomatic at presentation (3–5). Given the rarity of this disease, there are no large-volume,
Urinary symptoms, specifically hematuria, splayed stream, randomized data to guide management. Treated disease has a
and urinary retention, indicate the presence of an obstructing 5-year survival of roughly 50% (3,4); left untreated, almost
lesion. M any patients have long-standing symptoms and often all urethral carcinomas will progress, with a mean survival
have been diagnosed with and treated for a myriad of benign of 1 year. The presence of metastatic disease or deep pelvic
conditions, including urethral diverticuli, caruncles, and ure- lymphadenopathy represents a strong contraindication to
thral stenosis. Any process that does not respond to conserva- major extirpative surgery. Disease localized to the urethra
tive measures should be investigated to rule out a urethral may be treated in a variety of ways depending on the
malignancy. Physical examination may reveal a palpable mass anatomical location and local stage. Generally, low-stage,
at the meatus, induration of the urethra, a mass along the an- distal cancers carry a more favorable prognosis than higher-
terior vaginal wall, or a mass that ball valves and protrudes stage and more proximally located lesions and may be
from the urethral meatus. Ulceration of the meatus or the amenable to less radical extirpation. There appears to be a
vaginal wall can also occur. The diagnosis of urethral cancer limited role for topical ablative therapy in women presenting
within a urethral diverticulum is a rare occurrence (5). with superficial disease. Surgical therapy is suggested in
Endoscopy of the urethra and bladder neck and a well- women who are free from metastasis and will tolerate an
performed bimanual pelvic examination are essential to tu- operative intervention.
mor assessment. Examination under anesthesia, performed at
the time of tumor biopsy, is essential in confirming the diag-
nosis and aiding in the assessment of tumor resectability. ALTERNATIVE THERAPY
Evaluation of the proximal urethra and bladder neck for
disease extension guides the recommendation for bladder- External beam radiation, brachytherapy, and local ablative
preserving techniques. Either a CT scan of the abdomen and therapy either alone or in combination have been reported in
pelvis with and without intravenous contrast or an enhanced the treatment of both distal and proximally located tumors.
M RI of the pelvis can help assess local extension of the tumor Success is better with distal tumors; several small series report
to the vagina or bladder, as well as the status of the pelvic 5-year survival rates of 50% to 70% (5). Unfortunately, the
lymph nodes. A chest X-ray is used to complete staging stud- treatment of more proximal tumors is associated with a 5-year
ies, and a CT of the chest may be needed in the event an survival rate of 30% to 50% (5). As in the case with surgery,
equivocal lesion is noted. Liver function tests should also no randomized data exist to guide treatment.
be assessed. Suspiciously enlarged pelvic lymph nodes may be The role of chemotherapy in a neoadjuvant or adjuvant
biopsied via CT guidance or removed via laparoscopic node setting is also lacking in randomized data. Centers that see a
dissection. larger volume of this disease often utilize chemotherapy in a
neoadjuvant or adjuvant fashion, though specific management vagina to aid in the posterior urethral dissection. A combina-
strategies cannot be suggested based on the existing literature. tion of electrocautery and sharp dissection is utilized to free
There is case report evidence only that combined chemother- the urethra circumferentially, taking care not to enter the ure-
apy and radiation therapy can offer long-term control of female thra and using the Foley catheter to guide the dissection. The
urethral cancer. Using a combination of 5-fluorouracil, mito- anterior vaginal wall is also resected with a 1-cm margin of
mycin C, and/or cisplatin, as well as 30 to 60 Gy or radiation, healthy tissue. A margin of 1 cm of normal tissue from the
there are reports of survival exceeding 5 years in the literature. proximal margin of the tumor is desirable from an oncological
It is emphasized, however, that these data have been accrued standpoint. When healthy tissue has been encountered proxi-
over a period of 20 years and consist of nine case reports (6). mally, stay sutures of 3-0 Vicryl are placed into the urethra at
The failure of single-arm therapies to improve long-term out- 3 and 9 o’clock to prevent proximal migration, the specimen
comes has led clinicians to consider more flexible, multimodal is amputated, and the margin is assessed with a frozen section.
approaches to the treatment of urethral carcinoma. H emostasis is achieved with cautery, and the wound is copi-
ously irrigated with normal saline. The remaining urethral
stump is approximated to the edges of the vaginal incision with
SURGICAL TECHNIQ UE interrupted 3-0 Vicryl or other absorbable suture. The vaginal
wall is closed with interrupted 3-0 Vicryl sutures in two layers.
This chapter considers the operative techniques for both distal A vaginal pack with estrogen crème is placed, as is a new small-
and proximal lesions of squamous and glandular origin— caliber Foley catheter. The vaginal pack is removed on postop-
diseases that originate in the urethra—and bladder-sparing erative day 1, and the Foley catheter is removed 7 days after
approaches for large distal lesions. M anagement using mini- surgery. The patient is placed on a general diet the night of
mally invasive approaches such as neodymium or holmium: surgery and should ambulate as soon as she has recovered from
YAG lasers will not be described, as there is a paucity of data anesthesia. DVT prophylaxis is also maintained postopera-
in the literature to support their use. The specific management tively, and antibiotics are stopped within 24 hours of surgery.
of the female urethra in the case of TCC will not be discussed
because this represents pathology of the lower urinary tract
and should be considered separately. Dist al Tumo rs, Blad d e r-sp aring Ap p ro ach
Bladder sparing is feasible for large distal urethral tumors, in-
Dist al Ure t hral Tumo rs cluding T3 disease, not involving the bladder neck. Although
reports exist of bladder sparing for more aggressive tumors in-
Tumors involving the distal third of the urethra, and especially volving the genitalia, the high risk of local recurrence makes
those of the urethral meatus, are amenable to a distal ure- exenterative surgery the standard of care (4). Following resec-
threctomy. Preoperative preparation should include full stag- tion of the diseased urethra, the bladder neck is closed and one
ing studies, a detailed history and physical examination with of a variety of continent urinary diversions is performed.
particular attention given to a history of bleeding or anesthetic Currently there are no data to suggest that pelvic or inguinal
complications, and a urine culture, with any infection managed lymph node sampling improves survival, though pelvic node
before surgery. dissection is useful for staging purposes (4).
TED hose and sequential compression devices are manda- The presurgical regimen is identical to that described for
tory for deep venous thrombosis (DVT) prophylaxis, and the surgery of small distal disease, with the addition of a bowel
use of 5,000 U of subcutaneous heparin or 40 mg of subcuta- preparation and clear liquids the day before surgery. O nce in
neous enoxaparin is prudent in a patient with any pelvic the operating room, the patient is placed in the low lithotomy
malignancy prior to surgery. Prophylactic antibiotics should position in Allen stirrups. Both the abdomen and the genitals
be administered within the hour prior to the first incision, and are prepared into the field, and a weighted vaginal speculum is
a first-generation cephalosporin along with gram-negative placed. Cystoscopy can be performed to place bilateral ureteral
coverage from an aminoglycoside should be adequate; catheters if desired. To assess for tumor resectability and lymph
patients allergic to penicillin can receive either vancomycin or node status, the procedure is begun through a midline or
clindamycin as an alternative gram-positive prophylactic. Pfannenstiel trans- or extraperitoneal incision. Surgeons with
The patient should be placed in the lithotomy position, advanced laparoscopic skill may choose to perform the lymph
with attention paid to the padding of pressure points on the node dissection and mobilization of the bladder neck and prox-
legs; the patient’s perineum should sit at the edge of the oper- imal urethra in a laparoscopic fashion. The lymph nodes are
ating room table. After preparation and draping, a weighted sent for frozen section analysis if it is the intent of the surgeon
vaginal speculum is placed and the labia are retracted with a to alter the surgical plan in the face of lymphatic spread. There
1-0 silk suture that is then secured to the drape. The use of a are insufficient data in the literature to either support or refute
versatile perineal retraction system, that is, the Lone Star or abandoning resection in the face of positive pelvic lymph nodes.
Jordan-Bookwalter devices, facilitates exposure of the vaginal The endopelvic fascia is incised, allowing mobilization of
introitus. Placement of a Foley catheter aids in the palpation the lateral aspects of the bladder with electrocautery. Urethral
and localization of the urethra and tumor during dissection attachments to the pelvic floor are taken down with cautery
(Fig. 37.1). and between 2-0 or 3-0 silk ties as needed. The uterus and
O nce a circumcising incision is made around the urethral ovaries are preserved with this approach. O nce the bladder
meatus, it may be secured with an Allis clamp or silk tie, al- neck is mobilized, the vaginal portion of the procedure is
lowing for retraction and manipulation of the urethra during performed. If sufficient assistance is available, this can be per-
its dissection. An incision is made in the epithelium of the formed as a two-team simultaneous procedure.
Chap t e r 37: Carcinoma of the Fe male Ure thra 255
FIGURE 37.1 Technique of distal urethrectomy.
To excise the urethra, distal bladder neck, and a margin of thra, bladder neck, and vaginal wall are then removed en bloc.
anterior vaginal wall, again the meatus is circumscribed with a A frozen section is taken of the bladder neck margin, and if
scalpel, and then cautery and sharp dissection are used to take positive anterior exenteration is performed (Fig. 37.2).
down the periurethral tissues proximal to the palpable tumor. With a negative bladder neck margin, the vaginal defect is
The pubourethral ligaments are identified with blunt and closed in layers using a combination of 2-0 or 3-0 Vicryl or
sharp dissection and divided with cautery. other absorbable suture on the vaginal mucosa. Large partial
Through the abdominal incision, the bladder neck is opened vaginal wall defects resulting from this resection may require
anteriorly with electrocautery; the ureteral orifices are identi- coverage with a regional flap. A pudendal-based medial thigh
fied and cannulated with stents if these were not placed at the flap or rectus flap may be necessary to close such a defect, and
time of cystoscopy. With care taken to preserve the ureteral ori- given the propensity toward multimodality therapy in this dis-
fices, the bladder neck is divided distal to the orifices and the ease, consultation with a plastic surgeon is likely to yield the
incision is carried through the anterior vaginal wall. The ure- best outcome (7).
FIGURE 37.2 Technique of urethrectomy and

bladder preservation by excision of the tumor at
the level of the bladder neck, with subsequent
bladder neck closure.
Urinary diversion is then performed, as is bladder neck

closure. Postoperatively, the patient is managed with a 14Fr O UTCO MES
catheter running through the stoma, a 20Fr to 22Fr suprapubic
tube, a vaginal pack, and a pelvic drain. The vaginal pack is re- Data from multiple sources confirm that distal lesions have a
moved 24 hours after surgery. The diversion is irrigated with better prognosis than proximal disease or panurethral disease.
normal saline every 8 hours beginning on postoperative day 1. In a representative series, Dalbagni et al. (3) demonstrated a
Nasogastric suction is not needed postoperatively, and the diet 71% survival in distal lesions, 48% in proximal lesions, and
can be slowly advanced, beginning with sips of clear liquids on 24% in lesions involving the entire urethra. Local recurrence
postoperative day 1 or 2, followed by clear liquids ad lib, and fi- after partial urethrectomy occurs roughly 20% of the time,
nally a general diet prior to discharge (8). Return of flatus is not though this number is based on a series of 19 patients (4).
needed to advance the diet, though intake should be restricted if Pelvic lymph node disease is associated with a poor prognosis,
nausea or vomiting occur. The patient should ambulate as soon with only 23% disease-specific survival at 5 years (4). Disease-
as she has recovered from anesthesia. DVT prophylaxis is also specific survival at 5 and 10 years is roughly 50% , with the
maintained postoperatively, and antibiotics are stopped within best prognosis in low-grade, low-stage distal lesions without
24 hours of surgery. lymph node metastases (4). Roughly one-third of patients with
stage T3 or T4 disease remain recurrence-free. The overall re-
currence rate is roughly 50% , and after recurrence 71% of
Pro ximal Ure t hral Tumo rs women are dead within 5 years (4).
For patients who have large tumors or tumors involving the

bladder base, bladder-preserving approaches are not feasible CO MPLICATIO NS
and anterior pelvic exenteration is indicated. A stoma site on
the abdomen is selected preoperatively for urinary diversion. Distal urethrectomy is associated with urinary incontinence in
Preoperative preparation is identical to that for distal tumors, nearly 40% of patients (4), a finding drawn from a number of
and again a bowel preparation and clear liquids are utilized small series. Both worsening stress and urge incontinence are
the day before surgery. reported in this series, as is a small rate of urinary retention.
Radical cystourethrectomy, pelvic lymph node dissection, M ore proximal resections and pelvic exenteration are associ-
and urinary diversion are then performed in the standard fash- ated with risks of wound infection, wound dehiscence, DVT,
ion (see Chapters 19, 81, 83). For larger lesions, wide excision metabolic complications from urinary diversion, and bowel-
of the vulva, pelvic floor, and pubic rami may also be indi- related complications. We would direct the reader to the spe-
cated. The assistance of an orthpedic and plastic surgeon is in- cific chapters dealing with cystectomy and urinary diversion
valuable in these circumstances. Pelvic floor reconstruction for a better treatment of this topic.
with either rectus or gracilis flap will be necessary, and thus
planning with a plastic surgeon is mandatory preoperatively.
References
1. Swartz M A, Porter M P, Lin DW, et al. Incidence of primary urethral carci- 6. H ara I, H ikosaka S, Eto H , et al. Successful treatment for squamous cell
noma in the United States. Urology 2006;68:1164–1168. carcinoma of the female urethra with combined radio- and chemotherapy.
2. http://apps.nccd.cdc.gov/uscs/Table.aspx?Group=TableAll& Year=2003 Int J Urol 2004;11:678–682.
& Display=n, accessed December 2, 2007. 7. Pusic AL, M ehrara BJ. Vaginal reconstruction: an algorithm approach
3. Dalbagni G, Z hang Z F, Lacombe L, et al. Female urethral carcinoma: an to defect classification and flap reconstruction. J Surg O ncol 2006;94:
analysis of treatment outcome and a plea for a standardized management 515–521.
strategy. Br J Urol 1998;82:835–841. 8. Pruthi RS, Chun J, Richman M . Reducing time to oral diet and hospital
4. Z incke H , Webb M J, Bass SE, et al. Surgical treatment for local control of discharge in patients undergoing radical cystectomy using a perioperative
female urethral carcinoma. Urol O ncol 2004;22:404–409. care plan. Urology 2003;62:661–665; discussion 665–666.
5. Campbell M F, Wein AJ, Kavoussi LR, eds. Cam pbell-W alsh urology, 9th
ed. Philadelphia: Saunders Elsevier, 2007:1018–1023.
CHAPTER 38 ■ CARCINO MA O F THE MALE
URETHRA
PETER L. STEINBERG AND WILLIAM BIHRLE III
Carcinoma of the male urethra is a heterogeneous disease, en- anatomical segments (Fig. 38.1). The bulbomembranous ure-
compassing transitional cell carcinoma (TCC), squamous car- thra is the most common site of disease (60% ); the penile ure-
cinoma, adenocarcinoma, and very rare malignancies such as thra represents another 30% of cancers, and the prostatic
melanoma. This chapter focuses on management of primary urethra comprises 10% of all tumors (4). The anterior portion
malignancies of the urethra and does not discuss management of the urethra, penile and bulbomembranous, almost always
of TCC of the urethra or management of urethral recurrence develops squamous cell carcinomas, whereas the prostatic ure-
of TCC after cystectomy, though the operative principles are thra, lined by transitional epithelium, is the site of TCC
readily transferable. 90% of the time. Adenocarcinoma or undifferentiated tu-
Urethral cancer in men is an exceedingly rare condition, mors, which represent approximately 5% of all malignancies,
with an incidence of 1 case per 100,000 men annually (1,2). usually develop in the bulbomembranous urethra.
Fifty percent of male urethral cancers are of transitional cell Urethral cancers may spread through direct extension to
origin, with the remainder divided principally between ade- adjacent structures or via the lymphatic system to regional
nocarcinoma and squamous cell carcinoma, as well as a small lymph nodes. The anterior urethra of the male lymphatically
number of other tumors. Recent information from the SEER drains into the superficial and deep inguinal nodes, and the
database suggests that men may have a higher incidence of posterior urethra drains to the pelvic lymph nodes. Palpable
all three types of urethral tumor than women, indicating a inguinal adenopathy is worrisome for metastatic disease, as
major shift in the incidence ratio of this disease between the inflammatory nodal involvement occurs infrequently.
sexes (1,3). These tumors are rare in men under the age of 50; Disseminated disease is rare until late in the disease process.
the incidence is highest between ages 75 and 84. O ver the
past 20 years the incidence of all urethral cancers has declined
in men. Causal factors of urethral cancer may include chronic DIAGNO SIS
irritative processes, urethral stricture disease, and certain
forms of sexually transmitted disease. Evidence of an associa- N early all men are symptomatic at presentation, though the
tion between human papilloma virus (H PV-16) and squa- low incidence of this disease, combined with failure on the
mous cell carcinoma continues to mount. part of the clinician to consider it, often results in a significant
Tumors of the urethra are defined by location and histol- delay in diagnosis. In Dalbagni’s series of 46 patients, 96% of
ogy. The male urethra is divided into a number of discrete men presented with some form of lower-urinary-tract symptom
FIGURE 38.1 Changes in the histology of the epithelial lining within the
divisions of the male urethra tend to dictate the pathology of the tumor
most likely to occur. (From Webster GD. The urethra. In: Paulsen DF, ed.
Genitourinary surgery. N ew York: Churchill Livingstone, 1983:567, with
permission.)
257
or palpable mass (5). H ematuria, obstructed voiding, urethral For more proximal lesions, total penectomy is indicated. As in
discharge, and a palpable mass are the most common present- women, distal disease portends a better prognosis in men.
ing symptoms and signs. Approximately 25% of men diag- Carcinoma of the bulbomembranous urethra, often pre-
nosed with urethral cancer have a history of sexually senting at a higher stage with local extension into adjacent or-
transmitted infection. Fully half of these patients have been gans, is only occasionally amenable to local therapy, resection,
treated for urethral stricture disease; the diagnosis of cancer or segmental excision with primary anastomosis. Radical
needs to be suspected in men with recalcitrant or nonhealing cystoprostatectomy, complete penectomy, and pelvic lym-
strictures (4). Urethral stricture in association with bloody dis- phadenectomy represent the best option for local disease con-
charge, penile or urethral mass, or urethrocutaneous fistula trol and cure. The margins of excision may be extended into
should heighten the suspicion of urethral cancer. the urogenital diaphragm and pubis in an effort to extirpate
The diagnosis of urethral cancer is histologically confirmed locally advanced disease.
by transurethral or percutaneous biopsy of the suspicious lesion. Prophylactic ilioinguinal lymphadectomy is not routinely
Examination under anesthesia, complete with bimanual as- performed.
sessment of the external genitalia, rectum, and perineum, aids
in local staging of the disease. The inguinal lymph nodes are
palpated, as adenopathy is usually attributable to metastatic ALTERNATIVE THERAPY
disease rather than inflammation. Either a CT scan of the
abdomen and pelvis with and without contrast or M RI of the Given the rarity of this entity, there are no randomized data to
pelvis can help assess local extension of the tumor to the rec- delineate the role of radiation therapy, chemotherapy, or combi-
tum or bladder, as well as the status of the pelvic lymph nodes. nation therapy in this disorder. Radiation therapy and
The M RI may aid in the detection of corporal cavernosal chemotherapy have been used as part of multimodality therapy
invasion. Lung imaging with a chest radiograph, augmented or as monotherapy, but few conclusions can be inferred from
by CT scanning for equivocal lesions, completes the radiologi- most series, which are small in patient numbers and retrospec-
cal staging. Liver function tests should also be assessed. tive in nature. A recent series from the Lahey Clinic suggests
Staging is based upon the tumor-nodes-metastasis (TN M ) that a combination of 5-fluorouracil, mitomycin C, and per-
system. ineal, genital, and pelvic radiotherapy—an adaptation of the
regimen successfully employed in the treatment of squamous
carcinoma of the anus—has an 80% 5-year disease-specific
INDICATIO NS FO R SURGERY survival rate, a 30% improvement over that reported in most
published series (6). In this study salvage surgery was offered to
Given the paucity of data regarding this disorder, there are no patients who failed conservative therapy. General recommenda-
randomized trials to support a particular treatment approach. tions for treatment based on these data are limited due to the
That said, urethral cancer is a lethal disease that, if left un- small cohort of patients studied. It is difficult to support or refute
treated, has a median survival of 6 months. Although sur- the role of neoadjuvant or adjuvant chemo- or radiotherapy in
vival has not changed for this disease in the past 50 years, this disease, though the accruing data are provocative.
treatment still consists of extirpative surgery if the patient’s
condition will allow it (5). Evidence of distant metastatic dis-
ease limits treatment options to palliative measures. Local SURGICAL TECHNIQ UE
treatment is a function of the location of the disease within
the urethra as well as the local stage of the malignancy. Given the rarity of this disease and the limited experience
Superficial disease, especially of the penile urethra, may be with management even at large referral centers, there are no
managed with transurethral resection, local excision, or distal randomized data to guide management. Treated disease has a
urethrectomy. Partial penectomy with a 2-cm urethral margin 5-year survival of roughly 50% , and untreated disease has a
is the preferred treatment for disease of the distal half of the worse prognosis (5). O n the basis of these facts, surgical ther-
penile urethra with local invasion of the corpus spongiosum. apy is suggested in men who are free from metastasis and will
TA B LE 3 8 . 1
STAGIN G OF MALE URETHRAL CARCIN OMA
Ray TN M
Stage 0 Tis Confined to M ucosa O nly (In Situ)

Stage A Ta Into But N ot Beyond Lamina Propria
Stage B T2 Into But N ot Beyond Substance of Corpus Spongiosum or Into But N ot Beyond Prostate
Stage C T3, T4 Direct Extension Into Tissues Beyond Corpus Spongiosum
(Corpora Cavernosa, M uscle, Fat, Fascia, Skin, Direct Skeletal Involvement),
or Beyond Prostatic Capsule
Stage D1 N 1, N 2 Regional M etastasis Including Inguinal and/or Pelvic Lymph N odes
(With any Primary Tumor)
Stage D4 M1 Distant M etastasis (With Any Primary Tumor)
Chap t e r 38: Carcinoma of the Male Ure thra 259
tolerate an operative intervention. Distal lesions have a better giosus muscle. The bulbospongiosus is divided sharply over
response to surgery than more proximal lesions, and they of- the ventral aspect of the urethral bulb and dissected from the
ten are amenable to less radical curative surgery. lateral aspects of the urethra. Careful, sharp dissection of the
Tumors of the anterior urethra have a better prognosis dense attachment between the dorsum of the bulb and the cor-
than more proximal lesions. The surgical management of an- pus cavernosum circumferentially liberates the urethra; a ves-
terior lesions continues to evolve. Endoscopic ablation or local sel loop or small Penrose drain placed around the urethra
excision of the diseased urethra allows preservation of the serves as a “ handle” for the surgeon in mobilizing the urethra
penis in men with limited, superficial disease. Candidates for distally. Frequent palpation of the urethral catheter ensures
penile-sparing surgery must have well-defined disease with a that the plane between the spongiosum and corpora is accu-
negative surgical margin confirmed by frozen section analysis. rately assessed (Fig. 38.2) .
Any question of the adequacy of resection or the malignant As the dissection is carried distally, the penis will begin to
status of the proximal urethral margin should prompt the sur- invert into the wound. There is a tendency to overestimate the
geon to perform a more complete extirpative procedure, in- extent of distal urethral mobilization as the inverted glans is
cluding partial or total penectomy (7,8). Surgical description approached. Indeed, the urethral plane becomes less distinct
of partial and total penectomy is found in the chapter on within the spongy tissue of the glans penis. The authors find it
surgery of the penis. Smith et al. (8) have achieved impressive helpful at this point to evert the penis and complete the distal
results in the treatment of very distal urethral lesions by per- urethral dissection from the meatus.
forming local excision of the involved urethra followed by Using a no. 15 scalpel blade, the urethral meatus, including
penile reconstruction using skin grafts (8). The Indiana a small cuff of glanular skin, is circumscribed. A holding su-
University group has recently reported a series of men with ture may be placed through the meatal urethra to aid in the
in situ carcinoma of the pendulous urethra who were treated dissection of the intraglanular portion of the urethra. Sharp
with urethrectomy and one-stage urethroplasty with a tubu- and cautery dissection are used to free the urethra from its
larized penile fasciocutaneous pedicle flap (personal com m u- spongy glanular attachments. With the urethra liberated dis-
nication). In men who are not candidates for immediate tally, it is maneuvered into the perineal aspect of the wound
urethral reconstruction, creation of a penile urethrostomy and amputated at least 2 cm proximal to the tumor. Frozen
maintains standing micturition. section analysis of the proximal resection margin confirms
that a disease-free margin has been achieved. The wound is
copiously irrigated with sterile saline, and all bleeding is ar-
Ure t hre ct o my w it h Pe nile Pre se rvat io n rested with cautery.
Following resection of the surgical specimen, attention is di-
It must be emphasized that a penile-preserving approach is rected to the creation of a perineal urethrostomy. A site for the
indicated for disease limited to the corpus spongiosum and urethrostomy is selected ventral to the anus and, preferably,
urethra; any disease that extends into the corpora is best man- lateral to the initial skin incision. The urethra is spatulated on
aged with partial or total penectomy. Preoperative preparation its ventral aspect for a distance of at least 1 cm. The urethrocu-
should include full staging studies, a detailed history and taneous anastomosis is matured with a 3-0 or 4-0 absorbable
physical examination with particular attention to a history of suture, such as Vicryl or M onocryl. Four 3-0 interrupted su-
bleeding or anesthetic complications, and a urine culture, with tures are placed between the urethra and perineal skin at the
any infection managed before surgery. apical spatulation, the distal end of the urethra, and laterally
TED hose and sequential compression devices provide along each side of the urethra equidistant from the first two.
deep venous thrombosis (DVT) prophylaxis; the use of 5,000 The anastomosis is completed with 4-0 interrupted or running
U of subcutaneous heparin or 40 mg of subcutaneous enoxa- sutures placed between the quadrant sutures. Care is taken not
parin is prudent in a patient with a pelvic malignancy under- to kink or twist the urethra. With the urethrostomy complete,
going extirpative surgery. Prophylactic antibiotics with a a 16Fr Foley catheter is inserted into the bladder. The perineal
first-generation cephalosporin should be administered within incision is closed in a layered fashion; both the superficial fascia
the hour prior to the first incision; patients allergic to penicillin and deep dermis are approximated using a running 3-0 Vicryl
can receive either vancomycin or clindamycin as an alternative. or PDS suture, and the skin is closed with a running 4-0
An aminoglycoside or quinolone to augment gram-negative M onocryl subcuticular stitch. The incision is covered with a
coverage is reasonable. The patient should be placed in litho- layer of tissue glue, such as Dermabond or Indermil, obviating
tomy, with care taken to adequately pad all pressure points on the need for a wound dressing. A generous portion of
the legs and dorsum of the feet. The patient’s sacrum may be petroleum-based ointment is placed over the urethrostomy at
elevated with a rolled towel or Gelfoam pad to facilitate expo- the conclusion of the procedure. The catheter is left in place for
sure of the proximal bulbar urethra. The perineum, proximal 10 to 14 days and the urethrostomy inspected for stenotic
thigh, genitalia, and lower abdomen are prepared into the changes on a regular basis.
field; the anus is excluded from the operative field by a sterile
towel secured by staples to the perineum and posterior thighs.
A 16Fr Foley urethral catheter is placed. Pro ximal Ure t hral Tumo rs
A 4- to 5-cm vertical perineal incision extending inferiorly
from just below the scrotum provides exposure to the proxi- Tumors of the posterior urethra generally present at a more
mal portion of the anterior urethra. A Scott, Lone Star, or advanced stage, limiting the possibility of endoscopic resection
Jordan-Bookwalter ring retractor system facilitates exposure or segmental resection with end-to-end anastomosis.
of the bulbar urethra. Using electrocautery, the superficial fas- Bulbomembranous cancers, though responding poorly to all
cial and fatty tissue is dissected to the level of the bulbospon- forms of treatment, require radical extirpative techniques to
FIGURE 38.2 A and B: Incisions used for penile-sparing urethrectomy. C: The urethra is dissected off
the corpora cavernosa using electrocautery. D: Distal dissection of the urethra results in inversion of the
penis. E: The spatulated urethra is sewn to the skin edges with interrupted 3-0 chromic sutures, and the
drain is brought out through a separate stab incision.
achieve disease control. Radical cystoprostatectomy with an en gram-positive, gram-negative, and anaerobic bacteria are de-
bloc total penectomy, although mutilative and disfiguring, pro- livered 1 hour before the procedure. In all other respects the
vides the patient with his best opportunity for cure. Resection preparation is similar to that described for surgery of the dis-
of part of the pubic arch and urogenital diaphragm may be tal urethra.
needed to achieve an adequate surgical margin. Complete re- The patient is positioned in the low lithotomy position, and
moval of the tumor may result in the creation of a large pelvic all pressure points are well padded. The abdominal component
floor defect; in situations where this degree of extirpation is an- of the procedure is begun first; the abdominal and perineal
ticipated, consultation with a plastic surgeon will prove benefi- components may be performed simultaneously by two experi-
cial in planning for reconstruction and “ dead space” closure. enced surgical teams, reducing operative time. Although an ex-
Bladder-sparing procedures may be considered when it has perienced laparoscopic or robotic surgeon may be capable of
been confirmed, through biopsy, that the bladder neck is free performing both the pelvic node dissection and the cysto-
of disease. The extirpative portion of the procedure is similar prostatectomy, many urologists will feel more comfortable ap-
to what will be described herein except that the prostate and proaching the pelvic dissection through an open approach.
seminal vesicles are dissected, in an antegrade fashion, from A vertical midline incision is made between the umbilicus
the base of the bladder. O nce the bladder neck has been closed, and the pubis. The preperitoneal space is developed bluntly,
a continent or noncontinent small bowel limb (e.g., A M onti and the pelvic sidewalls are cleared for the pelvic lymph node
procedure) is matured to the lower abdominal wall. dissection. Following placement of a Bookwalter or O mni re-
A mechanical bowel preparation consisting of a clear liquid traction device, the external iliac, obturator, and internal iliac
diet and oral Fleet Phospho-Soda is initiated on the day prior nodes are dissected to the bifurcation of the iliac vessels and
to surgery. Broad-spectrum antibiotics to provide coverage for sent for frozen and permanent pathologic examination.
Chap t e r 38: Carcinoma of the Male Ure thra 261
N ext, the peritoneum is entered, the abdomen explored, with a scalpel. The incision may be extended along the median
and the bowel packed clear of the pelvis. The bladder is mobi- raphe of the scrotum, joining with the previously created per-
lized and the ureters divided as in a radical cystectomy for ineal dissection to allow for enhanced exposure of the distal
bladder cancer. Prostatectomy is performed in an antegrade bulb and pendulous urethra. Using electrocautery, the dartos
fashion, though the puboprostatic ligaments are not divided, fascia is divided to expose the neurovascular bundle of the
in the event the pubis is resected en bloc. Please see chapter on penis, which is divided between silk or Vicryl ties. If the sus-
cystoprostatectomy for a complete description of this surgical pensory ligament has not been divided during the perineal
technique. portion of the surgery, it is done so now. With the corporal
With the bladder and prostate widely mobilized, a modi- bodies and urethral spongiosum exposed, the penis may be
fied lambda or inverted U incision is made in the prepared per- transposed into the perineal aspect of the incision. The cor-
ineum, extending laterally to points just medial to the ischial pora cavernosa are then divided at the ischial tuberosities and
tuberosities. The apex of the incision is based in the midper- oversewn with a running 2-0 Vicryl or PDS suture. Dissection
ineum. The superficial fascia is opened with cautery, and the of the spongiosum from its investing tissues is performed
ischiorectal fossae are bluntly developed bilaterally. After divi- sharply, with care taken to avoid a positive surgical margin.
sion of the perineal body, a tunnel is developed anterior to the Tumor invasion of the superficial periosteum of the pubic arch
rectum in a manner similar to the technique described for the requires vigorous resection of the periosteum with electro-
perineal prostatectomy. The perineal contents are cleared off cautery. Deeper involvement of the pubic bone will require
between the ischial tuberosities and up to the pubic arch. The removal of the inferior portion of the pubic arch with ortho-
suspensory ligament of the penis and the neurovascular bun- pedic rongeurs and surgical drills. In the face of extensive
dles of the penis are divided between 0 silk ties (Fig. 38.3). disease, consultation with an orthopedic surgeon may be nec-
With mobilization of the prostate and proximal urethra com- essary to achieve an adequate margin. The puboprostatic liga-
plete, the penoscrotal junction is then incised circumferentially ments are generally divided at this time.
FIGURE 38.3 A and B: Incision used to gain

access to the perineum for total penectomy, total
urethrectomy, radical prostatectomy, and continent
cutaneous bladder augmentation. C: Electrocautery
and suture ligatures are used to resect the urethral
mass. D: If pubic bone invasion is present, the
pubic arch is first scored with electrocautery;
then, an orthopedic hammer and chisel are used to
resect the inferior pubic arch to ensure a negative
margin.
With the penis free, a negative surgical margin on the pubic pulmonary toilet with incentive spirometry is initiated on the
arch, and the cystoprostatectomy completed, the entire speci- day following surgery. The diet is advanced on a schedule, with
men is removed en bloc. If additional room is needed at the pe- sips begun on postoperative day 2 and advancing on a daily ba-
nile incision to remove the specimin, the scrotum can be incised sis to a regular diet on postoperative day 5. Ketorolac is utilized
along its median raphe as previously described. In patients in to minimize opiates and help bowel function, and metoclo-
whom a bladder-sparing procedure is being contemplated, the pramide is also given to enhance motility.
bladder neck margin is assessed with frozen section. Disease
found at the bladder neck should prompt the surgeon to con-
sider complete cystectomy and urinary diversion. O UTCO MES
The type of urinary diversion performed—conduit or con-
tinent reservoir—is a function of surgeon and patient prefer- Tumors of the distal urethra enjoy the best prognosis, with a
ence and should be discussed and planned prior to surgery. We nearly 70% 5-year survival rate. In patients with superficial
prefer a variation of the right colon detubularized continent squamous cell carcinoma resection, laser ablation or local
reservoir in motivated patients capable of performing inter- excision provides progression-free rates approaching 100% .
mittent catheterization. The ileal conduit is our preferred M ore locally advanced disease requiring partial penectomy
choice of intestinal segments for patients electing an inconti- can be cured when a 2-cm urethral margin is achieved.
nent diversion; in patients with irradiated small bowel or in- Proximal urethral tumors, on the other hand, due to the more
flammatory bowel disease, the transverse colon conduit, based advanced nature of disease at presentation, respond poorly to
on the middle or right colic arteries, provides a safe, easy-to- extirpative surgery; they are associated with a 25% to 40%
handle alternative to the terminal ileum. 5-year survival rate (5). The reported disease-specific survival
Small pelvic defects may be filled with a pedicled flap of rate in most series is around 50% , a figure that has changed
omentum, unhinged from the greated curvature of the stomach little over the last few decades, owing, in part, to little improve-
and based on either the right or left gastroepiploic vessels. Large ment in adjuvant therapies.
perineal defects, especially those resulting from wide resection
of the pubic arch, require placement of a pedicled muscle flap.
Many reconstructive urologists are conversant with the gracilis CO MPLICATIO NS
muscle flap, which is relatively easy to harvest and has a reliable
blood supply. Rectus abdominus or gluteal muscle flaps may be With penile-preserving surgery, the possibility of local recur-
necessary to fill even larger spaces. A Jackson-Pratt drain is rence dictates the need for compulsive monitoring. Endoscopic
placed deeply in the perineal wound and brought out through a therapies and local excision may result in the development of
stab incision. The superficial perineal fascia is closed with a urethral strictures. Stenotic lesions failing to respond to dila-
running 3-0 Vicryl suture, as is deep dermis. The skin is ap- tion should be evaluated for the presence of recurrent cancer.
proximated with a running 4-0 M onocryl suture. A tissue glue Recalcitrant benign stricture disease needs to be addressed
such as Indermil or Dermabond is utilized to seal the skin; in with open urethroplasty. Stenoses of the meatus or perineal
such cases, no dressing is needed. A Jackson-Pratt or Penrose urethrostomy are common complications seen in patients un-
drain, placed abdominally in close proximity to the ureteral re- dergoing partial and total penectomies, respectively, and may
construction, is exteriorized lateral to the midline incision. be managed conservatively with patient self-dilation.
Postoperatively patients are managed in a standard fashion Pelvic exenteration for bulbar urethral tumors carries a
(9). A nasogastric tube, placed at the time of surgery, is rou- similar profile of complications as that seen with other exen-
tinely removed on the first postoperative day. DVT prophylaxis terative procedures. Pelvic abscesses need immediate attention
is maintained with heparin or enoxaparin postoperatively, and with open or radiological drainage. Perineal wound break-
antibiotics are stopped within 24 hours, unless an active infec- down, especially when associated with the placement of pedi-
tion is being treated. Patients are aggressively ambulated begin- cled flaps, is treated with surgical debridement and local
ning the first night or the morning of postoperative day 1; wound care.
References
1. Swartz M A, Porter M P, Lin DW, et al. Incidence of primary urethral carci- 6. Cohen M S, Triaca V, Billmeyer B, et al. Updated outcomes with coordi-
noma in the United States. Urology 2006;68:1164. nated chemoradiation therapy as the primary treatment for invasive carci-
2. http://apps.nccd.cdc.gov/uscs/Table.aspx?Group=TableAll& Year=2003& noma of the male urethra. Abstract presented at the 2007 N E AUA
Display=n, accessed December 2, 2007. M eeting, Boston, M A.
3. Krieg R, H offman R. Current management of unusual genitourinary 7. Davis JW, Schellhammer PF, Schlossberg SM . Conservative surgical ther-
cancers. Part 2: Urethral cancer. O ncology (W illiston Park ) 1999;13: apy for penile and urethral carcinoma. Urology 1999;53:386–392.
1511–1517, 1520; discussion 1523–1524. 8. Smith Y, H adway P, Ahmed S, et al. Penile-preserving surgery for male dis-
4. Campbell M F, Wein AJ, Kavoussi LR. Cam pbell-W alsh urology, 9th ed. tal urethral carcinoma. BJU Int 2007;100:82–87.
Philadelphia: Saunders Elsevier, 2007. 9. Pruthi RS, Chun J, Richman M . Reducing time to oral diet and hospital
5. Dalbagni G, Z hang Z F, Lacombe L, et al. M ale urethral carcinoma: analy- discharge in patients undergoing radical cystectomy using a perioperative
sis of treatment outcome. Urology 1999;53:1126–1132. care plan. Urology 2003;62:661–665; discussion 665–666.
CHAPTER 39 ■ INJECTABLE THERAPIES FO R
INCO NTINENCE IN WO MEN
RO DNEY APPELL
The idea of increasing urethral resistance by an injectable be determined by placing a cotton swab through the urethra
agent is nothing new. It was first reported in 1938 (1). Twenty with the tip just past the urethrovesical junction. If the angle is
women had either sodium morrhuate or cod liver oil injected 30 degrees from the horizontal or the change in angle is 30
into the anterior vaginal wall to provoke an inflammatory re- degrees when the patient bears down or coughs, the patient is
sponse resulting in scar formation and contracture of tissue said to have a hypermobile rather than fixed urethra (5,6).
around the urethra. Seventeen patients reported being cured The use of intraurethral bulking agents in women with
or improved, but pulmonary infarction and cardiopulmonary urethral hypermobility, type II incontinence, is an area of con-
arrest were reported. In 1955 the first injections into the ure- troversy. A comparison between pubovaginal slings and in-
thra were reported by Q uackels (2). Two patients were treated traurethral collagen injections was performed by Kreder and
successfully without complications. In 1963 Sachse (3) used Austin (7). In their study, they compared success rates in pa-
Dondren, a sclerosing agent, to treat 7 women and 24 men. tients with ISD alone or mixed with urethral hypermobility. In
Four women and 12 men were reported as cured, but several the mixed group, those receiving a pubovaginal sling faired
patients experienced pulmonary embolism. These first bulking better, with a cure rate of 81% versus 25% in the collagen
agents were far from ideal. Such an ideal agent would be non- group. H owever, the collagen group only received a single in-
immunogenic, hypoallergenic, biocompatible, heal with mini- jection, whereas it has been demonstrated that many patients
mal fibrosis, be nonmigratory, and retain its bulking effect require two to three injection sessions to affect their conti-
over a long period of time (be durable) (4). nence (8). In another study, despite more injections and the
amount of material injected in the group with urethral hyper-
mobility, both those with and without hypermobility had
MECHANISM equal success (9). In a later study by H erschorn and Radomski
(10), no statistically significant difference was found between
Injectable agents work by forming a “ seal” through restoring those with and without urethral hypermobility. O ver time,
mucosal coaptation. They have several advantages over surgi- 72% remained dry at 1 year, 57% at 2 years, and 45% at 3
cal procedures in treating stress urinary incontinence (SUI). years, with no significant difference between the type of incon-
Compared to surgical procedures that create a functional ob- tinence and time to failure. O thers have documented similar
struction, injectable agents restore continence by increasing findings in patients with urethral hypermobility or type II in-
urethral resistance at rest. With bulking agents, the urethra continence (11–14).
maintains its ability to funnel and open, keeping urethral resis- Urodynamics should be performed to rule out other causes
tance low during micturition. This spares a resultant increase of urinary incontinence, such as detrusor overactivity. Ure-
in detrusor pressure (Pdet), which could lead to overactive thral function can be assessed by measuring the abdominal
bladder symptoms and/or upper-tract damage. In comparison, leak point pressure (ALPP), which is the amount of abdominal
surgical procedures may result in increased resistance at rest pressure (Pabd) necessary to overcome the bladder’s conti-
and during micturition by not allowing the urethra the same nence mechanism. The definition of ISD by ALPP has varied
physiologic movement. M ost bulking agents are placed at the from a low ALPP (60 cm H 2 O ) to an ALPP 100 cm H 2 O .
level of the bladder neck within the smooth muscle in the area An absolute value for ALPP suggesting ISD has become unim-
of the continence mechanism. Since the placement is within the portant due to limitations in urodynamic testing as well as
urethra, intraurethral is a more accurate term than the com- different values used by different clinicians. With videourody-
monly used terms periurethral or subm ucosal. namics, radiographic evidence of an open bladder neck and
proximal urethra without detrusor contraction during the
storage phase of the bladder is felt to imply ISD.
CRITERIA FO R SELECTIO N As more is understood about the continence mechanism, it
appears that most women with SUI have some component of
Ideal patients for intraurethral bulking have SUI due to intrin- ISD, since there are numerous women with urethral hypermobil-
sic sphincter deficiency (ISD) and a normal contractile blad- ity who do not leak with significant intra-abdominal pressures.
der. Clues such as leaking a large amount of urine with cough Women who do have a fixed, nonmobile urethra are, however,
or sneeze, significant leakage upon exertion, leakage while more likely to have a greater degree of ISD (15). Exclusion crite-
supine, bed wetting, or leakage with the sensation of urinary ria for intraurethral bulking would include urinary incontinence
urgency may suggest ISD. O n physical examination, the due to abnormal detrusor contractions, active urinary tract in-
patient should have a well-supported, fixed urethra. This can fection, or allergy to the material used as a bulking agent.
263
■ A 0-, 12-, or 30-degree lens is best for providing a good

Ke y Co nce p t s view of the urethra as w ell as the injection needle.
■ Ideal patients for intraurethral bulk ing have SUI due to in-
trinsic sphincter deficiency (ISD ) and a norm ally contractile
bladder.
PERIURETHRAL INJ ECTIO N
■ M ost w om en w ith SUI have som e com ponent of ISD .
Injections may also be performed periurethrally via a needle
placed percutaneously lateral to the urethral meatus and par-
allel to the urethra. While the needle is placed, the urethra is
INJ ECTIO N TECHNIQ UES visualized through a cystourethroscope (17,18). Localization
of the needle tip may be facilitated by preinjecting the urethra
When performing intraurethral bulking, precise placement of
with methylene blue during the periurethral approach (19).
the bulking material into the wall of the proximal urethra near
With the periurethral approach, there is often less bleeding,
the bladder neck in the area of the continence mechanism is
which can improve visualization. There is also less extrusion
of the utmost importance. The plane of delivery, the tissue
of the material injected, although this also depends upon the
quality at the injection site, and the cause of incontinence are all
type of material injected. The desired amount of coaptation is
important factors in successful therapy. If material is delivered
the same as when performed via a transurethral technique.
too distally, the treatment is likely to fail and may cause irrita-
After the periurethral block, a 20-gauge spinal needle is placed
tive voiding symptoms. Prior to injection, patients are placed
at the 4 o’clock position into the periurethral tissue within the
in lithotomy position and prepared in standard sterile fashion.
lamina propria. Urethroscopy is then performed as the needle
A local anesthetic in the form of 20% benzocaine ointment or
is further inserted with minimal resistance up to the level of
cream may be applied to the vestibule covering the urethra,
the bladder neck. The needle is then rocked in a horizontal
and a topical 2% lidocaine jelly may be applied to the urethra.
plane to assess the location of the needle tip and ensure place-
Approximately 4 mL of 1% lidocaine is then injected peri-
ment at the proper depth. The material is then injected slowly
urethrally at the 3 and 9 o’clock positions.
while observing for coaptation, similarly to the transurethral
technique, and the process is repeated at the 8 o’clock posi-
Ke y Co nce p t tion. If material is noted in the lumen of the urethra, the nee-
dle is removed and relocated to a more anterior position,
■ Precise placem ent of the bulk ing m aterial into the w all of where the injection is repeated again. O nce sufficient coapta-
the prox im al urethra near the bladder neck in the area of tion is noted, the procedure is ended. A needle with a “ bent
the continence m echanism is of the utm ost im portance. tip” has been manufactured (Boston Scientific Inc, N atick,
M A) to facilitate placement into the proper plane. With ad-
vancement of the needle, the tip is brought more medially.
TRANSURETHRAL INJ ECTIO N These needles were originally designed to ease the injection of
Durasphere, since a larger bore size (18 gauge) also aids in the
Several approaches may be taken when performing injections passage of the particles, but they certainly can be used for the
of bulking agents. They may be performed by placing a needle periurethral injection of other bulking agents.
through a cystourethroscope and injecting suburothelially, The differences between the transurethral and periurethral
also known as a “ transurethral injection” (16). A 0-, 12-, or techniques were reviewed by Faerber et al. (20). They found
30-degree lens is best for providing a good view of the urethra similar outcomes with no significant differences in adverse
as well as the injection needle. O nce the cystourethroscope is events using collagen. O f significance, the amount of material
placed into the urethra and passed into the bladder, the blad- injected was less using a transurethral approach. A prospec-
der is usually drained because the patient’s bladder may become tive, randomized comparison was later performed in women
distended toward the end of the procedure. The endoscope is with again no noted differences in efficacy, but a higher rate of
then backed to the midurethra, at which time the needle is de- urinary retention and also an increased volume of injected ma-
ployed at the 4 o’clock position. The needle is then inserted terial were seen in the periurethral group (21). It appears that
submucosally into the urethral muscle beyond the midurethra a periurethral approach tends to use larger volumes of mater-
and advanced to the proximal urethra near the bladder neck. ial and has been noted to have a longer learning curve than the
O nce the desired positioning is achieved, the bulking agent is transurethral approach.
slowly delivered to allow it to spread underneath the urethral
mucosa. O nce the mucosa on that side has expanded to the
midline, the needle is slowly withdrawn while injecting. ULTRASO UND GUIDANCE
Attention is then turned to the 8 o’clock position, where the
technique is repeated again. After completion of both sides, a Although transurethral and periurethral injections are the
fair amount of coaptation should be noted. most commonly performed injections, injections may also
be performed in women with an ultrasound probe (22).
Theoretically, this technique circumvents the passage of in-
Ke y Co nce p t s struments through the urethra, which may alter the placement
of the bulking agent affecting coaptation. First, a transrectal
■ O nce the m ucosa at the 4 o’clock position has ex panded to ultrasound probe with a biopsy port is placed into the vagina.
the m idline, the technique is repeated again at the 8 o’clock O nce the bladder neck has been identified, a needle of the
position. same type for transurethral injection is placed through the
Chap t e r 39: Inje ctab le The rap ie s for Incontine nce in Wome n 265
port. Longitudinal views by ultrasound are used to determine

coaptation of the bladder neck. Studies have demonstrated INJ ECTABLE AGENTS
that three-dimensional ultrasound views may predict long-
term outcomes and may provide an objective measure for the O ther methods of treatment for SUI include urethropexies,
amount of material to be placed (23). In later studies with slings, and artificial urinary sphincters. O ften bulking agents
three-dimensional ultrasound, collagen injections were shown are compared to these other methods of treatment. What has
to maintain their volume and ultrasound appearance with an been demonstrated in some studies is that midurethral slings
associated improved continence and quality of life. It was also and Burch urethropexies tend to have higher failure rates in
found that the most desirable appearance on ultrasound was patients with a “ fixed urethra” (27,28). These patients are
either a circumferential or horseshoe configuration (24). better off treated with intraurethral bulking agents, bladder
Regardless of the technique, coaptation of the urethra is the neck slings, or artificial urinary sphincters. Compared to in-
goal. jectable agents, the artificial urinary sphincter and bladder
neck slings both involve undergoing a surgical procedure,
which involves surgical risk as well as the risk of anesthesia,
whereas the intraurethral bulking agent involves only local
PO STO PERATIVE CARE anesthesia and minimal complications.
Immediate postoperative complications are rare. After com- Comparing the different injectable agents is a difficult task.
pletion of the procedure, the patient should demonstrate the There are few controlled, long-term studies involving com-
ability to void. If the patient is in acute urinary retention, most monly used bulking agents. Even within those rare studies,
often the patient will be able to urinate shortly after the peri- there are many variables that make it difficult to compare one
urethral block loses effect. M eanwhile, the patient is usually to another. This is due to the different patients with different
catheterized with a small 10Fr to 14Fr catheter to relieve the severities and etiologies of stress incontinence. N ot all studies
patient’s full bladder after cystourethroscopy. An indwelling differentiate the results in patients with and without urethral
Foley catheter should be avoided since there is a theoretical hypermobility and/or ISD. The procedures themselves have
risk of the bulking agent molding around the catheter and los- also varied due to different technical factors such as injection
ing its effect, although there is no evidence to support that technique and instrumentation. Additionally, reported results
short-term catheterization decreases the efficacy of intra- have been largely subjective rather than objective, creating a
urethral bulking. If long-term catheterization is necessary, a difficult situation to compare data. Variability also exists
suprapubic catheter until return of voiding would be best to within the reported outcomes, as different criteria have been
avoid disrupting the placement of the bulking agent. used to define cured or im proved.
Prophylactic treatment with antibiotics is recommended to
avoid urinary tract infections. M any patients will require
more than one treatment session to achieve maximal conti- AUTO LO GO US MATERIALS
nence. Different waiting periods are required for each individ-
ual bulking agent. Bulking agents such as GAX-collagen can Aut o lo g o us Blo o d
be repeated after 1 week (in the original multicenter study, a
4-week waiting period was used). With polytetrafluoroethylene, Autologous blood is readily available and accessible. In a
a 4-month wait is required since improved coaptation occurs study of 14 women, 30 mL of blood was obtained in a he-
with time. O n repeat injection, if erosion is noted, injection parinized syringe from the antecubital vein. Continence was
into that side should be avoided until re-epithelialization achieved after two treatments. Unfortunately, all patients be-
occurs. came incontinent again after 10 to 17 days (18).
Irritative voiding symptoms may also develop after place-
ment of bulking agents. Surprisingly, in a study by Steele et al.
(13), 50% of patients were reported to have developed de Aut o lo g o us Fat
novo detrusor overactivity. In a study by Cross et al. (25),
28% of patients were found to have de novo urge inconti- Although not as accessible as blood, autologous fat can be
nence without ISD when undergoing urodynamics for post- easily obtained through liposuction. In 1989 this technique
treatment incontinence. Stothers et al. (26) reported a 12.6% was reported in 10 women (29). In a different study with
rate of de novo urgency with urge incontinence in 337 women 1 year follow-up, 0 of 5 men and 5 of 15 women reported im-
enrolled in a prospective trial of which 21% failed anticholin- provement (30). In a study by Santarosa and Blaivas (31),
ergic treatment. Commonly, minor urethral bleeding may oc- 83% of 12 women with ISD were subjectively improved, al-
cur. If the urethral mucosa becomes disrupted, perforation and though at 1 year the results were much poorer. In a random-
extravasation of the bulking agent may occur. An advantage ized double-blind controlled trial of women with urethral
of the periurethral approach involves placement of the bulking hypermobility, fat was found to be as effective as the saline
agent without disruption of the mucosa. control group at 6 months (33).
These poor results are thought to be secondary to fat
degradation. After injection, neovascularization never be-
Ke y Co nce p t comes adequate at the fat graft’s center, leaving only a minis-
cule amount of viable fat, which may hinder its bulking effect.
■ If the patient is in acute urinary retention, catheterize w ith After 3 weeks, 60% of the fat injected is degraded. O nce the
a sm all 10Fr to 14Fr catheter to relieve the patient’s full fat is reabsorbed, inflammation occurs with resulting fibrosis,
bladder. which leads to the bulking effect (31). Although this material
is accessible and complications are rare, it has been reported improved rate, and 17% rate of failure. At 50 months, Corcos
to be associated with systemic embolization and death and Fournier (49) reported a cured rate of 30% and an im-
(33,35). Therefore, the use of autologous fat as a bulking proved rate of 40% in 40 women, although four women in the
agent is discouraged. cured group and five women in the improved group required
“ maintenance” injections. In a study up to 5 years, Gorton
et al. (50) reported that only 26% of 53 women reported con-
tinued improvement.
BIO MATERIALS Few complications have been found with the use of GAX-
collagen. In the U.S. clinical trials (51), 15% developed tran-
Glut arald e hyd e Cro ss-Linke d Bo vine sient urinary retention, 5% had a UTI, and 1% experienced
Co llag e n (GAX-Co llag e n) irritative voiding. Rates of de novo urgency and frequency have
been reported to be as high as 10% (49). There has been no
O f all the injectables, glutaraldehyde cross-linked bovine col- evidence of foreign-body response or migration (39), partly be-
lagen (GAX-collagen) is probably the most commonly used, cause of the small amount of glutaraldehyde in GAX-collagen,
with most publications describing its safety and efficacy. which creates minimal immunoreactivity and cytotoxicity (52).
Before its use as a bulking agent, bovine dermal collagen was GAX-collagen is biocompatible and allows fibroblasts to de-
primarily used to make absorbable sutures and hemostatic posit native collagen as well as neovascularization to occur as
agents. When used as a bulking agent, bovine collagen is the implant is degraded over 12 weeks (53). After 10 to 19
cross-linked with glutaraldehyde to create a stabilized, fibril- months all of the implant has completely degraded (40). There
lar collagen that confers resistance to denaturation by collage- have been several case reports of sterile abscesses at the injec-
nases. It consists of 35% purified bovine collagen in a tion sites, some of which required drainage (35,55).
phosphate buffer. The collagen itself is composed of 95% type O ne potential hazard of GAX-collagen involves an allergic
I collagen, which is the type found predominately in ligaments reaction to the bovine protein, although this is reduced by
and confers structural strength; however, between 1% and 5% cross-linking and skin testing. Approximately 4% of female
is composed of type III collagen, which is the type abundant in patients will have a positive skin test, which precludes them
vaginal tissue, giving added flexibility (36). GAX-collagen is from treatment (44). Despite being extraordinarily rare, de-
prepared by selective hydrolysis of the collagen molecule at layed hypersensitivity has been reported at the skin test site.
the nonhelicoidal amino-terminal and carboxy-terminal seg- O verall, due to its complete degradation with minimal inflam-
ments, also known as telopeptides. This serves two functions. matory response and lack of migration, GAX-collagen has
O ne is to decrease the antigenicity, and the other is to increase been the most popular intraurethral bulking agent used to
resistance to collagenases and thus to increase the durability treat incontinence.
of the implant (37,38).
When injecting this material, the surgeon inserts the exact
amount needed to achieve the desired effect, since there is no Ke y Co nce p t s
expansion or shrinking after injection. Acting as a matrix, the
material promotes ingrowth of new collagen within the im- ■ A s tim e progresses, a noted decline in efficacy has been
plant (39). Since GAX-collagen is both biocompatible and w itnessed.
biodegradable, only minimal inflammatory changes occur ■ A pprox im ately 4% of fem ale patients w ill have a positive
(40). After 12 weeks, the collagen starts to degrade, but it per- sk in test, w hich precludes them from treatm ent.
sists until 19 months (41). Despite the fact that GAX-collagen
is degraded, it maintains effectiveness in 80% of those who
become continent, a result that is thought to be secondary to SYNTHETIC MATERIALS
the ingrowth of new collagen (42).
O ne series reported that 55% of women could achieve Po lyt e t rafluo ro e t hyle ne (Po lyt e f)
continence after one injection session (43). In a multicenter
clinical study involving 127 women with ISD, 88 patients M any authors have been able to demonstrate the efficacy of
completed 2-year follow-up. At 2 years, 46% of patients were polytetrafluoroethylene (PTFE) as a bulking agent (58–63).
dry and 34% were significantly improved, requiring only a Success rates have ranged from 70% to 90% with PTFE
single pad or tissues. Urodynamic studies also revealed a rise (64). This material was also studied by the Department of
of 40 cm H 2 O in ALPP. A mean volume of 18.4 mL of GAX- Technology Assessment of the American M edical Association
collagen with a mean of 2.1 ( / 1.5) treatment sessions was and was found to be an easily performed, effective treatment
given to those who achieved continence (44). O ther indepen- with good short-term results (65). H owever, longer follow-up
dent studies have supported these results (9,45,46). These re- has proven otherwise. In one study, a 38% success rate be-
ported rates have compared favorably with other treatment tween 21 to 72 months (mean, 49 months) was noted in
modalities for ISD (47). As time progresses, a noted decline in women (66).
efficacy has been witnessed. Forty-five percent of elderly In addition to the shortcomings in long-term efficacy, rates
women were improved at 24.4 months in a report by Winters of urinary retention have ranged from 20% to 25% (67).
et al. (12). O f note in this group, at an average of 7.9 months, Transient irritative voiding symptoms may develop in approx-
40% required more injections; after additional material was imately 20% of patients (62). Urinary tract infection has been
injected, only 42% became continent again. Forty-two pa- reported to occur at a rate of 2% (61).
tients with ISD were followed at an average of 46 months by O f greater concern, the long-term safety profile of this
Richardson et al. (48), who reported a 40% dry rate, 43% agent has been brought into question. Foreign-body reaction
with granuloma formation is a known risk (68). After injec- concluded that there was no significant objective difference
tion, histiocytic and giant cells are responsible for this reac- between the two agents at 12 months. The only difference was
tion. Particles have been found in blood vessels as well as that the M acroplastique group had less volume injected, al-
lymphatics. These particles have been thought to elicit an although the pretreatment pad test loss was significantly less in
lergic response in some patients, which is believed to be re- that group.
sponsible for culture negative fevers in 25% of patients. Five Complications with the use of this material included uri-
percent of patients also complain of transient perineal discom- nary retention at a rate of 5.9% to 17.5% , urinary frequency
fort with spontaneous resolution, which is also thought to be at a rate of 0% to 72.4% , dysuria from 0% to 100% , and UTI
an immune-related phenomenon (67,69). from 0% to 6.25% (86). A study to determine the migratory
O nce inside blood vessels or lymphatics, particles can mi- properties of this material was performed on dogs. Small par-
grate to distant locations. In animal models, PTFE particles ticles were found in the lungs, kidney, brain, and lymph nodes
have been found in pelvic lymph nodes, lungs, brain, kidneys, within 4 months of injection. In comparison, only one large
and spleen at 1 year (70,71). Particle migration to distant sites particle was found in the lung without any associated reaction
has been reported in humans as well. First reported by (87). In a rat model, four sarcomas with the Bioplastique
M ittleman and M arraccini in 1983 (72), a PTFE granuloma group were associated with silicone particles. Given the recent
was found in the lung of a patient 2 years after injection. Claes controversy over silicone used in breast implants as well as the
et al. (73) reported on a patient experiencing fevers with possibility of migration, it is unlikely that silicone will become
biopsy-proven PTFE granulomas in the lung 3 years after PTFE a popular agent for intraurethral injections.
injection. In another field, PTFE was used to inject the larynx
for vocal cord paralysis. Twenty months after injection, a gran-
uloma was found in the anterior lobe of the thyroid (74). Carb o n-Co at e d Zirco nium Be ad s
Despite granuloma formation, patients rarely have had any (Durasp he re and Durasp he re EXP)
clinical consequences. It is the formation of granulomas and
their association with cancer that is of more concern, although Durasphere, a new synthetic material, was approved by the
PTFE has not been linked to carcinogenesis with 30 years of FDA in 1999. It is composed of pyrolytic carbon-coated zirco-
use as a bulking agent for the urethra and larynx (76). In fact, nium oxide beads in a 2.8% beta-glucan water-based gel. The
there have been reported cases of cancer near PTFE injection bulking effect lasts for at least 2 years as the beads are encap-
sites, but none have demonstrated PTFE as the precipitating sulated into the periurethral tissue. Compared to collagen, it is
factor (77–79). This risk was reviewed by Dewan et al. (80). It an inert and nonimmunogenic material, eliminating the need
was concluded that the available evidence did not support for skin testing. H owever, Durasphere can be more technically
PTFE as a carcinogenic agent but suggested that if a risk ex- difficult to inject given its higher viscosity.
isted, it was low. In 1995 Dewan et al. (80) reviewed the risk Durasphere was compared to GAX-collagen in a multi-
of both PTFE and Bioplastique in a rat model. A similar inci- center, randomized, controlled, double-blind study with follow-
dence of tumors was found in the PTFE, Bioplastique, and up at 1 year. The Durasphere group achieved improvement in
control groups. Additional late adverse events include fibrosis one Stamey grade or more in 80% of patients compared to
of the urethra and granuloma balls in the bladder at a rate of 69% of patients in the GAX-collagen group, although the
15% (66). Currently, the U.S. Food and Drug Administration difference did not reach statistical significance. Pad weights at
(FDA) is investigating the product. 12 months were equivalent between the two groups. The
Durasphere group had significantly less volume injected and
were more successfully treated with a single injection (88).
Ke y Co nce p t Although permanent, questions concerning longevity, similar
to GAX-collagen, were brought forth. Panneck et al. (89)
■ Particle m igration w ith granulom a form ation to distant noted a decrease in success from 77% at 6 months to 33% at
sites has been reported, though patients rarely have had any 12 months in a group of 13 women. In their study, one female
clinical consequences. patient was also noted to have asymptomatic distant particle
migration into the regional and distal lymph nodes. Due to in-
traneedle resistance secondary to bead size, injection of
Silico ne Po lyme rs (Macro p last iq ue , Durasphere can be technically difficult. In response to this is-
Bio p last iq ue ) sue, M adjar et al. (90) used a periurethral approach at a single
injection site. With 92% of 46 patients achieving excellent or
Silicone polymers such as M acroplastique and Bioplastique good coaptation, 65% considered themselves cured or im-
are made of polydimethylsiloxane macroparticles suspended proved at a mean of 9.4 months. Additionally, 50% of 36 pa-
in a carrier hydrogel consisting of polyvinylpyrrolidone (povi- tients had a 24-hour pad test with 8 g or less of urine.
done). The solid particles make up 33% of the total volume Long-term data have been reported in a multicenter, compara-
and are 100 m in size. Silicone polymer was first used in tive trial of Durasphere and GAX-collagen. Durasphere re-
1992 with encouraging short-term follow-up. Like other mained effective in 33% of patients at 24 months and in 21%
agents as time progressed, the cure rate fell from an initial at 36 months. Those who received GAX-collagen reported
82% to 70% at 14 months (82). In other studies with effectiveness in 19% of patients at 24 months and in 9% at
M acroplastique, 19.6% were considered cured and 41.1% 36 months. H owever, when controlled for differences in follow-
significantly improved at 19 months (83). To date there has up time, the time to failure between the two groups did not
been one prospective, randomized study comparing M acro- reach statistical significance. Interestingly, one third of each
plastique to GAX-collagen in 62 women (85). The authors group felt that treatment was successful (91).
In the trials for FDA approval, the most common adverse the length of tail left at the injection site. Injections should not
events were acute retention 7 days) at 13% , dysuria at 12% , be performed until coaptation is noted, unlike with many of the
UTI at 9% , hematuria at 6% , and retention 7 days at 6% . other bulking agents. Urethral coaptation may suggest that too
O ther adverse events occurred at 4% (92). There have also much material may have been injected.
been case reports of sterile abscess formation. Currently for EVO H , the only large study is from the
Durasphere’s beads are much larger than either PTFE or sili- trial for FDA approval. A multicenter, prospective, random-
cone polymers. In spite of their size, there have been reports of ized trial was conducted with 177 of 253 women completing
migration, although clear evidence is lacking. As determined by follow-up at 12 months comparing EVO H to GAX-collagen.
studies involving polytetrafluorethylene, macrophages are able The first 16 patients were excluded from the data since they
to phagocytize particles smaller than 80 m. Once phagocy- were the first patients undergoing a new technique. At 12
tized, the particles can then be carried to different parts of the months, efficacy was assessed by Stamey grade, pad weight,
body. Since Durasphere ranges from 212 to 500 m, phagocyto- and quality-of-life questionnaire. O f those who received
sis and therefore migration should not occur. Case reports in- EVO H , 18.4% of patients were dry by Stamey grade com-
volving beads found in lymphatics and other places are likely pared to 16.5% of those who received collagen. The differ-
due to a high-pressure embolization effect, which may displace ence between the two groups regarding who had improvement
beads into vascular or lymphatic spaces. Delivery with large by at least one Stamey grade did not reach clinical signifi-
particles under low pressure should eliminate the risk of em- cance. In respect to pad weights, 37.8% were dry in the EVO H
bolization. Durasphere-EXP is a modification of the original group compared to 32.1% undergoing collagen injection.
Durasphere that should allow lower-pressure injection due the This study resulted in FDA approval of EVO H (95,97).
smaller bead size (95 to 550 m) yet above 80 m to avoid In the trials for FDA approval, EVO H has been shown to
migration. have similar rates and severity of adverse events when com-
pared to collagen. The one exception is the 16% rate of
material exposure. During this study, it was noted that the
Ke y Co nce p t exposure rate was higher with periurethral injection, and
therefore this method is not recommended. Exposed mater-
■ D urasphere achieved im provem ent in one Stam ey grade or ial did not result in any adverse consequences and usually
m ore in 80% of patients com pared to 69% of patients in resolved. H owever, in the authors’ experience, erosion rates
the G A X -collagen group, although the difference did not of 37% in women and 41% in men necessitated multiple
reach statistical significance. office visits for several patients with severe dysuria. O ther
common adverse events included UTI (29% ), delayed void-
ing (18% ), dysuria (18% ), urinary urgency (14% ), and fre-
Et hyle ne Vinyl Alco ho l Co p o lyme r quency (13% ). Interestingly, 9% of patients developed urge
(Te g re ss, Uryx) incontinence and 8% had worsening of incontinence. This
injectable agent has been removed from utilization in the
Approved by the FDA in 2004, Tegress is composed of an 8% United States.
ethylene vinyl alcohol (EVO H ) copolymer dissolved in di-
methyl sulfoxide (DM SO ), which is a permanent, hypoaller-
genic, nonimmunogenic implant. It comes prepared in 3-mL Ke y Co nce p t s
glass vials with a 3-mL DM SO -compatible syringe. The mate-
rial is injected via a 25-gauge needle. O nce Tegress is exposed ■ W ith EV O H , injections should not be perform ed until
to fluid within the tissue, the DM SO diffuses out, causing the coaptation is noted, unlik e w ith m any of the other bulk ing
precipitation of EVO H into a soft, spongy, hydrophilic mater- agents.
ial. The time required for the chemical reaction to occur is
within 60 seconds. Care must be taken to avoid contamina-
tion of this agent with fluid prior to injection. At 1 month, an Calcium hyd ro xyap at it e (Co ap t it e )
acute inflammatory response has been noted to be at its great-
est. This effect lasts until 3 months, when the reaction has Approved in December 2005, calcium hydroxyapatite is a syn-
become more mild and localized with some resultant mineral- thetic agent that consists of carboxymethylcellulose in the
ization. There has been no evidence of EVO H affecting tissue form of an aqueous gel. Calcium hydroxyapatite is biocom-
at remote sites from the injection site. There also has been no patible, does not encapsulate, facilitates ingrowth of native tis-
evidence of migration. sues, and can be identified on radiographic studies as well as
When EVO H is used as a bulking agent, a different tech- ultrasound. Another advantage includes ease of injection of
nique must be applied. If an excessive amount of material is material.
injected, erosion through the urethral mucosa is likely to occur. In a study with 1 year follow-up, 7 of 10 women reported
To decrease the risk of erosion, the manufacturer suggests in- substantial improvement in continence, a 90% decrease in
jecting at a more distal location in the urethra approximately mean pad weight, and an increase in mean Valsalva leak point
1.5 cm distal to the bladder neck. Each injection is to take place pressure from 39 to 46 cm H 2 O (100). In the data for FDA ap-
over 1 minute, with an additional minute of waiting to allow proval, 158 patients received Coaptite with a mean follow-up
the chemical reaction to occur before removing the needle (95). of 11.2 months. N o statistical difference was found in change
When the needle is removed, a twisting motion often helps to in Stamey grade, pad weight, or quality of life when compared
separate the precipitated material off the needle tip and minimize to GAX-collagen as the control. (101).
Common adverse events included urinary retention (41% ), TA B LE 3 9 . 1

hematuria (19.6% ), dysuria (15.2% ), and UTI (8.3% ).
Changes in voiding occurred with urinary urgency at 7.6% ,
H yaluronic acid
frequency at 7.0% , and urge incontinence at 5.7% . Two
H yaluronic acid and dextranomer microspheres
serious adverse events occurred: one erosion through the vagi-
nal wall requiring surgery and dissection into the bladder Bioglass
causing tissue bridging, for which no surgical correction was Autologous tissue: chondrocytes (tissue engineering) in table
needed. The overall erosion rate was 1.3% (101). M yoblasts
M icroballoons
Ke y Co nce p t
■ N o statistical difference w as found in change in Stam ey Although numerous injectable agents have entered the
grade, pad w eight, or quality of life w hen com pared to market over the last several years, the search for the ideal
G A X -collagen as the control. bulking agent continues. Listed in Table 39-1 are some of the
current agents undergoing investigation.
FUTURE AGENTS
CO NCLUSIO N
In patients with minimal urethrovesical junction mobility,
ISD, and a stable bladder with an adequate capacity, intra- Currently, injectable agents are best used for those who are
urethral injections can offer treatment responses similar to good candidates for successful treatment, those who wish to
that of surgical correction with minimal complications. avoid a surgical procedure, or those who have problematic
H owever, most of these data are short-term; there is a scarcity medical comorbidities that preclude them from undergoing
of data over 5 years, with the majority of studies followed for surgical correction. Research continues the search for an effec-
much less time. For GAX-collagen, reinjection rates can be as tive, inert, nonmigratory, nonimmunogenic material that al-
high as 22% at 32 months after having achieved continence. lows incorporation into native tissue, maintains its shape, and
The other injectable agents on the market have much fewer injects with ease. Currently, intraurethral bulking remains an
data and lack long-term follow-up. For younger patients, the art, as there is no exact measurement or amount of material
cost of reinjection can become significant. used for each patient to achieve continence.
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CHAPTER 40 ■ PUBO VAGINAL FASCIAL

SLINGS
ANNE PELLETIER CAMERO N, CHRISTINA LEWICKY-GAUPP, AND EDWARD J. MCGUIRE
The first urethral sling procedure was described by Giordano with urethral sphincter weakness or scarring resulting in leak-
in 1907. This procedure was modified numerous times and age with increases in abdominal pressure. This is not effec-
employed several different sling materials, yet it never gained tively treated by correcting only hypermobility. Splitting SUI
popularity because of the high incidence of permanent uri- into these two distinct categories is not quite that simple be-
nary retention, de novo detrusor overactivity, and urethral cause urethral hypermobility and ISD are not mutually exclu-
erosion. The pubovaginal autologous fascial sling (PVS) was sive. It is important to note that the severities of urethral
repopularized by M cGuire and Lytton in 1978 when they hypermobility and sphincteric incompetence are on a contin-
reported their modification of the technique with little mor- uum and that both exist to some degree in all incontinent pa-
bidity and 80% success in a complicated population with tients. Also, significant urethral hypermobility can be present
urodynamic proven intrinsic sphincter deficiency (ISD)(1). In in a woman, yet she can be completely continent since her
a more contemporary series with 247 patients who had either sphincteric mechanism is intact (4).
Type II or III stress urinary incontinence (SUI) and 44% pa- Traditionally, many urologists routinely used a PVS for all
tients who had concomitant urge incontinence, the authors types of incontinence since it effectively corrected both ISD
reported a cure rate of 91% for Type II incontinence and and urethral hypermobility. In 1996 Ulmsten et al. (5) intro-
84% for Type III. Also in this series, of those patients with duced an effective synthetic midurethral sling procedure that
preoperative urge incontinence, 74% had resolution after was minimally invasive and very effective for SUI secondary to
surgery (2). O ther authors have duplicated these results, with urethral hypermobility [Tension-Free Vaginal Tape (TVT,
cure or improvement in up to 92% of women with 10 years Gynecare)]. In later studies, the TVT has been shown to be
of follow-up (3). somewhat effective in treating ISD; however, success rates
Female SUI is classified as being due to urethral hypermo- vary significantly, from 17.0% to 91.4% (6,7). The
bility (Type I and Type II SUI), intrinsic sphincter deficiency polypropylene midurethral sling and its modifications (includ-
(Type III SUI), or a combination of the two. In Type I and II ing the transobturator route of sling placement: the TO T)
SUI the urethral sphincter functions essentially normally, but have changed the landscape of stress incontinence surgery.
abdominal pressure drives the sphincter into a position where The need to determine if a patient has a small amount of ISD
its function is compromised. Therefore, procedures that cor- versus pure hypermobility is less critical, and for many sur-
rect this urethral hypermobility, such as the Burch colposus- geons synthetic slings are their operation of choice for primary
pension or synthetic midurethral slings, are effective. In treatment of SUI. Currently, more invasive surgery like the
contrast, ISD is characterized by a relatively immobile urethra pubovaginal sling is reserved for specific indications.
noted. If no leakage can be elicited with several well-performed

DIAGNO SIS Valsalva maneuvers, vigorous coughing can be used with the
knowledge that the ALPP will be falsely elevated. If the patient
Preoperative evaluation is directed toward identifying ISD, has significant prolapse, it should be reduced with a vaginal
which can often be done on history, as these patients have se- pack or pessary to ensure that the prolapse is not masking the
vere leakage with minimal activity. ISD only occurs in 9% of incontinence. Even if the patient has SUI without reduction of
women with SUI who have never had any incontinence the prolapse, placement of a vaginal pack will often demon-
surgery, but that percentage increases to 25% if they have had strate a greatly reduced ALPP, which can change the contem-
one prior failed incontinence surgery and to 75% after two plated procedure. The exact urodynamic definition of ISD is
failures (8). Concurrent urgency symptoms are not uncom- controversial, with some authors utilizing maximum urethral
mon, and most patients have a history of multiple urethral or closure pressure (M UCP) 20 cm H 2 O (6), others valsalva
vaginal surgeries, have had radiation therapy, or are elderly. leak point pressure (VLPP) 60 cm H 2 O (2), and some the
N eurologic ISD is characterized by severe incontinence with combination (7). We consider an ALPP 60 cm H 2 O to be
total nonfunction of the proximal sphincter and an open blad- consistent with ISD. A pubovaginal sling is ideal to correct
der neck on fluoroscopic urodynamics (FUDS). It is common this kind of severe incontinence. Pure urethral hypermobility
in myelodysplasia, sacral agenesis, and T12–L1 spinal cord in- is an ALPP 90 cm H 2 O , and a gray area exists where both
juries. These injuries result in loss of the sympathetic innerva- hypermobility and ISD coexist between 60 and 90 cm H 2 O . Both
tion of the urethra at a central level, and the incontinence is of these latter conditions with less severe incontinence, barring
almost always due to ISD. contraindications, are well suited for a midurethral sling.
PHYSICAL EXAMINATIO N INDICATIO NS FO R SURGERY

The physical examination is directed toward the pelvis. A thor- Before the era of the TVT and TO T, a pubovaginal sling could
ough vaginal examination in the supine position with a half- be used to treat any kind of incontinence. H owever, since
speculum both at rest and with straining is essential. If present, these minimally invasive procedures carry less morbidity, they
prolapse should be identified, since it can be concomitantly re- have become the primary treatment for uncomplicated stress
paired to achieve optimal surgical success. If the patient has had incontinence. Pubovaginal slings are now reserved for the fol-
previous vaginal or pelvic surgery, the mucosa should be as- lowing specific indications:
sessed thoroughly for the possibility of a fistula or erosion of
foreign material. The urethra should be palpated for lesions and 1. Severe ISD: Severe ISD with an ALPP 60 cm H 2 O , espe-
then visualized at rest and with straining to assess for hypermo- cially when combined with little urethral hypermobility, is
bility. We do not routinely perform a Q -tip test, but if there is poorly treated with the minimally invasive midurethral
any uncertainty about the amount of hypermobility, one can be slings. Cure rates are reported to be as low as 17% if both
performed. A supine stress test should then be done to identify conditions coexist (6). An autologous PVS is ideal in this
urethral incontinence. O ne can safely presume that a patient instance, and success is expected to be from 84% to 92%
with an immobile urethra plus severe SUI has ISD. even in the presence of DO (2,3).
2. N eurogenic incontinence: Children or adults with neuro-
genic voiding dysfunction from myelodysplasia, sacral
agenesis, or T12-S1 spinal cord injury are ideal candidates
INVESTIGATIO NS for autologous PVS (Fig. 40.1). Their incontinence is in-
variably due to ISD, and they have both proximal sphincter
O ne should always confirm the absence of urinary tract infec- dysfunction and an open bladder neck that requires a com-
tion with a urinalysis. If infection is present, it must be treated pressive sling to resolve their leakage (9). The anatomy is
preoperatively. A cystoscopy is performed if hematuria is pre- similar with incontinence from a pelvic nerve injury sec-
sent to rule out malignancy or if the patient has had previous ondary to rectal surgery, a traumatic pelvic crush injury, or
incontinence surgery to rule out suture or tape erosion. posthemipelvectomy incontinence. M idurethral slings are
Routine cystoscopy is not necessary. designed to be tension-free and do not compress the ure-
Urodynamic evaluation is performed on patients with se- thra. In addition, many of these patients have an areflexic
vere incontinence or mixed symptoms. A postvoid residual is bladder or have had augmentation cystoplasty and require
measured before insertion of the urodynamic catheter. A cys- lifelong clean intermittent catheterization that could cause
tometrogram is then carried out to rule out poor detrusor urethral erosion in the presence of synthetic mesh. Also, the
compliance and detrusor overactivity (DO ). Poor compliance use of an autologous material for a PVS is especially impor-
needs to be medically or surgically treated before PVS place- tant in the pediatric population since it will grow with the
ment or the upper tracts can be at risk of deterioration after child and can safely allow vaginal delivery if the child has a
the outlet no longer leaks. Also, one needs to counsel patients pregnancy later in life (9).
that although DO may actually resolve 74% to 77% of the 3. Failed midurethral sling: If patients have persistent stress
time (2,3), it may persist or worsen. The urodynamic abdomi- incontinence after a midurethral sling, it is possible that
nal leak point pressure (ALPP) is the key to diagnosing ISD. they had severe ISD initially. Their persistent incontinence
With the bladder filled to 200 mL (with children to one-half is unlikely to be corrected by placing another midurethral
their functional bladder capacity) and the patient in an upright sling. A prior midurethral sling does not make placement
position, a Valsalva maneuver is performed until leakage is of a PVS more difficult or less successful.
4. Previous tape erosion: Any patients with erosion of tape or

mesh into the urethra are at high risk of ISD after removal
and may have some urethral tissue loss. They should not
have any more synthetic material placed in their vagina
due to a high risk of re-erosion or urethrovaginal fistula
formation. Also, any patients with persistent incontinence
and a vaginal extrusion of mesh or a tape are better served
with removal of the foreign body and a PVS rather than
placement of more mesh.
5. Contraindications to midurethral slings: There are several
conditions in which urethral reconstruction is necessary,
such as an eroded urethra from a neglected indwelling
catheter, severe urethral stricture requiring female urethro-
plasty, urethrovaginal fistula, or a urethral diverticulum.
In these procedures, mesh cannot be left near the healing
urethra because there is a significant risk of erosion and/or
fistula formation. A pubovaginal sling provides another
A tissue layer of closure for the urethral repair that actually
promotes healing. Similarly, if a patient has SUI and has
had bladder or cervical radiation, the placement of syn-
thetic material in the vagina is at high risk for complica-
tions like erosion, so only autologous tissue PVS should be
used. O ther specific circumstances in which the use of syn-
thetics is contraindicated include neobladder-related SUI
or any other previous bowel substitution of the urethra.
6. Permanent clean intermittent catheterization: In any in-
stance where lifelong clean intermittent catheterization
(CIC) will be required, an autologous material should be
used, as patients are at risk for urethral erosion of their
mesh.
ALTERNATIVE THERAPY
M idurethral slings do have moderate success in cases of
milder ISD, and they could be attempted with the knowledge
B that the success will not be equivalent to a PVS. For patients
with significant comorbidities and high surgical risk, urethral
calcium hydroxyapatite or collagen injections are a good op-
tion for ISD. Published results show a 74% to 71% improve-
ment in incontinence and a 39% to 37% cure with an average
of two injections (10). Urinary diversion is a last resort when a
pubovaginal sling would be impossible, such as in instances of
complete urethral loss or concomitant intractable vesicovagi-
nal fistula.
SURGICAL TECHNIQ UE
A single dose of a prophylactic antimicrobial agent is adminis-
tered, and the patient is given a general or spinal anesthetic. The
procedure is performed in a low modified dorsal lithotomy po-
sition using Allen stirrups. A 16Fr urethral catheter is placed,
and the balloon is inflated with 10 mL of water to allow palpa-
tion of the bladder neck. Preparation and draping of the patient
is done in a manner to allow for the simultaneous exposure of
C
the vagina and lower abdomen. We prefer to perform the ab-
FIGURE 40.1 A: Fluoroscopic urodynamics (FUDS) image of a girl dominal dissection first to minimize vaginal bleeding.
with myelomeningocele and a previous bladder augmentation with In order to harvest the autologous fascial sling, an 8- to
small bowel. She has an artificial sphincter in place, but it has eroded
and requires removal. B: After removal she has severe stress inconti- 10-cm Pfannenstiel skin incision is made 2 cm above the sym-
nence from a wide-open bladder neck. C: A pubovaginal sling (PVS) physis. This incision is carried down to the underlying fascia,
was placed and this girl is now continent. and the subcutaneous fatty tissue is cleaned off the fascia. A
FIGURE 40.2 H arvesting of the rectus abdominis fascial sling. The

sling should be at least 8 to 10 cm long and 1.5 to 2.0 cm wide in the FIGURE 40.3 The vaginal dissection is performed superficially to the
center. The sling ends are folded and then sutured with 1-0 absorbable white periurethral fascia. With the scissors parallel to the plane of the
sutures incorporating all of the fibers. perineum and tips pointing superiorly and laterally, the retropubic
space is entered and subsequently enlarged by further advancing the
scissors 1 to 2 cm and then opening them.
relatively scar-free area of fascia is selected for the sling, but

even thickened and scarred fascia can be used with success.
Using a scalpel, the fascia is incised 2 cm above the symphysis inserts on the symphysis. The fascia is bluntly perforated,
in the midline. With the M etzenbaum scissors, the incision is and a tunnel is created by hugging the posterior aspect of the
carried out laterally, parallel to the fibers. The superior leaf of pubic symphysis to avoid perforating the bladder. The blunt
the fascia is grasped with two Allis clamps and the underlying dissection continues distally to the level of the bladder neck
rectus muscles dissected off for a distance of 2 to 3 cm. The in- (Fig. 40.4). If the patient has not had prior surgeries, this tis-
ferior leaf is then freed in a similar fashion. This aggressive sue plane is easily dissected. H owever, if the patient has had
mobilization will later allow a tension-free fascial closure. prior procedures (e.g., retropubic suspension, bone-anchored
N ext, the sling should be harvested from the inferior leaf. The sling, or transobturator tape placement), M etzenbaum
upper leaf can alternatively be used if the tissue appears scissors may need to be used to develop the retropubic tun-
healthier or stronger. The sling should ideally be 8 to 10 cm nels. In this instance, it is especially important to place the tips
long, 1.5 cm wide in the midline, and tapered to about 1 cm of the scissors only directly on the posterior pubis periosteum
on either end (Fig. 40.2). The ends of the sling are tapered to to avoid bladder or vascular injury. Also, scarring may neces-
facilitate its passage through the endopelvic fascia. Using sitate starting the tunnel dissection between the two rectus
0-Vicryl or Prolene, both ends of the sling are then sutured 0.5
cm from the end of the sling. A figure-of-eight stitch is placed
and then tied and cut, leaving 15 cm of free suture. O nce the
sling is harvested, it is placed in normal saline.
Attention should now be turned to the vaginal dissection. If
necessary, the position of the patient’s legs can be adjusted for
better visualization. A weighted vaginal speculum is placed.
Using the catheter as a reference, the urethrovesical junction is
identified via palpation. To assist with hemostasis, the vaginal
mucosa can then be injected with a dilute vasopressin solution
(we prefer 10 U or 0.5 mL of vasopressin in 50 mL of normal
saline). The mucosa inferolateral to the urethral meatus is
grasped with two Allis clamps and traction placed superiorly
for the entire vaginal part of the procedure. An inverted U inci-
sion is made in the vaginal epithelium at the level of the
midurethra (1 to 2 cm proximal to the urethral meatus) using a
scalpel. This flap is carefully dissected down to the level of the
periurethral fascia using Church scissors and carried out later-
ally to the endopelvic fascia with the M etzenbaum scissors.
Then, using blunt-tipped scissors, the retropubic space is en-
tered by perforating the endopelvic fascia bilaterally using a
careful “ push and spread” technique (Fig. 40.3).
In the abdominal incision, the transverse fascia can be seen FIGURE 40.4 Blunt finger dissection creates a tunnel to the rectus
with medial retraction on the lateral border of the rectus mus- muscles above. Wide dissection is unnecessary and may cause signifi-
cle. It appears as a yellowish cleft where the rectus muscle cant bleeding or bladder injury.
FIGURE 40.5 The approach to the retropubic space from above is lo-
cated below the rectus fascia and lateral to where the rectus muscles
attach to the pubic symphysis. M inimal dissection in the area allows
safe and easy access to the retropubic space previously dissected by FIGURE 40.6 Using manual guidance, a Crawford clamp is passed
the vaginal operator. from above toward the vaginal incision with the tip of the clamp in
contact with the pubic periosteum and the vaginal operator’s finger.
After the passage of clamps bilaterally, cystoscopy is performed to
ensure no injury to the bladder has occurred.
muscles (rather than lateral to them) before developing the

retropubic space.
Ultimately, the bladder should be cleared from the created
tunnels, and the tunnel should easily accommodate one finger.
This step ensures that the sling will be easily advanced
through the endopelvic fascia once it is placed and that the
bladder will not be perforated with passage of the sling.
A long curved clamp such as the Crawford clamp or, in
cases of scarring, the M cGuire ligature passer, can be used to
pass the sling through the created tunnels. The ligature can be
passed either from “ bottom to top” or “ top to bottom.”
Generally, we prefer to pass from “ top to bottom” unless
there is severe vaginal scarring. In order to accomplish this,
the carrier is gently advanced into the created cleft lateral to the
rectus from above until its leading flat portion is in contact
with the symphysis (Fig. 40.5). N ow with one hand above
and one below in the vagina, it is advanced along the symph-
ysis until its tip is palpable from the vaginal incision (Fig.
40.6). Then the carrier is advanced past the bladder into the
vaginal incision over one’s finger. There are typically only a
few millimeters of tissue that need to be perforated during
this step. If more tissue is present, one has to be highly suspi- FIGURE 40.7 The sling ends are pulled well into the retropubic space
cious that the bladder has not been mobilized sufficiently and to allow good fixation. The sling is seated at the proximal urethra and
sutured to the periurethral fascia using 3-0 absorbable sutures.
is at risk of perforation. The sling sutures on one end are
loaded on the passer, which is then pulled back up into the
abdominal incision and marked with a clamp. The same pro-
cedure is repeated on the opposite side. The sling is now in a N ext, the center of the sling is anchored to the midline peri-
position behind the proximal urethra with both suture ends urethral tissues with a fine, absorbable suture. This is to pre-
in the suprapubic incision. After each pass of the ligature car- vent malpositioning of the sling with tensioning later. The
rier, cystoscopy should be performed to ensure bladder in- vaginal epithelium is then closed with an absorbable suture in
tegrity. The longevity of the sling does not depend on the a running fashion to maintain hemostasis.
sutures to hold tension (because they are absorbable); rather, Tensioning the sling is the final abdominal portion of the
it depends on the sling being well advanced into the retropu- procedure. Using a pointed-tip clamp like a Tonsil, two lat-
bic space bilaterally. Thus, it is critical that a good portion of eral perforations are made through the inferior leaf of the
the sling extends into the retropubic space to allow proper rectus fascia. The sling sutures are passed through these per-
fixation with healing (Fig. 40.7). forations and marked with clamps. The rectus fascia is then
Cro sso ve r Sling

In patients with a widely open bladder neck and proximal ure-
thra, such as with myelomeningocele or with extremely low
ALPP ( 10 cm H 2 O ), more circumferential compression is re-
quired from the sling. To accomplish this, the sling can be
“ crossed over.” The sling is harvested longer than usual (10 to
14 cm). During retropubic dissection, not only are tunnels cre-
ated, but the entire retropubic space is dissected to expose the
anterior bladder and proximal urethra. The sling is passed in
the usual fashion and fixed on the urethra through the vaginal
incision, but before passing the sling sutures through the fascial
perforations, they are crossed over, allowing the sling to sur-
round the bladder neck rather than just suspending it. The su-
tures are tied as usual, but tensioning is more difficult to judge
since the force is compressive (Fig. 40.10).
Alt e rnat ive Graft Mat e rial

FIGURE 40.8 The sling sutures are passed through the rectus fascia When considering choices for sling graft materials, there is
before the fascia is closed. The vaginal mucosa is closed, the weighted much debate in the literature. Some have advocated decreas-
speculum removed, and the sling sutures tied down over the rectus ing the potential morbidity of harvesting the sling by using
fascia under minimal tension.
allografts such as cadaveric fascia (11) or other synthetic ma-
terials. H owever, autologous fascia has been shown to have
closed using a running delayed absorbable suture (Fig. 40.8). better surgical outcomes than any of these other materials.
The sling can then be tensioned. The appropriate tension Several synthetic materials have been used as sling material for
is the minimum amount required to stop urethral motion. the PVS: woven polyester injected with collagen (ProteGen, re-
This can be judged by pulling on the transurethral catheter called from market), polytetrafluoroethylene (Gore-Tex), sili-
and ensuring that the bladder neck descends no 0.5 to 1.0 cone, and polypropylene. They have all been associated with
cm. A shodded clamp can be used to hold tension on the significant complications like fistulas and urethral and vaginal
crossed sutures until this appropriate tension is obtained erosions (12), and none are in common usage for PVS.
(Fig. 40.9). The sutures are then tied down. Two fingers Recently, H owden et al. (13) compared cadaveric with au-
should be able to be passed under the sutures in the suprapu- tologous fascial slings in 303 women. They found that the
bic incision. Finally, the skin is closed with an absorbable group of women who underwent placement of cadaveric fas-
fine suture such as 4-0 M onocryl, and a vaginal pack is cia had a higher rate of urinary incontinence (16 versus 5 per
placed if needed. 100 woman-years, p 0.0001) and had greater reoperation
The urethral catheter and any vaginal packing are re- rates (4 versus 1 per 100 woman-years, p 0.0003) than the
moved the following morning, and patients are started on group with autologous fascia. Several studies have also shown
CIC. O nce they are adept at self-catheterization, they are dis-
charged home. M ost patients are discharged on the first post-
operative day since they were given instructions on CIC
preoperatively.
FIGURE 40.10 This crossed sling surrounds the urethra. It provides a

more compressive force than a traditional sling. For ease of place-
FIGURE 40.9 A lateral view of the completed pubovaginal sling ment, a slit can be made in the center of the sling and the other end
procedure. threaded through.
superior continence in the use of autologous fascia over the De No vo Urg e Inco nt ine nce
porcine xenograft Pelvichol as a PVS (14). While autologous M any patients have preexisting urge incontinence, and this
fascia remains the sling material of choice, Pevichol is a viable should not preclude PVS placement, since as many as 74% to
alternative when native fascia cannot be harvested due to poor 77% (2,3) will actually have resolution of their urge inconti-
quality. Autologous fascia lata is a good-quality alternative to nence along with their stress incontinence. De novo, or new-
rectus fascia (11), but its use is limited because it requires an- onset, urge incontinence will occur in 3% to 7% (2,3,15) of
other incision. patients. O ne needs to ensure that bladder outlet obstruction
is not present, since the symptoms of these two conditions of-
ten overlap. They can be differentiated with a careful history,
O UTCO MES physical examination, postvoid residual, and often urody-
namic examination. For de novo urge incontinence or overac-
Co mp licat io ns tive bladder symptoms that persist in the postoperative period,
anticholinergic medications are helpful and often can be dis-
Blad d e r Pe rfo rat io n and He mat o ma continued after 3 months (1). If patients do have actual ob-
struction, they require midline sling incision.
Bladder perforation is very rare during PVS, since the bladder is
exposed during dissection. It has been reported to occur in only Ero sio n
0.6% of cases in two large series (3,15). This is much lower in Erosion of sling material into the urethra or vagina is a diffi-
comparison to other surgeries for SUI like the TVT (8.6% ) (7) cult complication to treat, especially with synthetic materials.
and the Burch (3% ) (15). Bladder perforation occurs during Although not impossible, the occurrence of autologous PVS
passage of the ligature from above and is detected either by cys- has been reported in a few series, but the rate is estimated to
toscopy or by observing that the urine is bloody. The clamp be as low as 0.007% (12).
should be repassed and its position verified by cystoscopy. A
urethral catheter should be left in place for 7 to 10 days while
on antibiotic prophylaxis and a voiding trial done upon re- Re sult s
moval. Pelvic hematoma can also occur in 0.8% (2) of cases,
and these patients should be followed closely for superinfection. In 1998, Chaikin et al. (3) found that 92% of 251 women
with Type II or Type III SUI who underwent placement of a
Pro lo ng e d Urinary Re t e nt io n pubovaginal sling had cure or improvement of their inconti-
With autologous pubovaginal slings, all women will need to nence at a follow-up of 3 years with durable results at ten
initially perform CIC for a period of approximately 2 weeks, years. Similarly, M organ et al. (2) reported continence rates of
with an average of 8.4 days (2). Thus, all patients should be 88% at 4 years in 247 patients after sling placement. O f this
given preoperative instructions about CIC technique and reas- cohort, 92% reported that they were “ highly satisfied” with
sured that this is a common occurrence. H owever, the pro- their outcomes on a quality-of-life assessment. A randomized
longed need for CIC for 6 weeks occurs in 2.0% to 13.5% of controlled trial involving 520 women by the Urinary
women (2,3,14) and requires surgical intervention in 2.5% to Incontinence Treatment N etwork (15) compared the PVS to
6.3% (2,3,15). It is our practice to surgically intervene with the Burch colposuspension and at 2 years found the PVS to be
vaginal midline sling incision at a maximum of 4 to 6 weeks, superior in the treatment of SUI.
should spontaneous voiding not return. The goal of this proce-
dure is not to remove the sling, but to simply divide it in the
middle. It is a straightforward procedure with little morbidity, CO NCLUSIO N
and surprisingly few patients have recurrence of their SUI. Thiel
et al. (16) reported a case series with 11 patients who had their The autologous pubovaginal sling is a durable and highly suc-
PVS cut at an average of 65 days after surgery. Even after 5 cessful treatment for SUI. It is more invasive than the TVT or
years of follow-up, 7 out of 11 patients had no incontinence TO T, but it is the most appropriate treatment for SUI in cer-
episodes per day, and only 1 out of 11 had more than three tain specific instances like severe ISD or if the risk of erosion is
episodes of incontinence daily, with all 11 patients voiding high. The PVS should be included in the armamentarium of
spontaneously. any surgeon treating SUI.
References
1. M cGuire EJ, Lytton B. Pubovaginal sling procedure for stress incontinence. 5. Ulmsten U, H enriksson L, Johnson P, et al. An ambulatory surgical proce-
J Urol 1978;119:82–84. dure under local anesthesia for treatment of female urinary incontinence.
2. M organ TO Jr, Westney O L, M cGuire EJ. Pubovaginal sling: 4-year out- Int Urogynecol J Pelvic Floor D ysfunct 1996;7:81–86.
come analysis and quality of life assessment. J Urol 2000;163:1845–1848. 6. Clemons J, LaSala C. The tension free vaginal tape in women with a non-
3. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for all types of hypermobile urethra and low maximum urethral closure pressure. Int
stress urinary incontinence: long term analysis. J Urol 1998;160:1312–1316. Urogynecol J 2007;18:727–734.
4. Schick E, Dupont C, Bertrand PE, et al. Predictive value of maximum ure- 7. Ghezzi F, Serati M , Cromi A, et al. Tension-free vaginal tape for the
thral closure pressure, urethral hypermobility and urethral incompetence in treatment of urodynamic stress incontinence with intrinsic sphincteric
the diagnosis of clinically significant female genuine stress incontinence. deficiency. Int Urogynecol J 2006;17:335–339.
J Urol 2004;171:1871–1876.
8. M cGuire E. Urodynamic findings in patients after failure of stress inconti- 13. H owden N , Z yczynski H , M oalli P, et al. Comparison of autologous rectus
nence operations. In: Z inner N R, ed. Fem ale incontinence. N ew York: fascia and cadaveric fascia in pubovaginal sling continence outcomes.
Alan R. Liss, 1981:351–356. A m J O bstet G ynecol 2006;194(5):1444–1449.
9. M cGuire E, Wang CC, Usilato H , et al. M odified pubovaginal sling in girls 14. M organ D, Dunn R, Fenner D, et al. Comparative analysis of urinary in-
with myelodysplasia. J Urol 1986;135:94–96. continence severity after autologous fascia pubovaginal sling, pubovaginal
10. Mayer R, Dmochowski RR, Appell RA, et al. Multicentre prospective ran- sling and tension-free vaginal tape. J Urol 2007;177(2):604–608; discus-
domized 52-week trial of calcium hydroxyapatite versus bovine dermal colla- sion 608.
gen for treatment of stress urinary incontinence. Urology 2007;69:876–880. 15. Albo M E, et al. Burch colposuspension versus fascial sling to reduce uri-
11. Flynn B, Brian J, Yap W, et al. Pubovaginal sling using allograft fascia lata nary stress incontinence. N Engl J M ed 2007;356(21):2143–2155.
versus autograft fascia for all types of stress urinary incontinence: 2-year 16. Thiel D, Pettit P, M cClellan W, et al. Long-term urinary continence rates af-
minimum followup. J Urol 2002;167(2, Pt 1):608–612. ter simple sling incision for relief of urinary retention following fascia lata
12. Kobashi K, Dmochowski R, M ee SL, et al. Erosion of woven polyester pubovaginal slings. J Urol 2005;174(5):1878–1881.
pubovaginal sling. J Urol 1999;162:2070–2072.
CHAPTER 41 ■ SYNTHETIC MIDURETHRAL

RETRO PUBIC SLINGS
BHAVIN N. PATEL AND GO PAL H. BADLANI
The past decade has seen a shift from suspension procedures seled regarding an increased risk of urinary retention after a
to sling procedures as the treatment of choice for stress uri- midurethral sling.
nary incontinence (SUI). The bladder neck and proximal ure-
thra were considered zones for continence procedures in
patients with SUI. Traditionally, a sling at the bladder neck, INDICATIO NS FO R SURGERY
using fascia, was reserved for failed suspension or severe cases
of intrinsic sphincteric deficiency (ISD). Those patients with SUI and a moderate to severe bother on
The integral theory, proposed by Petros and Ulmsten, ad- the quality-of-life (Q O L) score who fail or cannot tolerate
vanced the concept of midurethral support for a hypermobile nonsurgical modes of management should be considered for
urethra and anterior vaginal wall (1). The tension-free syn- surgical correction. Patients with urethral hypermobility (indi-
thetic tape replaces and recreates the midurethral ligaments, cated by 30-degree deflection on office Q -tip test), no signif-
which results in kinking or coaptation of the urethra with icant prolapse, and mild to moderate intrinsic sphincteric
increase in the intra-abdominal pressure but has little or no deficiency (leak point pressures 60 cm H 2 O ) are ideal candi-
effect on detrusor-initiated voiding or incontinence. dates for midurethral synthetic slings. Patients with ISD, lack
of hypermobility, and leak point pressure (LPP) 60 cm H 2 O
are candidates for bladder neck sling.
DIAGNO SIS Prior anterior vaginal wall surgery, age over 70, obesity,
and prior failed sling are not contraindications to midurethral
Patients with SUI present with the complaint of involuntary slings but require a higher degree of skill and prior experience
urinary loss with increased intra-abdominal pressures, as in with vaginal surgery. Studies have demonstrated no overall
coughing, laughing, or during Valsalva. The diagnosis can be difference in outcome when procedures such as vaginal hys-
made based on history and physical examination and quanti- terectomy or vault suspension are performed in conjunction
fied with a pad test. Attention should be paid to any associated with a midurethral sling (2). Severe ISD at rest with or without
prolapse, symptoms of overactive bladder (O AB), urge inconti- hypermobility, previous urethral surgery or injury, urethral di-
nence (UI), or significant postvoid residual urine. The utility of verticulum, pelvic radiation, poor vaginal epithelium, pipe-
urodynamic testing is debatable in the diagnosis of primary stem urethra, and hypersensitivity to the synthetic materials
SUI; however, it is helpful in cases that are not as straightfor- are contraindications to midurethral synthetic slings.
ward and in cases complicated by the aforementioned patholo-
gies, and it is required in recurrent SUI after failed surgery.
In patients with associated vaginal prolapse, the SUI may ALTERNATIVE THERAPIES
be occult and become evident only with the reduction of the
prolapse. Patients with O AB and/or UI with SUI should be Nonsurgical alternative therapies to the midurethral sling
counseled regarding the fact that their O AB or UI may not im- include limited fluid intake, bladder training, timed voiding,
prove with a midurethral sling. Finally, patients with postvoid Kegel exercises, pessaries, and medical therapy, including
residual urine, depending upon its etiology, should be coun- alpha-adrenergic drugs and off-label use of imipramine and
Chap t e r 41: Synthe tic Mid ure thral Re trop ub ic Sling s 279
duloxetine. The use of hormone replacement therapy is contro- too, as stiffer slings are more prone to erosion. Additionally, our
versial. The use of pads and in rare cases an indwelling catheter research shows a biochemical defect in patients with SUI and
to deal with SUI is to be discouraged. N onsurgical manage- prolapse resulting in a faster rate of breakdown of collagen and
ment is only efficacious in mild SUI and often does not provide elastin, supporting the use of synthetic mesh (7).
adequate relief in moderate or severe SUI. Surgical alternatives
include injectable bulking agents, open or laparoscopic Burch
procedure, bladder neck sling, transobturator sling (TO T), and SURGICAL TECHNIQ UE
the recently introduced minisling and prepubic sling.
Injectable bulking agents work by increasing urethral resis- An informed consent is obtained, informing the patient of ex-
tance and are indicated in patients with ISD and a fixed (not pected outcomes and possible complications such as retention,
hypermobile) urethra. There are a variety of techniques and de novo or persistent O AB, adjacent organ injury, recurrence
injectable materials, each of which has a material-specific suc- of incontinence, risk of developing prolapse, erosion, and ex-
cess rate that decreases as time from injection increases. They posure of mesh, in addition to the standard surgical and anes-
require reinjection, and complications may include sterile ab- thetic risks.
scess formation, irritative voiding symptoms, pelvic pain, ec- Aspirin and other anticoagulants are discontinued 5 to 7
topic calcifications, and transient urinary retention. days preoperatively. A flouroquinolone is started 48 hours
O pen Burch and midurethral sling in a randomized trial prior to surgery, and the patient receives routine preanesthetic
showed an equal efficacy in a short-term follow-up with de- instructions for the night preceding the surgery. N o food or
creased morbidity with the midurethral sling (3). liquid is allowed 8 to 10 hours prior to the procedure, laxa-
Bladder neck sling is indicated in patients with ISD with or tives are prescribed for patients who suffer from constipation,
without urethral hypermobility and SUI manifested by lower and preoperative labs including complete blood count, serum
urethral closure pressures. The material used in the suspension electrolytes, coagulation studies, urinalysis, and urine culture
varies per the surgeon’s preference. To minimize the morbidity are obtained. The procedure should be postponed in the pres-
of the traditional fascial sling, synthetic and other biomaterials ence of active urinary tract infection or coagulopathy.
can be used; success with these materials has been reported (4). O n the day of surgery, a parenteral antibiotic, such as a
Transobturator suburethral support was developed in an first-generation cephalosporin or a fluoroquinolone, is admin-
effort to decrease the risk of injury to adjacent structures such istered and continued for 24 hours. The choice of local anes-
as large vessels, bowel, and the bladder. Its indications are the thesia with sedation, spinal block, or general anesthesia
same as those for the midurethral sling described above. depends on the surgeon, anesthesiologist, and patient prefer-
Compared with the midurethral sling, TO T required less oper- ences. Sequential compression devices are used on the lower
ative time (5) and had similar rates of success, but it was asso- extremities prior to the induction of anesthesia. The procedure
ciated with a higher rate of groin or thigh pain, vaginal is performed in the dorsal lithotomy position using Allen stir-
injuries, and tape erosion (6). rups. The lower abdominal and pubic areas are shaved, pre-
There is limited peer-reviewed information on the use of pared, and draped using a Lingeman Gyn surgery drape
minislings or prepubic slings. (M icrotek M edical, Isolyser H ealthcare, Columbus, M S).
To retract the labia, a Lone Star surgical retractor (M edical
Products Inc, H ouston, TX) is used. Alternatively, the labia
CHO ICE O F MATERIAL can be sutured laterally. Weighted vaginal speculums can be
used to better expose the anterior vaginal wall during dissec-
The choice of sling material is a key component of midurethral tion, but they should be removed before tensioning the sling.
sling surgery. The materials used for the slings are divided into A 20Fr urethral catheter is placed, the bladder is drained, and
the following categories: autologous fascia, cadaveric allograft, the balloon is palpated at the bladder neck.
xenograft, and synthetics. Rectus fascia and fascia lata have An Allis clamp is placed at the bladder neck and 1 cm
been harvested for SUI surgery. The advantages of using autol- proximal to the urethral meatus. Injectable M arcaine, 5 mL, is
ogous fascia are its durability, its availability, and its nonim- infiltrated into the anterior vaginal wall, along the midline be-
munogenic quality. H owever, difficulty in procurement, longer tween the two Allis clamps, to facilitate the dissection. A 2-cm
operative times, increased patient morbidity, and late sling con- midline incision is made between the urethral meatus and the
traction limit its use today. Cadaveric allograft and xenograft bladder neck to avoid injury to the somatic and autonomic
tissues have also been used because they are readily available neurons that travel laterally through the anterior vaginal wall
and do not require procurement from the patient. O n the other to the urethra and supply the urethral sphincter.
hand, their costs, theoretical risk of infectious transfer, me- With M etzenbaum scissors, flaps of the anterior vaginal
chanical variability, and unpredictable outcome have limited wall are developed bilaterally, aiming toward the ipsilateral
their use. In our practice we reserve cadaveric allograft and shoulder. Traction is applied on the vaginal wall with Allis
xenograft to cases where synthetic mesh is contraindicated. clamps to facilitate flap dissection, avoiding too much trac-
Synthetic meshes are readily available and highly durable, tion, which may tear the flap. M inimal bleeding is noted if the
maintain their strength over time, are free of potential correct depth of dissection is reached.
pathogens, and are less expensive. A variety of synthetic materi- For the suprapubic arch (SPARC) sling kit (American
als are available; the current standard is a monofilament, large- M edical Systems), 1% lidocaine is injected at the skin on the
pore, soft mesh made out of polypropylene. This mesh has lower superior portion of the symphysis, 2.5 cm lateral to the mid-
rates of erosion when compared to multifilament (Mersilene). line. Small stab incisions are made at the areas of infiltration
Pore size is pivotal in allowing incorporation of host fibroblasts, with a no. 15 blade knife. At this point, the bladder is once
macrophages, and leukocytes. Stiffness is an important factor again emptied to avoid injury, and the needle is passed with
FIGURE 41.2 Anatomic lie of the midurethral sling.
local anesthetic is injected suprapubically at the lateral aspects

of the pubic symphysis toward the ipsilateral vaginal dissection
to aid in sling placement. The tip of the Foley catheter with a
catheter guide is placed on contralateral traction to avoid injury
to the bladder. The TVT needle is placed in the vaginal incision
and aimed toward the ipsilateral scapula. The needle is ad-
FIGURE 41.1 Placement of the suprapubic arch (SPARC) needles. vanced along the posterior aspect of the pubic bone and then
brought to the skin at the lateral aspect of the symphysis, and a
stab incision is made to deliver the needle through the skin. The
the dominant hand through the suprapubic incision behind needle placment is repeated on the contralateral side. A key step
the pubic bone. The needle is advanced toward the ipsilateral is to avoid lateral rotation of the needle and avoid proximal
vaginal dissection, guided by contact with the posterior aspect passage away from the bone. Cystoscopy is performed to iden-
of the bone. The needle handle is displaced posteromedially as tify bladder injury. Extra care is needed if the patient has had an
the tip advances further through the space of Retzius. open or laparoscopic procedure in the pelvis, as bowel may be
At this point the nondominant hand should be placed along adherent to the retropubic space.
the ipsilateral vaginal dissection plane, and the needle tip The sling should be examined to ensure that no twisting has
should be palpated. The needle is then advanced out of the occurred. The sling is then adjusted until the appropriate ten-
vaginal wound. This method of needle placement minimizes sion has been achieved, avoiding too much or too little tension.
the risk of injuring adjacent large vessels and nerves but not the This is often done by ensuring that a 22Fr cystoscopic sheath
bladder or the urethra. The needle placement is then repeated passes freely through the urethra or by placing a pair of clamps
on the contralateral side (Fig. 41 . 1). The urethral catheter is re- between the tape and the midurethra as the sling is adjusted.
moved and cystoscopy is performed to assess for bladder in- O nce positioning is satisfactory, the plastic covering is cut and
jury. Injury to the bladder most commonly occurs along the removed, redundant sling at the suprapubic incision is excised,
superolateral aspects of the bladder. Blood seen on entering the and the suprapubic wounds are closed with Dermabond and
bladder, visualization of the needle, or bladder submucosal the vaginal wound closed with 2-0 Vicryl suture.
movement with motion of the needle are all indicators of blad- At the end of the case, a Foley catheter is placed as well as
der injury. If bladder injury has occurred, the ipsilateral needle a Betadine-soaked vaginal pack. Patients are then discharged
should be removed and repositioned once the bladder has been with or without the Foley or kept in observation overnight,
drained. Also, catheter drainage postoperatively for additional depending on surgeon preference. At discharge patients are
days is indicated. A key step here is to drain the bladder before given a 5-day course of antibiotics, pain medications, and
removing the cystoscope, as the connector width is larger than stool softeners. They are also told to abstain from sexual ac-
the needle, resulting in possible shearing injury of the bladder tivity for 4 to 6 weeks. Trial of voiding can be initiated in the
wall if it is full. The sling, covered in a protective plastic sheath, recovery room if the patient has had a local anesthesia. We
is locked onto the needles with the sling indicator positioned in prefer overnight use of a Foley catheter if general or spinal
the midline at the midurethra. Once secured, the needles with anesthesia was used.
attached sling are brought back out through the suprapubic
stab incisions (Fig. 41.2).
O UTCO MES
Te nsio n-Fre e Vag inal Tap e (Gyne care ) There is good initial and durable success in treating SUI
with midurethral sling compared to the standard Burch col-
The procedure for tension-free vaginal tape (TVT) follows the posuspension (3). A recent prospective randomized study
same vaginal dissection as described above, for the placement of showed no difference in outcome between TVT (95% ) and
the SPARC sling. At this point, a solution of normal saline and SPARC (83% ) (8). These findings have been confirmed by
Chap t e r 41: Synthe tic Mid ure thral Re trop ub ic Sling s 281
other studies. Further comparision has shown no difference

in the cure rate of SUI with TVT (95% ), SPARC (90% ), or
TO T (94% ) (8).
CO MPLICATIO NS
Pe rio p e rat ive Co mp licat io ns
Intraoperative complications are mostly related to the dissec-
tion and placement of the trocar. There have been four FDA-
reported deaths due to TVTs, two associated with bowel
injury, and two associated with vascular injury. During the
procedure there is a risk of bleeding, infection, and injury to
the bladder, urethra, ureter, bowel, vessels, and nerves. O ne
thousand cases of TVT in Finland were reviewed (10), and the FIGURE 41.3 Vaginal extrusion of midurethral tape.
incidence of bladder injury, the most common complication
during needle placement, was reported as 3.8% . The risk of
postoperative bleeding was 1.9% , and that of wound infec- Vaginal extrusion (Fig. 41.3) of the tape usually occurs
tion was 1% . M ortality associated with injury to vessels has within 6 months of the initial surgery. Patients often present
been reported but is exceedingly rare and has been mentioned with vaginal discharge, dyspareunia, and feeling the tape ma-
previously. A key point is awareness, immediate recognition, terial within the vagina. The treatment of the extrusion varies
and management of the complication. according to the degree of erosion and the patient’s sympto-
matology, but it can include partial or complete removal of the
tape and closure of the vaginal mucosa over the extrusion.
Po st o p e rat ive Co mp licat io ns Urethral or bladder erosion can occur at any time in the
postoperative course but often occurs in the first 6 months af-
Postoperative complications include outflow obstruction, de ter surgery. M ost patients present with recurrent SUI, hema-
novo or persistent OAB, extrusion, and erosion. Urinary ob- turia, perineal pain, urinary tract infections, and/or irritative
struction after a midurethral sling can be brief and transient or voiding symptoms. The treatment of erosion involves removal
persistent. Transient postoperative obstruction is often due to of the intraviscous sling. This can be achieved endoscopically
edema of the urethra and the supporting structures along with in the urethra or laparoscopically in the bladder. A vaginal
pelvic pain. As the edema and pain subside, so does the obstruc- approach can result in a fistula formation and recurrence of
tion. However, patients can have persistent urinary obstruction incontinence. Thus, for a bladder erosion we prefer removing
due to a combination of previously undiagnosed prolapse and/or the intravesical portion with either a laparoscopic or open
a “ tight” sling. They often present with urgency, frequency, de- approach without disturbing the suburethral portion.
creased force of stream, positional voiding, and/or retention.
Treatment includes anticholinergic medication with monitoring
of PVR, use of CIC or consideration of sling loosening, incision, CO NCLUSIO NS
or uretholysis with or without sling revision. A recent multicen-
ter trial of an adjustable sling is being evaluated. The cost of The midurethral sling has revolutionized the approach to SUI.
such a sling is considerably higher and not supported by the low It allows many patients to improve their quality of life with
rate of retention with tension-free slings. minimal morbidity. The success depends on proper case selec-
Persistent incontinence can occur after midurethral sling. The tion and patient education.
cause, whether it is persistence of SUI, urgency- or OAB-related,
urge-related, or rarely iatrogenic fistula, must be determined.
References
1. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. 6. Latthe PM , Foon R, Toozs-H obson P. Transobturator and retropubic
Experimental and Clinical considerations. A cta O bstet G ynecol Scand tape procedures in stress urinary incontinence: a systematic review and
Suppl 1990;153:7–31. meta-analysis of the effectiveness and complications. Br J O bstet G ynecol
2. Schraffordt Koops SE, Bisseling TM , van Brummen H J, et al. Result of the 2007;114(5):522–531.
tension-free vaginal tape in patients with concomitant prolapse surgery: a 2 7. Kushner L, M athrubutham M , Burney T, et al. Excretion of collagen de-
year follow up study. An analysis from the N etherlands TVT Database. Int rived peptides is increased in women with stress urinary incontinence.
Urogynecol J Pelvic Floor D ysfunct 2007;18(4):437–442. N eurourol Urodynam 2004;23(3):198–203.
3. Ward KL, H ilton P. Tension-free vaginal tape versus colposuspension for 8. Adonian S, Chen T, St-Denis B, et al. Randomized clinical trial comparing
primary urodynamic stress incontinence: 5 year follow up. Br J O bstet suprapubic arch sling (SPARC) and tension-free vaginal tape (TVT): one-
G ynecol 2008;115(2):226–233. year results. Eur Urol 2005;47(4):537–541.
4. H om D, Desautel M G, Lumerman JH, et al. Pubovaginal sling using 9. Paick JS, Oh SJ, Kim SW, et al. Tension-free vaginal tape, suprapubic arc sling,
polypropylene mesh and Vesica bone anchors. Urology 1998;51(5):708–713. and transobturator tape in the treatment of mixed urinary incontinence in
5. deTayrac R, Deffieux X, Droupy S, et al. A prospective randomized trial women. Int Urogynecol J Pelvic Floor D ysfunct 2008;19(1): 123–129.
comparing tension-free vaginal tape and transobturator suburethral tape 10. Kuuva N , N ilsson CG. A nationwide analysis of complications associated
for surgical treatment of stress urinary incontinence. A m J O bstet G ynecol with the tension-free vaginal tape (TVT) procedure. A cta O bstet G ynecol
2004;190(3):602–608. Scand 2002;81(1):72–77.
CHAPTER 42 ■ THE TRANSO BTURATO R
APPRO ACH TO THE MIDURETHRAL SLING
PAUL HANISSIAN AND JAMES WHITESIDE
There has been significant innovation in the treatment of uri- other types of urinary incontinence, including urge inconti-
nary incontinence over the last 15 years. In the early 1990s nence. The symptom of stress urinary leakage can alone be
there was growing understanding that needle urethropexies misleading; hence it is imperative to document the sign of
did not have long-term efficacy compared to retropubic ure- stress urinary leakage before performing surgery. It is also
thropexies and pubovaginal slings. The morbidity of these lat- worthwhile to understand the patient’s fluid intake volume
ter procedures, however, set the stage for the development of a and output (i.e., bladder diary) before surgery to support the
minimally invasive approach. The tension-free vaginal tape patient’s perceptions of leakage and exclude other inconti-
(TVT) procedure was the first minimally invasive midurethral nence etiologies.
sling that came into use in the late 1990s. Developed by the There is disagreement regarding the optimal preoperative
late Ulf Ulmstem, the TVT placed a polypropylene mesh sub- testing for urinary incontinence among women. At initial eval-
urethrally with the use of curved needles passed transvaginally uation, the patient should provide a urine specimen for dip-
through the retropubic space and out through cutaneous ab- stick analysis, and then urine microscopy and culture can be
dominal incisions (1). Unlike its pubovaginal sling predeces- done as necessary. Postvoid residual volumes should be deter-
sors, the TVT mesh was not fixed to bone or fascia. The TVT mined to assess the possibility of disordered bladder sensation
mesh maintains its position through friction with the sur- or detrusor pathology leading to retention. Documentation of
rounding tissue and ultimately through fibroblast ingrowth stress urine leakage should be done; this could include multi-
into the mesh. Though clinical trials ultimately showed this channel urodynamic studies or could be done with a standard-
procedure to have similar efficacy to more traditional ap- ized cough stress test. A cough stress test involves filling the
proaches (e.g., Burch urethropexy [2]), rare complications bladder to 300 mL or to subjective fullness and then having
such as life-threatening bowel and major vascular injury along the patient forcefully cough while in an upright position.
with the requirement of cystoscopy inspired improvements in Witness of gross urine loss from the urethral meatus during
this technique. coughing is considered a positive test. The necessity of multi-
In 2001 Delorme (3) published “ Transobturator Urethral channel urodynamic testing is unclear, particularly in the low-
Suspension: M ini-invasive Procedure in the Treatment of risk patient, if the sign of stress urinary leakage is documented
Stress Urinary Incontinence in Women,” introducing the by some alternative means and the postvoid residual volumes
transobturator approach for the placement of a midurethral are normal. M ultichannel urodynamic testing could render in-
sling. Using a two-dimensional Emmet needle, a polypropy- sight into voiding and urethral competency issues. The relia-
lene mesh was passed through thigh muscles, around the bility and value of this insight are a matter of debate. Ideally,
ischiopubic ramus, and into a vaginal epithelial tunnel for the patient should not have urge incontinence or voiding dys-
placement at the midurethra. This approach dramatically re- function. Patients with mixed urinary incontinence may be ap-
duced the possibility of an intra-abdominal injury. While two propriate candidates for a transobturator midurethral sling if
approaches have evolved in the placement of the mesh (inside- their stress symptoms outweigh their urge symptoms and they
out [e.g., TVT-O , Gynecare] versus outside-in [e.g., M onarc, recognize what the surgery could do to their incontinence
American M edical Systems]), the transobturator procedure is problems. Urge incontinence can be exacerbated or occur de
relatively simple to learn and can be accomplished with mini- novo following surgical treatment of stress incontinence, al-
mal anesthesia in an awake patient. Controlled randomized though it is also possible that urge leakage improves following
studies have documented the safety and efficacy of the trans- sling surgery. Information gleaned from the bladder diary can
obturator approach compared to retropubic midurethral clarify ambiguous mixed urinary incontinence symptoms.
slings (4). Vaginal examination and assessment for pelvic organ pro-
lapse are essential. It has been long recognized that patients
with pelvic organ prolapse (particularly anterior vaginal wall
DIAGNO SIS prolapse) can become newly incontinent of urine with reduc-
tion of the prolapse (occult urinary incontinence). A corollary
A thorough understanding of urinary incontinence is impor- to this recognition is that if an incontinence procedure alone is
tant before implementing therapy. Urinary incontinence as de- done in a woman with Stage III or IV prolapse that is not con-
fined by the International Continence Society can be a currently treated, postoperative urinary retention or voiding
symptom, sign, or condition. It is the condition of stress in- dysfunction can ensue. In addition, placement of a transobtu-
continence that is appropriate for surgical treatment, and a rator midurethral sling carries a higher risk of bladder injury
distinction needs to be drawn between stress incontinence and without reduction of the prolapse at the time of insertion. The
282
Chap t e r 42: The Transob turator Ap p roach to the Mid ure thral Sling 283
question of whether and how the prolapse should be corrected slings (TVT-SECUR, Gynecare; M iniArc, American M edical
and the nuances of simultaneous continence surgery are be- Systems) have been introduced with claims of better safety and
yond the scope of this chapter. the possibility of office placement. These third-generation
midurethral slings differ in that they are inserted through a mid-
line suburethral vaginal incision, traverse the periurethral tis-
INDICATIO NS sue, and are anchored in some fashion retropubically or behind
the ischiopubic ramus. To date, there are no long-term efficacy
Transobturator midurethral slings are indicated for urinary in- and safety data for these products. Prior to 1995, traditional
continence that by both symptom and sign is consistent with pubovaginal slings and retropubic procedures (e.g., Burch,
urethral incompetence and where placement of the sling could M arshall-Marchetti-Krantz) were the mainstay of surgical
not be expected to compromise voiding (e.g., pelvic organ treatment of female stress urinary incontinence. These proce-
prolapse, diabetes, neuropathy). Stress-associated urine leak- dures continue to be viable options; however, they are mostly
age occurs when urethral pressure is exceeded by transmitted reserved for patients who will otherwise need laparotomy. It is
bladder pressure. The reasons this may occur are not well un- worth noting that in the SISTEr trial traditional pubovaginal
derstood, despite years of definitions and debate. H istorically, slings were found to be more successful in correcting female uri-
when selecting the appropriate surgical procedure for treat- nary incontinence but at the price of greater morbidity relative
ment of stress incontinence, it has been considered important to the Burch colposuspension (5).
to distinguish between incontinence related to hypermobility
of the bladder neck and incontinence related to a urethral
sphincter that cannot maintain a watertight seal even at rest SURGICAL TECHNIQ UE
(e.g., intrinsic sphincter deficiency, ISD). This dichotomy,
from a pathophysiologic view, could be distilled into support In placement of a midurethral sling, the technical goal is to
versus sphincter problems. In the case of a hypermobile position the sling material through the obturator foramen
urethra, inadequate pelvic floor support allows the urethra to and beneath the midurethra with as little trauma as possible
escape transmitted abdominal pressure to the urethra. In the (Fig. 42.1). Using one of the commercially available kits, a
case of ISD, the urethra is fixed and theoretically does benefit transobturator suburethral mesh is placed through three inci-
from transmitted abdominal pressures, but this cannot sions: a 1- to 2-cm midline suburethral vaginal incision, and
compensate for whatever issues led to a nonfunctioning two smaller groin incisions. Device needles are passed either
sphincteric mechanism. The dichotomy, while appealing on toward or away from the urethra, depending on the manufac-
theoretical grounds, finds little experimental support. turer. Table 42.1 lists various products on the market.
Although it is true that lower abdominal pressures are re- Irrespective of the direction of passage, the needles will tra-
quired to induce leakage in women whose incontinence is verse skin; subcutaneous fat; the gracilis, adductor brevis,
more subjectively severe, this relationship is fuzzy at best, and and obturator externus muscles; the obturator membrane; the
it must be accepted that the treatment outcomes among sub- obturator internus muscle; and the periurethral endopelvic
jectively severe incontinent women will likely be less ideal fascia (6). Although there are differences in the type of mesh
than among women with subjectively less severe incontinence. offered by the various manufacturers, there are few con-
This relationship is not necessarily offset by information trolled studies comparing them. M ost available mesh used in
gleaned from measurements of urethral competence (e.g., ure- this application today are macroporous polypropylene.
thral pressure profilometry or leak point pressures). Indeed, Anesthesia for the procedure can be delivered by local block
the outcomes of transobturator midurethral slings appear to with sedation, by spinal block, or by general anesthesia. The
be independent of leak point pressures, allowing us to leave patient should be administered preoperative antibiotics based
this quandary for the laboratory. on their utility in vaginal surgery; however, there is no evidence
to support soaking the mesh in antibiotic solution or giving
antibiotics postoperatively. Following adequate anesthesia, the
ALTERNATIVE THERAPY
Though the most common treatments for stress incontinence
are surgical, a number of nonsurgical alternatives are available
for women who either do not desire surgery or who are not
good surgical candidates. These approaches include behav-
ioral techniques, medications, urethral inserts and occlusive
devices, and vaginal pessaries. It would not be uncommon for
more difficult cases of urinary incontinence to require more
than one treatment to achieve a satisfactory outcome.
N onsurgical and nonsling surgical options (e.g., Burch ure-
thropexy) for female urinary incontinence are beyond the
scope of this chapter.
The transobturator approach to placement of a midurethral
sling represents a second-generation concept based on the TVT
FIGURE 42.1 Transobturator tape in final anatomic position. The
that was popularized in the mid 1990s. Retropubic midurethral tape has been passed under the midurethra, through the periurethral
procedures continue to be popular and enjoy considerable sup- tissues and obtuator membrane, and exits through skin incisions on
portive evidence. M ost recently, single-incision midurethral the lateral thigh.
TA B LE 4 2 . 1
TRAN SOBTURATOR MIDURETHRAL
SLIN GS
N ame Manufacturer Approach
Aris Coloplast a O utside-in

M onarc AM Sb O utside-in
O bTape M entor c O utside-in
O btyrx Boston Scientificd O utside-in
TVT-O Ethicon e Inside-out
Desara Caldera f Either
Uratape Porges-M entor g Inside-out
All of the above use a polypropylene mesh; they vary regarding pore
size and weave. a Coloplast AVS, Copenhagen, Denmark. b American
M edical Systems Research Corp., M innetonka, M N . cM entor Corp.,
Santa Barbara, CA. d Boston Scientific Scimed Inc., M aple Grove, FIGURE 42.2 Blunting of the vaginal crease while injecting lidocaine
M N . eEthicon Inc., Somerville, N J. fCaldera M edical, Inc., Agoura helps to decrease the risk of buttonholing the vaginal mucosa as the
H ills, CA. gLePlessis, Robinson, France. needles are passed through the periurethral tissues.
patient is positioned in a neurologically neutral lithotomy sues toward the ischiopubic ramus, until a tunnel is created
position using padded stirrups. A Foley catheter is inserted and the tip of the surgeon’s finger can touch the ischiopubic
and the position of the midurethra determined as the midpoint ramus. The dissection is carried out bilaterally. It is also ad-
between the palpable Foley bulb at the bladder neck and the vantageous to continue developing the plane between the
urethral meatus. A weighted speculum is inserted for exposure vagina and urethra at the inferior aspect of the incision for ap-
of the anterior vaginal wall. N ext, 10 to 20 cc of a vasoactive proximately 0.5 cm to create a pocket for the mesh and to
solution (1% lidocaine with 1:200,000 epinephrine or vaso- limit tearing the vaginal tissue with digital manipulation of the
pressin, 20 U diluted in 100 cc of sterile saline) is injected in subepithelial tunnel.
the subepithelial vagina before making a 1.5- to 2.0-cm verti- The adductor longus tendon is palpated, and a marking
cal vaginal incision at the midurethra. The injection is also pen is used to identify the genital crural fold below the tendon.
carried laterally toward the vaginal sulcus medial to the is- This typically is at the level of the clitoris at the lateral edge of
chiopubic ramus bilaterally. Ideally, the operator will see the labia majora (Fig. 42.3). Local anesthetic is injected along
blunting of this vaginal crease as the injected epithelium ex- the proposed needle path followed by a small stab incision. In
pands outward (Fig. 42.2). Applying this technique may help reference to the outside-in technique, the cut edge of the vagi-
the surgeon avoid “ buttonholing” the vagina while passing nal incision is grasped with an Allis clamp, and the operator’s
the helical needles. Allis clamps are useful for grasping the same-hand index finger is placed behind the Allis clamp into
vaginal epithelium for exposure. the vaginal epithelial tunnel. The needle passer is then grasped
The midurethral vaginal incision should include both the in the operator’s opposite hand and positioned so that the axis
vaginal epithelium and portions of the muscularis. Too shal- of the passer is parallel to the ischiopubic ramus. The needle
low of an incision may promote postoperative vaginal mesh tip is placed perpendicular to the skin and advanced through
extrusion. The operator then dissects using a fine scissors the soft tissues around the ramus, meeting the operator’s index
(Church, M etzenbaum, or sternotomy) in the periurethral tis- finger that guides the needle tip out of the vaginal epithelial
Exit point Entry point

2 cm
2 cm
FIGURE 42.3 Demonstration of placement

for the groin incisions. The patient’s right
side shows the exit points of the needles for
the outside in technique, and the patients left
side shows the entry points for the inside out
technique.
FIGURE 42.4 The needle tip is placed perpendicular to the skin and
advanced through the soft tissues around the ramus meeting the
operators index finger that guides the needle tip out of the vaginal
FIGURE 42.5 The winged guide is inserted into the dissected track
epithelial tunnel lateral to the urethra.
and through the obturator membrane. The helical needle passer is
then inserted through the vaginal incision following the channel of the
winged guide so the tip is beyond the obturator membrane.
tunnel lateral to the urethra (Fig. 42.4). At this point, it is im-

portant to determine that the lateral sulci of the vagina are reverse rotation of the handle. The tubing is then pulled
free of inadvertent mesh passage. This done, the mesh is at- through the skin until the plastic-covered mesh appears. At
tached to the needle and removed, reversing the path of inser- this point, the previous steps are repeated on the contralateral
tion. The process is then repeated on the contralateral side. side.
The products are marketed such that the mesh is ensheathed O nce bladder and urethral integrity is confirmed by cys-
in plastic that overlaps in the middle. The plastic allows the toscopy, the mesh is tensioned. There is considerable variabil-
mesh to slip through the tissue during placement. It is useful to ity in how “ proper” tension is determined. Given that a
place a hemostat to stabilize the overlapping plastic, ensuring transobturator sling can be done with the patient awake, per-
that the mesh is not prematurely exposed. At this point, cys- haps the best technique involves having the patient perform a
toscopy is recommended. cough stress test at a specific bladder volume (usually 300 cc).
Although the concept for the inside-out technique is simi- There is evidence that deeper anesthesia techniques are associ-
lar, the surgical steps do vary from the outside-in technique ated with lower treatment outcomes; however, it cannot be
described above. Gynecare manufactures the TVT O bturator said that the “ tailoring” of the mesh tension in the awake pa-
System, which includes helical passers, a plastic ensheathed tient is responsible for this finding. Another technique for ten-
polypropylene mesh, and a winged guide that facilitates intro- sioning mesh is to place a no. 9 H egar dilator between the
duction and passage of the helical needle passers. The groin mesh and the urethra before pulling back on the plastic
incisions are made along a line 2 cm above the level of the ure- sheaths exiting the groin incisions. Alternatively, a Babcock
thral meatus. The exit points for the helical needle lie on this clamp can be used to grasp a 4-mm knuckle of mesh under the
line, 2 cm lateral to the folds of the thigh (Fig. 42.3). A midurethra before tensioning that, when released, will render
line vaginal incision is then made superficial to the urethra as “ proper” tension. Care should be taken to use a similar tech-
described above. Sharp and blunt dissection is employed to nique on all patients. O nce the appropriate tension has been
traverse the periurethral tissues to the obturator membrane, determined, the mesh is stabilized, the hemostat in the middle
which is perforated with scissor tips. The winged guide is in- is released, the plastic sheaths alone are grasped, and, apply-
serted into the dissected track and through the obturator ing equal pressure, the sheaths are removed out of the groin
membrane. The helical needle passer is then inserted through incisions. The vaginal epithelial incision is next closed with a
the vaginal incision following the channel of the winged guide running suture of delayed absorbable suture on a taper needle.
so that the tip is beyond the obturator membrane (Fig. 42.5). The groin incisions are closed with suture or skin adhesive.
At the starting point, the handle is 45 degrees from midline.
The guide is then removed and the helical needle passer is ro-
tated (clockwise for the patient’s left side and counterclock- O UTCO MES
wise for the right) while the handle is moved simultaneously
toward the midline. The tip of the needle passer with an over- O f equal importance to the technical issues of pelvic floor
lying plastic tube that is attached to the mesh then exits the surgery is the measurement of treatment outcomes by the per-
marked groin incisions. The tubing is grasped with a clamp, forming surgeon. In general, treatment outcomes can be as-
and the needle passer is backed out of the plastic tubing by sessed with objective or subjective measures, and these should
TA B LE 4 2 . 2
IN CON TIN EN CE SEVERITY IN DEX
H ow often do you experience urinary leakage? H ow much urine do you lose each time?
1. Less than once a month 1. Drops

2. A few times a month 2. Small splashes
3. A few times a week 3. M ore
4. Every day and/or night
The four-level severity index is based on the following index values (1–12), which is a product
of the score of each question.
1–2 slight
3–6 moderate
8–9 severe
12 very severe
Source: Sandvik H , Seim A, Vanvik A, et al. A severity index for epidemiological surveys of female urinary
incontinence: comparison with 48-hour pad-weighing tests. N eurourol Urodynam 2000;19(2):137–145.
match those used before treatment. There are several subjec- score blends these issues and is less concise in assessing the
tive survey tools to assess urinary incontinence. These tools overall severity of leakage. In contrast, the Incontinence
vary in length and psychometric properties (e.g., validity, reli- Severity Index (ISI) (Table 42.2) renders a quick assessment of
ability, and responsiveness) and also in the degree to which leakage severity but does not distinguish the kind of leakage.
they indicate the kind of incontinence. For example, the Pelvic floor disorders are multidimensional issues and should
Urinary Distress Inventory (UDI) can render insight into be assessed with composite outcomes to capture, reasonably,
whether the leakage is stress or urge; however, the overall as many aspects as possible. In clinical practice the burden to
TA B LE 4 2 . 3
THE 3 IN CON TIN EN CE QUESTION S (3IQ)
1. During the last 3 months, have you leaked urine (even a small amount)?
■ Yes ■ No
Q uestionnaire completed.
2. During the last 3 months, did you leak urine:
(Check all that apply)
■ a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
■ b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to
the toilet fast enough?
■ c. Without physical activity, and without a sense of urgency?
3. During the last 3 months, did you leak urine most often:
(Check only one)
■ a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
■ b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to
the toilet fast enough?
■ c. Without physical activity, and without a sense of urgency?
■ d. About equally as often with physical activity as with a sense of urgency?
Definitions of type of urinary incontinence are based on responses to question 3:
Response to Question 3 Type of Incontinence
a. M ost often with physical activity Stress only or stress predominant
b. M ost often with the urge to empty the bladder Urge only or urge predominant
c. Without physical activity or sense of urgency O ther cause only or other cause predominant
d. About equally with physical activity and M ixed
sense of urgency
Source: Brown JS, Bradley CS, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress uri-
nary incontinence. A nn Intern M ed 2006;144:715–723.
patient and provider of using validated surveys to assess erosion, including operative technique, mesh properties
pelvic organ prolapse, bowel dysfunction, sexual function, (pore size, stiffness, elasticity), and tissue properties (local
and bladder function can be daunting. Subjective outcomes, as ischemia, infection, and tissue integrity). Depending on the
noted previously, can identify (UDI) and quantify (ISI) symp- extent of the erosion, it can be managed by freshening up the
toms or assess general (SF-36) or condition-specific quality of vaginal edges and oversewing the epithelium, or by excision
life (Incontinence Impact Q uestionnaire, IIQ ). of the exposed mesh followed by closure of the epithelium.
O bjective outcomes include the pelvic organ prolapse Infectious complications can present in a number of ways.
quantification system (7), bladder diaries, cough stress tests, Cellulitis can occur in both the groin and vaginal incisions,
pad tests, office cystometrics with cough stress testing, and and it can lead to mesh erosion even after the infection has
multichannel urodynamics. Although there are settings in cleared. Abscess formation has been reported in both the ad-
which objective assessment would be useful in routine clinical ductor muscles of the thigh and the ischiorectal fossa.
practice (e.g., treatment failure), regular posttreatment use can Treatment of these can be challenging, as they are rare and
be burdensome to both patient and clinician, rendering little there is minimal experience in any single institution. Based
additional information than that gathered from the subjective on individual cases, drainage of the abscess, debridement of
assessments. H owever, long-term outcomes data are not cur- the infected tissue, and removal of the mesh are options. The
rently available. latter can be challenging, depending on the time course of
the infection and the amount of tissue ingrowth that has
occurred.
CO MPLICATIO NS O ther complications that can have either short- or long-
term sequelae include new-onset detrusor instability, contin-
As with any surgical procedure, complications can arise intra- ued incontinence, urinary retention, nerve injuries, and pain
operatively or postoperatively that can have either short- or or dyspareunia.
long-term sequelae. The transobturator technique was devel- Rates of major complications, including abscess formation,
oped as a safer approach compared to the retropubic tech- nerve injury, and life-threatening hemorrhage, are unknown,
nique. The needles are unlikely to enter the peritoneal cavity, as they are rare events and even large studies are underpow-
virtually eliminating the potential for bowel injury, and they ered to report them. In 2006 Boyles (10) published on compli-
do not pass near large blood vessels, making major vascular cations of three commercially available transobturator slings
injury less likely. Regardless, brisk bleeding can ensue intraop- reported to the M AUDE data base (maintained by the FDA to
eratively from the vaginal incision, periurethral tissues, or collect and report complications of medical devices) between
while passing the needles close to the obturator artery and its January 2004 and July 2005. During this time, 173 complica-
branches. Typically this responds to pressure applied for a tions were listed in 140 reports. Sixty percent of these compli-
short duration or vaginal packing. Vaginal mucosal damage is cations were mesh erosions, and one third of those were
more likely with transobturator than retropubic midurethral associated with infection. O ne urethral erosion was reported.
slings (8). In patients with deep lateral vaginal sulci, the helical Two abscesses of the ischiorectal fossa presented 2 months af-
needle can “ buttonhole” : doubly pierce the vaginal epithelium ter the surgical procedure and required drainage. Two infec-
and result in a “ bridge” of mesh superficial to the epithelium. tions involved abscesses of the adductor muscles. Four cases
Bladder injury is less common than with retropubic techniques of neuropathy were reported, and in two of these cases the pa-
(9), but cystoscopy is still recommended to ensure the integrity tients had difficulty with ambulation. Five cases of bleeding in
of the bladder and urethra. Recurrent postoperative urinary excess of 300 cc were reported. There was one documented
tract infections should alert the physician to the possibility of case of injury to an iliac vessel with the medial to lateral tech-
mesh in the bladder. It is notable, however, that postoperative nique that required embolization in radiology. Although these
urinary tract infections can be common following any inconti- data are useful for understanding the types of complications
nence surgery. that can occur, the number of cases they are pooled from are
Short-term complications of bleeding include hematomas, unknown. The FDA estimates that the actual number of com-
ecchymosis, and anemia. Vaginal erosion can present days to plications is 10 to 100 times higher than reported to the
months postoperatively. N umerous factors may contribute to M AUDE database.
References
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N ephrol 1995;29(1):75–82. 7. Bump RC, et al. The standardization of terminology of female pelvic organ
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5. Albo M E, et al. Burch colposuspension versus fascial sling to reduce urinary 10. Boyles SH , et al. Complications associated with transobturator sling proce-
stress incontinence [see comment]. N Engl J M ed 2007;356(21):2143–2155. dures. Int Urogynecol J Pelvic Floor D ysfunct 2007;18(1):19–22.
CHAPTER 43 ■ ABDO MINAL RETRO PUBIC
APPRO ACHES FO R FEMALE INCO NTINENCE
LESLIE M. RICKEY
Urinary incontinence (UI) is common, with approximately as an outdated procedure as well, it is still a reasonable option
30% of women reporting any incontinence; about 25% to for a woman desiring an incontinence procedure, particularly
50% of these cases are estimated to be stress urinary inconti- if she is undergoing a concomitant abdominal surgery. In ad-
nence (SUI) (1–3). In addition, the number of women seeking dition, as will be discussed later in the chapter, it is indicated
care for UI is increasing. O ffice visits for UI more than dou- for an asymptomatic, stress-continent woman undergoing an
bled, from 815,832 visits in 1992 to 1,932,768 visits in 2000 abdominal sacrocolpopexy for prolapse.
(4). A recent analysis of population growth and future de-
mand for care concluded that consults for pelvic floor disor-
ders will increase by 45% from 2000 to 2030 (5). In terms of
surgical management, one out of nine women will have DIAGNO SIS
surgery for a pelvic floor disorder in their lifetime, and this
number represents only a subset of women who have the con- A thorough and detailed patient history should elicit
dition (6). About one third of the surgeries were for SUI alone, whether the patient has stress incontinence, urge inconti-
and another 20% of surgeries were performed for combined nence, or mixed incontinence. It is important to ascertain a
SUI and pelvic organ prolapse (PO P). history of previous incontinence or pelvic surgeries, as this
Although the exact mechanism that leads to SUI is not may affect surgical decision making. Prolapse symptoms
known, proposed theories include loss of proximal urethral should also be queried, as almost two thirds of women with
support, or the “ hammock” theory, and intrinsic deficiency of SUI have coexisting PO P (7), and additional procedures may
the external urethral sphincter. Surgical procedures are directed be necessary at the time of the incontinence surgery. Finally,
towards correction of the deficiency, either re-establishing it is prudent for physicians performing pelvic surgery to
support of the proximal urethral or improving urethral inquire about whether the patients Pap screening is up to
closure. The suburethral sling procedure can be performed date.
using autologous fascia (rectus fascia or fascia lata) or The physical examination should include a bimanual
synthetic material. The sling procedures are covered in other and speculum examination to assess the vaginal tissue and
chapters. vaginal support and to rule out any pelvic masses. A positive
Urethral position depends on anterior vaginal wall sup- empty supine cough stress test is highly predictive of urody-
port. Retropubic colposuspension, or urethropexy, aims to namic stress incontinence (8). Urethral hypermobility should
improve the support of the vesicourethral junction by lifting be confirmed before considering a Burch urethropexy.
the periurethral tissue towards the pubic bone, thus restoring Traditional teaching has utilized the cotton-tipped swab test
the proper anatomy. The procedure is believed to treat incon- to measure urethral hypermobility. A cotton-tipped swab is
tinence by providing improved resistance to increases in intra- inserted transurethrally to the proximal urethra, and the pa-
abdominal pressure, resulting in more effective urethral tient is asked to maximally Valsalva. A deflection of 30 de-
compression. The M arshall–M archetti–Krantz (M M K) proce- grees from the resting angle during Valsalva is considered to
dure involves suturing the periurethral tissue at the level of the reflect urethral hypermobility. The surgeon should inspect the
bladder neck directly to the periosteum of the pubic symph- lower abdominal wall for scars indicative of previous pelvic
ysis. Burch, a gynecologist, modified this technique by altering surgery and correlate with the patient’s surgical history.
the suspension laterally to the iliopectineal line, or Cooper’s If the patient relates SUI symptoms and desires surgical
ligament. The Burch technique was further modified by treatment, many surgeons choose to perform urodynamics
Tanagho, a urologist, to include a suture bridge instead of (UDS) to confirm the diagnosis. It is believed that the Burch is
direct apposition of the anterior vaginal wall to Cooper’s not as effective in women with “ intrinsic sphincter defi-
ligament. The Burch urethropexy has traditionally been per- ciency,” typically defined by indirect measures of urethral
formed via a small Pfannenstiel incision, but the laparoscopic function, including leak point pressure 60 mm H g or ure-
approach has been utilized as well. thral closure pressure of 20 mm H g or less. H owever, a ran-
The M M K is largely a historical procedure as the Burch domized trial comparing Burch to sling in women with low
appears to be slightly more efficacious. In addition, the urethral closure pressures (20 cm H 2 O or less) did not show a
complication of osteitis pubis is specific to the M M K difference in subjective success between the two procedures at
approach due to the placement of suture directly into the a mean 5 years of follow-up (84% versus 93% , respectively,
periosteum. Although the Burch urethropexy may be regarded p 0.47) (9). Although the study was not powered to detect
288
Chap t e r 43: Ab d ominal Re trop ub ic Ap p roache s for Fe male Incontine nce 289
small differences between the treatment groups, the findings were satisfied with symptom improvement and desired no fur-
still demonstrate that the Burch procedure can be effective in ther treatment (20,21).
women with low urethral closure pressures. Valsalva leak
point pressure (VLPP) has not been shown to be a significant
predictor of success after the Burch procedure (10). In addi- SURGICAL TECHNIQ UE
tion, a retrospective review of women who underwent a
Burch urethropexy with preoperative VLPPs of 60 cm H 2 O
showed an objective success rate of 91.7% , indicating that a
O p e n Burch Ure t hro p e xy
low VLPP is not necessarily predictive of Burch failure (11).
The patient is placed in the low dorsal lithotomy position and
Direct measurement of striated urethral sphincter function the vagina and abdomen are prepped and draped for com-
using electromyography suggested that women with better bined access. A Foley catheter is placed and a Pfannenstiel in-
innervation of their urethral sphincters were more likely to cision is made. Dissection of the space of Retzius is performed
be cured by the Burch urethropexy (12). In summary, there (Fig. 43.1). The first and second fingers of the surgeon’s non-
are no UDS parameters clearly predictive of Burch success dominant hand are placed in the vagina, with one finger on
or failure. Therefore, traditional urodynamic testing does each side of the urethral catheter. The bladder is retracted me-
not seem to aid in the surgeon’s decision of which inconti- dially so that the perivaginal tissue lateral to the vesi-
nence procedure to perform. H owever, the study can provide courethral junction is exposed. Using the vaginal finger as a
helpful information about the coexistence of detrusor overac- guide, a peanut sponge can be used to carefully sweep away
tivity, clarify confusing symptomatology, and confirm diag- the overlying fat until the glistening white perivaginal “ fascia”
noses in patients who have undergone previous incontinence
is visualized. Care must be used as vaginal and pelvic veins are
surgeries.
often encountered in this area. Palpation of the Foley balloon
will help delineate the vesicourethral junction. Two figure-of-
eight sutures are placed in the periurethral vaginal tissue, one
INDICATIO NS FO R SURGERY at the vesicourethral junction and another more distally at the
level of the midurethra. Avoid placing the sutures through any
The main indication for an incontinence procedure is the fatty tissue. Placement of the sutures into the vagina is aided
presence of symptomatic SUI that adversely affects the by elevation of the anterior vaginal wall using the hand in the
woman’s quality of life. The patient should also have the sign vagina (Fig. 43.2A). The vaginal finger should be used as a
of transurethral loss of urine with a cough stress test or dur- guide to ensure that the sutures are sufficiently lateral to the
ing formal urodynamic testing. Additionally, the patient urethra. The suture bite should encompass vaginal tissue with-
must be sufficiently healthy to undergo regional or general out perforating the vaginal epithelium (Fig. 43.2B). The proce-
anesthesia, be able to be placed in dorsal lithotomy position dure is repeated on the other side. A total of four permanent,
and have a habitus that allows a suprapubic incision. There nonabsorbable sutures such as no. 0 or no. 1 polyester
appears to be a risk of worsening PO P after a Burch proce- (Ethibond) or polytetrafluoroethylene (Gore-Tex) sutures are
dure (13–15); therefore, a Burch urethropexy probably placed (two on each side; Fig. 43.3A). Cooper’s ligament is
should not be performed as a solitary procedure if there is identified and any overlying tissue is gently swept off using a
significant apical descent. Lack of urethral hypermobility peanut sponge.
and a previously failed retropubic approach would be The sutures are then placed through Cooper’s ligament on
considered indications for a suburethral sling by most pelvic the respective sides (Fig. 43.3B). N ote that the sutures are tied
surgeons. off the midline. The proximal sutures will be placed slightly
A Burch urethropexy is also appropriate for an asympto-
matic woman (without SUI) undergoing a sacrocolpopexy
for PO P. A randomized controlled trial showed that per-
forming a concomitant Burch urethropexy at the time of ab-
dominal sacrocolpopexy resulted in a decrease of new-onset
postoperative SUI from 40% to 20% in stress-continent
women (16).
ALTERNATIVE THERAPY
Conservative therapies for SUI may involve use of pessaries or
physical therapy for pelvic floor muscle (PFM ) rehabilitation.
In women successfully fitted with a pessary for UI, rates of
continued use and satisfaction range from 16% to 59% at 1
year (17,18). PFM physical therapy includes both strengthen-
ing and instruction on timing of activation of PFM s to avoid
leakage. A Cochrane review in 2007 supported that PFM
training should be included in first-line conservative manage-
ment for women with UI (19). In women with SUI who partic- FIGURE 43.1 Retropubic space showing the bladder neck, Foley
ipated in a course of PFM exercise, 44% to 56% of patients balloon, and Cooper’s ligament.
B
FIGURE 43.3 A: A total of four sutures are placed in the periurethral
tissue. B: The two right-sided sutures are passed through Cooper’s
B ligament and tied; note that there is a gap between the vaginal tissue
and Cooper’s ligament, creating a suture bridge.
FIGURE 43.2 A: The first suture at the level of the vesicourethral
junction. The surgeon’s finger in the vagina helps guide the suture
lateral to the urinary tract. B: The finger in the vagina also helps Lap aro sco p ic Burch Ure t hro p e xy
exclude the suture from the vaginal epithelium.
Apart from the incisions, the laparoscopic Burch is performed
lateral to the more distal midurethral sutures. The obturator
in an identical manner to the open Burch procedure. There are
vessels and nerve pass through the obturator fascia; this obtu-
a variety of port placement strategies described. A common
rator “ notch” is the lateral limit for suture placement into
approach is to place a 10-mm laparoscopic port at the umbili-
Cooper’s ligament and should be avoided. The assistant ties
cus and two 5-mm ports in the lower lateral abdominal wall,
the sutures down while the operator’s fingers remain in the
approximately two fingerbreadths superior and medial to the
vagina to ensure the proper degree of suspension. The opera-
anterior superior iliac spine. An additional suprapubic port is
tor should feel that the anterior wall is slightly lifted without
sometimes utilized. As in the open approach, cystoscopy
overcorrection of the urethrovesical junction. It is imperative
should be performed at the end of the procedure to exclude in-
that the sutures are tied such that there is distance between
travesical suture and ensure ureteral patency. The laparo-
Cooper’s ligament and the vaginal tissue (Fig. 43.3B), seen as
scopic procedure is covered in more detail in the chapter
a suture bridge of approximately 2 cm. This prevents over-
dedicated to laparoscopic surgery for urinary incontinence.
compression of the urethra, which can cause obstruction. The
placement of these sutures and how tightly they are tied differ
from the initial description of Burch, in which the sutures O UTCO MES
were tied down with complete approximation of the perivagi-
nal tissue onto Cooper’s ligament. After tying the sutures, cys- Re sult s
toscopy is performed to ensure that the sutures did not
perforate the bladder and that the ureters are patent. A recent Cochrane review showed overall cure rates between
M ethylene blue can be used to help identify efflux of urine 69% and 88% for open retropubic colposuspension (22). A
from the ureteral orifices. randomized controlled trial comparing Burch to suburethral
Chap t e r 43: Ab d ominal Re trop ub ic Ap p roache s for Fe male Incontine nce 291
sling showed stress-specific success of 49% (compared to 66% tomies in the TVT group and two patients with bladder sutures
for the sling group) at 2 years, using a very strict definition of detected intraoperatively in the laparoscopic Burch group.
success (23). H owever, there was also a lower rate of adverse
events in the Burch group. The overall patient satisfaction was
slightly lower in the Burch group (78% versus 86% , p 0.02).
Co mp licat io ns
Another randomized trial comparing Burch to tension-free
Delayed bladder emptying was seen in 2% of patients after
vaginal tape (TVT) revealed 63% of women reporting cure af-
undergoing a Burch urethropexy in a large multicenter study,
ter the Burch (versus 70% in TVT group, p 0.54) at 5 years,
but no additional procedures were required for urinary reten-
but overall 90% of women who had undergone colposuspen-
tion (23). These patients may require temporary intermittent
sion were satisfied or very satisfied with the results of surgery
self-catheterization. O ccasionally, the periurethral sutures
(14). Using a negative 1-hour pad test ( 1 g change in weight)
must be released transvaginally to relieve the urethral obstruc-
for definition of cure, and using pad test data from the last
tion if there is not adequate bladder emptying at 4 to 6 weeks
available follow-up visit for missing data, the cure rates were
postoperatively. N ew-onset urge urinary incontinence occurs
computed as 69% for colposuspension versus 75% for TVT
in 3% to 4% of patients, and 5% report de novo urgency
(p 0.28).
(14,23). In a patient with significant postoperative urgency
In a randomized controlled trial comparing laparoscopic
and frequency, urinary retention and urinary tract infection
to open Burch, there were no significant differences seen at
should be ruled out: as many as 30% of patients may develop
24 months in patient-reported cure of stress incontinence (66% ),
a urinary tract infection in the postoperative period (23).
although the study was not powered to detect a difference of
Ureteral injuries occur in 1% of patients. Bladder injury is
20% (24). There was not a significant difference in perioper-
more common, with incidental cystotomy rates of 2% to 4% ,
ative complications. Out of six cases of suture penetration into
usually due to suture passage into the bladder. A recent study
the bladder, five occurred in the laparoscopic group, but this
showed that 2 of 329 (0.6% ) patients sustained a ureteral in-
difference did not reach statistical significance (p 0.11). M ean
jury and 10 of 329 (3.3% ) had an incidental cystotomy when
operating time was less in the open group (87 versus 42 min-
undergoing a Burch urethropexy (23). A cystoscopy at the time
utes, p 0.0001), and blood loss was less in the laparoscopic
of surgery can aid in identifying intravesical sutures, and
group (126 versus 170 mL, p 0.03). There was no difference
ureteral patency can be confirmed as well.
in length of hospital stay, but the average return to normal ac-
Approximately 8% to 13% of women are found to have
tivities was 5 days less in the laparoscopic group (24.6 versus
vaginal vault or uterine prolapse during the follow-up period
19.7 days, p 0.01). A meta-analysis of studies comparing la-
after Burch (14,15,27). The clinical significance of the pro-
paroscopic versus open Burch had similar findings of longer op-
lapse has been unclear; however, a randomized controlled trial
erating times, marginally less blood loss, decreased hospital
comparing Burch to TVT showed that surgery for prolapse
stay, and faster return to normal activity in the laparoscopic
was more common after the Burch colposuspension (7.5%
group (25). There was not a significant difference in subjective
versus 1.8% , p 0.025) (14). Therefore, a sling may be a
or objective cure rates up to 2 years postoperatively.
more appropriate choice for a woman desiring an inconti-
Finally, a randomized trial comparing laparoscopic Burch to
nence procedure who has asymptomatic prolapse with apical
TVT with a median follow-up of 65 months concluded that the
descent of several centimeters or more.
two procedures have similar long-term efficacy (26). Although
only 52% of subjects in the TVT group and 43% in the Burch
group reported no urine leakage under any circumstances, CO NCLUSIO N
bothersome urine leakage was present in only 8% and 11% , re-
spectively (p 0.26), and overall patient satisfaction rates were A Burch urethropexy should be considered for a woman desir-
similar as well (79% versus 88% ). Operating time was less in ing an incontinence procedure, particularly if she is undergoing
the TVT group, but there was no difference in blood loss or a concomitant abdominal surgery, or for a stress-continent
hospital stay. In terms of bladder injury, there were two cysto- woman undergoing an abdominal sacrocolpopexy.
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11(5):301–319. 2002;47(7):559–563.
2. M elville JL, Katon W, Delaney K, et al. Urinary incontinence in US women: 8. Lobel RW, Sand PK. The empty supine stress test as a predictor of intrinsic
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4. Thom DH , N ygaard IE, Calhoun EA. Urologic diseases in America project: sling for treatment of genuine stress incontinence with low-pressure ure-
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12. Kenton K, FitzGerald M P, Shott S, et al. Role of urethral electromyography management of genuine stress incontinence in women. BM J 1999;
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395–404. 22. Lapitan M C, Cody DJ, Grant AM . O pen retropubic colposuspension for
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primary urodynamic stress incontinence: 5-year follow up. Br J O bstet CD002912.
G ynaecol 2008;115(2):226–233. 23. Albo M E, Richter H E, Brubaker L, et al. Burch colposuspension versus
15. Enzelsberger H , H elmer H , Schatten C. Comparison of Burch and lyodura fascial sling to reduce urinary stress incontinence. N Engl J M ed 2007;
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floor exercises, electrical stimulation, vaginal cones, and no treatment in
CHAPTER 44 ■ THE ARTIFICIAL URINARY

SPHINCTER
HELEN ZAFIRAKIS AND O . LENAINE WESTNEY
The artificial urinary sphincter (AUS) is the most effective of mechanical failures. The pump, which is placed either in
treatment for intrinsic urethral sphincter dysfunction. The the scrotum in men or the labium majorum in women, has
three components, consisting of a cuff that is placed around both a mechanical pump section and a deactivation button.
the urethra, a reservoir, and a pump (Fig. 44.1), have not When activated, the cuff maintains continence by circumfer-
changed since the initial device was introduced in 1983. ential compression of the urethra. If voiding is desired, the pa-
H owever, in the late 1980s several modifications were made tient uses the pump to force fluid from the cuff toward the
to the device, such a narrow-backed cuff and kink-resistant reservoir. Fluid automatically returns into the cuff over about
tubing, that resulted in a significant reduction in the number 2 minutes as the pressure reequilibrates in the system, allow-
ing adequate time for bladder emptying. The deactivation but-
ton prevents the reentry of fluid in the cuff. To reactivate the
device, the patient presses the pump forcefully and thus re-
leases the poppet valve, allowing the fluid to enter the cuff and
thus restore continence.
DIAGNO SIS
Physical examination should include examination of the geni-
talia, neurological assessment, and assessment of the integrity of
the perineal skin. Investigations should include a voiding diary
and cystoscopy to look at the quality of the urethral tissue, espe-
cially at the bladder neck and bulbar urethra, in order to exclude
conditions that would need to be dealt with prior to placing the
AUS, such as stricture disease. Fluoroscopic urodynamics are
necessary to verify the cause of incontinence, assess bladder ca-
FIGURE 44.1 The AM S 800 Artificial Urinary Sphincter. The three
pacity and compliance, and exclude detrusor overactivity,
components are the pump, the reservoir, and the cuff, connected with which, in conjunction with an AUS being placed and especially
tubing and connectors. in the setting of neurogenic patients, can be dangerous to kidney
Chap t e r 44: The Artificial Urinary Sp hincte r 293
function over time. Urethral pressure profiles are not obligatory

but may add weight to the diagnosis of intrinsic sphincter defi- AUS Place me nt in Me n
ciency, depending on the leak point pressures.
Pe rine al Incisio n
The traditional method of AUS placement involves a perineal
INDICATIO NS FO R SURGERY incision. For bulbous urethra cuff placement, a midline per-
ineal incision is made over the bulbar urethra with dissection
The most common indication for AUS insertion is postprosta- extended to just distal to the bulbocavernosus muscle so that a
tectomy sphincter incompetence. O ther indications include 2-cm length of urethra has been dissected (Fig. 44.2). The
congenital or acquired neurogenic conditions of the bladder. most proximal placement of the cuff possible should be at-
Patients with congenital genitourinary abnormalities (such as tempted. Care should be handle the corpus spongiosum gently
exstrophy-epispadias complex), those with posterior trauma and to avoid opening the urethral lumen. Injury to the spon-
where the sphincter has been compromised, and female incon- giosal tissue should be repaired with a 4-0 absorbable suture
tinence where other anti-incontinence therapies have failed rather than with cautery. Circumferential dissection of the
may also benefit from an AUS. urethra requires careful sharp removal of the midline dorsal
The AUS is contraindicated in patients who have an intel- urethra attachment to the corpora. The sound of the scissor
lectual or physical disability that would render them unable to blade when dissect in the correct plane should be a distinct
utilize the device properly. O ther relative contraindications in- snip. O nce the urethral dissection is complete, the cuff size is
clude patients with progressive neuromuscular disorders who determined using a sizer in the AUS kit. The most common
would develop such a disability in a relatively short time or
patients with an untreated small-capacity or noncompliant
bladder or with detrusor overactivity that is not controlled.
Women with a previous history of pelvic irradiation [1] also
fall into the group of relative contraindications because they
may have a poor outcome with AUS due to urethral and/or
vaginal device erosion.
ALTERNATIVE THERAPIES
Alternative therapies to the artificial sphincter include closure
of the bladder neck, injection of bulking agents, and urinary
diversion.
SURGICAL TECHNIQ UE
Pre o p e rat ive Pre p arat io n
Urinary tract infection must be either excluded or treated if
identified prior to surgery. The perineal skin must be in good
condition and intact. If there is irritation of the skin due to A
urine contact, a catheter should be placed and then removed a
week or so before implantation of the AUS. Antibiotics are
given 1 hour preoperatively or at induction, and they need to
cover both aerobic and anaerobic organisms. Common com-
binations of antibiotics include vancomycin and gentamicin or
cefuroxime, and metronidazole and gentamicin (2).The pa-
tient is shaved on the operating table, not beforehand, to re-
duce the risk of infection. An additional measure is the use of
a chlorhexidine wash to reduce the microbial load 24 hours
prior to surgery. If the patient was on an intermittent catheter-
ization program, prophylactic antibiotics should be given for
3 days leading up to surgery (3).
Spinal or general anesthesia is usually given, and the lower
abdomen and genitalia are shaved carefully. A povidone-iodine
or chlorhexidine wash of the skin is performed for 10 minutes,
with a separate povidone-iodine or equivalent skin preparation B
followed by an alcohol scrub. The patient is draped to allow ac-
FIGURE 44.2 A: Diagram demonstrating the perineal incision for
cess to the lower abdomen, suprapubic area, and genitalia and placement of the AUS. B: Dissection of the urethra. The urethra is dis-
is placed supine in a lithotomy or spreader bar position. A 16Fr sected free circumferentially (demonstrated by the Penrose drain be-
Foley catheter is then placed into the bladder. hind the urethra).
size for an adult male bulbar urethra in this position is 4.5 cm.
The cuff should be snug, but not too loose or tight.
A small lateral transverse groin incision is made approxi-
mately 2 to 3 cm above the symphysis pubica to the side of the
desired pump placement. A transverse 2-cm incision is made
in the fascia. Closure sutures are placed in the fascia at this
point prior to reservoir placement. After opening the rectus
fascia, a space is developed beneath the transversalis fascia in
the retropubic space for the reservoir. The reservoir is posi-
tioned and inflated to 23 to 25 mL of solution, depending on
the size and number of cuffs. The most commonly selected
reservoir pressure is 61 to 70 cm of water in postprostatec-
tomy patients. The pathway for the pump tubing is developed
from the suprapubic incision, beneath the Scarpa fascia, utiliz-
ing a ring clamp. The subdartos space is developed by spread-
ing the clamp in the most dependent scrotal position. The
FIGURE 44.3 Initial dissection of the urethra, showing the urethra
pump should be on the lateral aspect of the scrotum with the (U) and the corpora cavernosa (C) on either side.
deactivation button directed laterally. The length of tubing re-
quired to ensure continued dependent placement is facilitated
by securing the tubing to the scrotal skin with a Babcock position more proximal to the original urethral position, and
clamp until the connections are performed. using the urethra distal to the bulbar urethra can generate
The pressure of the reservoir balloon is a balance between problems with a thin urethral wall, increasing the risk of
adequate continence and avoidance of extreme cuff pressures. recurrent erosion. The ability to augment in the urethra
Generally, in most postprostatectomy patients, a balloon with while protecting from the pressure from the cuff would theo-
61–70 cm of water pressure is adequate; however, where the retically decrease the risk of erosion. There are also reports
urethra has been compromised or in cases of previous irradia- of some encouraging results using a gracilis muscle trans-
tion, a reduced pressure, such as 51 to 60 cm of water, is used position flap to the proximal urethra in conjunction with
to reduce the risk of urethral erosion and atrophy. electrical stimulation (5).
The cuff tubing is directed to the suprapubic incision utiliz- Guralnick et al. (6) developed the technique of transcorpo-
ing a tubing passer. At this time, the tubing connections are real cuff placement, which utilizes a buttress of tunica albu-
completed using either the Q uick Connect (American M edical ginea from the corpora cavernosa to protect the dorsal
Systems, M innetonka, M N ) system or tied connections. urethral wall from erosion in cases of revision due to either
Injectable normal saline is preferred to the use of isotonic con- erosion or atrophy. The essential principles of this technique
trast solutions as these can alter the pressure dynamics in the involve utilizing a segment of urethra 2 to 3 cm distal to the
system over time. bulbar urethra (where the original cuff was placed), avoiding
After inserting the AUS, the system should be cycled to dissection of intervening urethra. A urethral site is selected
ensure that it functions, then deactivated to allow healing using urethroscopy, and an incision is made over the urethra
for 4 to 6 weeks. It is important to allow the pump to parat this site, exposing both the urethra and corporal bodies
tially fill prior to deactivation to decrease the difficulty of (Fig. 44.3). Longitudinal incisions 2.5 cm long are made in
activation. This is done by waiting until there is enough the corporal bodies bilaterally, with a tunnel being formed
fluid in the pump to create a small dimple when it is pal- between the two corporotomies (Fig. 44.4A). This results in a
pated as the AUS is activated, then deactivating it. O nce all layer of tunica albuginea attached onto the roof of the ure-
the components are in place and tested, the wounds are thra, around which the new cuff is placed, giving extra pro-
closed in layers with absorbable sutures. N o urethral tection to the urethra at this point (6) (Fig. 44.4B). The tunica
catheter needs to be left in situ, unless there are concerns left on the corpora cavernosa is reconstituted behind the cuff
about bladder emptying, such as in some neurogenic pa- prior to cuff placement (Fig. 44.4C). With the supplemental
tients. Antibiotics are continued for 24 hours parenterally tissue, the circumferential measurement is increased, allowing
and then orally for a further 5 to 7 days. This implies that for larger cuff placement (6).
the patient can usually be discharged the following day. N o
drains are left. The AUS is left in the deactivated position
for 6 weeks to allow healing. Patients are encouraged to Transve rse Scro t al Incisio n fo r
gently milk the pump inferiorly to encourage maintenance Place me nt o f AUS
of the appropriate scrotal dependency.
Conventional placement of the AUS is via a perineal incision
and a separate suprapubic incision for the pressure-regulating
Transco rp o re al Cuff Place me nt balloon. In 2003, Wilson et al. (7) reported on the transverse
scrotal incision, which uses a single incision to place all com-
Patients with urethral erosion or infection of the AUS device ponents of the AUS (Fig. 44.5). The patient is placed in the
can be difficult to manage. The cuff can be placed at a differ- supine position with gentle abduction of the hips with the legs
ent site once the urethral tissues are ready for reimplanta- on spreader bars, rather than in the lithotomy position.
tion; however, the urethral re-erosion rate is 11.8% (4). In The perineum and lower abdomen are prepared and draped
some cases there is not adequate room to place a cuff in a in the standard fashion. A 2.5- to 3.0-cm upper transverse
B
C
FIGURE 44.4 A: Transcorporeal cuff placement: Vertical

corporotomies are made bilaterally. B: The tunica over the
corpora is left attached to the urethra for extra support of
urethral tissues. C: The remaining tunica albuginea is re-
constituted behind the position of the cuff. (Adapted from
Guralnick M L, et al. J Urol 2002;167(5):2075–2079, with
permission.)
FIGURE 44.5 Transverse scrotal incision for placement of AUS with

Lone Star ring retractor in place.
scrotal incision is made. The dissection is optimized by utiliza-

tion of a self-retaining retractor combined with a dorsal meatal
glans hook to stretch the penis superiorly and a penile band at
the dorsal aspect of the base of the penile shaft.
The corpora are exposed proximally, and the midline at-
tachment between the Corpora spongiosa and the scrotal sep-
tum is divided sharply (7). Pediatric Deaver retractors deavers
positioned adjacent to the corpora cavernosa are utilized to
retract the scrotal wall and the bulbocavernosus muscle. The
dissection is carried to the level of the perineal body. The
bulbar urethra is then dissected circumferentially at the de-
sired cuff location (Fig. 44.6). Blunt dissection is used to iden- B
tify the external ring, which is placed on tension by upward FIGURE 44.6 A: Transverse scrotal incision with completely dis-
retraction with a Rich or Deaver retractor. M etzenbaum scis- sected urethra. A Penrose drain is slung behind the urethra.
sors are used to perforate the transversalis fascia just above B: Placement of the sizer to determine the size of the cuff required.
C A
FIGURE 44.6 C: Urethral cuff (c) in position.
the pubic bone (7) (Fig. 44.7). The reservoir is placed and
filled with either normal saline or isotonic contrast solution
(Fig. 44.8). The pump is then placed in a subdartos pouch
(Fig. 44.9).
FIGURE 44.9 A: Creation of a subdartos pouch with the transverse

scrotal incision for placement of the pump. B: The AUS pump is in
position in the scrotum and is held by a Babcock clamp.
Blad d e r Ne ck Cuff Place me nt

For bladder neck cuff placement, a suprapubic incision
FIGURE 44.7 Through the same transverse scrotal incision, (either transverse or vertical) is made to allow access to the
M etzenbaum scissors are used to perforate the transversalis fascia and prevesical space. Blunt dissection continues to expose the
develop the pocket for placement of the reservoir. endopelvic fascia, prostate, and bladder neck area. Some
surgeons leave the endopelvic fascia intact while others opt to
open it, but ultimately, a plane is developed between the blad-
der neck and the rectum posteriorly to allow room for the
cuff. If additional space is required, the endopelvic fascia may
be incised and the dissection can involve some of the prostate
laterally and posteriorly. The bladder can also be opened to
facilitate this dissection. The dorsal vein complex can usually
be left undisturbed. The sizing tape is then passed around the
dissected bladder neck to determine the cuff size of the AUS,
and the cuff is placed. At this level, larger cuff sizes are often
used 6–8 cm. The balloon is then placed in the prevesical
space. The cuff tubing is passed anteriorly and the balloon
tubing inferiorly and above the rectus fascia. The reservoir
balloon is filled with 22 mL of fluid. The pump is placed in
the ipsilateral scrotum in a subdartos space similar to the
two-incision approach. The tubing is then positioned,
trimmed, and connected Q uick Connect connectors. At all
FIGURE 44.8 The reservoir is in position in the space of Retzius. The stages of insertion of the AUS, extreme care should be taken
tubing connecting to the reservoir can be seen caudally. The blue circle to avoid air bubbles getting into the system by the use of rub-
represents the position of the reservoir. ber shods.
pack is used for 24 hours, and a Foley catheter is left in place

AUS Place me nt in Wo me n for 1 or 2 days. There have been concerns raised over an in-
creased risk of infections and erosions using the transvaginal
The main indication for insertion of AUS in the female patient
approach; however, in Appell’s series (9), out of the 34
is in the neurogenic population, especially those with congeni-
women studied, 56% were dry at 3 years and there were no
tal neurogenic conditions, such as spina bifida. Increasingly,
infections or erosions reported. O thers have reported con-
however, the sphincter is being placed for patients with pri-
flicting opinions (10).
mary, secondary, or recurrent incontinence, especially when
alternative or less invasive procedures have failed. The evalua-
tion prior to AUS insertion is the same as that previously dis- Synchro no us AUS and Pe nile
cussed. H owever, the use of topical estrogens to the vaginal
tissues in postmenopausal women can improve the quality and
Imp lant Inse rt io n
resilience of these tissues preoperatively.
The transscrotal approach for insertion of the AUS has nat-
There are two approaches to the female AUS: abdominal
urally led to the development of an extended procedure to
(8) and transvaginal (9). The bladder neck is the only position
place penile implants via the same incision. The upper trans-
available for insertion of the cuff in women. There is limited
verse scrotal incision used to insert an AUS is also ideal for
urethral length, and the dissection is more difficult due to a
exposing the corpora for access to penile prosthesis proce-
lack of a surgical plane between the posterior urethra and
dures. Despite this, there have been concerns about the risk
vagina. This increases the risk of early erosion in this gender.
of infection and erosion with this technique. The prepara-
The abdominal approach involves a transverse lower midline,
tion of the patient is the same as for AUS, except that the
or Pfannenstiel, incision. A 2-cm area of bladder neck is devel-
patient is supine with legs slightly abducted. After the inci-
oped, carefully avoiding perforation of the urethra, bladder,
sion is made, the septum is incised to free the corpora. The
and vagina (Fig. 44.10). The dissected area is measured and
urethra is dissected enough to place a bulbar cuff, followed
the cuff is placed, with the tubing away from the vaginal wall
by corporotomy for insertion of the penile prosthesis. The
toward the desired placement for the reservoir. N ext, the bal-
reservoirs are placed in either retropubic space and the
loon is placed in the paravesical space, with care taken to
pumps in the scrotum as usual. Bhalchandra et al. (21) rec-
avoid direct contact with the tubing and connections. The
ommend implanting the AUS first and deactivating the de-
pump is placed in a dependent subcutaneous portion of the
vice, prior to placing the penile prosthesis. They also suggest
ipsilateral labia majora.
that, to reduce the rate of erosion, primary deactivation and
The transvaginal technique involves an inverted U incision
nocturnal deactivation are used. Furthermore, they suggest
in the anterior vaginal wall, centered at the level of the blad-
the use of a low-pressure reservoir and an inflatable penile
der neck. The posterior urethral and bladder neck dissection
prosthesis.
is done under direct vision; however, the anterior part of the
urethra needs to be dissected bluntly and with careful sharp
dissection to avoid entering the urethral lumen and bladder. AUS in t he Pe d iat ric Po p ulat io n
If this dissection is difficult because of previous scarring, a
separate supraurethral vaginal incision can be made. The cuff Simult ane o us w it h Blad d e r Aug me nt at io n
is then positioned once the circumferential dissection is com-
The usual subgroup requiring AUS in the pediatric population
pleted. A separate small transverse suprapubic incision is used
is either those with congenital neurogenic bladder dysfunction
to place the reservoir balloon and the pump, which is tunneled
or those with exstrophy-epispadias complex. They often have
into the labia majora. The tubing from the cuff is passed on
abnormal detrusor function, which can often manifest after
the suprapubic incision utilizing the tubing passer. A vaginal
insertion of the AUS. Studies that have looked at the medium-
and long-term outcome in the pediatric group have noted ex-
cellent continence rates of 92% at 4 years (11) and 71% to
86% at 10 years (12,13). In patients with neurogenic bladder
dysfunction who are inadequately controlled by antimus-
carinic medication, an augmentation cystoplasty is required.
Ideally, AUS placement and augmentation may be performed
at the same setting. Also, post-AUS bladder dysfunction is be-
ing recognized as a potential problem. Following augmenta-
tion with AUS, the rate of needing to self-catheterize is 60% to
70% (11–14); therefore, it is important that the patient is ca-
pable of catheterizing in some way prior to operation.
Finally, the potential problem of renal failure needs to be
discussed. Levesque et al. (12) reported an 11% risk of renal
failure due to high bladder pressures in their population.
These patients failed to attend follow-up because they were
continent and otherwise well. This problem has also been seen
in other studies and highlights the need to educate patients
FIGURE 44.10 The abdominal approach to implantation of the AUS and their family about the importance of regular follow-up
in women. The bladder neck region has been dissected ready for after insertion of an AUS, irrespective of whether they have
placement of the cuff. had an augmentation.
Revision rates of the AUS vary, but of the studies looking

CO MPLICATIO NS at long-term survival of grafts, the overall revision rates are
between 26% and 32% (16,17). H ajivassiliou (16) found a re-
Early complications of AUS insertion are commonly urinary vision rate of 32% , with 90% of revisions needing to be done
retention and hematoma. Urinary retention can be managed within the first 3 years following insertion of the AUS.
easily with either a temporary Foley catheter or intermittent Revisions are generally due to mechanical or nonmechanical
catheterization. H ematomas can occur adjacent to any part of failure. M echanical failure is usually due to leakage of the de-
the AUS but are more commonly found around the pump. vice, malfunction of the pump, or kinks in the AUS tubing.
Infection and urethral erosion are often discussed simulta- N onmechanical failure is due to infection or erosion and ure-
neously in studies on the AUS. Although the generally quoted thral atrophy. The incidence of mechanical failure is between
incidence for this serious complication is around 3% , its inci- 13% and 27% , and that of nonmechanical failure is 13% to
dence has varied considerably and in some studies is surpris- 37% (13,17,18). Problems with the pump account for the ma-
ingly high. A recent review of 270 AUS patients with 36 jority of mechanical failures (43.8% ) (17).
months follow-up reports an infection rate of 5.5% and an In women, results of AUS are variable and population num-
erosion rate of 6% (15). In a long-term study with a mean bers often small. O ne recent series (19) studied the long-term
follow-up of 11 years, the infection and erosion rate was 25% follow-up of 68 female patients. They found that at 7 years,
(13), and in H ajivassiliou’s review of the literature the inci- 81% were dry, with a revision rate for erosion or infection of
dence of erosion is 12% with infection in 4% to 5% (16). 46% . Those with neuropathic etiologies had a continence rate
O nce suspected, all components of the AUS have to be re- of 90% , although 50% of these required revision surgery. In
moved and a period of antimicrobial treatment and recovery the Type III incontinence group, 83% were dry.
needs to take place before reimplantation. The standard wait-
ing period prior to attempting replacement is usually 3 to 6
months. Erosion can occur early and is often due to an unrec- Influe nce o f Pre vio us Rad io t he rap y
ognized perforation in the urethra, or it may occur late due to
chronic pressure of the cuff on the urethral tissues. Previous ir-
o n Re sult s o f AUS
radiation, trauma, or urethral scarring for any reason may in-
Previous irradiation is known to be a risk factor for urethral
crease the risk of erosion. Women are also at increased risk, as
erosion and the need for revision of the AUS (4). Irradiation of
discussed previously.
tissues is thought to produce a change in vascularity and fi-
M echanical failure can occur from the outset of AUS inser-
brosis over time. It can cause hypovasculation of the urethral
tion or later due to wear and tear on the AUS components. The
tissue and may affect the function of the bladder by similar
long-term incidence of revisions secondary to mechanical fail-
mechanisms. Continence rates following insertion of the AUS
ure is 32% over 11 years (13); however, in one review the figure
in irradiated patients vary from 64% to 70% (20,22), and
is 12% (16). This percentage has decreased to 7.6% due to de-
overall continence rates do not differ significantly between the
velopments in AUS design such as the narrow-backed cuff (17).
nonirradiated and irradiated groups. Revision rates can be
If incontinence recurs, one needs to consider the patient,
higher in the irradiated group, usually due to atrophy. In one
the device, and the bladder. It may be due to the patient not
study, 42% of patients had previous radiotherapy, and in this
using the device properly, mechanical failure of the device,
group, 51% (compared with 15% of the nonirradiated group)
urethral spongiosal atrophy, the development of detrusor
needed revision, mostly for urethral atrophy (22). Urethral at-
overactivity, or overflow incontinence. If the device seems to
rophy seems to be related to intrinsic urethral hypovascularity,
be cycling correctly, one should perform urodynamics with
which has been reported in many studies looking at this
leak point pressures and cystoscopy to investigate the cause. If
group. In other studies, however, the revision rates for those
urethral atrophy is the cause, the cuff can be downsized, or, if
with and without previous radiation treatment are similar,
a small cuff is already in situ, another cuff can be placed in
with rates of 25% versus 22.5% (20) and 15.4% versus
tandem or transcorporeal cuff placement can be attempted.
20.6% (17). The risk of infection and erosion may also be
O veractivity of the detrusor can usually be treated with an-
higher in irradiated patients, although evidence is inconsistent.
timuscarinics; however, in the neuropathic population it often
Cuffs are usually placed at the bulb in this group, and the
requires augmentation of the bladder.
cuff size is determined in the usual way by sizing the urethra.
Generally, however, most authors prefer to place lower-pressure
reservoir balloons to reduce the risk of pressure necrosis of the
O UTCO MES urethra and thereby reduce urethral atrophy and erosion
(22,23). There is a higher reported incidence of detrusor over-
O f the long-term follow-up studies for the AUS, H ajivassiliou activity in patients who have been previously irradiated (20,22);
(16) found that the overall continence rates are 73% with 88% however, this does not seem to influence the failure rate of AUS
improved continence. Venn et al. (13) found an overall conti- insertion, presumably because this is treated prior to placement.
nence rate at 10 years of 84% . The best results were in the AUS insertion is currently the best long-term treatment in
postprostatectomy group, who had cuffs placed at the bulb patients with sphincter dysfunction and previous irradiation.
(92% dry at 10 years). This group also had the least chance of Despite higher revision rates, the results are good in the male
infection of the AUS. The overall risk of revision was 54% population. Importantly, patient satisfaction rates are consis-
(13). The continence rate in patients with postprostatectomy tently high (20). In women, the results of AUS insertion in
incontinence is excellent, with long-term continence exceeding conjunction with radiotherapy are particularly poor. In one
90% (13,17,18). The revision rate in this group is about one- series (19), all women with a history of irradiation failed and
third, but patient satisfaction is consistently high. had their AUS removed.
Chap t e r 45: The Male Sling for Postp rostate ctomy Incontine nce : Curre nt Conce p ts and Controve rsie s 299
References
1. Scott FB, Bradley WE, Timm GW. Treatment of urinary incontinence by an 13. Venn SN , Greenwell TJ, M undy AR. The long-term outcome of artificial
implantable prosthetic urinary sphincter. 1974. J Urol 2002;(2, Pt 2): urinary sphincters. J Urol 2000;164(3, Pt 1):702–707.
1125–1129. 14. Kryger JV, et al. The outcome of artificial urinary sphincter placement after
2. Classen DC, Evans RS, Pestotnick SL, et al. Timing of prophylactic admin- a mean of 15 year follow up in a pediatric population. Br J Urol 1999;83:
istration of antibiotics and the risk of surgical wound infection. N Eng 1026.
J M ed 1992;326:281–286. 15. Lai H H , H su EI, The Es, et al. 13 years of experience with artificial urinary
3. Carson CC. Infections in genitourinary prostheses. Urol Clin N orth A m sphincter implantation at Baylor College of M edicine. J Urol 2007;177(3):
1989;16:139–147. 1021–1025.
4. Raj GV, Perterson AL, Webster GD. O utcomes following erosions of the 16. H ajivassiliou CA. A review of the complications and results of implanta-
artificial urinary sphincter. J Urol 2006;175(6):2186–2190. tion of the AM S artificial urinary sphincter. Eur Urol 1999;35:36.
5. Chancellor M B, H eesakkers JP, Janknergt RA. Gracilis muscle transposi- 17. Elliot Ds, Barrett DM . M ayo clinic long term analysis of the functional
tion with electrical stimulation for sphincteric incontinence: a new durability of the AM S 800 artificial urinary sphincter: a review of 323
approach. World J Urol 1997;15(5):320–328. cases. J Urol 1998;159:1206–1208.
6. Guralnick M L, M iller E, Toh KL, et al. Transcorporeal artificial urinary 18. Singh G, Thomas DG. Artificial urinary sphincter for post-prostatectomy
sphincter cuff placement in cases requiring revision for erosion and ure- incontinence. Br J Urol 1996;77:248.
thral atrophy. J Urol 2002;167:2075–2078. 19. Thomas K, Venn SN , M undy AR. O utcome of the artificial urinary sphinc-
7. Wilson SK, Delk JR, H enry GH , et al. N ew surgical technique for sphinter ter in female patients. J Urol 2002;167:1720–1722.
urinary control system using upper transverse scrotal incision. J Urol 2003; 20. Gomha M A, Boone TB. Artificial urinary sphincter for post-prostatectomy
169:261–264. incontinence in men who had prior radiotherapy; a risk and outcome
8. Scott FB. The use of the artificial sphincter in the treatment of urinary in- analysis. J Urol 2002;167(2, Pt 1):591–596.
continence in the female patient. Urol Clin N orth A m 1985;12(2):305. 21. Bhalchandra G, Parulkar BG, Barrett DM . Combined implantation of arti-
9. Appell RA. Techniques and results in the implantation of the artificial ficial sphincter and penile prosthesis. J Urol 1989;142:732–735.
urinary sphincter in women with type III stress incontinence by a vaginal 22. M artins FE, Boyd SD. Artificial urinary sphincter in patients following ma-
approach. N eurourol Urodynam 1988;7:613–619. jor pelvic surgery and/or radiotherapy: are they less favorable candidates?
10. Barrett DM , Goldwasser B. The AUS: current management philosophy. J Urol 1995;153:1188–1193.
1988;5:lesson 32. 23. Perez LM , Webster GD. Successful outcome of artificial urinary sphincters
11. Singh G, Thomas DG. Artificial urinary sphincter for post-prostatectomy in men with post prostatectomy urinary incontinence despite adverse im-
incontinence. Br J Urol 1996;77:248. plantation features. J Urol 1992;148:1166.
12. Levesque PE, et al. Ten-year experience with the artificial urinary sphincter
in children. J Urol 1996;156:625–628.
CHAPTER 45 ■ THE MALE SLING FO R

PO STPRO STATECTO MY INCO NTINENCE:
CURRENT CO NCEPTS AND CO NTRO VERSIES
CRAIG V. CO MITER
postoperatively. Regarding pad usage, 18% utilized one to

PREVALENCE O F two pads per day, while only 3% required 3 or more pads per
PO STPRO STATECTO MY day (3). Regardless of the definition of PPI, a significant mi-
INCO NTINENCE nority of patients will have enough urinary leakage to require
pad usage and seek further therapy.
The most common cause of stress urinary incontinence (SUI) The male sling (M S) has recently emerged as an alternative
in men is iatrogenic injury during prostate surgery. The rate of to the artificial urinary sphincter (AUS) for the surgical treat-
incontinence following surgery for benign prostatic hyperpla- ment for PPI. The modern M S is based on the early concepts
sia is approximately 2% (1). O n the other hand, the risk of described by Berry in the 1960s and Kaufman and Kishev in
urinary incontinence is significantly higher following surgery the early 1970s. The Kaufman and Kishev prostheses ulti-
for prostate cancer. While reports of postprostatectomy incon- mately fell out of favor due to long-term failure, infectious
tinence (PPI) vary, contemporary cohort studies generally complications, and pelvic pain, concomitant with the emer-
agree that between 5% and 11% of patients will have enough gence of the modern artificial urinary sphincter (AUS).
leakage after radical prostatectomy to seek further treatment Schaeffer from N orthwestern (Clemens et al., [4]) described a
(2,3). In a recent study by Stanford et al, patients were evalu- novel bulbourethral sling procedure in 1999. Bolsters were
ated using a self-administered questionnaire. O nly 32% claimed placed beneath the bulbar urethra to form a sling; the bolsters
total urinary control, 40% had occasional leakage, 7% had were suspended from the rectus fascia by sutures. H owever,
frequent leakage, and 2% suffered from no control at 2 years despite excellent continence rates, 21% of patients required
revision of the sling, and in 6% bolster removal was necessary The frequency, severity, social impact, and effect on hy-
secondary to infection or erosion (4). Recent alterations of the giene and quality of life of the incontinence must be balanced
M S have been described with modification of the sling mater- against the ability of the patient to conservatively manage the
ial but preservation of the concept of suburethral compres- condition. In addition, reasonable physician and patient ex-
sion. By far, the most significant innovation affecting male pectations based on reproducible results of clinical efficacy,
sling surgery has been the use of bone screws. T his purely per- acceptable morbidity (severity, duration, and need for addi-
ineal approach transform ed the surgery into a reproducible, tional therapy), and the avoidance of serious complications
standardized, and m inim ally invasive outpatient procedure. are essential. The AUS and the M S should be implanted cau-
tiously in patients with uncontrolled detrusor overactivity or
decreased compliance. In addition, those conditions that may
DIAGNO SIS require future transurethral management are relative con-
traindications to outlet surgery, especially if the AUS or M S
Evaluation of a patient should begin with a detailed history of would impair transurethral access or if repeated instrumenta-
the lower-urinary-tract symptoms. H owever, the pathophysi- tion would put the devices at risk for infection or erosion.
ology of PPI is variable, and history alone is not sufficient to
distinguish between bladder causes (poor compliance, detru-
sor overactivity, detrusor underactivity) and outlet causes ALTERNATIVE THERAPY
(sphincteric insufficiency or bladder outlet obstruction) of
incontinence. A micturition diary is useful for quantifying fre- No no p e rat ive Manag e me nt
quency, incontinence episodes, and functional bladder capac-
ity. Physical examination should focus on neurourological M any patients will regain satisfactory continence within the
assessment, and urinalysis is helpful to rule out infection. first 12 months following prostate cancer surgery. Thus treat-
Urodynamic evaluation is strongly recommended prior to con- ment within the first year is usually conservative. Unfortunately,
sideration of invasive therapy. Filling cystometry can assess there is currently no effective FDA-approved pharmacother-
bladder storage, and outlet function may be evaluated by mea- apy for intrinsic sphincter deficiency. Furthermore, blood
surement of antegrade or retrograde leak point pressure. pressure effects and a generalized lack of supportive evidence
While the majority of men with PPI suffer from intrinsic for the use of alpha-agonists have limited their utility in the
sphincter deficiency (ISD), only 25% to 50% will have ISD management of PPI. Active conservative management there-
alone on urodynamics. Approximately 40% of patients with fore usually relies on fluid restriction, prompted voiding, and
ISD will demonstrate concomitant bladder dysfunction, pelvic floor exercises. While pelvic floor exercise therapy insti-
and 15% of patients with PPI demonstrate only bladder tuted prior to radical prostatectomy aids in the earlier achieve-
dysfunction (5). ment of urinary continence, the value of the various approaches
While patient preference and pad usage clearly dictate the to prolonged conservative management for PPI generally re-
implementation of surgical treatment, it is important to accu- mains uncertain.
rately quantify the degree of sphincteric incompetence, as this N oncurative management options to control urinary leak-
factor may affect the type of treatment recommended for the age also include the use of an indwelling catheter, an external
management of the stress incontinence. For example, patients collection device (condom catheter or pads), or a penile
with higher abdominal leak point pressure (ALPP) (and there- clamp. H owever, these conservative options are not without
fore a lower degree of ISD) tend to respond better to peri- risk. An indwelling catheter may cause recurrent urinary tract
urethral bulking agents than do patients with a lower ALPP. infections, stone formation, urethral injury, and even meta-
Patients with more profound sphincteric incompetence are plastic and neoplastic changes in the bladder mucosa. A con-
more appropriately treated with artificial sphincter or sling dom catheter requires a drainage bag, and with the penile
surgery. shortening that commonly occurs after radical prostatectomy,
it may be difficult to secure. The penile clamp may cause dis-
comfort and skin irritation but may be particularly useful dur-
INDICATIO NS FO R SURGERY ing the period of active conservative management.
Periurethral bulking agents represent another “ nonopera-
Surgical intervention is indicated for treating bothersome SUI tive” treatment for PPI. Carbon-coated zirconium beads in
due to ISD that fails to adequately improve following 12 beta-glucan gel, bovine glutaraldehyde cross-linked collagen,
months of active conservative management. Severity, effect on and polydimethylsiloxane are the most popular injectable agents
quality of life, and the ability of the patient to conservatively for SUI in men due to ISD. “ Cure” rates for transurethral (ret-
manage incontinence must be balanced against the risks of rograde) collagen injection have generally been low for PPI,
surgery. The male sling and artificial urinary sphincter both and antegrade injection does not offer any significant advan-
address the underactive outlet by increasing resistance to uri- tage over the retrograde technique.
nary flow during storage. Resistance to leakage is created by
applying pressure over a length of urethra utilizing the M S
mesh or the AUS cuff. These forces are concomitantly applied Art ificial Urinary Sp hinct e r
to the blood supply of the compressed urethral segment, and
may thereby result in urethral ischemia. Device construction, The AUS circumferentially occludes the urethra by exerting
component selection, and implantation technique must there- continuous compressive pressure. The AUS was introduced in
fore aim to optimize urethral compression while minimizing 1973, and numerous design changes have culminated in the
the risk to urethral viability. AM S 800 urinary prosthesis (American M edical Systems,
M innetonka, M N ; hereafter AM S). Cuff closure pressure is

controlled by a balloon reservoir, generally at 61- to 70-cm
H 2 O pressure. N ormal voiding can only occur during tempo-
rary relief of urethral occlusion by activation of a scrotal pump
that diverts compressive fluid from the cuff to the balloon
reservoir. Ex perience w ith the A US for greater than three
decades has dem onstrated consistent and ex cellent results. T he
circum ferential com pression of the urethra, w ith an appropri-
ately sized cuff and appropriately pressurized balloon reservoir,
appears to be efficacious in treating all degrees of SUI.
When reported by itself, the infection rate with initial AUS
surgery is generally 1% to 3% , but it can be as high as 10% in
patients’ status after pelvic radiation and in reoperations (2).
In most recent reports, with the routine practice of delayed
FIGURE 45.1 Three bone anchors with no. 1 polypropylene sutures
cuff activation, erosion rates are in the range of 1% to 5% fol- are placed into each descending ramus.
lowing initial surgery (2). The introduction of the narrow-
backed cuff has led to substantial decreases in device failure,
with nonmechanical failure decreasing from 17% to 9% and rami are then exposed bilaterally. Using the InVance bone drill
mechanical failure decreasing from 21% to 8% (2). With re- (AM S), three titanium bone screws, each loaded with a pair of
current ISD due to urethral atrophy, revision of the AUS no. 1 polypropylene or braided polyester sutures, are inserted
may be indicated. The AUS revision rate is generally 17% to in the medial aspect of each descending ramus: just beneath
25% at 5 years since the introduction of the narrow-backed the pubic symphysis, at the level of the bulbar urethra, and
cuff (2). midway between the proximal and distal screws (Fig. 45.1).
Retrograde leak point pressure (RLPP) is measured via
perfusion sphincterometry. With the catheter repositioned to
RATIO NALE FO R THE MALE SLING the penile urethra and the balloon inflated with 0.5 cc saline, a
1-L saline bag is connected to the catheter via cystoscopy tub-
The impetus for the design of the modern male sling (M S) was ing. The RLPP is recorded in centimeters of water as the
to decrease the risk of device infection and urethral erosion, height of the fluid column above the symphysis at which fluid
minimize the incidence of urethral atrophy that is associated flow commences (6). The RLPP represents that pressure
with the AUS, and allow for spontaneous voiding without the required to overcome sphincteric resistance.
need for device manipulation. The M S is a noncircumferential A 4- by 7-cm silicone-coated polyester mesh (InteM esh,
device that is placed with the aim of applying sufficient ure- AM S) is recommended for the sling. The left-sided bone-
thral occlusive pressure to prevent leakage yet permit normal anchored sutures are passed through the sling 0.5 cm from
spontaneous voiding without the need for device manipula- the left edge, equally spaced along the width of the sling, and
tion. Recent experience with the M S has taught several lessons tied down to the bone. The right-sided sutures are then
regarding the management of PPI with sling surgery: (a) ade- passed through the sling (Fig. 45.2) and temporarily ten-
quate but not excessive tension is necessary for urethral com- sioned with a single throw. RLPP is again measured, and sling
pression and continence; (b) well-designed synthetic materials tension may be adjusted by moving the right sutures medially
have an acceptably low rate of infection and erosion; (c) ade- or laterally along the sling edge until an RLPP of 60 cm of
quate detrusor contractility is necessary to overcome the fixed water can be demonstrated. The sutures are then tied down to
resistance of the sling; (d) various methods of sling fixation the pubic bone to maintain proper sling compression. The
can achieve successful urethral compression; and (e) patients
with more severe or total urinary incontinence appear to have
a lower success rate with the M S than do patients with more
mild to moderate degrees of incontinence (6).
SURGICAL TECHNIQ UE
As the bone-anchored M S is the most commonly performed
sling procedure for the treatment of PPI, the technique for this
particular approach is described. The surgery is performed un-
der general anesthesia with the patient in lithotomy position.
A negative urine culture is required prior to surgery.
Intravenous cephazolin (or vancomycin plus gentamycin, if
allergic) is given within 1 hour of surgery. After the patient is
prepared and draped in a sterile fashion, a 14Fr Foley catheter
is passed per urethra to help identify the perineal portion of
the urethra. A 3- to 4-cm midline incision centered over the FIGURE 45.2 The left sutures have been tied and cut. The right
bulbous urethra is made. The bulbospongiosa are exposed in sutures are passed through the sling. Tension is determined by how
the midline, and the medial aspects of the descending pubic laterally or medially the right sutures are placed through the sling.
catheter is then replaced into the bladder, and the wound is ir- TA B LE 4 5 . 1
rigated with antibiotic solution and closed in multiple layers
with running suture, using 2-0 polyglycolic acid suture for the URODYN AMIC EFFECT OF MALE SLIN G
deep layer, 3-0 polyglycolic acid suture for the dartos layer, ON VOIDIN G
and 4-0 polyglycolic acid suture for the skin. A trial of void- Q max (mL/ s) PdetQ max (cm water)
ing is performed when the patient is able to stand comfort-
ably to void, usually within 6 to 36 hours postoperatively. Preoperative 19.2 9.7 40.3 9.2
Alternatively, a 14Fr suprapubic tube may be placed intraop- Postoperative 17.7 6.5 45.8 14.7
eratively and used to monitor residual urine volume. The
suprapubic tube may be removed when residual urine volume
is appropriately low (i.e., equal to the preoperative postvoid Urodynamic evaluation of a subgroup of 22 volunteer
residual urine volume). patients at an average of 25 months follow-up revealed an
increase in RLPP from a mean of 30.4 15.7 to 59.9 9.7 cm
water following sling surgery (p 0.001). There was no sig-
O UTCO MES nificant change between intraoperative RLPP and RLPP on
postoperative urodynamics (59.9 9.7 versus 56.7 10.4
Unlike the AUS literature, reports of the success for the M S cm water). N o patient demonstrated BO O on urodynamics
are more difficult to interpret, as most reports come from preoperatively, and none developed iatrogenic bladder outlet
single-institution cohorts that are hampered by small numbers obstruction (BO O ) following sling surgery. The average maxi-
and usually short follow-up. mum flow rate (Q max ) following surgery (17.7 6.5 mL per
Similar to reports of AUS surgical results, “ success” de- second) did not significantly differ from preoperative Q max
pends on the definition of continence, the method of evalua- (19.2 9.7 mL per second) N or was there a significant
tion, the length of follow-up, and the experience of the change in detrusor pressure at Q max (Pdet Q max ), averaging
surgeon. In addition, the sling material and method of ten- 40.3 9.2 cm water preoperatively and 45.8 14.7 cm wa-
sioning may also contribute to the success or failure of the ter postoperatively (Table 45.1). Average postvoid residual
procedure. H owever, despite these limitations that may hin- urine was 17 26 mL (range, 0 to 94 mL). While 4 patients
der the objective evaluation of this relatively new technique, demonstrated detrusor overactivity (DO ) postoperatively,
there is relatively good consistency within the literature, none developed symptomatic de novo urgency or urge urinary
with success rates for the M S generally ranging from 65% incontinence postoperatively.
to 90% (2,6).
At the author’s institution, a cohort of 48 patients with a
minimum follow-up of 24 months (range, 24 to 60 months) CO MPLICATIO NS
and a median follow-up of 48 months have been followed
The infection or erosion rate for the M S is quite low (2.1% ),
since they underwent M S surgery between 1999 and 2003.
and the rate for the need for revision (secondary to bone-
Twenty patients had follow-up of at least 48 months, and
anchor dislodgement) is 4.2% (6). In addition, there have been
35 patients had follow-up of at least 36 months. The average
no reported instances of urethral atrophy resulting in recur-
age was 67.6 9.7 years. Six patients had a previous artificial
rent incontinence. Bothersome scrotal pain or numbness
urinary sphincter, 8 had adjuvant radiation treatment (XRT),
affects 5% to 16% of patients, which typically resolves within
2 had primary XRT, and 9 had a previous collagen injection.
3 months (6).
All patients rated their incontinence as a “ big problem” on
the UCLA Prostate Cancer Index (PCI) incontinence score,
and all used three or more pads daily. Preoperative mean
RLPP was 27.3 8.0 cm of water, and patients used an aver-
CO NTRO VERSIES IN MALE
age of 4.6 2.1 pads per day. The median preoperative SLING SURGERY
UCLA PCI incontinence score was 63 (scale of 0 to 500) (6).
At a mean follow-up of 48 months (range, 24 to 60 months), Te nsio ning Sling
the median UCLA PCI incontinence score improved to 343,
and postoperative pad usage decreased to a mean of 1.0 1.7 Unlike the woman with urethral hypermobility and preserved
pads per day. O verall, 31 out of 48 patients (65% ) were cured intrinsic sphincter function, the male with SUI suffers mostly
of their leakage (no problem, no pads), 7 out of 48 (15% ) from ISD. And just as one measures the circumference of the
were much improved (small problem, 1 pad), 3 out of 48 (6% ) urethra to determine appropriate AUS cuff size, one should
were mildly improved (moderate problem, 2 pads daily), and measure sling tension to provide sufficient urethral compres-
7 out of 48 (15% ) failed (big problem, 3 or more pads). sion when placing the M S as a surgical treatment for ISD.
Thirty-eight out of 48 patients (79% ) were cured or much im- Various successful tensioning techniques have been described,
proved and were “ socially continent,” using 0 to 1 pad per including measurement of leak point pressure, tensioning
day (6). based on “ cough leakage,” and tensioning based on visual es-
Previous collagen injection and previous adjuvant XRT did timation. The author recommends perfusion sphincterometry,
not affect outcome, but both patients with primary XRT with a goal of 60 to 70 cm water compression pressure based
failed, and 5 out of 6 patients (83% ) who had previously had on the well-known success of the 61- to 70-cm water balloon
AUS implantation failed. In the group of 7 patients who failed pressure of the AUS. Ullrich and Comiter (7) demonstrated
to improve, 2 had primary XRT, 5 had previous AUS, and 1 that patients who achieve a RLPP of 60 cm have a better out-
had pelvic trauma. come than those who demonstrated a lower compression
pressure. Furthermore, in patients who have undergone

surgery with targeted tensioning based on measurement of Sling Failure
RLPP, there have been no instances of prolonged urinary re-
In the case of suboptimal continence following sling surgery,
tention (6).
it is preferential to leave the previously placed sling in situ
and to place the AUS cuff distal to the sling, via a transscrotal
Sling Mat e rial approach. This approach has two advantages: (a) it avoids
the previous operative field, minimizing dissection through
It is vital that synthetic material be utilized so that the tension potentially scarred tissue; and (b) it leaves the proximally
can be maintained adequately over time. The rate of infection placed sling as a partially effective compressive device, similar
with synthetic material is acceptably low. to a tandem-cuff AUS. In cases where the surgeon elects to
place the AUS cuff transperineally, the previous sling neither
Co nt raind icat io ns renders the operation more difficult nor decreases AUS effi-
cacy (2,6). The silicone-coated polyester sling is only partially
Similar to AUS surgery, M S surgery is contraindicated in pa- incorporated into the subcutaneous or periurethral tissue,
tients who may require future transurethral surgery (e.g., re- and it is relatively straightforward to remove. The bul-
current urolithiasis, transitional cell carcinoma, or unstable bospongiosus may then be split and dissected off the underly-
anastomotic or urethral stricture disease). N ot only might the ing spongy urethra without difficulty, and the AUS may be
M S impair transurethral access, but also repeated instrumen- placed in routine fashion.
tation may put the devices at risk for infection or erosion. In
addition, sling surgery should be carefully considered in pa-
Pre vio us AUS Surg e ry o r
tients with uncontrolled detrusor overactivity or decreased
compliance, as increasing outlet resistance will not help either Pre vio us MS Surg e ry
of these conditions and could theoretically put the upper uri-
nary tract at risk. In patients who have failed previous AUS surgery or previous
M S surgery, AUS is preferred over the M S, as previous AUS
implantation and explantation may contribute to urethral fi-
De t ruso r Hyp o co nt ract ilit y brosis, thereby preventing adequate urethral coaptation with
the ventrally placed sling (2,6) In cases of severe urethral atro-
Bladder contractility can be measured preoperatively via pres- phy, double-cuff AUS placement or transcorporal AUS cuff
sure flow study. In patients with normal detrusor contractility, placement may be indicated.
there have been no reported instances of prolonged postopera-
tive urinary retention when using 60 cm water RLPP as an in-
traoperative guide to sling tensioning (6). Whereas the AUS Transo b t urat o r Male Sling
can be deflated to allow voiding with abdominal straining, the
fixed resistance of the sling will interfere with Valsalva voiding. The advent of bone screws has simplified the sling procedure
T herefore, in patients w ith detrusor hypocontractility, A US im - and obviated the need for an abdominal incision, and subse-
plantation is recom m ended rather than M S surgery. quently the bone-anchored perineal sling has become the most
common sling surgery for PPI. H owever, despite the small size
of the perineal incision, bothersome, albeit temporary, scrotal
Rad iat io n pain or numbness affects 5% to 16% of patients and can last
for up to 3 months (2,6). Such pain is likely due to irritation of
Full-course external beam radiotherapy appears to be a con-
pudendal nerve branches along the medial pubic rami in the
traindication to sling surgery. In fact, radiation was the only
area of the bone screws and/or to the sling “ pulling” the pubic
factor that predisposed to failure of the N orthwestern sling
rami toward each other. O ther limitations include the theoret-
(success rate was only 29% for irradiated patients, versus
ical risk of osteitis and osteomyelitis, and the high cost of the
68% for nonirradiated patients) (4). Interestingly, the success
disposable drill and bone screws. H ence there is a quest for a
rate for bone-anchored M S surgery is not adversely affected
suburethral sling independent of bone-anchor fixation, which
by adjuvant radiation following prostatectomy (6).
at the same time does not rely on retropubic suture placement
and the associated risk of bladder injury.
Se ve re Inco nt ine nce This has led to a recent interest in an M S placed via a trans-
obturator approach. H owever, a recent report comparing
Two recent reports demonstrated that patients with more se- transobturator sling and retropubic sling demonstrated that
vere incontinence preoperatively are at higher risk for postop- the tension-free transobturator sling has been shown to be
erative incontinence following sling surgery (8). Experience six times more likely to fail than a retropubic sling in women
with the AUS for greater than three decades has demonstrated with significant ISD, due to the fact that the transobturator
consistent and excellent continence results for all levels of uri- placement of the sling results in lower upward tension on the
nary incontinence (7). The circumferential compression of the urethra than with retropubic slings (9). Since PPI is due to
urethra, with an appropriately sized cuff and appropriately ISD rather than urethral hyperm obility, it is unlik ely that a
pressurized balloon reservoir, appears to be efficacious in transobturator sling alone can provide enough urethral resis-
treating most cases of male SUI. T hus, in m en w ith severe tance for adequate continence in m en w ith PPI.
incontinence ( 450 g per 24 hours urinary leak age), A US A recent series of 20 patients who underwent transobtura-
m ay be m ore appropriate than M S surgery. tor sling placement (AdVance, AM S) for PPI had disappointing
results, with a continence rate of only 40% at 6 weeks post-

operatively (10). Klingler and M arberger (11) observed in
their series of removal of unsuccessful transobturator slings
that there was significant narrowing and kinking of the ure-
thra, which led to voiding symptoms and elevated residual
urine without providing significant continence. They hy-
pothesized that the narrow transobturator sling could not
adequately stabilize the posterior urethra and bladder neck,
but rather produced a narrow and suboptimal urethral
compression.
It appears, based on these early reports, that the transob-
turator approach, by ventral elevation and compression of A
the bulbous urethra, may not be an adequate substitute for
the more distal urethral compression against the perineal
membrane and pubis provided by a perineal sling. O n the
other hand, the transobturator ventral urethral elevation
and compression may be more successful as an adjunct to the
perineal sling, rather than a substitute for it, by adding a
component of ventral urethral elevation to the urethral com-
pression provided by the perineal sling. Comiter and Rhee
(12) have recently described a combination transobturator-
plus-suprapubic sling utilizing a 5.5- by 7-cm woven
polypropylene sling with two 1.5- by 22.5-cm inferior exten-
sions and two 1.5- by 25-cm superior extensions (Fig. 45.3A).
The inferior extensions are passed via a transobturator ap-
proach, providing ventral urethral elevation and compres-
sion, and the superior extensions are passed via a suprapubic
approach, providing broad perineal urethral compression,
similar to the bone-anchored sling (Fig. 45.3B). This combi-
nation sling, using the VIRTUE sling system (Coloplast,
M inneapolis, M N ), was initially evaluated in a cadaveric
study, with each of the two sling components mediating in-
creased urethral resistance (as demonstrated by urethral pres-
sure profilometry). Two patients with severe ISD who had B
failed previous artificial sphincter placement, each requiring
FIGURE 45.3 A: The combined transobturator-prepubic VIRTUE
six pads per day, have realized total resolution of their SUI at (Coloplast, M inneapolis, M N ) sling. B: The inferior extensions are
1 year follow-up (12). passed in a transobturator fashion, and the superior extensions are
passed suprapubically.
SUMMARY mild to moderate SUI, where the patient has sufficient intrin-
sic sphincteric function to store urine but leaks during strenu-
M ale SUI is usually iatrogenic and can be a bothersome com- ous activity, the success rates for the two procedures appear
plication of prostate cancer surgery, causing approximately more or less equivalent. While the AUS has a longer track
10% of patients to seek further treatment. After 12 months of record of success than the more recently described M S, the
active conservative management, surgical intervention is often complication rate and revision rate for the latter appear
indicated. Transurethral injection of bulking agents, while lower, at least in the short term. And while spontaneous void-
minimally invasive, has not proven successful in either the ing without the need for device manipulation is a relative ad-
short or long term. The AUS and suburethral sling are both vantage of the M S, the patient must have adequate detrusor
safe and efficacious treatments for PPI secondary to ISD. contractility to realize this benefit. Both techniques represent
For severe incontinence, including total urinary inconti- efficacious and acceptably safe methods for the treatment of
nence due to profound sphincteric insufficiency, the AUS ap- PPI, yet each has its specific role in managing patients with
pears to have higher efficacy than does the M S. For more various degrees of leakage.
References
1. M cConnell JD, Barry M J, Bruskewitz RC. Benign prostatic hyperplasia: di- Wein AJ, Kavoussi LR, N ovick AC, et al., eds. Cam pbell-W alsh urology,
agnosis and treatment. Agency for H ealth Care Policy and Research. Clin 9th ed. Philadelphia: WB Saunders, 2006:2391–2404.
Pract G uidelines Q uick R ef G uide Clin 1994;8:1–17. 3. Stanford JL, Feng Z , H amilton AS, et al. Urinary and sexual function after
2. Staskin DR, Comiter CV. Surgical treatment of male sphincteric urinary in- radical prostatectomy for clinically localized prostate cancer: The Prostate
continence. The male perineal sling and artificial urinary sphincter. In: Cancer O utcomes Study. JA M A 2000;283:354–360.
Chap t e r 46: Sacral Ne uromod ulation 305
4. Clemens JQ , Bushman W, Schaeffer AJ. Q uestionnaire based results of the 9. M iller JJ, Botros SM , Akl M N , et al. Is transobturator tape as effective as
bulbourethral sling procedure. J Urol 1999;162:1972–1976. tension-free vaginal tape in patients with borderline maximum urethral
5. Foote J, Yun S, Leach GE. Postprostatectomy incontinence. Pathophysiology, closure pressure? A m J O bstet G ynecol 2006;195:1799–1804.
evaluation, and management. Urol Clin N orth A m 1991;18:229–241. 10. Rehder P, Gozzi C. Transobturator sling suspension for male urinary incon-
6. Comiter CV. The male perineal sling: intermediate-term results. N eurourol tinence including post-radical prostatectomy. Eur Urol 2007;52:860–867.
Urodynam 2005;24:648–653. 11. Klingler H C, M arberger M . Incontinence after radical prostatectomy: sur-
7. Ullrich N F, Comiter CV. The male sling for stress urinary incontinence: gical treatment options. Curr O pin Urol 2006;16:60–64.
urodynamic and subjective assessment. J Urol 2004;172:204–206. 12. Comiter CV, Rhee EY. The ventral urethral elevation plus sling: a novel
8. Fischer M C, H uckabay C, N itti VW. The male perineal sling: assessment approach for the treatment of stress urinary incontinence. BJU Int
and predication of outcome. J Urol 2007;177:1414–1418. 2008;101:187–191
CHAPTER 46 ■ SACRAL NEURO MO DULATIO N

SARAH E. MCACHRAN, RAYMO ND R. RACKLEY, AND SANDIP VASAVADA
The refractory overactive bladder represents one of the most action (11). The U.S. Food and Drug Administration
challenging problems in urology as well as a clinical problem (FDA) approved SN M for intractable urge incontinence in
that significantly erodes patient quality of life. Symptoms in- 1997 and for urgency-frequency and nonobstructive urinary
clude urinary frequency, urgency, urge incontinence, and noc- retention in 1999. Later labeling was changed to include
turia. Initial treatment for patients with overactive bladder “ overactive bladder” as an appropriate diagnostic category.
without any remediable anatomic cause is anticholinergic Since its inception, 40,000 InterStim neurostimulators
therapy. For patients who are not candidates for, refractory to, (M edtronic, Inc., M inneapolis, M N ) have been implanted for
or cannot tolerate anticholinergic pharmacotherapy, options the three approved indications for SN M of the lower urinary
are limited. Augmentation cystoplasty, in which a piece of tract (LUT).
small or large intestine is used to enlarge the bladder, has tra-
ditionally been offered as a last resort. H owever, this is a ma-
jor operation with significant potential short-term and
MECHANISMS O F ACTIO N O F
long-term complications. Even without complications, most SACRAL NERVE STIMULATIO N
patients are troubled by the need for lifelong intermittent
bladder catheterization after such reconstructive procedures. O ve ract ive Blad d e r
Sacral neuromodulation (SN M ) offers an alternative to pa-
tients who have failed more conservative treatments and may The ability to volitionally store and evacuate urine is modulated
be considering irreversible surgical options. by several centers in the brain. It is thought that patients with
The neuromodulation that we practice today has its roots overactive bladder may have suffered an insult that effectively
in the 1960s work of Boyce, Dees, Caldwell, and N ashold, unmasks involuntary bladder contractions (Fig. 46.1) (6). SN M
who experimented with various modes of bladder stimulation of these primitive reflexes may restore normal micturition by
including a transurethral approach, direct detrusor stimula- suppressing or inhibiting interneuronal transmission in the
tion, pelvic nerve and pelvic floor stimulation, and finally bladder reflex pathway (6). This inhibition may, in part, modulate
spinal cord stimulation. The pioneering work of Tanagho and the sensory outflow from the bladder through the ascending
Schmidt in the 1980s demonstrated that the stimulation of the pathways to the pontine micturition center (PMC), thereby pre-
sacral nerve root S3 generally induces detrusor and sphincter venting involuntary contractions by modulating the micturition
FIGURE 46.1 The concept of SN M is to modulate the ab-

normal involuntary reflexes of the lower urinary tract and
restore voluntary control. (Adapted from Leng WW,
Chancellor M B. H ow sacral nerve stimulation neuromodu-
lation works. Urol Clin N orth A m 2005;32:11–18.)
reflex circuit. In clinical practice, SNM improves abnormal Bladder wall trabeculation may help to confirm a clinical sus-
bladder sensations, involuntary voids, and detrusor contrac- picion of bladder outlet obstruction or neurogenic pathology.
tions. Interestingly, voluntary voiding is preserved.
Urinary Re t e nt io n
As yet, there are still no clear predictive factors suggesting
To allow for complete bladder emptying, detrusor contractions who will and will not be helped with SN M . Therefore, all pa-
must be coordinated with urethral sphincteric relaxation. When tients with voiding dysfunction, both overactive bladder and
the suprasacral pathways that coordinate sphincteric activity idiopathic urinary retention, who are not helped by other
are altered, the guarding and urethral reflexes that allow for measures may be considered candidates. A therapy trial,
urine storage without leakage still exist and cannot be turned whether a peripheral nerve evaluation (PN E) or Stage 1 of a
off. This may result in urinary retention and is seen in certain two-stage implant, is a minimal-risk, reversible procedure,
patients with spinal cord injury and detrusor sphincter dyssyn- making it the ultimate predictive test for patient selection (8).
ergia. These patients have functional detrusor contractions but There are several important contraindications to SN M . In
are unable to coordinate this with a relaxed urethral sphincter, patients with anatomic changes such as bony abnormalities of
resulting in urinary retention. Inhibition of the guarding re- the sacrum, access to the sacral neural foramina may be diffi-
flexes may improve urinary retention. SN M is postulated to cult or impossible. Patients with cognitive impairment render-
turn off excitatory flow to the urethral outlet and facilitate ing them incapable of operating the device or giving
bladder emptying. appropriate feedback regarding the level and comfort of stim-
ulation are poor candidates. Because of the unknown terato-
genic potential of electrical stimulation, it has been considered
DIAGNO SIS contraindicated in pregnant women with various voiding dys-
functions. H owever, women with electrical stimulation de-
A thorough history will help delineate the nature (acute vs. vices for pelvic health conditions who become pregnant may
chronic) and help classify the causes (neurogenic, anatomic, simply turn off their devices when considering, and during,
postsurgical, functional, inflammatory, and/or idiopathic) of a pregnancy.
patient’s LUT symptoms. Physical examination should focus on SN M is relatively contraindicated for those patients who
ruling out treatable causes of incontinence such as stress urinary have an anticipated need for future magnetic resonance imag-
incontinence and pelvic organ prolapse. Levator tone and func- ing (M RI). The potential hazards of M RI include motion, dis-
tion are assessed with rectal and vaginal examination; evidence location, or torquing of the implanted pulse generator (IPG),
of high-tone pelvic floor muscle dysfunction is often seen in pa- heating of the leads, and damage to the IPG, resulting in
tients who suffer from both overactive bladder and idiopathic painful stimulation. A recent pilot study from Toronto evalu-
urinary retention. A neurourologic examination should be per- ated eight patients with sacral nerve stimulator devices as they
formed to check for saddle sensation, sphincter tone, and intact underwent M RI examinations at 1.5 T to study areas outside
bulbocavernosus reflex. Postvoid residual urine volume is deter- the pelvis (3). Patients were monitored continuously during
mined. Urinalysis and urine culture are routinely performed. and after the procedure. Voiding diaries were collected after
Urine cytology should be considered to screen for bladder can- the procedure and compared with previous records. N o pa-
cer and bladder carcinoma in situ in those patients who present tient experienced painful stimulation during or after the M RI,
with refractory symptoms of dysuria and urgency or frequency, and there were no changes in perception of stimulation.
especially with coexistent hematuria. Furthermore, there were no changes in voiding diaries after
Voiding diaries are invaluable. They provide an objective as- the M RI. Until further evidence is collected proving the safety
sessment of symptoms for both initial evaluation and for assess- of M RI for this population, we advocate removal of the neu-
ing response to treatment. For patients with overactive bladder, roelectrode lead without removal of the pulse generator prior
the number of voids and incontinence episodes per 24-hour pe- to elective M RI. Following the M RI procedure, a new neuro-
riod, voided volumes, and degree of urgency should be assessed. electrode may be placed and connected to the previously im-
For patients with idiopathic retention, the amount sponta- planted and preserved pulse generator.
neously voided versus the catheterized volume per 24-hour pe-
riod is useful information. Urodynamic studies (UDS) including
cystometrogram, pressure-flow studies, and electromyography ALTERNATIVE THERAPY
(EM G) of sphincters and pelvic floor muscles are performed on
a selected basis. M any patients without known neurologic dis- Generally, patients are considered candidates for SN M once
orders can be thoroughly evaluated with the use of a voiding di- they have failed other forms of therapy. For the overactive
ary and a focused history and physical examination of the bladder population, anticholinergics tend to be prescribed
pelvis. H owever, EM G is recommended in suspected cases of first. While still considered experimental, clinical experience
neurogenic bladder dysfunction, detrusor sphincter dyssyner- with botulinum toxin for the treatment of neurogenic and
gia, or Fowler syndrome and may be considered for evaluation nonneurogenic overactive bladder is accumulating. As a last
of inappropriate pelvic floor muscle behavior. Additionally, resort, bladder augmentation may be considered. Patients with
urodynamics may be used to rule out treatable causes of urinary idiopathic urinary retention, particularly when attributable to
incontinence or obstruction. a hypertonic pelvic floor, should undergo a course of pelvic
Cystourethroscopy may be helpful. Urethral strictures and floor physical therapy with a physical therapist who special-
bladder neck contractures or fibrosis can be diagnosed. izes in treating pelvic floor disorders.
TA B LE 4 6 . 1
SURGICAL TECHNIQ UE
PATIEN T TEST BOX SETTIN GS
The procedure consists of two stages: a testing stage or first
stage and an implantation stage or second stage. Since its in- Rate 15 H z
troduction, several modifications have been made in the tech- Amplitude O ff
nology, with resultant changes in the surgical technique. Rate and pulse width Position A
The most significant of these changes was the shift from selection switch
peripheral nerve evaluation to the anchored lead staged proce- Pulse width 210 microseconds
dure, and finally to the current tined lead staged procedure. Amp limit 10 V
The tined lead was introduced in 2002 and offers the advan- Electrode select switches: 0 M inus
tage of simplified placement of the stimulation lead through a 1 O ff
percutaneous approach without the need for lead anchoring to 2 O ff
the fascia, significantly minimizing the invasiveness of the pro-
3 Plus
cedure (10). The lead is secured through the action of the tines
(Fig. 46.2). Another surgical modification was the movement
of the location of the IPG unit from the lower anterior ab-
can be used. The sacrum and buttocks are prepared and
dominal wall to the posterior gluteal region.
the patient is draped so that the sacrum, buttocks, and feet are
The peripheral nerve evaluation was originally developed
exposed, allowing observation of the bellows and great toe re-
to evaluate whether or not patients would respond to SN M
sponse. The ground pad is placed on the patient’s heel or calf.
before implanting the IPG. Before the inception of the tined
The red plug of the long test stimulation cable is connected to
lead, implantation required a significant sacral incision and
the grounding pad. The black plug is connected to the test
dissection to anchor the lead to the sacral fascia. A less inva-
stimulation cable and the other end to the test stimulator. The
sive screening test was therefore desirable before committing
initial settings for the test stimulator can be seen in Table 46.1.
the patient to permanent implantation. Unfortunately, the
PN E lead is precarious, and it is often difficult to replicate Lo cat ing Sacral Land marks
placement with the permanent lead and therefore to replicate
There are several methods to locate the S3 neural foramen, the
patient responses. Several reports have confirmed lower re-
desired location for tined lead placement (Fig. 46.3). Using
sponse rates and a higher rate of lead migration with the PN E
surface landmarks, the S3 foramen is generally located 2 to 3
(5). Therefore, after the introduction of the significantly less
cm off the midline on either side approximately 9 to 11 cm
invasive tined lead, the two-stage implantation approach
cephalad to the tip of the coccyx. If the sciatic notch can be
gained favor. H owever, the PN E still has proponents because
it can be performed in the office setting with local anesthesia,
thereby eliminating one trip to the operating room.
PNE Te st St imulat io n
The patient is placed prone with slight flexion at the hips to
position the sacrum horizontally. A jelly roll or other buttress
FIGURE 46.2 The tined lead allows for suture-free anchoring to the FIGURE 46.3 The S3 foramen is the desired location for the lead.
fascia. (From M edtronic, Inc. © 2006, with permission.) (From M edtronic, Inc. © 2006, with permission.)
FIGURE 46.4 Chai and M amo’s “ cross-hair” technique for S3 localization. Fluoroscopic image and sur-
face image of the same patient. The midline is marked by the directional guide, which is placed over the
spinous processes of the lower lumbar vertebrae. The foramen needle is placed so that it connects the
most inferior border of the sacroiliac joints. The S3 foramina are located approximately 2 cm lateral to
the junction of the two lines.
palpated, this provides a useful landmark as well. A line is marker is used to trace a line along the path of both needles,
drawn connecting the sciatic notches bilaterally, and an inter- creating a “ cross-hair.” The S3 foramen can be found approx-
secting line is drawn at the midline of the sacrum. The S3 fora- imately 2 cm lateral to the cross-hairs on either side.
men can be located approximately 1 fingerbreadth, or 2 cm,
lateral to the midline of the sacrum along the line connecting Inse rt ing t he Fo rame n Ne e d le
the sciatic notches. Less reliably, one can look for the least After injecting a buffered lidocaine solution into the skin, the
curved portion of the sacrum by balancing a pen on the sacral subcutaneous layers and bony surface of the sacrum in the
crest. This marks the level of the S4 foramen; S3 will be lo- vicinity of the selected foramen are anesthetized. Care is taken
cated about 2 cm cephalad to S4. not to inject anesthetic into the foramen itself as this can anes-
In 2001, Chai and M amo (1) introduced the use of the thetize the nerve intended for test stimulation. The foramen
“ cross-hair” fluoroscopic technique for S3 localization (Fig. needle comes in two lengths, 3.5 and 5.0 in. After the appro-
46.4). An anterior and posterior fluoroscopic image is used to priate needle is selected, it is inserted at the desired site at an
locate the inferior borders of the sacroiliac joints. This is angle perpendicular to the bony surface of the sacrum, thus
marked with a foramen needle. The directional guide can be causing it to pierce the skin at approximately a 60-degree
used to identify the spinous processes in the midline. A sterile angle (Fig. 46.5).
FIGURE 46.5 A wire is passed through the foramen nee-

dle so that the foramen needle can be exchanged for the
introducer sheath. N ote that the foramen needle is
inserted at a 60-degree angle to the skin. (From
M edtronic, Inc. © 2006, with permission.)
TA B LE 4 6 . 2 patient’s skin to secure it, leaving the proximal end exposed.

The ground pad is relocated to the patient’s lower back. The
SACRAL N ERVE RESPON SES lead is connected to the test stimulation cable and the test stim-
MOTOR AN D SEN SORY
ulator. It should not be left in place for 7 days.
SACRAL N ERVE RESPON SE
S2 Motor: Plantar flexion of the entire St ag e 1 Tine d Le ad Place me nt
foot with lateral rotation and clamp
movement of the anal sphincter For Stage 1, preoperative intravenous antibiotics are given and
Sensory: Sensations in the leg and standard aseptic techniques for the implantation of foreign
buttock bodies are implemented. An intravenous dose of either a
S3 Motor: Dorsiflexion of the great toe
cephalosporin, vancomycin, or a fluoroquinolone is preferred.
and a Bellows reflex (anal wink)
Sensory: Parasthesias or sensation
Either general anesthesia or monitored anesthesia care (M AC)
of pulling in the rectum, scrotum, is used. M AC is preferable as it allows the patient to commu-
or vagina nicate sensory responses during the procedure. If a general
S4 M otor: Bellows reflex only anesthetic is used, no long-acting muscle relaxants should be
Sensory: Sensation of pulling in the administered as they can inhibit motor responses. The patient
rectum only is prone and the buttocks are held apart using wide tape re-
traction so that the anus is visible during test stimulation. The
anus and tape are prepared into the sterile field and then cov-
ered with a separate plastic drape until visualization of the
The operator should walk off the bone by feeling the nee- anus is required. The patient’s feet will also need to be visible
dle as it drops through the foramen. The J hook of the patient during the procedure.
cable is then attached to the black, uninsulated portion of the The foramen needle is inserted at a 60-degree angle to the
needle, just below the hub. Beginning at zero, the amplitude of skin, approximately 1 to 2 cm cephalad to the marked location
the test stimulator is then slowly increased until the desired of the S3 foramen. If the patient is obese, the 5-in. needle
response is seen. The nerve is tested for the appropriate motor should be used and the insertion point may need to be even
response: dorsiflexion of the great toe and bellows contraction more cephalad. Because the pelvic plexus and pudendal nerve
of the perineal area (Table 46.2). The so-called bellows reflex run alongside the pelvis, the needle should be placed just in-
represents contraction of the levator muscles. A fluttering or side the ventral foramen. Fluoroscopy is used to confirm nee-
tugging sensation in the rectum, vagina, or labia is considered dle position. The nerve is tested for the appropriate motor
the ideal sensory response. response. The foramen needle is exchanged for the introducer
When the desired response is confirmed, the stimulation lead sheath over the directional guide, and the lead is passed so
is placed. After the stylet is removed from the foramen needle, that the electrodes, numbered 0 (distal) through 3 (proximal),
the test lead is threaded through the foramen needle until the are positioned with electrodes 2 and 3 straddling the ventral
depth indicator on the lead is properly aligned with the needle. surface of the sacrum (Fig. 46.6). Test stimulation is repeated
The distal indicator aligns with the hub of the 3.5-in. needle, on each electrode and the responses are observed. An S3 re-
and the proximal indicator aligns with the hub of the 5-in. nee- sponse should be noted at a minimum of two of the four elec-
dle. Care must be taken as the lead is delicate and easily dam- trodes. O nce the operator is satisfied with the position, the
aged. The lead is stimulated once again. After the appropriate sheath is removed, releasing the tines that anchor the lead
response is confirmed, the foramen needle and lead stylet are re- (Fig. 46.6). Confirmation of an S3 sensory response, a sensa-
moved, leaving the lead in place. O nce the lead stylet is re- tion of stimulation in the perineum, is not required to confirm
moved, the lead cannot be repositioned. The lead is taped to the proper placement if the correct S3 motor response is observed
FIGURE 46.6 The foramen needle is exchanged for the

introducer sheath over the directional guide, and the lead is
passed so that the electrodes, numbered 0 (distal) through
3 (proximal), are positioned with electrodes 2 and 3 strad-
dling the ventral surface of the sacrum. (From M edtronic,
Inc. © 2006, with permission.)
(2). H owever, if a motor response is absent despite what

appears to be fluoroscopically appropriate placement, the
patient’s sedation is lightened and sensory responses are
elicited. Patient verification of the correct sensory response
can then confirm proper localization. Fluoroscopically appro-
priate lead placement demonstrates the lead curving cephalad
to caudad on the lateral image and with electrodes 2 and 3
straddling the interior portion of the sacrum. The lead should
lie medial to lateral on the anteroposterior image.
A 2- to 4-cm incision into the subcutaneous tissues in the
upper lateral buttock is made below the beltline, 3 to 5 cm be-
low the superior iliac crest with the outer edge of the incision
meeting the posterior axillary line. This will be the site for
connecting the permanent lead to the percutaneous extension
lead wire. If the screening trial is successful, this connection
site will be the site of implantation for the IPG. The perma-
nent lead is transferred to the medial aspect of the lateral but-
tock incision using the tunneling device. The lead is then
connected to the extension wire and the tunneling device is
used again to transfer the extension wire from the medial as- FIGURE 46.7 The InterStim II. (From M edtronic, Inc. © 2006, with
pect of the incision to an exit point on the contralateral side of permission.)
the back. The long tunnel created by this transfer reduces the
occurrence of infection from the percutaneous exit site of the
wire. The extension wire is connected to the test stimulator.
The pocket is closed in two layers with a deep, interrupted 2-0 CO MPLICATIO NS
absorbable suture layer and a superficial, running 4-0 ab-
sorbable suture layer to close the skin. Patients are able to re- The sacral nerve stimulation study group has published sev-
sume their normal activities immediately but are advised to eral reports on the efficacy and safety of the procedure for in-
limit excessive movement, such as during high-impact exer- dividual indications (9). The complications were pooled from
cises, for the duration of the trial period. the different studies based on the fact that the protocols,
The external generator can be flexibly programmed for the devices, efficacy results, and safety profiles were identical. A
duration of the intended trial while patients record their total of 581 patients were recruited, 219 of whom underwent
symptoms and bladder function in a voiding diary. If there is implantation of the InterStim system. The complications were
50% improvement in the symptoms or voiding function, a divided into problems related to percutaneous test stimula-
Stage 2 procedure is performed. tion and postimplant-related problems. O f the 914 test stim-
ulation procedures done on the 581 patients, 181 adverse
events occurred in 166 of these procedures (18.2% of the 914
St ag e II procedures). The vast majority of complications were related
to lead migration (108 events, 11.8% of procedures).
At the Stage 2 procedure, the IPG is placed. Fluoroscopy is not Technical problems and pain represented 2.6% and 2.1% of
required during Stage 2 when a permanent neuroelectrode has the adverse events. For the 219 patients who underwent im-
been placed for the Stage 1 procedure; however, if a PN E was plantation of the InterStim system (lead and generator), pain
performed for Stage 1, then fluoroscopic confirmation of the at the neurostimulator site was the most commonly observed
neuroelectrode placement is advised. The buttock incision adverse effect at 12 months (15.3% ). Surgical revisions of the
overlying the lead connections is opened, the percutaneous ex- implanted neurostimulator or lead system were performed in
tension wire is removed, and the extension lead is secured to 33.3% of cases (73 of 219 patients) to resolve an adverse
the permanent lead and subsequently to the IPG. The newer- event. These included relocation of the neurostimulator be-
generation IPG, the InterStim II, is connected directly to cause of pain at the subcutaneous pocket site and revision of
the permanent lead without the need for an extension lead the lead for suspected migration. Explantation of the system
(Fig. 46.7). It is smaller than the original IPG but also has a was performed in 10.5% for lack of efficacy. O ne should con-
shorter battery life. The IPG pocket should be large enough to sider the fact that at the time, the generator was implanted in
accommodate the IPG without tension and deep enough to the lower abdomen.
prevent erosion and provide cosmetic results. The etched side H ijaz et al. (5) have presented algorithms for the trouble-
of the IPG faces up when it is inserted into the pocket. The shooting of SN M problems. Generator site infection is best
lead should be wrapped around the IPG, not placed on top of treated with explanation of the whole system. Despite at-
the IPG. This protects the lead if the pocket needs to be re- tempts to salvage some of these patients, follow-up revealed
opened for revision or IPG replacement. Prior to closing the that the infection persisted in all and eventual explantation
incision in two layers, impedances should be checked. was inevitable. The troubleshooting algorithm includes
Patients are discharged after patient education regarding the search for causes of (a) pocket (IPG site) discomfort;
the test stimulator and with prescriptions for oral pain med- (b) recurrent symptoms; (c) stimulation occurring in the
ication and 1 week of oral antibiotics, either cephalosporins wrong area of pelvis; (d) no stimulation; and (e) intermittent
or fluoroquinolones. stimulation.
Chap t e r 47: Surg ical Tre atme nt of Pe lvic O rg an Prolap se : Anatomy of the Pe lvic Floor 311
of daily voids (16.9 9.7 to 9.3 5.1), volume voided

O UTCO MES (118 74 to 226 124 mL), degree of urgency (rank score of
2.2 0.6 to 1.6 0.9), and quality-of-life measures. At
The original reported outcomes of SN M for the indications of
6 months post implant, stimulators in the active group were
idiopathic urgency-frequency and urge incontinence were de-
turned off and urinary symptoms returned to baseline values.
rived from two studies that randomized patients to active or
After reactivation of SN M , sustained efficacy was docu-
delayed therapy, as well as reports from numerous prospective
mented at 12 and 24 months.
and retrospective reviews of case series and registry databases.
In 2007, the results of a 5-year, prospective, multicenter
Schmidt et al. (7) reported on SN M therapy in 76 patients
trial confirmed the long-term efficacy of SN M in patients with
with refractory urge incontinence. During the 6-month study
refractory urge incontinence, urgency-frequency, and retention
period, at 16 different centers, patients were randomized to
(12). Seventeen centers enrolled 163 patients, and 152 patients
active or delayed therapy (control group). O f the 34 patients
underwent permanent implantation. Voiding diaries were col-
receiving active SN M therapy, 16 (47% ) were completely dry,
lected annually for 5 years. Study patient retention was fairly
and an additional 10 (29% ) demonstrated a 50% reduction
good: at 5 years a total of 105 patients completed follow-up
in incontinence episodes.
and 87 completed the voiding diary. At 5 years after implanta-
In a similar study design, H assouna et al. (4) reported
tion, 68% of patients with urge incontinence, 56% with
the outcomes of SN M for refractory urgency-frequency
urgency-frequency, and 71% with retention had successful out-
conditions in 51 randomized patients. At 6 months patients
comes, confirming the durability of this therapy.
in the active SN M group showed improvement in the number
References
1. Chai TC, M amo GJ. M odified techniques of S3 foramen localization and 8. Siegel SW. Selecting patients for sacral nerve stimulation. Urol Clin N orth
lead implantation in S3 neuromodulation. Urology 2001;58(5):786–790. A m 2005;32(1):19–26.
2. Cohen BL, Tunuguntla H S, et al. Predictors of success for first stage neuro- 9. Siegel SW, Catanzaro F, et al. Long-term results of a multicenter study on
modulation: motor versus sensory response. J Urol 2006;175(6): 2178–2180; sacral nerve stimulation for treatment of urinary urge incontinence,
discussion 2180–2181. urgency-frequency, and retention. Urology 2000;56(6)[Suppl 1]:87–91.
3. Elkelini M S, H assouna M M . Safety of M RI at 1.5 tesla in patients with 10. Spinelli M , Giardiello G, et al. N ew sacral neuromodulation lead for per-
implanted sacral nerve neurostimulator. Eur Urol 2006;50(2):311–316. cutaneous implantation using local anesthesia: description and first experi-
4. H assouna M M , Siegel SW, et al. Sacral neuromodulation in the treatment ence. J Urol 2003;170(5):1905–1907.
of urgency-frequency symptoms: a multicenter study on efficacy and safety. 11. Tanagho EA, Schmidt RA, et al. N eural stimulation for control of voiding
J Urol 2000;163(6):1849–1854. dysfunction: a preliminary report in 22 patients with serious neuropathic
5. H ijaz A, Vasavada SP, et al. Complications and troubleshooting of two- voiding disorders. J Urol 1989;142(2, Pt 1):340–345.
stage sacral neuromodulation therapy: a single-institution experience. 12. van Kerrebroeck PE, van Voskuilen AC, et al. Results of sacral neuromod-
Urology 2006;68(3):533–537. ulation therapy for urinary voiding dysfunction: outcomes of a prospective,
6. Leng WW, Chancellor M B. H ow sacral nerve stimulation neuromodula- worldwide clinical study. J Urol 2007;178(5):2029–2034.
tion works. Urol Clin N orth A m 2005;32(1):11–18.
7. Schmidt RA, Jonas U, et al. Sacral nerve stimulation for treatment of re-
fractory urinary urge incontinence. Sacral N erve Stimulation Study Group.
J Urol 1999;162(2):352–357.
CHAPTER 47 ■ SURGICAL TREATMENT

O F PELVIC O RGAN PRO LAPSE: ANATO MY
O F THE PELVIC FLO O R
ARIANA L. SMITH, JA-HO NG KIM, AND SHLO MO RAZ
The etiology of pelvic organ prolapse (PO P) is multifactorial, Understanding pelvic floor anatomy is critical for any
with at most 40% of cases being attributable to genetics (1). pelvic surgeon before undertaking reconstructive surgery. N ot
O ther factors that contribute to the development of prolapse only restoring pelvic floor anatomy but also maintaining and
include aging, hormonal status, birth and surgical trauma, pu- restoring appropriate function is essential for successful pa-
dendal neuropathy, elongation or detachment of support, and tient outcomes. Therefore, it is crucial to understand the com-
myopathy. While genetic and environmental effects are being plex combination of muscles, ligaments, and fascia that act
investigated and preventive measures sought, there remain dynamically to provide support to the female pelvic anatomy,
millions of women who have developed or will develop PO P including the urethra, bladder, uterus, and rectum. When nor-
in their lifetime. mal mechanisms of support fail, pelvic floor relaxation and
organ descent occurs. Depending on the compartment af-

fected, symptoms may vary from voiding dysfunction and uri-
nary incontinence to bowel dysfunction and stool incontinence.
N umerous techniques are available for surgical repair of
PO P, and many of these will be described in upcoming chap-
ters. This chapter will review female pelvic anatomy and mus-
culofascial support, emphasizing the supporting structures
that allow normal voiding and defecatory function, as well
as the pathophysiology of pelvic floor relaxation, with a de-
scription of the various components of PO P.
ANATO MY O F PELVIC SUPPO RT

Conceptually, the vaginal canal can be divided into three com-
partments that have distinct anatomic structures: (i) the ante-
rior compartment, which includes the urethra, bladder neck,
and bladder, (ii) the superior compartment, which includes the
uterus and cul-de-sac after hysterectomy, and (iii) the poste-
rior compartment, which includes the rectum, anal canal, and
perineum. These compartments have functional and anatomic
interactions such that the function and support of one com- FIGURE 47.1 The framework of the pelvic floor is formed by the pu-
partment depend on intact support of the others. Structurally, bic symphysis, pubic rami, and sacrum. The ischial tuberosities divide
the vaginal and pelvic anatomy starts with a framework of the pelvic floor into the anterior and posterior compartments. The
urethra is shown in the anterior compartment behind the pubic sym-
bones and ligaments that are lined with fascia and muscles. physis. The obturator fascia is an important area of anchoring for
These structures are intimately related and in some cases are pelvic support.
continuations of each other, especially in the case of ligaments
and fascia.
The Pe lvic Diap hrag m

Bo ne s
The framework of the pelvic floor is provided by the bony
structures, including the pubis, ilium, ischium, sacrum, and
coccyx. The pelvic bones create a diamond shape, with the
pubic symphysis and coccyx at the apices and the ischial
tuberosities dividing the diamond into anterior and posterior
compartments (Fig. 47.1). The anterior or urogenital triangle
contains the clitoris, urethra, and vaginal vestibule. The poste-
rior or anal triangle contains the anal canal and anal sphincter.
The pubic rami, ischial spines, and sacrum are important
anchoring points of muscular and fascial structures in the
pelvis (2).
Lig ame nt s
The name ligam ent has been given to what are truly dense
condensations of connective tissue in the pelvis. FIGURE 47.2 Abdominal view of the pelvis in a cadaver. The retro-
pubic space has been entered from the vaginal side, detaching the ure-
Pubourethral Ligaments. The pubourethral ligaments anchor thropelvic ligaments from the lateral pelvic wall and exposing the
the urethra anteriorly to the inferior ramus of the pubic sym- pubourethral ligament.
physis (Fig. 47.2). They also divide the urethra into proximal
and distal halves, with the proximal, intra-abdominal portion
responsible for passive, involuntary continence. The midpor- lateral pelvic wall (Fig. 47.3). They do so by anchoring the
tion, or the striated external sphincter, is responsible for ac- urethra laterally to the arcus tendineus fasciae pelvis (ATFP,
tive, voluntary continence. The distal third of the urethra is see below). The urethropelvic ligaments provide elastic, mus-
simply a conduit for urine passage and does not significantly culofascial support to the bladder outlet, thereby maintaining
change function when damaged or removed. passive continence. Voluntary or reflex contractions of the
pelvic floor increase the tensile force across these ligaments,
Urethropelvic Ligaments. The urethropelvic ligaments are a enhancing outlet resistance and preventing incontinence.
condensation of periurethral fascia that provides anatomic Thus, restoration of these ligamentous structures is critically
support of the bladder neck and proximal urethra to the important in the surgical correction of stress incontinence.
FIGURE 47.3 Urethropelvic ligaments supporting the urethra to the

levator musculature of the lateral pelvic sidewall. In patients with
multiple deliveries, the levator musculature is weakened and the liga-
ment is thin, elongated, or detached from the lateral pelvic wall.
Vesicopelvic Ligaments. The vesicopelvic ligaments anchor

the bladder to the pelvic sidewall. During voluntary or reac-
tive pelvic floor contraction (i.e., contraction of the levator FIGURE 47.5 Dissection of the bladder wall during repair of grade
muscles), the ligamentous structures tighten and elevate the IV cystocele exposes the cardinal ligaments as they attach to the blad-
der base.
bladder, preventing mobility and descent into the vagina.
Restoration of these ligaments is important in the correction
of anterior wall prolapse, or cystocele.
Cardinal–Sacrouterine Ligament Complex. The cardinal liga-

ments, or ligaments of M ackenrodt, are thick, triangular con-
densations of pelvic fascia that originate from the greater
sciatic foramen and insert into the cervix and vaginal wall.
They also extend to the perivesical fascia, providing support
to the bladder base (Figs. 47.4 and 47.5). These ligaments
contain numerous blood vessels branching from the hy-
pogastrics that supply the uterus and upper vagina (2). The
cardinal ligaments fuse posteriorly with the sacrouterine liga-
ments, which stabilize the uterus, cervix, and upper vagina
FIGURE 47.6 Uterine support and its relations to the bladder and
rectum. The cardinal ligaments provide support of the cervix to the
lateral pelvic wall.
posteriorly toward the sacrum (3) (Fig. 47.6). The sacrouter-

ine ligaments originate from the second, third, and fourth
sacral vertebrae and insert posterolaterally into the cervix and
vaginal fornices (4). The trauma of vaginal delivery can cause
relaxation of the cardinal-sacrouterine complex and allow de-
FIGURE 47.4 The vaginal wall has been dissected free to expose the scent of the cervix and uterus. Poor surgical technique at the
anterior support of the bladder and urethra. The periurethral fascia time of hysterectomy may not restore the ligaments to the
covers and supports the urethra distally. The perivesical fascia covers midline position, thus allowing a wide gap for the bladder to
the bladder wall from the bladder neck to the cervix. The cardinal lig-
aments are attached to the cervix in the midline with proximal exten-
herniate. It is very important to reapproximate the cardinal
sions to the bladder. They provide important support to the bladder ligaments in the midline when repairing anterior or posterior
base. wall prolapse.
FIGURE 47.7 The sacrospinous ligament is an important area of an-

choring for vaginal vault suspension.
FIGURE 47.8 Repair of the perineal body. The bulbocavernosus
muscle, the transverse perineal muscles, and the anal sphincter fibers
Broad Ligaments. The broad ligaments provide additional
are approximated to recreate the central tendon of the perineum.
uterine support superior to the previously named structures.
They attach the lateral walls of the uterine body to the pelvic
sidewall and contain the fallopian tubes, the round and ovar-
ian ligaments, and the uterine and ovarian vessels. The broad Pubocervical Fascia. O n the vaginal side is it often referred to
ligaments are covered by an anterior and posterior sheet of as the pubocervical fascia, but can be divided into discrete
peritoneum. areas of specialization depending on the associated organ it
supports (periurethral and perivesical fascia). As a whole, the
Sacrospinous Ligaments. The sacrospinous ligaments span pubocervical fascia is a trapezoid-shaped continuous sheet of
the posterior portion of the pelvic floor, from the ischial spines connective tissue support that extends from the pubic symph-
to the sacrum and coccyx (Fig. 47.7). The coccygeus muscle ysis to the cervix and laterally to the ATFP (8). The fascia is
lies over the top of the sacrospinous ligament and is a very im- fused to the bony scaffold by the cardinal ligaments laterally
portant landmark in vaginal surgery. Cephalad to the coc- and the sacrouterine ligaments posteriorly.
cygeus muscle, the lumbosacral plexus spreads its fibers,
which if injured can cause chronic debilitating pain. Lateral to Arcus Tendineus Fasciae Pelvis. ATFP is a curvilinear conden-
the coccygeus muscle the pudendal nerves and vessels traverse sation of pelvic fascia that arises from the obturator internus
in the canal of Alcock. Also in this area is the ureter, which muscle and runs from the pubic symphysis to the ischial spines
can be occluded with a suture placed too laterally (5). (Fig. 47.9). This tendinous arc of the obturator is the line of
insertion of the levator muscles on the obturator fascia. This
Perineal Body. The perineal body is a tendinous structure lo- crucial structure provides musculofascial attachment for the
cated in the midline of the perineum between the anus and anterior and posterior pelvic organs. It also provides an an-
vaginal introitus. It provides a central point of fixation for the choring point during reconstructive surgery of organs that
transverse perineal muscles, which extend from the ischial have descended.
tuberosities laterally (6) (Fig. 47.8). The perineal body pro-
vides an additional level of support to the posterior vaginal Periurethral Fascia. Around the urethra, the periurethral fas-
wall and rectum, incorporating the levator ani, bulbocaver- cia represents two wings of tissue extending from the urethra
nosus muscle, and transverse perineal musculature as well as to the ATFP, fused by the pubourethral ligaments.
the external anal sphincter. This level of support is elastic in
nature, allowing distortion and recoil during childbirth and Perivesical Fascia. Around the bladder, the perivesical fascia
intercourse. extends as wings from the bladder to the ATFP, fused by the
vesicopelvic ligaments.
Fascia
Like vaginal ligaments, there are no true vaginal fascias. The Prerectal/ Pararectal Fascia. Prerectal and pararectal fascia ex-
structures commonly called fascia are condensations of contends from the cardinal-sacrouterine complex to the perineal
nective tissue separating the vagina from the urethra, bladder, body and is sometimes referred to as the rectovaginal septum.
cervix, or rectum (7). The fascia overlying the pelvic floor
musculature plays a critical role in pelvic support. Both sides Musculat ure
of the muscle, the abdominal side and the vaginal side, are The striated musculature supporting the pelvic floor is com-
covered with fascia, and therefore the fascia comprises two posed of the levator ani muscles and the coccygeus muscles.
components. O n the abdominal side it is called endopelvic Together they cradle the visceral contents of the pelvis, pro-
fascia and represents a continuation of the transversalis fascia. viding dynamic support.
FIGURE 47.9 View of the anterior pelvis.

The endopelvic fascia covers the bladder and
urethra. The levator musculature is attached
to the arcus tendineus fasciae pelvis.
Levator Ani. The levator ani has two main components, the Coccygeus. The posterior portions of the levator ani, together
pubococcygeus and the iliococcygeus, which are named ac- with the coccygeus muscle, provide a horizontal plate from
cording to their origin from the pelvic sidewall (9). This broad the rectal hiatus to the coccyx. This plate maintains a normal
sheet of muscle extends from the pubic symphysis to the is- vaginal and uterine axis. The uterus and proximal vagina, as
chial spines and coccyx, taking origin from the ATFP laterally. well as the bladder and rectum, lie horizontally on this plate,
These muscle groups have overlying endopelvic fascia that preventing their descent. Resting tone of the levator ani and
allows direct attachment to the bladder, urethra, vagina, coccygeus, as well as reflex and voluntary contraction, acts to
uterus, and rectum to permit active visceral control (Fig. 47.10). pull the vagina and rectum forward, closing the lumens of
These muscles supply support during increases in intra- these structures. Re-establishing this axis is important for re-
abdominal pressure, preventing organ descent and more im- establishing normal anatomy and sexual function as well as
portantly preventing the release of urine and stool (2). The long-term success in prolapse surgery.
medial fibers of the pubococcygeus muscles are also referred
to as the puborectalis muscle or “ pullator” because of its role Levator Hiatus. The levator hiatus is a U-shaped midline
in pulling forward the anal canal and distal vagina, closing the aperture in the levator ani that allows passage of the urethra,
levator hiatus. vagina, and rectum (Fig. 47.11). These structures are sup-
ported by a fascial hammock, the urogenital diaphragm, as
they exit the pelvis (10). Fibers from the pubococcygeus enter
FIGURE 47.10 Pelvic support provided by the levator ani muscles.

The levator ani is divided into two main segments: the pubococcygeus
and the iliococcygeus. These muscles take origin in the arcus FIGURE 47.11 Three-dimensional M RI reconstruction of the levator
tendineus fasciae pelvis, a thickening of the obturator fascia. The me- musculature, bony pelvis, and obturator musculature in a patient with
dial portion of the pubococcygeus, the puborectalis, forms a sling multiple deliveries. The levator hiatus is widened (arrow ); this repre-
around the distal rectum. PR, puborectalis; PC, pubococcygeus; IC, sents the distance between the rectal canal and the pubic bone, called
iliococcygeus; O , obturator musculature; TA, tendinous arc. the puborectal line.
into the hiatus and surround the urethra and anus, forming bladder base, creating a valvular effect. The bladder neck and
the sphincter musculatures. urethra are supported by a musculofascial layer that suspends
these structures from the pubic bone and pelvic sidewalls,
thereby preventing their descent during increases in intra-
Are as o f Sp e cial Int e re st : abdominal pressure (11). Further, direct transmission of intra-
O b t urat o r Anat o my abdominal forces to a well-supported proximal urethra increases
its resistance and promotes coaptation (12). Relaxation of the
Prior to the introduction of the transobturator tape, the ob- pelvic floor as well as weakening of the urethropelvic liga-
turator anatomy was rarely studied. With the dramatic in- ments and midurethral complex produces significant posterior
crease in the number of procedures performed in this area and downward rotation of the urethra and bladder neck. This
and the arising complications, it is important for all urolo- anatomic repositioning of the urethra and bladder neck to a
gists to understand the anatomic landmarks. The adductor more dependent pelvic position eliminates the valvular effect.
longus tendon is a major landmark for trocar passage and Thus, a poorly supported urethra will tend to funnel and open
protects the patient from injury to the neurovascular bundle. during increases in intra-abdominal pressure. Interestingly, the
Safe entry and exit zones exist when the patient is properly same mechanism of restoring continence by repositioning the
positioned and landmarks are obeyed. When a sling is placed urethra higher than the bladder base and trigone (classic
using this technique, it is important to understand that the Burch procedure) can produce outlet obstruction in patients
mesh sling is placed through the obturator internus muscle who develop a secondary cystocele. This occurs due to a kink-
via passage of the trocar (Fig. 47.1). Complications are possi- ing effect when the prolapsing bladder drops further below
ble as a result of this placement; these include walking diffi- the suspended urethra.
culty and pain with contraction of the obturator internus Essentially, three mechanisms of support maintain conti-
muscle. nence during increases in intra-abdominal pressure: (i) the
backboard effect of urethral support maintained by the peri-
urethral fascia and urethropelvic ligaments, (ii) the valvular ef-
fect at the bladder neck, and (iii) the voluntary and reflex
PATHO PHYSIO LO GY O F PELVIC contraction of the pelvic floor.
FLO O R DYSFUNCTIO N With aging there is a decrease in skeletal and smooth mus-
cle density as a result of atrophy. This can affect the urethral
Me chanisms o f Ure t hral Co nt ine nce sphincter mechanism as well as the contributing pelvic floor.
Continence should therefore be perceived as a dynamic func-
Bladder outlet resistance in women is attained by several faction that changes with age. As a result, surgery for repair
tors working together to provide continence at rest and during should not be viewed as a cure that will last forever, but rather
stress maneuvers. Urethral anatomy, including functional as a treatment. Current methods are not actually curing the
length and elastic closure, is an important determinant of con- defect in urethral function but rather temporizing or treating
tinence. In addition, activity of the muscular pelvic floor with the symptoms. Therapies aimed at cure are being employed
its associated connective tissue elements helps maintain outlet using stem cells to regenerate smooth and striated muscle.
resistance during times of increased intra-abdominal pressure. Stress incontinence is just one manifestation of pelvic relax-
The anatomic position of the urethra is another factor con- ation. O ften other pelvic defects coexist and should be
tributing to continence. Each of these entities will be discussed addressed simultaneously.
separately to provide a basis for understanding the pathophys-
iology of pelvic floor relaxation.
Structural support of the urethra alone is not enough for Cyst o ce le
the maintenance of urinary continence; there are also integral
features of the urethra that contribute. The urethra is made up When defects in pubocervical fascia exist, a cystocele develops
of three functional anatomic components that result in an (Fig. 47.12). Usually the defect is in both the lateral fascia and
elastic, dynamic conduit with mucosal coaptation. The ure- the midline of the fascia, with also a notable defect in cuff sup-
thral mucosa is transitional epithelium with numerous infold- port (13). The defect can be treated by using a trapezoid-shaped
ings that allow distensibility and closure with excellent piece of mesh and anchoring it to the obturator fascia laterally
coaptation. Beneath the mucosa is a spongy tissue made up of (via the ATFP), the sacrouterine complex apically, and the
vascular networks, analogous to the corpus spongiosum in bladder neck distally, thus reapproximating the trapezoid-
men. Surrounding the spongy tissue is a thin musculofascial shaped pubocervical fascia. This is usually performed in com-
envelope, the periurethral fascia, which appears as a glisten- bination with anterior colporrhaphy, or plication of the
ing, white membrane during surgery. These three components pubocervical fascia in the midline. Because of the risk of de
contribute to form a coaptive seal. Surrounding the mucosa novo stress incontinence after cystocele repair, many authors
are layers of smooth and striated muscle that are part of the recommend performing a concomitant sling at the time of
sphincter mechanism. These muscles are under both voluntary bladder repair. We agree with this. In fact, there is evidence to
and involuntary control. When functioning properly, they support not only a decrease in incontinence, but also a de-
maintain enough compression, or resistance, of the urethra to crease in recurrence of prolapse when a sling is added to the
prevent leakage of urine. repair (14). It is also important to reapproximate the cardinal
Both the bladder neck and urethra are normally maintained ligament complex in the midline to support the bladder base
in a high retropubic position relative to the more dependent and prevent recurrence.
plate. Rectocele is a poor name to encompass all of these de-

fects. It is important to address and repair all of these poten-
tial weaknesses and avoid segmental repairs—in particular,
reinforcing attenuated prerectal and pararectal fascia by plica-
tion or with mesh, reapproximating the levator musculature
to close the levator hiatus, and rebuilding the perineal body to
provide normal introital size and improved support. These
measures prevent descent of the organs and the need for sec-
ondary surgery.
RESTO RATIO N O F SUPPO RT

The normal vaginal length is approximately 8 to 9 cm, with
the ischial spines as a good landmark. The caliber should ap-
proximate two fingerbreadths. The axis should be such that
the vagina rests on the levator plate in a banana shape, much
like its natural position (Fig. 47.13). The proximal half of the
vagina is practically horizontal resting over the levator plate.
We can see that the axis of the vagina points down to S4–S5
(Fig. 47.14), not to the promontory where sacrocolpopexy is
often performed. Suspending the vaginal cuff to this location
can allow the formation of other defects, specifically enteroce-
les and rectoceles. Simply placing the cuff to the sacrospinous
FIGURE 47.12 Severe prolapse of the anterior vaginal wall with
central and lateral defect. The normal H -shape of the vagina is lost.
ligament restores proper anatomy, allows approximation of
The lateral walls of the vagina are detached from supporting struc- the perivesical and perirectal fasciae, and prevents recurrent
tures, allowing downward displacement and disappearance of the prolapse. Lateral, anterior, and posterior dissection allows one
lateral sulci. to obtain good strong tissue for plication of the anterior and
posterior vaginal walls. Anteriorly the surgeon must extend
dissection to the inferior pubic ramus at the level of the obtu-
Re ct o ce le rator muscle, and posteriorly dissection must be taken to the
rectal gutter, the groove between the rectum and the iliococ-
The posterior vaginal wall has a complex fascial and muscular cygeus muscle. The distal vagina is elevated with closure of the
arrangement that provides support not only to the vagina but perineal defect, allowing achievement of normal introital cal-
also to the rectum, perineum, and anal sphincter. There are iber and shape.
four components that contribute to failing posterior support: Placement of the vault suspension sutures can be daunting.
prerectal/pararectal fascia attenuation, perineal membrane It is important to understand where it is safe and where it is
widening, levator hiatus widening, and descent of the levator dangerous to place these sutures. These sutures should be
FIGURE 47.13 Dynamic M RI in a patient with normal vagi-

nal support. The banana-shaped vaginal curvature is seen. The
angulation between proximal and distal vagina (located at
the level of the proximal anal canal) points to the insertion of
the puborectalis musculature. P, pubic bone; Ur, urethra; PU,
pubourethral ligaments; R, rectum; A, anal canal; B, bladder;
U, uterus.
avoid going cephalad to the sacrospinous ligament, as the

lumbosacral plexus can be injured or trapped with a suture.
The ureter can be damaged, as can the pudendal nerve, if the
needle is placed laterally. T-shaped soft polypropylene mesh is
used to replicate cardinal–sacrouterine support by anchoring
the cuff to the sacrospinous ligament.
The importance of a thorough evaluation and complete
repair of the whole pelvic floor cannot be overemphasized.
Segmental repairs allow exaggeration of pre-existing defects
due to functional and anatomic changes. Repair of concomi-
tant prolapse also has an important impact on the outcome of
stress incontinence surgery (10). The reverse has also been
found to be true: the addition of a sling procedure to anterior
colporrhaphy reduces the cystocele recurrence rate by 50%
(14). These findings are likely due to the dissipation of intra-
abdominal pressure in the setting of PO P. With restoration of
strong support to the pelvic organs, there is more efficient
transmission of abdominal pressure to the urethra and there-
FIGURE 47.14 Vaginal support. The distal vagina is approximately fore better continence (10). The need to augment support with
45 degrees from the vertical axis and the proximal vagina is approxi-
mately 10 degrees from the horizontal axis. The angulation between
mesh or biologic fascia is debated. M ost experts in the field
the two areas marks the insertion of the puborectalis muscle, which believe that supporting the patient’s weakened fascia can
pulls the vagina anteriorly. achieve a more durable response.
Regardless of technique, three basic tenets must be obeyed
in pelvic reconstruction: (i) restoration of normal vaginal
placed in the sacrospinous ligament with the needle pointing depth, caliber, and axis, (ii) prevention of further PO P, and
downward rather than laterally or superiorly in the direction (iii) restoration and maintenance of normal bladder, bowel,
of other important structures (Fig. 47.7). It is imperative to and sexual function (7).
References
1. Altman D, Forsman M , Falconer C, et al. Genetic influence on stress urinary 9. Redman JF. Surgical anatomy of the female genitorurinary system. In:
incontinence and pelvic organ prolapse. Eur Urol 2008;54(5):918–922. Buchsbaum H J, Schmidt JD, eds. G ynecologic and O bstetric Urology.
2. Klutke CG, Siegel CL. Functional female pelvic anatomy. Urol Clin N orth Philadelphia: WB Saunders, 1993:25–60.
A m 1995;22:487–498. 10. Raz S. A tlas of Transvaginal Surgery. 2nd ed. Philadelphia: WB Saunders,
3. Baden WF, Walker T. The anatomy of uterovaginal support. In: Baden WF, 2002.
Walker T, eds. Vaginal D efects. Philadelphia: Lippincott, 1992:25–50. 11. N itti V, Blaivas JG. Urinary incontinence: epidemiology, pathophysiology,
4. DeLancey JO , Richardson AC. Anatomy of genital support. In: H urt WG, ed. evaluation, and management overview. In: Wein AJ, Kavoussi LR, N ovick
Urogynecologic Surgery. Gaithersburg, IL: Aspen Publishers, 1992: 19–33. AC, et al., eds. Cam pbell-W alsh Urology. 9th ed. Philadelphia: Saunders-
5. DeLancey JO. Surgical anatomy of the female pelvis. In: Rock JA, ed. Te Elsevier, 2007:2046–2077.
L inde’s O perative Gynecology. Philadelphia: Lippincott-Raven, 1997: 63–93. 12. Enhorning G. Simultaneous recording of intravesical and intra-urethral
6. Brooks JD. Anatomy of the lower urinary tract and male genitalia. In: Wein pressure. A study on urethral closure in normal and stress incontinent
AJ, Kavoussi LR, N ovick AC, et al., eds. Cam pbell-W alsh Urology. 9th ed. women. A cta Chir Scand Suppl 1961(276):1–68.
Philadelphia: Saunders-Elsevier, 2007:43–46. 13. Scarpero H M , N itti VW. Anterior vaginal wall prolapse: mild/moderate
7. Twiss CO , Triaca V, Konijeti R, et al. Reconstructive surgery for pelvic floor cystoceles. In: Vasavada SP, Appell RA, Sand PK, et al., eds. Fem ale
relaxation. In: M ontague D, Angermeier KW, Ross J, Gill I, eds. Tex tbook of Urology, Urogynecology, and Voiding D ysfunction. N ew York: M arcel
R econstructive Urologic Surgery. Informa H ealthcare Press, London , 2008: Dekker, 2005:575–594.
532–552. 14. Goldberg RP, Koduri S, Lobel RW, et al. Protective effect of suburethral
8. DeLancey JO . Fascial and muscular abnormalities in women with urethral slings on postoperative cystocele recurrence after reconstructive pelvic op-
hypermobility and anterior vaginal wall prolapse. A m J O bstet G ynecol eration. A m J O bstet G ynecol 2001;185:1307–1313.
2002;187:93–98.
CHAPTER 48 ■ VAGINAL HYSTERECTO MY

FO R UTERINE PRO LAPSE
JA-HO NG KIM, ARIANA L. SMITH, AND SHLO MO RAZ
H ysterectomy is the second most commonly performed surgi- most common indications for hysterectomy are uterine fi-
cal procedure in the United States, with 66% of the cases done broids (33% ) and menstrual disorders (17% ), followed by
through the abdominal approach, followed by the vaginal prolapse (13% ) and endometriosis (9% ). There is a growing
route in 22% and the laparoscopic route in 12% (1). The body of evidence has shown that vaginal hysterectomy is the
Chap t e r 48: Vag inal Hyste re ctomy for Ute rine Prolap se 319
preferred surgical route due to shorter operative time, fewer segment to the sacrum and lateral pelvic sidewalls at the
postoperative complications, and a shorter hospital stay (2,3). piriformis, coccygeus, levator ani, and arcus tendineus. During
M ore importantly, it avoids the morbidity of an abdominal in- hysterectomy, these ligaments must be carefully identified and
cision and offers optimal opportunity to correct and prevent controlled, as they will be incorporated into the vaginal cuff to
pelvic organ prolapse. Relative contraindications for vaginal successfully re-establish proper vault support.
hysterectomy include a large uterus in proportion to a narrow The natural vaginal axis is a banana shape, with the upper
introitus, ovarian pathology, previous cesarean delivery, en- third of the vagina lying in a horizontal position and the apex
dometriosis, and a history of pelvic inflammatory disease, directed towards the lower sacrum (S3–S5). This axis is nor-
which may result in extensive scarring in the pelvis, making mally maintained partly by the support of the levator ani and
dissection difficult. The ultimate decision regarding the surgi- coccygeus muscle group, especially during increased intra-
cal approach to hysterectomy, however, rests on the surgeon’s abdominal pressure. Therefore, complete correction of
experience and preference. As a genitourinary surgeon, one uterovaginal prolapse at the time of hysterectomy should in-
should be familiar with the surgical principles and technique clude not only reattachment of the cardinal and uterosacral
of vaginal hysterectomy, as it is a crucial component of female ligaments to the vaginal vault, but also vault or apical suspen-
pelvic reconstruction. sion to the area of the coccygeus to re-establish the banana-
This chapter will focus on four major concepts that are im- shaped axis. In the substance of the coccygeus lies a cordlike
portant to performing a successful vaginal hysterectomy for structure called the sacrospinous ligament, which extends
uterine prolapse: (i) pertinent female pelvic anatomy as it re- from the ischial spines on each side to the lower portion of the
lates to the pathophysiology of uterine prolapse, (ii) standard sacrum and coccyx. This sacrospinous ligament provides a
evaluation, including a focused history and imaging, (iii) sur- consistently strong site for apical fixation that can restore
gical technique, highlighting the principles for vascular con- vaginal depth and axis. It is crucial to accurately identify this
trol and restoring vaginal support, and (iv) review of potential important structure when placing vault suspension sutures, as
complications and outcomes. the pudendal neurovascular bundle, lumbosacral plexus, and
ureters live in close proximity and can be injured during su-
ture placement. Various techniques for vault suspension at the
time of hysterectomy have been described in the literature,
SURGICAL ANATO MY and a thorough comparison of these procedures is beyond the
scope of this chapter. There is no randomized control study
The female pelvic organs are supported by the dynamic inter- that has shown long-term superiority of one technique over
action between their connective tissue attachments (ligaments the other. In our experience, bilateral fixation of the vaginal
and fascia) and the pelvic floor muscles (levator ani muscle cuff to the origin of the uterosacral–cardinal ligament at the
group and coccygeus), which provide a firm yet elastic base on coccygeus–sacrospinous ligament complex provides the optimal
which they rest. H istologically, the term endopelvic fascia is restoration of vaginal depth and vault support with minimal
used to describe this continuous network of connective tissue morbidity. We routinely utilize a piece of soft polypropylene
that envelops all of the pelvic organs and connects them to mesh to add strength to the uterosacral–cardinal ligament
supportive musculature and pelvic bones, which is located on complex, which is often attenuated in patients undergoing
the peritoneal side. O n the vaginal side, the fasciae acquire dif- vaginal hysterectomy for prolapse repair.
ferent nomenclature and are distinctively named according to
their anatomic location and the organ that they support. The
thick condensations of the connective tissue are further orga-
nized to a trilevel support system that was described by De PATHO PHYSIO LO GY O F UTERINE
Lancey as they relate to the pathophysiology of uterovaginal PRO LAPSE
prolapse (4). Level I refers to the fused ligamentous complex
in the most cephalad portion (cervix and upper vagina) that Although the exact etiology of pelvic prolapse has yet to be
maintains vaginal length and horizontal axis. Level II support clearly defined, many risk factors have been proposed in the
is provided by the paravaginal attachments along the length of development of prolapse. Bump and N orton (5) categorized
the vagina to the arcus tendineus fasciae pelvis. Level III sup- these risk factors into four categories: (i) predisposing factors
port describes the most inferior or distal portions of the are genetics, race, and gender; (ii) inciting factors are preg-
vagina, including the perineum. nancy and delivery, surgery, myopathy, and neuropathy; (iii)
The pear-shaped uterus consists of the corpus and the promoting factors are obesity, smoking, pulmonary disease,
cervix and lies in the medial axial position, anteverted with constipation, and recreational or occupational activities that
the vertical axis of the uterus perpendicular to the axis of the cause chronic increases in intra-abdominal pressure; and (iv)
vagina. The corpus or body of the uterus is enclosed between decompensating factors are aging, menopause, debilitation,
the double-layered broad ligaments, which contain the fallop- and medications. Any of the above risk factors can result in at-
ian tubes, the round and ovarian ligaments, and the uterine tenuation of the uterosacral–cardinal ligament complex or
and ovarian vessels. N o fixed uterine support is provided by breaks along the endopelvic fascia. Furthermore, muscle atro-
the broad ligaments, as demonstrated by its ability to enlarge phy of the levator ani and coccygeus can lead to a wider leva-
without restriction during pregnancy. Thus, the main uterine tor hiatus and a compromise in the excretory function of the
support is provided by the uterosacral and cardinal bladder and rectum. The loss of uterine support causes the
(M ackenrodt) ligaments, which attach to the cervix from the cervix to move anteriorly, and the uterus then begins to shift
posterior and lateral sides, respectively. Together, the fused posteriorly such that the intra-abdominal pressure is then
uterosacral–cardinal ligament complex represents level I sup- directed on the anterior surface of the uterus. The uterus
port and attaches the upper vagina, cervix, and lower uterine becomes progressively more retroverted until the axis of the
uterus is essentially vertical. This position allows uterine

prolapse to occur (6).
DIAGNO SIS
Standard evaluation of the patient with uterine prolapse in-
cludes a comprehensive history and physical examination,
focusing on urinary and defecatory symptoms, sexual func-
tion, reproductive status, and other pelvic pathology. Urinary
or bowel symptoms may be present if there is prolapse of
other organs. Less commonly, a patient presents because uter-
ine prolapse was incidentally found on routine physical exam-
ination. Validated questionnaires measuring symptom severity,
impact on quality of life, voiding log, and sexual function can
be premailed to allow the patient time to consider her symp-
toms. An important piece of information in the patient’s surgi-
cal history is whether the patient had a partial hysterectomy. FIGURE 48.1 M agnetic resonance imaging (M RI) of the pelvis.
Dynamic M RI of the pelvis demonstrating uterine and bladder prolapse.
O ften, what is assumed to be uterine descent is only cervical
descent resulting from a supracervical hysterectomy. It is also
important to ask about any uterine pathology, such as en-
should evaluate gross sensory and motor function of both
dometriosis, fibroids, and pelvic inflammatory disease, which
lower extremities, and lumbosacral function. This can be
can influence surgical planning.
quickly achieved by assessing pelvic floor muscle strength,
Postvoid residual urine volume and urinalysis are obtained
anal sphincter resting tone, voluntary anal contraction, and
for all patients. Urodynamic evaluation is not routinely per-
perineal sensation.
formed for prolapse patients unless there is a history of stress
Imaging of the upper urinary tracts is recommended
or urge incontinence, incomplete emptying, obstructive void-
since patients with uterine prolapse may have associated
ing complaints, or bothersome overactive bladder symptoms.
hydronephrosis. O ur preferred imaging modality to assess the
For these patients with urinary symptoms, we recommend as-
presence of hydronephrosis as well as other pelvic pathology
sessment of the lower urinary tract with a videourodynamic
is dynamic magnetic resonance imaging (M RI). Dynamic M RI
evaluation and office cystoscopy. It is important to recognize
is unrivaled in its ability to characterize pelvic soft tissue, and
that stress incontinence may be masked by the prolapse,
thereby it can accurately diagnose other uterine and ovarian
which can cause kinking of the urethra. As many patients with
pathology. It is a relatively simple, noninvasive test that takes
prolapse are elderly, detrusor instability secondary to obstruc-
only minutes to complete. N o contrast is used as the bladder is
tion versus hyperreflexia secondary to an occult neurologic
distinct on T-2 weighted images. Sagittal images are taken of
condition must be ruled out in this patient population.
the pelvis with the patient at rest and then performing the
Cystoscopy is useful to rule out any intrinsic urethral or blad-
Valsalva maneuvers. Uterine or other pelvic organ prolapse is
der lesions that may be contributing to lower urinary tract
readily identified with this imaging modality (Fig. 48.1).
symptoms.
The Pelvic O rgan Prolapse Q uantification System (PO P-Q )
General, gynecologic, and basic lower neurologic examina-
is a commonly used staging system for describing vaginal pro-
tion should be performed on every woman with prolapse.
lapse and is based on physical examination (7). We classify
O ccasionally, surgical scars detected on the abdominal exami-
uterine prolapse based on the dynamic M RI findings. Prolapse
nation can provide an important piece of surgical history that
is classified in reference to the puborectalis hiatus. The pub-
was previously unmentioned. The pelvic examination begins
orectalis hiatus is formed by the puborectalis muscle (the most
with external genitalia inspection for atrophy, discharge, epi-
inferior part of the levator ani) and includes the urethra,
siotomy scars, and integrity of the perineum. The uterus and
vagina, and rectum. The degree of prolapse is measured by
cervix is assessed for size, mobility, and any abnormal gross
2-cm increments. M ild uterine prolapse is 0 to 2 cm distal to
pathology. The anterior, posterior, and apical vaginal walls are
the hiatus, moderate prolapse is 2 to 4 cm, and severe prolapse
examined separately with the aid of a half speculum to assess
is 4 cm distal to the hiatus (8).
the presence of other prolapse such as cystocele or rectocele.
The size of the introitus and evidence of vaginal stenosis
should be noted, as a size disproportion between the uterus ALTERNATIVE THERAPY
and vaginal opening may limit transvaginal delivery of the
uterus. Physical examination should be performed both in the N onsurgical alternative therapy to hysterectomy and vault
supine and standing positions. The severity of prolapse may suspension for uterine prolapse is no treatment, pelvic floor
not be appreciated in the supine position. In both positions muscle training, or pessary. These options are reserved for
the patient needs to perform a Valsalva maneuver to fully those patients who are deemed poor candidates for surgery.
elicit the prolapse. The physical examination should be Uterine-sparing procedures can be offered to patients who
repeated at the time of surgery with the patient under anesthe- wish to maintain fertility or have strong opinions regarding
sia. O ften, with anesthesia-induced relaxation of the pelvic sexual and personal identity related to the uterus and cervix.
floor, the degree of uterine descent and other prolapse becomes O bliterative procedures, such as colpocleisis, are also viable
more pronounced. The screening neurologic examination options for the appropriate patient population.
FIGURE 48.2 Incision: A circumferential incision is made approxi-

mately 1 cm from the cervical os with electrocautery.
SURGICAL TECHNIQ UE
As previously mentioned, vaginal hysterectomy alone is not
sufficient to relieve symptoms of uterine prolapse or restore
functional anatomy. Thus, every effort must be made to recreate
normal pelvic anatomy with adequate support of the vaginal
vault and functional depth. These measures include reapprox-
imating the bladder and rectum to close the cul-de-sac and fix-
ing the vaginal apex to the origin of the uterosacral–cardinal
ligament at the coccygeus-sacrospinous ligament complex for
vault support.
Broad-spectrum prophylactic antibiotics are administered
preoperatively. Compression stockings are placed prior to in-
B
cision to prevent venous thromboembolic events. Following
successful induction of anesthesia, the patient is placed in the FIGURE 48.3 Exposure of the anterior uterus: Sharp dissection is
used to (A) expose the anterior cul-de-sac and (B) place a H eaney
high lithotomy position. Care should be taken to avoid hyper-
retractor.
flexion of the hips, which can result in femoral neuropathy.
An iodine-based solution is used to cleanse the skin from the
suprapubic area to the posterior perineum. Sutures are used to
retract the labia laterally and a weighted speculum is inserted
for vault exposure. A Lowsley retractor is used to place a
suprapubic tube in every patient undergoing hysterectomy, and
the bladder is drained by both urethral and suprapubic catheters.
A ring retractor with skin hooks is used to maintain exposure.
The cervix is grasped at the 12 o’clock and 6 o’clock positions
using Lahey clamps to maintain the axis. A circumferential in-
cision is made at the cervicovaginal junction using electro-
cautery (Fig. 48.2). The vagina and bladder base is dissected
off the cervix for several centimeters. The anterior cul-de-sac is
carefully entered using sharp dissection (Fig. 48.3A). Gentle
downward traction, visualization of the glistening surface of
the uterus, and limiting the dissection to the midline of the
uterus help to minimize risk of cystotomy. O nce the anterior
cul-de-sac is entered, we use electrocautery to extend the incision
laterally to allow placement of a H eaney retractor (Fig. 48.3B).
The posterior cul-de-sac is entered similarly, and the peri-
toneum is opened sharply using curved Mayo scissors (Fig. 48.4).
Any adhesions encountered should be lysed with limited sharp FIGURE 48.4 Exposure of posterior cul-de-sac and sharp entry into
dissection to allow placement of another H eaney retractor. If the peritoneum.
A
A
B
FIGURE 48.5 Isolation of cardinal–uterosacral ligaments. Right-angle
and Phaneuf clamps are used in succession to (A) better delineate the
cardinal–uterosacral complex before (B) transection.
B
FIGURE 48.6 The uterine pedicles are carefully identified (A),
difficulty is encountered when attempting to enter the peri- isolated, and divided (B).
toneum, the hysterectomy can be initiated in an extraperi-
toneal fashion by severing the uterosacral ligament and caudal
portions of the cardinal ligament close to the cervix. This ma- into the anterior peritoneum can be made by placing a finger
neuver mobilizes the uterus to provide better visualization. anteriorly over the uterine fundus to elevate the peritoneum.
N ext, the uterosacral and cardinal ligament complex is di- Electrocautery can then be used to incise the peritoneum over-
vided by placing the cervix on careful traction and passing a lying the surgeon’s finger. The broad ligaments are now ligated
large right-angle clamp from the posterior cul-de-sac parallel as above (Fig. 48.8). If an oophorectomy is not planned, the
to the cervix. The right-angle clamp is used to expose the liga- ovarian attachments are also now divided. The uterus is finally
ment, which is then grasped with a Phaneuf clamp and ligated removed. A circular arrangement of the six ligated pedicles and
with electrocautery (Fig. 48.5). The stumps are oversewn with their attached sutures remain (Fig. 48.9).
figure-of-eight 0 Vicryl sutures. The ends of the sutures are After hysterectomy, the vault support and vaginal depth
clamped and secured on the ring retractor. Then the uterine must be restored. This is accomplished by obliterating the cul-
pedicles are carefully identified, isolated, and divided in similar de-sac to prevent enterocele recurrence and by sacrospinous
fashion (Fig. 48.6). After the contralateral ligament and pedi- fixation of the apex to recreate the natural banana shape. To
cles are likewise controlled, the uterus can then be manually perform this procedure correctly and safely, the surgeon must
everted and brought outside the introitus (Fig. 48.7). Safe entry be familiar with the pararectal anatomy and obtain adequate
FIGURE 48.7 Eversion of the uterus. After the bilateral cardinal–

uterosacral ligaments have been ligated, the uterus is manually everted.
exposure. First, the patient is placed in Trendelenburg position,

and two Betadine-soaked laparotomy pads are placed intra-
peritoneally to pack away the peritoneal contents. N ext, the
coccygeus–sacrospinous ligament complex is identified by pal-
pating the ischial spine and tracing the taut triangular band of
fascia medially and posteriorly as it attaches to the edges of
the sacrum. N ext, we use two Allis clamps to grasp the area
of the future vaginal cuff and apply downward traction toward
the coccygeus–sacrospinous ligament complex to determine the
extent of the apical prolapse and associated pelvic support
defects. If concomitant cystocele still exists after reducing the
apical prolapse, we will perform a formal cystocele repair.
O therwise, we will incise an oval shaped soft polypropylene
mesh with two arms, which is designed so that the horizontal
arms are attached to the corresponding sides of the vaginal cuff B
(at the uterosacral–cardinal ligament complex). The middle cir- FIGURE 48.8 Division of the broad ligament. The surgeon’s index
cular portion of the mesh is incorporated extraperitoneally to finger is (A) inserted into the peritoneal cavity and hooked around the
reinforce the pursestring closure of the cul-de-sac (Fig. 48.10). broad ligament, which is (B) then ligated in the same fashion as the
The technique of bilateral sacrospinous ligament fixation is cardinal–uterosacral ligaments.
challenging due to the difficulty in maintaining good visualiza-
tion in the deep pelvis through the vagina and the risk of carefully palpate and identify the tight cordlike sacrospinous
injuring the pudendal vessels, the lumbosacral plexus, and ligament structure in the substance of the coccygeus prior to
the ureters, which are in close proximity. To optimize this ex- suture placement. The same suture is then brought through
posure, three retractors are employed: (i) a long-handled one end of the mesh, then exited through the vaginal wall just
Breisky is placed anteriorly to retract the peritoneal contents above the area of the uterosacral–cardinal ligament complex,
from descending; (ii) another Breisky or H eaney is used to and tagged separately. The adjunctive use of mesh is necessary
displace the rectum laterally; and (iii) a H eaney retractor is because we cannot rely on the native attenuated connective
then carefully placed posteriorly just distal to the tight cord- tissues to suspend the vaginal vault. A second 1 Vicryl suture
like coccygeus-sacrospinous ligament complex. We begin by is placed on the contralateral side in the exact same fashion.
placing a 1-0 Vicryl suture brought from outside the vagi- Two pursestring sutures of 1 Vicryl are now placed to close
nal wall into the peritoneal cavity (in the area of the the cul-de-sac. These sutures incorporate the prerectal fascia,
ligated uterosacral–cardinal ligament complex) (Fig. 48.11). the uterosacral–cardinal ligament complex, the broad liga-
Instruments are switched to a long-handled needle driver and ments, segment of the circular mesh, segment of the circular
long gastroplasty forceps to place that same suture in figure-of- mesh, and the perivesical fascia (Fig. 48.13). It is important
eight fashion in the coccygeus–sacrospinous ligament com- to stay in the midline when incorporating the perivesical fascia
plex on the corresponding side (Fig. 48.12). The direction to avoid ureteral injury. The pursestring sutures are tagged
of the needle must be horizontal, since one can easily damage at this time. The sutures of the previously ligated pedicles of
the nearby neurovascular structures and ureters. It helps to the broad ligaments and the uterosacral–cardinal ligament
FIGURE 48.11 A 1 Vicryl suture brought from outside the vaginal

wall into the peritoneal cavity in the area of the ligated cardinal–
uterosacral complex.
FIGURE 48.9 A circular arrangement of the six ligated pedicles and
their attached sutures remain.
FIGURE 48.10 The oval shaped soft polypropylene mesh with hori-
zontal arms is used to add strength to vault support. The horizontal
arms are attached to the corresponding sides of the vaginal cuff (at the
uterosacral–cardinal ligament complex). The middle circular segment
of mesh is used to reinforce the pursestring closure of the cul-de-sac.
complex are identified on each side and tied in the midline. FIGURE 48.12 The same suture is placed in figure-of-eight fashion in
The pursestring culdoplasty sutures are now cinched and tied. the coccygeus–sacrospinous ligament complex.
If simultaneous repair of other prolapse is planned, it is now
performed. The sacrospinous ligament vault suspension performed at this time. A detailed description of rectocele and
sutures are tied last after any cystocele repair and vaginal cuff cystocele repair will not be addressed in this chapter.
closure. It is important to use Allis clamps to grasp and push
down the vault to the sacrum while tying down the vault
suspension sutures to achieve optimal depth. O UTCO MES
Cystoscopy is performed routinely after giving indigo
carmine and a bolus of 500 mL normal saline to assess for a Co mp licat io ns
healthy jet stream of urine from the ureteric orifices prior to ty-
ing down the vault suspension sutures. If there is any question H ysterectomy is a relatively safe procedure. Intraoperative
of ureteric injury, the repair is taken down systematically start- complications include cystotomy (especially in patients with
ing with the vault suspension sutures to correct the problem. history of cesarean delivery), ureteral injury, hemorrhage, and
Vaginal depth is restored when the vault suspension sutures gastrointestinal injury, although these complications occur less
are tied down. Excess vaginal wall is excised before closure frequently compared to when the abdominal approach is used
with an absorbable suture. Finally, if rectocele is planned, it is (9–11). Interestingly, bladder and ureteral injury occurs less
may be an enterocele that was missed at the time of surgery or,

more commonly, that occurred because of insufficient closure
and/or support of the cuff. An enterocele may also develop
postoperatively if other affected compartments are not re-
paired. Absence of the normal vaginal axis promotes prolapse
of the cuff.
Ureterovaginal and vesicovaginal fistulas occur in 0.09%
to 0.5% and 0.6% , respectively, of cases (6). Adequate ante-
rior retraction of the bladder, ligation of the pedicles close to
the cervix, and avoidance of lateral placement of the purse-
string sutures in the perivesical fascia aid in the prevention of
bladder and ureteral injury.
Re sult s
In regard to overall postoperative genitourinary function,
Roovers et al used validated questionnaires to assess urogeni-
tal symptoms and quality of life after prolapse surgery and
found improvement in all domains and quality of life follow-
FIGURE 48.13 Placement of pursestring culdoplasty sutures. Inside the ing vaginal hysterectomy (14). Sexual function has always
peritoneal cavity, two 1 Vicryl pursestring sutures are placed to obliter- been a concern following hysterectomy. Recent data indicate
ate the cul-de-sacs and approximate the prevesical and prerectal fascia. that hysterectomy actually improves sexual functioning and
overall quality of life. Rhodes et al. found that following hys-
commonly with the vaginal approach. By performing routine terectomy, the occurrence of sexual relations and orgasm in-
cystoscopy, we are able to diagnose and address any ureteral creased, while the rates of dyspareunia and low libido
injury in a systematic fashion by taking down any offending decreased (15). Similarly, researchers from the M aine M edical
suture and/or placing a ureteral stent if needed (12). Assessment Foundation concluded that hysterectomy relieved
Complications during and after surgery include infection pelvic pain, fatigue, depression, and sexual dysfunction and
(cuff cellulitis or abscess), bleeding, urinary retention, rectal in- improved the overall quality of life 1 year after surgery (16).
jury, bladder injury, mesh erosion, bowel obstruction, fistulas,
and ileus. O ur patients are discharged on postoperative day 2
with a capped suprapubic tube and instructed to check CO NCLUSIO N
postvoid residuals. The suprapubic tube is removed when the
residuals are 50 mL. Ileus may also occur but usually re- All genitourinary and pelvic reconstructive surgeons should be
sponds to conservative treatment. Delay in bowel function 3 familiar with the relevant female pelvic anatomy and surgical
days should be taken seriously, with appropriate assessment to technique of vaginal hysterectomy, which is being performed
rule out bowel injury or colonic obstruction (from misplaced in increasing numbers in this country. Vaginal hysterectomy is
vault suspension sutures). Avoiding abdominal incision facili- considered the preferred surgical approach for treatment of
tates early ambulation and fewer respiratory complications. benign uterine pathology, especially uterine prolapse, since it
Apical cure rate of uterine prolapse following vaginal hysterec- avoids the morbidities associated with an abdominal incision
tomy range from 88–100% (13). The majority of cases of and has lower rates of bladder and ureteral injury. Successful
recurrent prolapse involve only the upper vagina and are vault suspension is an integral part of vaginal hysterectomy to
asymptomatic. Prolapse that develops following hysterectomy restore normal vaginal axis and functional depth.
References
1. N ationwide Inpatient Sample (N IS) of the H ealthcare Cost and Utilization States. The collaborative review of sterilization. A m J O bstet G ynecol
Project (H CUP). April 19. www.hcupnet.ahrq.gov. 1982;144:841–848.
2. Johnson N , Barlow D, Lethaby A, et al. Surgical approach to hysterectomy 10. Gitsch G, Berger E, Tatra G. Trends in thirty years of vaginal hysterectomy.
for benign gynecological disease. Cochrane D atabse Syst R ev 2006, Issue 2. Surg G ynecol O bstet 1991;172:207–210.
Art. N o.:CD003677. 11. Scott JR, Sharp HT, Dodson M K, et al. Subtotal hysterectomy in modern
3. M ontefiore ED, Rouzier R, Chapron C, et al. Surgical routes and compli- gynecology; a decision analysis. Am J O bstet Gynecol 1997;176:1186–1191.
cations of hysterectomy for benign disorders: a prospective observational 12. Kim JH , M oore C, Jones JS, et al. M anagement of ureteral injuries associ-
study in French university hospitals. H um R eprod 2006;22:260–265. ated with vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic
4. De Lancey JO L. Anatomic aspects of vaginal eversion after hysterectomy. Floor D ysfunct 2006;17:531–535.
A m J O bstet G ynecol 1992;166:1717–1724. 13. Dietz V, Koops S, van der Vaart C. Vaginal surgery for uterine descent;
5. Bump RC, N orton PA. Epidemiology and natural history of pelvic floor which options do we have? A review of the literature. Int Urogynecol J
dysfunction. O bstet G ynecol Clin N orth A m 1998;25:723. 2009;20:349–356.
6. Chopra A, Stothers L, Raz S. Uterine prolapse. In: Raz S, ed. Fem ale 14. Roovers JP, van der Vaart CH , van der Bom JG, et al. A randomized con-
Urology, 2nd ed. Philadelphia: WB Saunders, 1996:457–464. trolled trial comparing abdominal and vaginal prolapse surgery: effects on
7. Bump RC, M attiasson A, Bo K, et al. The standardization of terminology urogenital function. BJO G 2004;111:50–56
of female pelvic organ prolapse and pelvic floor dysfunction. A m J O bstet 15. Rhodes JC, Kjerulff KH , Langenberg PW, et al. H ysterectomy and sexual
G ynecol 1996;175:10–17. functioning. JA M A 1999;282:1934–1941.
8. Barbaric Z L, M arumoto AK, Raz S. M agnetic resonance imaging of the 16. Carlson KJ, M iller BA, Fowler FJ Jr. The M aine Women’s H ealth Study I:
perineum and pelvic floor. Top M agn R eson Im ag 2001;12:83–92. O utcomes of hysterectomy. O bstet G ynecol 1994;83:556–572.
9. Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal
and vaginal hysterectomy among women of reproductive age in the United
CHAPTER 49 ■ CYSTO CELE AND ANTERIO R
VAGINAL PRO LAPSE
MELISSA R. KAUFMAN, HARRIETTE M. SCARPERO , AND RO GER R. DMO CHO WSKI
Anterior compartment vaginal prolapse, commonly referred composed of endopelvic and perivesical fascia, extends from
to as cystocele (1), is the most common category of pelvic the ATFP of the pelvic sidewall to the bladder base and ante-
floor relaxation. Anterior defects arise from weakening of the rior vaginal wall. Distally, the urethropelvic ligaments provide
endopelvic fascia and herniation of pelvic viscera into the po- support from the urethral meatus to the bladder neck. The
tential space of the vagina. Compromise of the levator fascia ATFP, which is actually a thickened condensation of the obtu-
and laxity of pelvic floor musculature both result in structural rator internus fascia and endopelvic fascia, provides a lateral
defects causing loss of pelvic floor support and subsequent insertion for all these structures. Indeed, the sturdy shelf of the
formation of anterior compartment prolapse. ATFP provides a stabilization point for the entire pelvic floor
The fascia of the levator floor has a primary supportive hammock (3,4). Cystocele defects are commonly associated
function for not only the anterior vaginal wall but also the with other forms of pelvic relaxation, namely loss of support
bladder and urethra in composite. DeLancey (2) elegantly of the uterus and vaginal apex resulting in uterine or entero-
described three levels of vaginal support to elucidate the prox- cele vault prolapse and/or loss of posterior compartment sup-
imal and distal structures involved in pelvic organ biomechan- port with ensuing perineal relaxation and rectocele as well as
ics. The abdominal aspect of this fascia is referred to as the functional deficits such as incontinence.
endopelvic fascia, while the vaginal side is termed perivesical Defects of the anterior compartment may produce either
fascia at the level of the bladder base and periurethral fascia at isolated urethral or bladder support defects or a combination
the level of the bladder neck. The term pubocervical often of deficiencies of both structures. Loss of structural integrity
refers to the combined periurethral and perivesical fascia com- surrounding the urethra can result in urethral hypermobility
plex. The vaginal and abdominal components of these fascial without a concomitant cystocele defect being identified.
sheets fuse laterally at their insertion into the tendinous arch Cystocele defects tend to be more complex and may involve
of the obturator internus, formally termed the arcus tendineus isolated central, lateral, or combination defects (Fig. 49.2).
fasciae pelvis (ATFP), which forms a pelvic sidewall anchor Lateral, or paravaginal, cystoceles result from disruption or
for these structures. separation of the condensation of the vesical pelvic ligament
When viewing vaginal support from cephalad to caudad, to the arcus tendineus on either side of the vagina. Central de-
the uterosacral–cardinal ligament complex supports the upper fect cystoceles result from attenuation of the pubocervical fas-
vagina and cervix and anchors them to the pelvic sidewall cia without compromise of the urethropelvic and vesicopelvic
(Fig. 49.1). In the midvagina, the vesicopelvic ligament, ligaments. Central defect cystoceles are often associated with
Endopelvic fascia Bladder
ATFP
Vesicopelvic
ligament
FIGURE 49.1 The vesicopelvic ligament

Cardinal ligament
Cervix supporting the bladder is composed of
endopelvic and perivesical fascia. The
cardinal ligaments support the upper
vagina and cervix and anchor them to
the pelvic sidewall.
326
Chap t e r 49: Cystoce le and Ante rior Vag inal Prolap se 327
FIGURE 49.2 Defects of the anterior compartment may result in either isolated urethral or bladder sup-
port defects or a combination of support defects of both structures. A: Cross section demonstrating blad-
der support to fascial attachments (FA) and the arcus tendineus fasciae pelvis (ATFP). B: Central
cystocele. C: Lateral support defect. D: Combined central and lateral anterior prolapse. (Reprinted with
permission from H erschorn S. Vaginal reconstructive surgery for sphincteric incontinence and prolapse.
In: Walsh PC, ed. Cam pbell-Walsh Urology, 9th ed. Philadelphia: Saunders, 2007.)
attenuation of upper vaginal support as well, including loss of dysfunction, and in exceptional cases defecatory symptoms.
cardinal ligament support, which on occasion will manifest as Women may be required to manually reduce the anterior pro-
a concomitant enterocele. Isolated central defects actually rep- lapse for successful voiding. Surprisingly, even large cystoceles
resent the minority of diagnosed anterior prolapse cases, with can be totally asymptomatic. Profound cystocele defects may
the most frequent presentation being a combination cystocele be associated with angulation of the proximal urethra by the
(5). Lateral defects are more numerous and are often associ- bladder base, resulting in concomitant incomplete emptying,
ated with urethral hypermobility (6). When combined central obstructive voiding symptoms and urinary retention. Severe
and lateral defects are present, more severe degrees of pro- cystoceles might also precipitate upper urinary tract changes,
lapse regularly result. including hydronephrosis and, rarely, renal failure due to ure-
thral or ureteral obstruction. Smaller cystoceles could be re-
sponsible for dyspareunia or incontinence only during sexual
DIAGNO SIS activity and, in select individuals, provoke early presentation
prior to the onset of pelvic descensus symptoms.
Anterior compartment prolapse produces a diversity of symp- Physical examination of the vagina will demonstrate a
toms, including “ mass effect” discomfort such as perineal or mass occupying the anterior vaginal wall from the vaginal
intravaginal bulge or sensation of a mass in the vagina, stress apex or cervix, if hysterectomy has not been performed, ex-
or urge urinary incontinence, dyspareunia, low back pain, tending to the bladder neck and/or urethra. If significant
vaginal irritation or bleeding due to excoriation of exposed pelvic relaxation is present, this anterior prolapse may actu-
vaginal mucosa, recurrent urinary tract infections, voiding ally protrude from the vaginal introitus with activity or may
present exteriorized at rest. Vaginal examination with the pa-

tient in dorsal lithotomy position with a full bladder is aided NO NSURGICAL THERAPY
by the lower blade of a Graves speculum. The examination
should include anatomy at rest and with straining maneuvers O ptional management strategies for pelvic floor descensus in-
to evaluate for stress incontinence, urethral hypermobility, clude pelvic floor exercises, physical therapy combined with
and the degree of anterior prolapse. Examination should also biofeedback, and behavioral modifications, although efficacy
focus on the integrity of the bladder base and presence or ab- is usually confined to incontinence and not prolapse. The uti-
sence of defects in the lateral vaginal fornices. Isolated central lization of topical estrogens may augment the symptomatic
defect cystoceles will present with a large anterior vaginal wall response to this intervention in those patients who demon-
bulge that blunts the vaginal rugae with preservation of the strate vaginal mucosal atrophy and have a component of as-
lateral fornices. H owever, central cystoceles are often associ- sociated urinary irritative symptoms. Estrogens may also
ated with lateral defects with little preservation of the par- bolster vaginal tissues for improved tolerance of pessaries. A
avaginal support. Unfortunately, physical examination is not patient with an asymptomatic small cystocele, adequate vesi-
particularly reliable or accurate for diagnosis of paravaginal cal emptying, and no incontinence does not require surgical
defects (7). With isolated central defects, urethral hypermobil- intervention.
ity is often not noted; however, this finding is not universal. Large prolapse defects can often be managed effectively
Lateral cystoceles are usually associated with combined ante- with pessary placement. This option should be discussed with
rior vaginal wall defects and urethral hypermobility. Bimanual all women who experience symptoms of anterior compart-
examination or placement of an instrument such as a curved ment mass effect, as substantive clinical improvement may re-
ring forceps in the lateral sulci may help reveal paravaginal de- sult. In some women, the use of a pessary may actually
fects. Evaluation should be repeated in the standing position unmask occult incontinence and nullify any symptomatic ben-
to discover more subtle defects, to recapitulate the prolapse efit that the device has conveyed.
experienced during daily activity, and to identify concomitant
apical or posterior prolapse.
Cystocele grading uses several different taxonomies, with INDICATIO NS FO R SURGERY
the Baden-Walker being the simplest and most reproducible
and the Pelvic O rgan Prolapse Q uantification System (PO P-Q ) Surgical intervention is predicated on several factors.
providing the most descriptive method, often reserved for re- Symptoms arising from the anterior prolapse, including in-
search protocols (8,9). Vaginal apical examination is crucial to complete emptying, vaginal mass, perineal prolapse, or the
locate the vaginal cuff and identify other forms of prolapse presence of urinary incontinence are the cornerstone indica-
that may be present posteriorly or behind the cuff, such as en- tions for repair. The presence of dyspareunia should be care-
terocele and/or high rectocele. The location of the cuff estab- fully considered, as this symptom often coexists with cystocele
lishes the usual limit of surgical dissection for the vaginal mass effect complaints. Dyspareunia as an isolated indication
cystocele repair, and recognition of cuff position facilitates for surgery, however, must be judiciously evaluated as the
evaluation of a concomitant enterocele. complaint may or may not respond to anatomic correction.
During the pelvic examination, it is imperative to ascertain The choice of appropriate technique for operative manage-
the presence or absence of urinary incontinence. With signifi- ment of anterior prolapse is based upon the degree and severity
cant anterior compartment defects, urinary urgency and urge of the patient’s incontinence, the magnitude of the cystocele,
incontinence from detrusor instability may be identified. The the underlying nature of the fascial defect, and the presence of
possibility of bladder outlet obstruction should be considered concurrent voiding dysfunction. Comprehensive surgical plan-
in patients who have undergone a prior incontinence proce- ning also includes identification of associated prolapse elements,
dure and developed de novo anterior prolapse. In those pa- including enterocele, rectocele, and apical prolapse defects, as
tients, a hyperangulated or nonmobile urethra with increased well as possible indications for concurrent hysterectomy.
urinary residuals and symptoms compatible with outlet ob- The type of anterior compartment repair is suggested by
struction should warrant consideration of urethrolysis prior to the preoperatively defined fascial defect, although patients
or at the time of cystocele correction. Reduction of the pro- should always be counseled that intraoperative findings may
lapse during the vaginal examination with a speculum, pack- alter the prescribed course of therapy (Table 49.1). Central
ing, or pessary will on occasion unmask occult stress urinary fascial defects may be managed with a plication type of repair
incontinence. Video urodynamic evaluation may be indicated and/or an interposition graft repair with or without concomi-
for these patients to best discover any contributing obstructive tant sling, dependent upon the presence of incontinence.
voiding component, as this patient may experience persistent Indeed, an isolated central defect repair is rare in the absence
outlet obstruction postoperatively and should be alerted to the of a concomitant stress incontinence procedure.
risk of long-term catheterization. Some reconstructive surgeons Lateral defect repairs may be performed with a variety of
advocate preoperative videourodynamics for all prolapse pa- techniques, including multiple-point suspensions as well as
tients to assess for bladder dysfunction and provide a baseline vaginal paravaginal repairs or abdominal paravaginal repairs
for comparison (10). If the prolapse patient possesses addi- combined with an incontinence intervention. Severe cystoceles
tional lower urinary tract symptoms, office cystoscopy may be with attendant central and lateral defects require simultaneous
useful to illuminate concomitant bladder or urethral pathol- stress procedures as well as interpositional graft placement to
ogy. In complicated scenarios, dynamic magnetic resonance compensate for complete disruption of the supportive pelvic
imaging (M RI) of the pelvis can provide dramatic anatomic in- floor structures.
formation on the type and degree of pelvic organ prolapse and Lower-grade cystoceles may be effectively repaired by out-
aid in operative planning. let procedures performed at the level of the bladder neck,
TA B LE 4 9 . 1
OPTION S FOR AN TERIOR PROLAPSE REPAIR SUMMARIZED BY
CLASSIFICATION OF DEFECT
A nterior prolapse repair options
Central Defect Lateral Defect Combination Defect
anterior colporrhaphy suspensions interposition graft

interposition graft vaginal paravaginal incontinence procedure
incontinence procedure abdominal paravaginal
incontinence procedure
including pubovaginal slings and earlier forms of suspensions

such as needle suspensions.
Recent innovative approaches to be discussed below in-
clude transobturator techniques for tension-free placement of
polypropylene mesh that will accommodate both central and
paravaginal fascial deficits and are often accomplished in con-
junction with placement of a polypropylene midurethral sling.
H owever, the surgeon must always consider to risks of trans-
vaginal mesh placement and carefully select patients for such
procedures.
SURGICAL TECHNIQ UE
Re p air o f Co mb inat io n De fe ct s
w it h Int e rp o sit io n Graft
Simultaneous lateral and central defects with associated ure-
thral hypermobility may be addressed by a combined mesh in-
lay and pubovaginal sling procedure (Fig. 49.3). The choices
for mesh interposition include synthetic, xenograft, autograft
of free full-thickness vaginal wall, as well as allograft materi-
als. Long-term data are not yet available to support one mater-
ial as preferred; however, some evidence exists from experience
with alternative slings that may be extrapolated to these inlays
(11–13). When considering synthetic materials, polypropylene,
polyglactin 910, and polyglycolic acid meshes are all viable
choices. Polyglactin 910 and polyglycolic acid materials are
conformal, modestly rigid, and, most importantly, eventually
degraded and replaced by host fibrosis. N ewer knitted filament
polypropylene meshes, although permanent, elicit minimal in-
flammatory response and have pore sizes that allow excellent
tissue ingrowth. Allografts that are fresh frozen appear to have
poor durability, whereas those that are solvent deactivated or
radiated maintain structural integrity, which has translated to
increased durability. Dermis xenografts are the most conformal
to underlying tissues and are less rigid and relatively less
expensive, but some iterations tend to encapsulate as opposed
FIGURE 49.3 A: The incision for the interposition graph is made in
to integrate into the tissue (14). the midline from the midurethra to vaginal apex. B: After completion
Defect repair may be approached either with a single- of dissection and entry into the retropubic space, identification of the
component interposition that serves as both bladder base and cardinal ligament complex and the obturator internus is completed.
urethral support (14) or with a two-component interposition The area of the cardinal ligament complex on either side is identified
with separate strips of material providing the sling and the and the ligaments are reapproximated to reconstruct the vaginal apex.
C: The interposition graft is inlaid in the defect. Sutures are placed
anterior compartment repair. The authors favor the two- sequentially in the obturator internus fascia and through the inlay
component method, particularly considering the advent of material. D: Final repair demonstrating placement of the free graft
midurethral tapes for use in cases of urethral hypermobility. from the bladder neck to vaginal apex.
Consideration should be given to concurrent stabilization bladder base descensus. The uterosacral ligaments can often be
of the vaginal apex with cardinal ligament plication sutures identified at this level of the dissection, and when found, plica-
and/or apical suspension to the iliococcygeus muscle fascia or tion with a 0 or 2-0 synthetic absorbable suture (SAS) can be
the sacrospinalis ligament. Inlay repairs tackle both central performed. For high-grade cystocele, placement of sutures pos-
and lateral defects. Further paravaginal defect correction may teriorly in the iliococcygeus muscle fascia will provide further
also be fashioned by suture placement through the vesi- support and stability to the anterior compartment repair. These
copelvic ligaments and subsequent suspension to the anterior sutures are then brought through the vaginal apex to be tied at
rectus fascia. the completion of the procedure, after the vaginal wall has been
After appropriate administration of perioperative antibi- closed. O nce dissection of the retropubic space is completed
otics (16) and placement of graded compression stockings and and it is freely mobile, a pubovaginal sling is placed. The sling
pneumatic compression devices, the patient is placed in hy- may be autologous tissue harvested through a separate abdom-
draulic stirrups in the dorsal lithotomy position. After prepara- inal incision, or if a midurethral transvaginal tape is selected, it
tion of the abdomen, perineum, and vagina, the posterior should be placed through a separate incision following final clo-
compartment is draped away from the surgical field. H owever, sure of the anterior repair. For autologous fascial slings, ligature
if the surgeon is concerned that access to the rectum may be re- passage needles are directed from suprapubic to vaginal inci-
quired, an adherent drape may be placed for an isolation bar- sions on either side of the proximal urethra and bladder neck
rier that will still permit entrance. A weighted speculum and a with digital guidance. O nce placed, cystoscopy is performed to
ring retractor are used for vaginal exposure. A 16Fr indwelling exclude needle entry into the bladder or urethra. Suspending su-
catheter is inserted and the incision delineated on the anterior tures of 0 or 1 polydioxanone are placed through either end of
vaginal wall in the midline extending from the midurethra to the sling material and the suspending suture is then transposed
the vaginal apex (Fig. 49.3). The anterior vaginal wall overly- from vaginal to suprapubic incisions using the ligature carrier.
ing the cystocele is infiltrated with 20 to 50 cc of either normal The sling is then affixed to the underlying periurethral fascia
saline or dilute vasoconstrictor for hydrodissection prior to in- with 4-0 SAS. Following these steps, absorbable 1 polydiox-
cision with a scalpel. Lateral vaginal flaps are then developed anone sutures are placed in the obturator internus fascia at the
by sharp dissection of the vaginal wall away from the underly- level of the ATFP in an interrupted manner from the bladder
ing attenuated pubocervical fascia. The appropriate plane is neck to vaginal apex. This step usually requires two to four su-
recognized by the glistening white pubocervical fascia, with the tures in sequence. A sheet of graft material is tailored to the di-
vaginal wall itself often noted to be very thin in this plane. mensions of the defect and affixed to the preplaced sutures in
Dissection in the incorrect plane is usually associated with sig- the arcuate internus fascia. The material should be placed
nificant bleeding and inability to identify the underlying fascia. loosely under the bladder base from the bladder neck to vaginal
When placing mesh in the anterior compartment, some authors apex. Apical relocation sutures are then delivered through the
advocate developing a thicker vaginal flap that preserves some vaginal wall, utilizing a free needle to pass the blunt end of the
muscularis on the vaginal epithelium to decrease the risk of suture. Next, the vaginal wall is closed with running 2-0 SAS,
mesh extrusion. Placement of an Allis clamp on the lateral as- and in our experience, it is rarely necessary to trim excess vagi-
pect and supporting the vaginal wall inferior to the clamp with nal mucosa. If previously brought through the vaginal wall, api-
the index finger can facilitate proprioception of the proper cal relocation sutures are tied at this juncture.
plane and substantially aid dissection. O nce the dissection of After completion of the above steps, cystoscopy is again
the vaginal wall has been completed to the fornix on either side performed to ensure no penetration of graft or sutures into the
of the bladder neck, sharp dissection is utilized to enter the bladder has occurred, as well as confirming bilateral efflux
retropubic space immediately under the arch of the pubis. This from the ureteral orifices and assessing the degree of reduction
plane is in general avascular and should separate well from the of the prolapse at the bladder base with the inlay material.
underlying fascial components. In previously operated cases, Sling tension is then set by loosely tying the suspension sutures
this space may be difficult to identify and it is important to uti- over two fingers, followed by closure of the suprapubic inci-
lize sharp, shallow dissection in immediate tactile proximity to sion. Vaginal packing impregnated with estrogen cream is
the arch of the symphysis pubis to avoid inadvertent entry into placed at the conclusion of the procedure. The vaginal pack is
pelvic viscera such as the bladder and urethra. removed 12 to 24 hours postoperatively and the urinary
After sharp entry into the retropubic space, blunt lateral catheter is removed for a voiding trial. If this is not successful,
and anterior dissection is carried out to extend the space, pal- an indwelling catheter is reinserted or clean intermittent
pate the arcus tendineus and ischial spine, and mobilize the catheterization may be instituted. Alternatively, if a suprapu-
bladder and urethra. Subsequently, dissection is performed to bic tube has been placed at the time of surgery, the patient cy-
the vaginal cuff in a line parallel to the vaginal vault. During cles the suprapubic tube during at-home convalescence.
this dissection in posthysterectomy patients, the stump of the Patients are counseled to refrain from lifting over 5 lbs or en-
uterine arterial complex is commonly encountered, and bleeding gaging in intercourse for 6 weeks postoperatively.
may occur due to disruption of remaining vessels. Suture liga-
ture with 4-0 polydioxanone should be contemplated to avoid
persistent blood loss during the reconstructive segment of the Re p air o f Iso lat e d Ce nt ral
operation. Cautery should be minimized to avoid devascular- De fe ct Cyst o ce le s
ization of the underlying tissues. The authors prefer bipolar
diathermy for vessel coagulation. Primary colporrhaphy of isolated central defects with a well-
Apical dissection should be meticulous so as to identify any supported, nonobstructive urethra may be performed with
enterocele component; if found, the defect is excised and closed. plication of the pubocervical fascia (Fig. 49.4). Urethral
Apical enteroceles may be small and somewhat obscured by the sphincteric function should be evaluated to determine if a
concurrent sling is indicated. Patient preparation and position of the cardinal ligament complex at the apex of the
tioning are similar to the previously described procedure vagina is identified on either side.
utilizing mesh. The anterior vaginal wall is infiltrated with After vaginal dissection has been completed, four or six
injectable saline and a single midline incision is formed from suspending sutures of 1 polypropylene are placed in the pubo-
the bladder neck to vaginal apex. The anterior vaginal wall is cervical fascia in pairs—two proximal at the vaginal apex, two
then dissected off the underlying attenuated pubocervical midvaginal, and two distal at the level of the bladder neck.
fascia utilizing countertraction with Allis clamps facilitated by Sutures are placed to incorporate the pubocervical fascia and,
the operative finger of the nondominant hand. This technique at the vaginal apex, the cardinal ligaments. The most distal su-
splays and flattens the tissue, easing dissection and identifica- tures are placed in the midurethral complex. These sutures are
tion of the correct surgical plane. The dissection is continued then transferred from the vaginal to the suprapubic incision
to the level of perivesical fascia. O nce this is reached, the using specially designed needle carriers. This repair may be
retropubic space is entered and the defect is defined from the augmented with SAS mesh or other inlay materials affixed to
introitus to vaginal apex. the pubocervical fascia with 0 or 2-0 SAS or PDS sutures. The
Repair commences with reapproximation of the pubocervi- vaginal wall is closed with a 2-0 absorbable suture, and finally
cal fascia with 2-0 interrupted SAS along the base of the blad- the suprapubic incision is irrigated and closed.
der from the bladder neck to vaginal apex. The fascial
plication effectively relocates the cystocele behind the recon-
stituted pelvic floor. This repair may be bolstered with ab- Ab d o minal Re p airs
sorbable mesh to reduce the cystocele during plication and
further strengthen the fascial reapproximation. The cardinal The abdominal approach for cystocele repairs is exclusively
ligaments should also be reapproximated in the midline to se- for lateral defects (5) (Fig. 49.5). This approach yields superb
cure the apex of the repair. The cardinal ligaments are then visualization of the lateral defect and surrounding structures.
corrected with interrupted 2-0 absorbable sutures. Also, retropubic incontinence procedures or slings may both be
Cystoscopy is performed to ensure that the bladder is in- performed with this approach (19). Preparation includes posi-
tact and ureteral efflux is present. Vaginal closure is then car- tioning the patient in the low lithotomy or frog-leg position so
ried out utilizing a running 2-0 absorbable suture. as to have sterile access to the vagina. A lower-abdominal inci-
sion is made, either horizontal or transverse.
The retropubic space is entered and developed on either
Vag inal Paravag inal Re p air side of the bladder and urethra to identify the obturator inter-
nus fascia. This is best performed bluntly, with the suction tip
The paravaginal procedure performed through a vaginal inci- or a sponge stick, so as to sweep the overlying adipose tissue
sion does not use inlay material, instead exploiting the ATFP as from the underlying structures. The ischial spine is identified
an anchoring point for sutures placed through the anterior and the white line of the ATFP traced from its origin at the is-
vaginal wall on either side of the bladder base (17). The surgi- chial spine to the urethrovesical angle. The fascial defect will
cal field is prepared as above with dissection of the retropubic often be easily identifiable once this dissection is complete.
space, which frees the base of the bladder from the pelvic floor. The surgeon may also place a sponge stick or the nondomi-
O nce the dissection is complete, the bladder base is retracted nant hand in the vagina to displace the vaginal wall superiorly
medially with curved retractors and the ischial spine is pal- and better demonstrate the edges of the fascial defect.
pated. A 1-0 permanent suture is placed into the white line of O nce dissection is complete, four to six interrupted sutures
the ATFP just distal to the spine. A series of four to six 1-0 su- are placed in the disrupted edges of the defect to reappose the
tures are then placed in sequence to the urethrovesical junc- obturator internus fascia and the medially displaced pubocer-
tion. These sutures are then passed through the pubocervical vical fascia. After all sutures are placed, they are tied sequen-
fascia and vaginal wall beneath the bladder base from the blad- tially. Prior to closure of the abdomen, cystoscopy is
der neck to the apex of the vagina. These steps are repeated on performed to exclude suture entry into the bladder and con-
the contralateral side and then all are tied to reduce the cysto- firm ureteral efflux.
cele. Subsequent sutures of 1-0 delayed absorbable material
may be used to plicate the vaginal muscularis prior to closure.
Inno vat ive Transo b t urat o r Ap p ro ache s
Ne e d le Susp e nsio n
Several comprehensive pelvic organ prolapse systems have re-
These procedures rely on a sequence of sutures placed through cently been released and are gaining substantial acceptance
the pubocervical fascia that are then secured to the anterior from urologists and urogynecologists for the treatment of cys-
rectus muscle (18). The authors find these types of procedures tocele. These mesh-based systems utilize the minimally invasive
are of minimal utility for most patients. Preparation is similar approach of a vaginal incision with a reproducible, standardized
to the previously described inlay repair. Two parallel anterior kit allowing simultaneous repair of multiple fascial defects
vaginal wall incisions that extend from the bladder neck to the (Perigee, American M edical Systems, M innetonka, M N ; and
vaginal apex are created. These incisions are made on either Anterior Prolift, Gynecare, Somerville, N J). Current systems
side of the midline in an oblique fashion so as to be able to re- allow anchoring of allograft, xenograft, or polypropylene
flect the lateral wall off the underlying anterior vaginal wall. mesh through the obturator foramen and into the ATFP with
O nce the incisions are completed, sharp dissection is carried specially designed passage devices (Figs. 49.6 and 49.7). The
out laterally to enter the retropubic space and identify the at- appropriate placement of these supporting materials allows
tenuated edge of the pubocervical fascia. In addition, the loca- simultaneous repair of both central and lateral defects. Patient
Urethra Incision
Retracted labia
Cystocele
Weighted
speculum
A B
Vaginal
sling
Urethropelvic ligament Urethropelvic ligament
Perivesical fascia
Vesicopelvic ligament
Approximation
of cardinals
Cardinal ligament
C D
E F
FIGURE 49.4 A: Demonstration of the central cystocele defect with preservation of the lateral vaginal sulci. B: A midline incision is created from
the midurethra to vaginal apex in the vaginal wall. The retropubic space is developed on either side of the urethra and bladder. C: The vesicopelvic
ligaments are identified, as are the cardinal ligaments. The cardinal ligament complex is reconstituted in the midline with sutures so as to provide
apical support for the repair. D: For those repairs involving suture suspension techniques, sutures may be placed throughout the vesical pelvic liga-
ment and transposed from the vaginal to suprapubic area for subsequent stabilization. These steps are repeated on the contralateral side. E: In those
circumstances where plication alone is performed, sutures are placed across the base of the bladder from the vesicopelvic ligament on one side to
the vesicopelvic ligament on the contralateral side and the two structures are reapproximated. F: Completion of combined plication repair with
needle suspension of the proximal urethra and bladder neck.
preparation and positioning are similar to anterior colporrha- is placed and hydrodissection of the anterior vaginal wall per-
phy, except draping of the operative field must include the me- formed with saline or a dilute vasoconstrictor prior to creating
dial thigh overlying the obturator foramen. A urethral catheter a midline incision from the bladder neck to the vaginal apex.
FIGURE 49.5 Positioning and incision for retropubic repair of lateral

cystocele defects. A Pfannenstiel incision is made in the lower
abdomen to expose the retropubic space. The dissection exposes the
obturator internus fascia, and the fascial defect is identified as seen in
the right aspect of the diagram. Using interrupted delayed absorbable
or permanent sutures, the disrupted fascial edges are reapproximated.
The sutures are placed from the ischial spine to the level of ure-
throvesical angle as noted.
Vaginal epithelial flaps are intentionally created so as to be

thicker for purposes of graft coverage. Lateral dissection pro-
ceeds to the endopelvic fascia, but entry into the retropubic
space is not performed. The surgeon must be able to palpate
the ischial spine for appropriate placement of the proximal
graft arm. External skin incisions are made over the medial C
border of the obturator foramen and the passage devices are FIGURE 49.6 Perigee mesh placement. A and B: H elical needles are
delivered from the outside to the inside of the vaginal dissec- passed through the superior and inferior medial aspects of the obtura-
tor foramen to secure the graft arms. C: Final placement of the graft
tion with guidance of the surgeon’s finger. The distal incision is demonstrating fixation points in the arcus tendineus fasciae pelvis.
at the level of the clitoris, and the proximal incision is 2 cm in- (Reproduced with permission from American M edical Systems, Inc.)
ferior and 1 cm lateral to the clitoral incision. The distal trocar
is placed in the ATFP at the level of the bladder neck and the
proximal trocar is placed approximately 2 cm distal to the is-
chial spine. Cystoscopy is performed at this juncture to ensure with 2-0 absorbable suture and the vaginal incision closed with
no violation of the bladder has occurred during dissection or 2-0 SAS. Tailoring of redundant anterior vaginal wall skin is
trocar passage. The graft is attached to the passage devices and not recommended, as redundant mucosa will contract and may
guided back out of the skin incisions. Tension is set by manip- provide an additional barrier for prevention of mesh extrusion.
ulation of the graft arms and cystoscopy is again performed to Skin incisions may be closed with 4-0 SAS subcuticular sutures
ensure bilateral ureteral reflux. The graft is secured proximally or secured with a biologic tissue adhesive. Using a separate
result in stone formation or recurrent infections and should

be removed and relocated. The use of the transobturator
approach has added the variable of leg pain due to inexact
placement of trocars during graft insertion. When encoun-
tered, this pain may be persistent and quite troublesome.
Postoperative voiding dysfunction may be caused by detru-
sor instability, urethral obstruction, or recurrence of the cysto-
cele. Resolution of preoperative urgency will occur in up to
63% of patients (22); however, de novo detrusor instability
will occur in approximately 5% . Although degrees of urinary
retention may occur in patients on a transient basis, prolonged
obstruction manifests in 1% of women. Poor or inadequate
detrusor contractility may be a reason for incomplete empty-
ing and should be predictable on the basis of preoperative uro-
dynamic evaluation. Clean intermittent catheterization or
long-term indwelling catheterization may be indicated in these
patients.
Persistent dyspareunia, pelvic pain, or vaginal stenosis may
ensue from aggressive plication and/or excision of vaginal mu-
cosa. H owever, the majority of women appear to have im-
proved dyspareunia after surgery, largely due to resolution or
improvement of stress urinary incontinence (23). In those
FIGURE 49.7 Prolift mesh placement with critical landmarks— women who had deterioration of sexual function, the majority
1 denotes uterosacral ligament, 2 indicates sacrospinous ligament, and of cases appear to be associated with simultaneous posterior
3 overlies the arcus tendineus fasciae pelvis, demonstrating the posi- colporrhaphy (24). Vaginal shortening from inadequate apical
tion of graft anchoring through this fascial condensation. (Reproduced reconstruction also may contribute to dyspareunia. Finally,
with permission from Gynecare, Inc.)
late-onset apical prolapse and enterocele formation may occur
due to alterations of the vaginal axis and insufficient repair of
the apex. M eticulous attention to apical reconstruction should
midline incision, a midurethral sling can now be placed for avert this consequence.
treatment of concomitant incontinence.
Re sult s
O UTCO MES Long-term results for these procedures are still undergoing
evaluation, and as evidenced by recent meta-analysis, most
Co mp licat io ns published studies reflect uncontrolled case series (25). Results
should reveal cure of prolapse and remediation of inconti-
Significant intraoperative complications occur relatively infre- nence. Risk factors for operative failure may include ad-
quently with anterior vaginal prolapse repairs. In addition to vanced age, hormonal depletion, inadequate preoperative
the general risks of hemorrhage and urinary or soft tissue in- identification of all anatomic defects, incomplete surgical re-
fections, the most common complication seen with cystocele construction, or technical failure (26). In addition, obesity,
repair is injury to underlying structures such as the urethra, chronic pulmonary disease, bowel dysmotility, and genetic
bladder, and rarely, other pelvic viscera, including bowel. predisposition have also been implicated in surgical failure.
Incidental cystostomy may be repaired with a layered closure Some studies have reported that interpositional grafts convey
with absorbable suture, nonopposing suture lines, and maxi- a significant reduction in prolapse recurrence, with plication
mization of urinary drainage. Although reported to occur at repairs demonstrating only a moderate success rates (25,27);
an incidence of 2% , the prolapse surgeon must always be however, other authors have found similar objective anatomic
cognizant of the risk of ureteral damage or obstruction (20). outcomes (28).
Cystoscopic evaluation intraoperatively should indicate the Vaginal paravaginal repairs have reported failure rates of
possibility of ureteral obstruction with nonreflux from one 3% to 14% at 1 year (29). The six-corner bladder suspension
side. Sutures may be removed at this time prior to completion has shown reasonable results at 2 years. Combined repairs
of the procedure. Stenting should be considered only in the have a small associated risk of cystocele and enterocele forma-
case of significant disruption or trauma to the ureteric orifice. tion but have been reported to have a 94% success rate for
Failure to recognize ureteral injury intraoperatively sets the cure of incontinence.
stage for one of the most devastating complications of ante- Little data have yet to be published on the transobturator
rior prolapse repair, namely ureterovaginal or vesicovaginal mesh kits, but short-term results appear promising, with up to
fistula. 95.3% anatomic correction of the anterior compartment, with
Increasing use of permanent mesh materials for prolapse an acceptable complication profile (30–32). Enthusiasm for
repair may increase the risk for erosions, infections, sinuses, these early results must be tempered by emerging reports of
fistulas, and development of robust vaginal granulation tissue exceptional complications possible with extensive transvagi-
(13,21). N onabsorbable suture present in the bladder can nal mesh procedures (33).
Chap t e r 50: Transvag inal Re p air of Ap ical Prolap se 335
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CHAPTER 50 ■ TRANSVAGINAL REPAIR

O F APICAL PRO LAPSE
KATIE N. BALLERT AND VICTO R W. NITTI
M ost women who present with pelvic organ prolapse (PO P) reduced rate of recurrence (by 7% ) after vaginal repair of large
have a combination of pelvic floor support defects affecting PO P by routine performance of a transverse defect repair.
multiple compartments (anterior, apical, and posterior). In our After hysterectomy, the apical portion of the vagina is sup-
opinion, the majority of anterior prolapse cases significant ported by sheet-like extensions of the endopelvic fascia that
enough to require repair have an apical component. In addi- attach it to the pelvic sidewall and levator ani fascia, referred
tion, we believe that the high recurrence rate after PO P repair to as the paracolpium (Fig. 50.1) (2). The paracolpium pro-
may in part be due to failure to adequately address the apical vides two levels of support. Level I, or upper support, “ sus-
component. For example, Shull et al. (1) demonstrated a pends” the vagina, attaching it to the pelvic sidewall. Level II,
ment may be quantified using a variety of systems. Currently,

the Pelvic O rgan Prolapse Q uantification System (PO P-Q ) is
the most comprehensive (3). Imaging studies, including cys-
tography, defecography, ultrasound, computerized tomogra-
phy scan, and magnetic resonance imaging, may also be used
to help define pelvic anatomy if necessary.
In general, the degree of pelvic prolapse and the severity of the
symptoms it causes are the main indications for treatment.
Low-stage prolapse is often asymptomatic and does not re-
quire treatment. Treatment is typically driven by the patient’s
symptoms, which may include an uncomfortable feeling of
prolapse that may limit activity, obstructive voiding symp-
toms, and/or constipation. PO P may be associated with stress
incontinence, which may ultimately drive the patient toward
treatment. The patient’s age, general health, performance sta-
tus, degree of sexual activity, and expectations from treatment
will play a role in the type of treatment or surgical procedure
performed. Finally, some patients may suffer serious sequelae
FIGURE 50.1 Level I (suspension) and level II (attachment). In level I
the paracolpium suspends the vagina from the lateral pelvic walls. of prolapse, such as hydronephrosis from ureteral obstruction
Fibers of level I extend both vertically and also posteriorly toward the or urinary retention from urethral obstruction.
sacrum. In level II the vagina is attached to the arcus tendineus fasciae
pelvis and superior fascia of levator ani. (From DeLancey JO L.
Anatomic aspects of vaginal eversion after hysterectomy. A m J O bstet
G ynecol. 1992;166:1717–1728, with permission.)
ALTERNATIVE THERAPY
N onsurgical treatment involves supporting the pelvic floor
with a device such as a pessary. Pessaries come in a variety of
or midvaginal support, which includes the pubocervical fascia, shapes and sizes and are fit depending on the patient’s size and
“ attaches” the midvagina more directly to the pelvic walls, in- anatomy and the components of the prolapse. M any women
cluding the levator fascia and arcus tendineus. Damage to mid- find pessaries a satisfying alternative to surgery that can com-
level support usually results in anterior and posterior defects, fortably control the symptoms of pelvic prolapse, while others
while damage to upper-level support results in apical prolapse, are unable to maintain a pessary due to their specific anatomy
including enterocele and/or vault or uterine prolapse. or cannot use one due to symptoms such as discomfort, both-
ersome discharge, or bleeding. For those women who do not
remove the pessary, regular follow-up (every 1 to 3 months) is
DIAGNO SIS necessary so the pessary can be removed, cleaned, and re-
placed and the patient examined.
Prolapse is described in terms of anterior, apical, and posterior
as opposed to “ cystocele, enterocele, and rectocele.” This is be-
cause most cases of prolapse are multicompartmental, and the SURGICAL TECHNIQ UE
support of one pelvic structure is dependent on the support of
other structures. Second, it is sometimes difficult to tell on There are several options for surgical management of apical
physical examination exactly what organs are prolapsed. An prolapse. Prolapse can be approached vaginally or abdominally
enterocele may present as anterior prolapse (usually in con- depending on its degree, patient characteristics, and desired
junction with a cystocele), apical prolapse, posterior prolapse, outcomes. While the focus of this chapter is on transvaginal re-
or a combination, depending on where the break in support is pair, there are situations where the abdominal approach (either
located. It is also important to ascertain if the vaginal vault is open or laparoscopic) is preferred, such as in young women
prolapsed, as this will affect the type of repair performed. with vaginal vault prolapse or those with failed transvaginal
The extent of prolapse is first evaluated with the patient in procedures (4). In the frail elderly population, colpocleisis, in
the lithotomy position. The presence of urethral mobility, which the entire vagina is closed, may also be considered.
stress incontinence, and anterior, apical, and posterior pro-
lapse should be assessed. The patient should be instructed to
cough and perform a Valsalva maneuver to assess the effect of Transvag inal Ent e ro ce le Re p air
increased abdominal pressure on the prolapse. With the pro-
lapse reduced (manually or with a ring forceps, packing, or Transvaginal enterocele repair may be performed either intra-
pessary), the patient should be asked to cough and perform a peritoneally or extraperitoneally. In cases of large enterocele,
Valsalva maneuver to evaluate for occult stress incontinence. we prefer the intraperitoneal approach; however, in cases
To ascertain the full extent of the prolapse, the patient should where the enterocele is small or difficult to find, an extraperi-
also be examined in the standing position with one foot toneal approach may be appropriate. There are several varia-
elevated on a stool. The degree of prolapse of each compart- tions of the repair, depending on the degree of prolapse and
FIGURE 50.2 The vaginal wall is grasped with two Allis clamps and
brought outside the vaginal introitus. A midline incision is made.
(From N itti VW. Transvaginal enterocele repair with variations. FIGURE 50.3 Enterocele sac completely dissected to its neck. (From
Contem p Urol 1994;6:50–64, with permission.) N itti VW. Transvaginal enterocele repair with variations. Contem p
Urol 1994;6:50–64, with permission.)
whether or not a vault suspension is necessary, yet most varia-

tions start with the basic intraperitoneal repair.
The patient is placed in the dorsal lithotomy position. She
is prepped, with attention placed on adequately scrubbing the
inside of the vagina. If necessary, the labia are retracted with
silk sutures. A Scott ring retractor (Lone Star M edical Corp.)
is useful in exposing the operative field.
The first step in intraperitoneal repair is to isolate the ente-
rocele sac. This is begun by grasping the prolapsed vaginal wall
with two Allis clamps and bringing it outside of the vaginal in-
troitus. A longitudinal incision is made in the vaginal wall
along the entire length of the enterocele (Fig. 50.2). The vagi-
nal wall is then carefully dissected away from the underlying
pubocervical fascia and enterocele sac. In the initial dissection,
care must be taken to stay very superficial and develop the
proper plane. This is best accomplished by placing the curve of
the M etzenbaum scissors against the vaginal wall. A finger can
be placed on the outside of the vaginal wall to stabilize the ini-
tial dissection. O nce the proper plane is entered, it is usually
easy to dissect the vaginal wall away from the underlying ente-
rocele sac. Care taken here will prevent early entry into the
peritoneal cavity. The dissection of the enterocele is continued
all the way to the neck of the enterocele sac (Fig. 50.3). After
the enterocele has been completely isolated, the sac is opened FIGURE 50.4 The enterocele sac is opened, exposing intra-abdominal
contents. (From N itti VW. Transvaginal enterocele repair with varia-
and the peritoneal cavity is entered. At this time, one may see tions. Contem p Urol 1994;6:50–64, with permission.)
small bowel, omentum, or ovary and fallopian tube in cases
where previous hysterectomy without oophorectomy has been
performed (Fig. 50.4).
The next step is closure of the enterocele defect or pouch of using the retractor. A no. 1 polyglactic acid (PGA) suture is
Douglas. Retraction of the peritoneal contents is best per- first placed through the peritoneum and into the prerectal
formed using a moist pediatric laparotomy pad and a narrow fascia that overlies the rectum (Fig. 50.5). A circumferential
Deaver or H eaney retractor. Placing the patient in the closure of the defect is then performed by placing the purse-
Trendelenburg position so that abdominal organs fall slightly string suture laterally in the right uterosacral–cardinal ligament
cephalad assists with this. The enterocele repair begins poste- complex, anteriorly in the peritoneum overlying the base of the
riorly while the abdominal contents are retracted anteriorly bladder, laterally on the left in the uterosacral–cardinal
excess enterocele sac may be excised and the ends oversewn

with a 2-0 PGA suture.
Cystoscopy is performed to document that there has been
no injury to the bladder. Ureteral injury is ruled out by intra-
venous indigo carmine. Excess vaginal wall is then excised,
and the vaginal wall is closed with a 2-0 PGA suture incorpo-
rating deep tissue to obliterate any dead space. Antibiotic-
impregnated vaginal packing is placed for 24 hours.
Ent e ro ce le Re p air w it h Vault Susp e nsio n

In most cases of enterocele, the vaginal apex is also prolapsed
and requires new support. It is also common to have concomi-
tant anterior and posterior defects, and therefore repair of
more than one compartment is typically necessary. There are
several techniques commonly used to accomplish a transvagi-
nal vault suspension, and the best technique is still debated.
We will review nonaugmented repairs, including the McCall cul-
doplasty, the uterosacral ligament suspension, the sacrospinous
ligament fixation, and the iliococcygeus fixation, as well as
augmented repairs, including sacrospinous ligament fixation
with mesh. Lastly, we will briefly discuss uterine-sparing
FIGURE 50.5 A Deaver retractor is used to retract abdominal con- procedures and the mesh kits that have recently emerged as
tents so that pursestring sutures can be placed. (From N itti VW. treatment options for POP.
Transvaginal enterocele repair with variations. Contem p Urol
1994;6:50–64, with permission.)
No naug me nt e d Re p airs
McCall Culd o p last y
In 1957 M cCall (5) originally described a technique of poste-
rior culdoplasty used to correct enterocele at the time of vagi-
nal hysterectomy. Several modifications of the procedure have
been reported, but the concept remains the same. As described
above, retraction of the peritoneal contents is best performed
using a moist pediatric laparotomy pad and a narrow Deaver
retractor with the patient in the Trendelenburg position.
Permanent or delayed absorbable suture can be used for the
internal M cCall sutures. The suture is passed through one
uterosacral ligament approximately 2 cm above its cut edge.
Successive passes are then made through the posterior peri-
toneum, and lastly the suture is placed through the contralat-
eral uterosacral ligament. The suture is not tied, and
FIGURE 50.6 Placement of pursestring sutures. (From N itti VW. additional sutures are placed in a similar fashion as needed
Transvaginal enterocele repair with variations. Contem p Urol (Fig. 50.7). After all of the internal M cCall sutures have been
1994;6:50–64, with permission.) placed, one or two external M cCall sutures are placed using
delayed absorbable suture. External M cCall sutures are placed
ligament complex, and finally again posteriorly in the prerec- through the vaginal epithelium (from outside to inside),
tal fascia (Fig. 50.6). After this pursestring suture has been through the peritoneum and the ipsilateral uterosacral liga-
placed, a second one may be placed in the identical structures ment. Similar to the internal M cCall sutures, successive passes
in close proximity to the first. If one is not going to perform a are again made through the posterior peritoneum until the
further vault suspension, it is especially important to incorpo- contralateral uterosacral ligament is reached. The suture is
rate the uterosacral–cardinal ligament complex into the clo- then passed through the peritoneum and the vaginal epithe-
sure, as this will be the main support of the vaginal apex. In lium close to the entry point. The internal sutures are each
addition, care should be taken to place these sutures deep tied, followed by the external sutures, which suspend the vagi-
enough to ensure that adequate vaginal depth can be achieved. nal wall at the level of the uterosacral ligaments.
When an additional apical support procedure is preformed,
the main purpose of the pursestring suture is simply to close Ut e ro sacral Lig ame nt Fixat io n
the peritoneum. After all sutures are placed, the assistant Suspension of the vaginal vault to the uterosacral ligaments,
cinches down and places tension on one of the pursestrings as described by Shull et al. (1), provides a more natural vagi-
while the surgeon ties the other. After this has been tied, the nal axis than the sacrospinous ligament fixation. Without the
second pursestring (if placed) is tied in a similar manner. The posterior deflection of the vagina caused by fixation to the
FIGURE 50.7 Placement of internal M cCall sutures. (From M cCall

M L. Posterior culdoplasty: surgical correction of enterocele during
vaginal hysterectomy: a preliminary report. A m J O bstet G ynecol
1957;10:595–602, with permission.)
FIGURE 50.8 Sutures are placed in uterosacral ligaments bilaterally.

O ne arm of each suture is placed in the pubocervical fascia and the
sacrospinous ligament, the risk of prolapse of the anterior vagi- other in the rectovaginal fascia. (From Shull BL, Bachofen C, Coates
nal compartment is reduced. Identification of the uterosacral KW, et al. A transvaginal approach to repair of apical and other asso-
ligaments posthysterectomy can be difficult. Their origin is at ciated sites of pelvic organ prolapse with uterosacral ligaments. A m J
the sacrum, and they reflect anteromedially toward insertion at O bstet G ynecol 2000;183:1365–1373, with permission.)
the cervix. After the uterus and cervix are removed, these liga-
ments meld into the surrounding connective tissue. The opti-
mal site of fixation to the uterosacral ligament is in the
intermediate portion of the ligament, which has fewer vital ad-
jacent structures and is a strong fixation site, and tension on
this area has little effect on the nearby ureter. The ischial spine
can be used to reliably identify the intermediate portion of the
uterosacral ligament. Sutures should be placed at the level of
the ischial spine, 1 cm posterior to the anteriormost palpable
margin of the uterosacral ligament. The uterosacral ligament is
very close to the intrapelvic ureter and the ureter can be injured
if incorporated by one of the sutures or kinked by traction
from a suture. The intraperitoneal approach, however, allows
for better visualization and thus better suture placement com-
pared to the visualization in the narrow, deep pararectal space.
A vertical midline incision is made in the vaginal epithe-
lium. The vaginal wall is then carefully dissected away from
the underlying pubocervical fascia and enterocele sac and the
enterocele sac is entered and the bowel is packed away as de-
scribed above for transvaginal enterocele repair. The following
technique is as described by Shull et al. (1) in 2000, with mi-
nor modifications. The remnants of the uterosacral ligaments FIGURE 50.9 Sagittal view of suspensory suture in uterosacral liga-
are identified posterior and medial to the ischial spines at ap- ment (USL), pubocervical fascia (PCF), and rectovaginal fascia (RVF).
(From Shull BL, Bachofen C, Coates KW, et al. A transvaginal ap-
proximately the 4 o’clock and 8 o’clock positions. An Allis proach to repair of apical and other associated sites of pelvic organ
clamp can be used to apply traction to the tissue and the prolapse with uterosacral ligaments. A m J O bstet G ynecol
uterosacral ligament can be palpated towards the sacrum. 2000;183:1365–1373, with permission.)
Two or three delayed absorbable or permanent (Ethibond) su-
tures (double-armed) are placed through the uterosacral liga- and rectovaginal fascia are repaired by plication. The double-
ments on each side. In an effort to minimize ureteral injury, it armed sutures are placed through the pubocervical and recto-
is recommended that sutures be passed in a lateral-to-medial vaginal fascia (Figs. 50.8 and 50.9). The distal remnants of the
fashion as the surgeon has better control over the entry point of uterosacral ligaments are then plicated across the midline. The
the needle than its exit point. Central defects in the pubocervical previously placed absorbable suspension sutures may be
placed through the posterior vaginal wall. If one prefers, two performed until the sacrospinous ligament is palpated and the
permanent sutures and one absorbable suture (to be brought overlying coccygeus muscle is seen. The Breisky-N avratil re-
through the vaginal wall) can be used. Intravenous indigo tractors will help expose the ligament. O nce the ligament is
carmine is administered. The vaginal epithelium is then closed identified, a no. 1 permanent braided suture is placed through
as described previously, and the suspension sutures are tied, the ligament and coccygeus muscle complex 2 cm medial to
but left long and tagged. Cystoscopy is performed with indigo the ischial spine, which is also identified by palpation. It is
carmine as described above, and once ureteral patency is important to place the suture in this position to avoid injury
ensured the suspension sutures are trimmed. to the pudendal nerve and vessels, which run just below the
ischial spine. It is also important to include the strong liga-
Sacro sp ino us Lig ame nt Fixat io n ment in addition to the overlying coccygeus muscle. These
Sacrospinous ligament fixation is used to correct vault pro- tasks can be made easier by carefully dissecting over the liga-
lapse when the anterior vaginal wall is well supported, or it ment with a spreading motion of the M etzenbaum scissors
can be used with simultaneous anterior repair. Vaginal depth and with the aid of a Kittner dissector. Visualization of the
and axis are restored by posterior fixation of the vaginal vault ligament itself helps avoid incorrect placement of the sutures.
to the sacrospinous ligaments. The sacrospinous ligament Another helpful tool is the Capio transvaginal suture-capturing
stretches from the ischial spine to the sacrum and is covered device (Boston Scientific). This tool allows for placement of
by the coccygeus muscle. the suture and retrieval of the needle in this deep and narrow
O nce the enterocele repair is complete, the posterior vagi- space with just the depression of a lever on the instrument’s
nal wall must be opened far enough distally to facilitate dis- end. It has greatly simplified suture placement in our proce-
section to the sacrospinous ligament. When a simultaneous dures. Tension should be placed on the suture to make certain
rectocele repair is to be performed, the entire posterior vagi- that it is in the strong ligament. A second suture should be
nal wall is opened through the perineum. After the posterior placed adjacent to the first. Each of these sutures is then
vaginal wall is incised in the midline, it is gently dissected lat- placed through the vaginal wall, excluding the epithelial layer
erally from the underlying prerectal fascia for a short dis- at the level of the apex, approximately 1 cm apart, and left
tance. N ext, the sacrospinous ligament must be identified. untied. If a rectocele is present, it is repaired at this time. The
This is done by penetrating the right or left rectal pillar apex of the vagina can be directed under finger guidance to
(pararectal fascia) sharply and entering the pararectal space the deepest possible portion, where it will be fixed. The vagi-
(Fig. 50.10). Blunt dissection of the pararectal space can be nal wall is then closed with a running interlocking 2-0 PGA
performed with a combination of finger dissection and the suture, and then the previously placed sacrospinous ligament
use of deep Breisky-N avratil retractors. This dissection is fixation sutures are individually tied. Antibiotic-impregnated
vaginal packing is then placed.
After sacrospinous ligament fixation, recurrences usually
occur in the anterior vaginal compartment. This observation
has led some investigators to try a modification of the
sacrospinous ligament fixation meant to reduce recurrences in
the anterior compartment by avoiding the downward deflec-
tion of the vagina. The anterior approach to sacrospinous lig-
ament fixation approaches the ligament from the retropubic
space and dissection of the ipsilateral paravaginal space from
the level of the bladder neck to the ischial spine. Theoretically
this approach should reduce postoperative vaginal narrowing
and posterolateral deviation of the upper vagina, resulting in
improved functional outcome. An additional modification is
the bilateral anterior sacrospinous ligament fixation. Bilateral
fixation should provide additional support and longevity over
a single fixation point and may also increase the area of the
vagina over the pelvic floor, improving its ability to withstand
increases in intra-abdominal pressure. A limitation of this
technique is that not all women have vaginal anatomy that is
able to stretch to bilateral ligaments.
Ilio co ccyg e us Fixat io n

Iliococcygeus or prespinous fixation for vaginal vault prolapse
is yet another method to suspend the vaginal vault, created to
address what was considered to be a high rate of anterior
compartment prolapse after sacrospinous ligament fixation
FIGURE 50.10 Dissection for sacrospinous ligament fixation. The and damage to the pudendal neurovascular bundle. In an ilio-
rectal pillars are sharply penetrated and the pararectal space is coccygeus fixation the vaginal apex is fixed bilaterally to the
entered. The space is widened with blunt dissection to expose the su- iliococcygeus fascia using one no. 1 polydioxanone suture.
perior surface of the pelvic diaphragm. The sacrospinous ligament can
The incision and dissection are carried out posteriorly. The
then be palpated and the coccygeus muscle overlying it can be seen.
(From N itti VW. Transvaginal enterocele repair with variations. rectovaginal fascia is dissected off the posterior vaginal wall
Contem p Urol. 1994;6:50–64, with permission.) laterally all the way to the pelvic sidewall. The ischial spine
and sacrospinous ligament are identified as a landmark for the

iliococcygeus fascia, which will be found anterior to them.
Cystoscopy with indigo carmine is recommended with each
of the previous procedures to evaluate for bladder injury and
ureteral patency.
Me sh-Aug me nt e d Re p airs
The use of mesh at the time of PO P repair is becoming in-
creasingly popular. This is in part due to the high incidence of
recurrence following primary repair. H owever, there are mini-
mal long-term safety and efficacy data on graft utilization in
pelvic reconstruction.
There are various mesh-augmented repairs described in the
literature. In 2004, Shah et al. (6) described a procedure using
polypropylene mesh for total pelvic reconstruction.
Subsequently, Amrute et al. (7) described their modification,
in which a tension-free method is used for the anterior arms of FIGURE 50.11 Placement of 2-0 PDS suture into sacrospinous liga-
ment using a Capio needle driver. (From Boston Scientific
the mesh. A horizontal incision is made at the most dependent Corporation, with permission.)
portion of prolapsed vagina. Sharp and blunt dissection is per-
formed extraperitoneally towards the ischial spine and
sacrospinous ligament bilaterally. Two delayed absorbable su-
tures are placed bilaterally in the sacrospinous ligament (1 cm
medial to the ischial spine) using the Capio needle driver. The
vaginal epithelium is dissected off the bladder sharply, and if
necessary the endopelvic fascia is imbricated with absorbable
suture. Sharp dissection of the periurethral space is performed
superiorly toward the retropubic space. An approximately
6 8-cm piece of polypropylene mesh is configured in an H
and the anterior arms are sutured to the arms of a BioArc de-
vice (American M edical Systems). Using the BioArc needle
passers, the anterior arms are passed retropubically through
the anterior abdominal wall. The distal edge of the mesh is po-
sitioned at the level of the midurethra. Cystoscopy is per-
formed to place a suprapubic tube, the bladder is evaluated to
identify injury, and indigo carmine is administered to assess
ureteral patency. The sacrospinous ligament sutures are
passed through the lateral arms of the mesh and tied down.
The sutures are then brought through the posterolateral aspect FIGURE 50.12 Sutures are placed in the arcus tendineus at the level
of the bladder neck and 1 cm above the ischial spine as well as into the
of the vaginal mucosa. Absorbable sutures are placed as sacrospinous ligament bilaterally.
needed to prevent folding and kinking of the mesh. The vagina
is then closed in a running fashion.
O ur current mesh-augmented repair for patients with severe polypropylene mesh is then configured in the shape of a trape-
apical and anterior prolapse includes a simultaneous paravagi- zoid approximately 5 cm wide at the top, 10 cm wide at the
nal and apical repair using soft polypropylene mesh and in- bottom, and 10 cm long (Fig. 50.13). The previously placed
volves sacrospinous ligament fixation through an anterior Vicryl sutures are then placed in the mesh with the narrow por-
approach. It is a modification of the technique described by tion corresponding to the level of the bladder neck, the middle
Shah et al. (6). The prolapsed anterior vaginal wall is grasped portion corresponding to the level of the ischial spines, and the
with Allis clamps and infiltrated with 1% lidocaine with epi- widest portion of the mesh at the level of the sacrospinous lig-
nephrine. A vertical midline incision is made from the area of ament. The sacrospinous ligament sutures are tied down first
the bladder neck to the vaginal apex. The vaginal wall is dis- and left long. The sutures 1 cm above the ischial spine and the
sected off the bladder and the enterocele sac to the level of the sutures at the bladder neck are then tied down and cut. The
endopelvic fascia. The enterocele sac may be opened and re- wound is irrigated with antibiotic solution. Cystoscopy after
paired as described above for transvaginal enterocele repair or intravenous indigo carmine is then performed to ensure
simply reduced, depending on its size. After repair of the ente- ureteral patency. The sacrospinous ligament sutures are passed
rocele, the endopelvic fascia is perforated and the space of through the vaginal wall bilaterally at the vaginal apex, about
Retzius entered bilaterally. A Capio needle driver is then used 2 cm from the midline. The proximal two thirds of the vaginal
to place a 2-0 Vicryl suture into the arcus tendineus at the level wall is closed, and then the sacrospinous ligament sutures are
of the bladder neck and 1 cm above the ischial spine, as well as tied down. The remainder of the anterior vaginal wall is closed.
a PDS suture into the sacrospinous ligament. These sutures are Sometimes a small amount of vaginal wall is excised prior to
placed bilaterally (Figs. 50.11 and 50.12). A piece of soft completing the closure. We have recently modified our procedure
previously. An anterior colporrhaphy is performed, suturing

the pubocervical fascia across midline and securing it to the
cervix at the most proximal extent. The Capio needle driver is
used as described previously to place Vicryl sutures in the arcus
tendineus at the level of the bladder neck and just above the is-
chial spine. It is also used to place a PDS suture in the
sacrospinous ligament bilaterally. A 5 5 10-cm trape-
zoidal piece of polypropylene mesh (same as previously) is
fashioned and secured using the previously placed sutures. The
mesh is also secured to the paracervical fascia in the midline
using Vicryl suture. Cystoscopy is performed prior to passing
the previously placed PDS sutures through the vaginal wall just
lateral to the cervix. Anecdotally, we have had some success
with this procedure, but no long-term data are available.
Me sh Pro lap se Re p air De vice s

FIGURE 50.13 Soft polypropylene mesh configured in the shape of a
trapezoid (approximately 5 5 10 cm). Recently a number of prepackaged mesh kits have been mar-
keted for prolapse repair. These kits include polypropylene
meshes with various arms that are anchored by passage
to include an anterior colporrhaphy with plication of the through support tissues (including the sacrospinous ligament,
pubocervical fascia across midline prior to placement of su- iliococcygeus muscle, and arcus tendineus) using insertion tro-
tures into the arcus tendineus and sacrospinous ligament. cars. We have very limited experience with these procedures,
Unfortunately this is not demonstrated in the figures. and there are currently no long-term data regarding their use.
Further discussion is beyond the scope of this text.
Transvag inal Pro ce d ure s fo r Pre se rvat io n

o f t he Pro lap se d Ut e rus O UTCO MES
There has been a recent trend towards uterine-sparing proce- The results of apical prolapse repair are difficult to evaluate
dures despite limited long-term data. Various vaginal, abdom- because the definition of success varies between studies and
inal, and laparoscopic techniques have been described. few studies report long-term follow-up. Colombo and M ilani
(9) found no statistical difference in recurrence of vault pro-
Manche st e r Pro ce d ure lapse in a retrospective study comparing sacrospinous
The M anchester procedure was originally described in 1888 ligament fixation and M cCall culdoplasty (8% versus 3% , re-
by Archibald Donald of M anchester, England, and subse- spectively). Shull et al. (1) reported “ optimal anatomic out-
quently modified by W.E. Fothergill (8). It is an alternative to comes” in 87% of patients undergoing uterosacral fixation,
vaginal hysterectomy for patients with uterine prolapse, cervi- while Karram et al. (10) reported that 89% of women ex-
cal elongation, and nonattenuated uterosacral–cardinal liga- pressed satisfaction following the procedure. Success rates
ments. A circumferential incision is made around the cervix ranging from 8% to 97% have been reported for traditional
(similar to the incision for a vaginal hysterectomy). The vagi- sacrospinous ligament fixation (11,12). Shull et al. (13) and
nal epithelium is dissected off the cervix. The cardinal liga- M eeks et al. (14) reported 95% and 96% cure rates following
ment, including the cervical branch of the uterine artery, is iliococcygeus fixation, while more recently M aher et al. (15)
clamped, divided, and suture-ligated bilaterally. A portion of reported equal efficacy when comparing the iliococcygeus fix-
the cervix is then amputated with a scalpel. Sturmdorf sutures ation to sacrospinous ligament fixation.
are placed to invaginate the vaginal epithelium into the cervi- There are even fewer data regarding outcomes of mesh-
cal os. The previously ligated cardinal ligaments are sewn to augmented repairs. Amrute et al. (7) reported a 5.2% recur-
the anterior cervical stump. Anterior and posterior colporrha- rence rate and a 2.1% rate of vaginal erosion with a mean
phy procedures are performed as needed, and the vaginal follow-up time of 31 months.
epithelium is closed.
O n occasion, we have performed a uterine-preserving
transvaginal mesh-augmented sacrospinous ligament fixation Co mp licat io ns
repair. We typically prefer the abdominal approach when pre-
serving the uterus. H owever, in patients in whom an abdomi- In all the previous procedures, the major risks are bleeding
nal approach is not ideal and mild (grade II or less) uterine due to vascular injury, nerve entrapment, ureteral injury or
prolapse exists in the setting of more severe anterior prolapse kinking, bowel injury, wound infection, and persistent or re-
(a rare situation), this approach may be considered. It is current prolapse. During placement of the pursestring sutures
performed in a similar fashion as the above-described of an enterocele repair, one must take care not to disturb the
sacrospinous ligament fixation. A midline incision is made in ovarian vessels, which lie near the uterosacral–cardinal com-
the anterior vaginal wall from the level of the bladder neck to plexes. The pudendal vessels and nerve, which lie beneath the
the cervix. The dissection is then performed as described sacrospinous ligament, are at high risk of injury during
Chap t e r 51: Poste rior Vag inal Prolap se Re p air 343
sacrospinous ligament fixation. Pudendal entrapment may oc- but can be injured or kinked by any of the transvaginal vault
cur if sutures are placed too laterally, whereas the sciatic nerve suspensions. Ureteral injury or kinking in cases of vault sus-
is at risk if the sutures are placed too cephalad. Pelvic and pension has a reported rate of 1% to 11% (10). The anterior
gluteal pain, although usually transient, can occur as a result vaginal compartment is at highest risk for persistent or recur-
of injury to the pudendal and sciatic nerves. The intrapelvic rent prolapse, but in many cases this prolapse is asymptomatic
ureter is intimately associated with the uterosacral ligaments and does not require reoperation.
References
1. Shull BL, Bachofen C, Coates KW, et al. A transvaginal approach to repair 8. Fothergill W. Anterior colporrhaphy and amputation of the cervix com-
of apical and other associated sites of pelvic organ prolapse with bined as a single operation for the use in the treatment of genital prolapse.
uterosacral ligaments. A m J O bstet G ynecol 2000;183:1365–1373. A m J Surg 1915;29:161.
2. Delancey JO L. Anatomic aspects of vaginal eversion after hysterectomy. 9. Colombo M , M ilani R. Sacrospinous ligament fixation and modified
A m J O bstet G ynecol 1992;166:1717–1728. M cCall culdoplasty during vaginal hysterectomy for advanced uterovagi-
3. Bump RC, M attiasson A, Bo K, et al. The standardization of terminology nal prolapse. A m J O bstet G ynecol 1998;179:13–20.
of female pelvic organ prolapse and pelvic floor dysfunction. A m J O bstet 10. Karram M , Goldwasser S, Kleeman S, et al. H igh uterosacral vaginal vault
G ynecol 1996;175:10–17. suspension with fascial reconstruction for vaginal repair of enterocele and
4. Sze EH , Kohli N , M iklos JR, et al. A retrospective comparison of abdomi- vaginal vault prolapse. A m J O bstet G ynecol 2001;185:1339–1342.
nal sacrocolpopexy with Burch colposuspension versus sacrospinous fixa- 11. H olly RJ, Varner RE, Gleason BP, et al. Recurrent pelvic support defects af-
tion with transvaginal needle suspension for the management of vaginal ter sacrospinous ligament fixation for vaginal vault prolapse. J A m Coll
vault prolapse and coexisting stress incontinence. Int Urogynecol J Pelvic Surg 1995;180:444–448.
Floor D ysfunct 1999;10:390–393. 12. N ichols DH . Sacrospinous fixation for massive eversion of the vagina. A m
5. M cCall M L. Posterior culdoplasty: surgical correction of enterocele during J O bstet G ynecol 1982;142:901–904.
vaginal hysterectomy: a preliminary report. A m J O bstet G ynecol. 13. Shull BL, Capen CV, Riggs M W, et al. Bilateral attachment of the vaginal
1957;10:595–602. cuff to iliococcygeus fascia: an effective method of cuff suspension. A m J
6. Shah DK, Paul EM , Rastinehad AR, et al. Short-term outcome analysis of O bstet G ynecol 1993;168:1669–1674.
total pelvic reconstruction with mesh: The vaginal approach. J Urol 14. M eeks GR, Washburne JF, M cGehee PR, et al. Repair of vaginal vault pro-
2004;171:261–263. lapse by suspension of the vaginal to iliococcygeus (prespinous) fascia. A m
7. Amrute KV, Eisenberg ER, Ardeshir RR, et al. Analysis of outcomes of sin- J O bstet G ynecol 1994;171:1444–1454.
gle polypropylene mesh in total pelvic floor reconstruction. N eurourol 15. M aher CF, M urray CJ, Carey M P, et al. Iliococcygeus or sacrospinous fix-
Urodynam 2007;26:53–58. ation for vaginal vault prolapse. O bstet G ynecol 2001;98:40–44.
CHAPTER 51 ■ PO STERIO R VAGINAL

PRO LAPSE REPAIR
LIO R LO WENSTEIN AND ELIZABETH R. MUELLER
Pelvic organ prolapse (PO P) is prevalent in the United States, women aged 50 to 79 years had PO P on physical examina-
with approximately 200,000 surgeries in women annually (1). tion. The vaginal compartment most frequently associated
An epidemiologic study of a large U.S. northwest health care with the prolapse was the anterior vaginal wall (also known as
population suggests that a woman has an 11.1% risk of un- cystocele) at 34% , followed by the posterior compartment
dergoing PO P surgery by the age of 80. O ver the next 30 years (rectocele, 19% ) and uterine prolapse (14% ). Parity and
it is predicted that the number of women seeking care for obesity were strongly associated with an increased risk for
pelvic floor disorders will increase by 45% (2). prolapse.
O ne of the confounding factors in diagnosing and treating Posterior vaginal wall prolapse is thought to be herniation
PO P is that “ less than perfect” support of the anterior and of the posterior vaginal wall or anterior rectal wall into the
posterior vaginal walls is a normal finding in the majority of lumen of the vagina. Vaginal childbirth is one of the most fre-
vaginally parous women. Swift (3) reported on vaginal exami- quent risk factors associated with prolapse. Labor and vaginal
nation findings of 497 women who presented for their annual delivery results in damage to the pudendal nerve and dis-
Pap and pelvic examination. All women were 18 years of ruption of connective tissue and muscular attachments.
age, with a median parity of two. The incidence of cases in Denonvilliers fascia, which is fused to the inner layer of the
which the leading edge of the most prolapsed segment was posterior vaginal wall, may be torn during vaginal delivery at
1 cm distal to the hymen or beyond was 52% , with only 6% its caudal and lateral attachments to the perineal body.
of women demonstrating no prolapse or perfect support. N onobstetric risk factors associated with PO P include pelvic
Likewise, the Women’s H ealth Initiative hormone replacement surgery, conditions leading to elevated intra-abdominal pressure
clinical trial performed baseline pelvic examinations on (e.g., obesity and chronic constipation with excessive strain-
16,616 women with a uterus (4). They found that 41% of ing), inherited connective tissue disorders (e.g., Ehlers-Danlos
and M arfan syndromes), and genetic predisposition. Though O ne of the possible explanations for the high recurrence rate
menopause is often cited as a risk factor for PO P, several rein prolapse repairs (~30% ) is that concomitant vaginal defects
searchers have failed to find an association with estrogen sta- are not recognized at the time of surgery. Apical prolapse may
tus. Suspension of the anterior vaginal wall for incontinence go unrecognized during the supine examination. We evaluated
procedures such as the Burch urethropexy is also a risk factor the relationship between the anterior, posterior, and apical com-
for apical prolapse. This is most likely due to the change in the partment in 325 consecutive new patients (7). Thirty-nine per-
vaginal axis following the surgical procedure, resulting in ab- cent had a previous hysterectomy and only 3% had a previous
dominal forces being directed over the genital hiatus instead anterior, posterior, or apical repair. The vaginal apex (POP-Q
of the posterior levator ani. point C) strongly correlated with the most prolapsed portion of
The symptoms attributed to PO P are numerous and in- the anterior vaginal wall, Ba (Spearman 0.835, p 0.001),
clude colorectal and urinary symptoms, dyspareunia, pelvic and moderately correlated with the most prolapsed portion of
heaviness, and the protrusion of the vaginal wall beyond the the posterior vaginal wall, Bp (Spearman 0.556, p 0.001).
introitus. Bowel symptoms such as constipation, incomplete O f 113 women who had the leading edge of the posterior vagi-
bowel emptying, straining, splinting to defecate, and anal in- nal wall at the introitus or beyond, a significant amount of con-
continence are common in women and are often attributed to current apical prolapse was present (Fig. 51.1).
posterior vaginal prolapse (5). O f all of these symptoms, the Radiologic imaging may be indicated more for understand-
most reliable predictor of PO P appears to be simply the self- ing the cause of defecatory dysfunction than for diagnosing
reported presence of a palpable bulge at the introitus. Numerous PO P. Defecography involves dynamic evaluation of the pelvic
studies have demonstrated that bowel symptoms do not corre- floor, providing both structural and functional information.
late with the degree of POP or objective measures of anorectal Standardization of the testing and interpretation of defecogra-
function (6); however, these symptoms may improve following phy is not established, however, and therefore it is not recom-
surgical intervention, as we will discuss later. mended for routine clinical use, although it can be helpful in
“ high” rectoceles when an enterocele is suspected. M agnetic
resonance imaging (M RI) has been used to describe the loca-
DIAGNO SIS tion of the defects during PO P, but we do not routinely use it
in our practice.
At our institution, the physical examination of a patient with
suspected POP is initially done with the patient in the standing,
straining position and the physician seated or kneeling. If a bulge ALTERNATIVE THERAPIES
is palpable past the introitus on straining, then we place our fin-
gers in the vagina and determine the extent of the prolapse. Asymptomatic patients or women with minor symptoms may
Following the standing examination, the woman under- report little or no bother as a result of the disorder, and obser-
goes a complete gynecologic examination including bimanual vation or watchful waiting is appropriate. Pelvic floor muscle
examination in the dorsolithotomy position. The pelvic ex- rehabilitation may be offered despite the lack of data support-
amination of the vagina (especially the apical segment) can ing its use to prevent progression.
be facilitated by using the lower blade of a Graves speculum. M echanical support, such as a pessary, can be used to re-
The single blade is placed against the anterior wall and then duce the PO P. Support pessaries are made of silicon or soft
the posterior wall of the vagina during Valsalva, for the eval- plastic and can be offered to women with symptomatic PO P
uation of the opposing wall and apex. Isolated distal protru- who prefer a nonsurgical approach. O ther indications include
sion of the posterior vaginal wall with lack of descent of the women who are poor surgical candidates because of medical
vaginal apex represents an isolated rectocele. O ften the vis- comorbidities, or patients needing temporary relief of
cera behind the vaginal wall cannot be accurately deter- pregnancy-related PO P or incontinence. In most patients, the
mined. For example, prolapse of the posterior vaginal wall pessary can be fitted successfully in one or two office visits.
and apex in a woman who has had a hysterectomy may be Women with symptomatic improvement are taught to place
due to small bowel herniation (enterocele) or a defect in the and remove the pessary at least twice weekly and prior to in-
rectovaginal fascia (rectocele). A bimanual straining recto- tercourse and should return every 6 to 12 months. Women
vaginal examination with a finger simultaneously in the rec- who cannot remove the pessary will leave it in continuously
tum and the thumb in the vagina can help distinguish and return every 3 months for pessary care. They may benefit
rectocele from an enterocele. An enterocele will often fill the from vaginal estrogen cream, unless contraindicated, to re-
space between the two viscera, while a rectocele will result in duce the risk of erosion. If vaginal erosion develops, the pes-
no change in the plane. sary should be removed and vaginal estrogen cream applied
The two most commonly used systems to document the de- until the erosion is healed. The pessary can then be replaced,
gree of prolapse are the Pelvic O rgan Prolapse Q uantification although a reduction in pessary size is advisable. Pessaries
(PO P-Q ) and the Baden-Walker. The PO P-Q consists of nine generally are less effective in supporting the posterior vaginal
measurements and describes the topography of the vagina, wall than in apical and anterior vaginal wall prolapse.
genital hiatus, and perineal body. The anterior, posterior, and
apical compartments are described and the prolapse stage is
based on the compartment that is most prolapsed relative to INDICATIO NS FO R SURGERY
the hymenal remnant. The Baden-Walker grading system is
based on the position of the most protruding part of the Due to the possibility of postoperative dyspareunia, it is be-
vagina relative to the hymen and is usually reported as the lieved that an isolated rectocele should not be repaired unless
prolapse grade. the patient is bothered by symptoms. O ur practice is to refer
15
10
Vaginal cuff or cervix (Point C)
–5
FIGURE 51.1 A scatter plot of the lead-

–10 ing edge of the posterior vaginal wall and
the vaginal apex in 122 women who had
the leading edge of the posterior vaginal
0 2 4 6 8 10 12 wall at the introitus or beyond in a stand-
Most prolapsed position of the posterior vaginal wall (Bp) ing straining exam.
the patient to colorectal surgery or occupational therapy for

defecation disorders prior to undergoing a procedure for Po st e rio r Co lp o rrhap hy
posterior vaginal wall prolapse.
Posterior colporrhaphy is still commonly practiced today by
N umerous factors must be considered when counseling
general gynecologists and urologists. O ur protocol includes
patients about the best surgical treatment:
giving 2 g of cefoxitin intravenously at the start of the procedure.
■ Surgical route Though we find that bowel preparation is often recommended
■ Durability before surgery by our colleagues, this has not been our practice.
■ Recovery time Following the administration of general or spinal anesthe-
■ Immediate and delayed postoperative complications sia, the patient is positioned in the dorsal lithotomy position
with her legs in Yellofin stirrups (Allen M edical Systems).
Care is taken to ensure the neural safety and positioning of all
SURGICAL TECHNIQ UES four extremities. She is prepped and draped in a sterile fashion
and a Foley catheter is inserted.
There are three surgical routes that may be used for rectocele A bimanual examination is performed to reassess the PO P
repair: abdominal, transanal, and transvaginal. Among the and ensure that the surgical procedures chosen are adequate
different surgical routes, the transvaginal approach is the most (Fig. 51.2). A self-retaining vaginal wall retractor such as the
commonly practiced route for the “ noncolorectal” surgeon. Lone Star (Lone Star M edical Products) is placed. Twenty mil-
The abdominal approach is indicated for rare cases when rec- liliters of 1/200,000 epinephrine/saline solution is injected into
tocele is associated and repaired with the rectal prolapse. The the submucosal tissue to aid in the dissection and help with
transanal route was thought to be indicated for cases of small hemostasis. The posterior commissure of the vagina is clamped
distal rectocele. Today, this is less commonly practiced be- approximately 2 to 3 cm from the midline on the right and left
cause of the possible impairment of the anal sphincter as a with Allis clamps. A transverse incision is made in between the
result of its dilatation during the surgery. Although rectocele two Allis forceps. In cases where perinorrhaphy is performed
repair has been practiced for 100 years, the most effective concomitantly, an additional incision is made in the perineum
surgical treatment remains undetermined. to remove a triangular piece of skin, allowing exposure of the
As stated earlier, the position of the vaginal apex or cervix perineal body, as will be discussed in a later section. A vertical
is well correlated to the most prolapsed part of the posterior incision is made in the posterior vaginal mucosa from the mid-
and anterior vaginal walls in women with PO P. When per- dle of the transverse incision reaching the apex of the recto-
forming sacrocolpopexy, the apical segment is resuspended cele, which is held by an Allis clamp in the midline (Fig. 51.3).
and the vaginal axis is adequately restored; the anterior and Using a M etzenbaum scissors the vaginal mucosa is dissected
posterior vaginal walls are also restored to a nonprolapsed po- from the underlying perirectal fascia using a “ snip and push”
sition without additional anterior or posterior repairs (8). technique. O nce an avascular plane is established, an index
The following procedures are indicated for women who finger wrapped with a moist vaginal laparotomy sponge can
have a distal defect of the posterior vaginal wall or who are be used for further dissection, although this technique should
having a concomitant apical suspension. be abandoned if significant tissue resistance is met. It is also
FIGURE 51.2 Rectal examination of a woman with a rectocele. The FIGURE 51.4 The vaginal epithelium overlying the rectocele is dis-
vaginal apex is 6 centimeters proximal to the hymen but the posterior sected off using a “ snip and push” technique with M etzenbaum scis-
vaginal wall distal edge protrudes past the introitus when standing. sors held at a 90˚ to the vaginal epithelium. The excess epithelium is
N otice how by placing the nondominant hand’s third digit in the rec- removed.
tum, the thumb and index finger can still be utilized by the operating
surgeon.
Sit e -Sp e cific Re ct o ce le Re p air

important to do the dissection close to the vaginal wall side to
avoid incising the rectum. The dissection is extended upward The site-specific repair of rectocele was proposed by Richardson
in the midline to well above the bulge of the rectocele (Fig. et al. (9) in 1976. This technique is based on Richardson’s obser-
51.4). At this point it is necessary to obtain sufficient hemo- vations during cadaveric dissection that rectoceles are the result
stasis to identify the anatomic structures. of a specific defect in the rectovaginal fascia.
The surgeon then should insert the nondominant middle The initial steps of this procedure are similar to the classic
finger into the rectum, which allows the thumb and index posterior colporrhaphy. The vaginal epithelium is opened and
finger to be available to the surgeon. The bulge is reduced to dissected from the underlying rectovaginal fascia. A rectal ex-
aid in the identification of the lateral rectovaginal fascia. amination assists in the identification of the edges of the de-
Care is taken not to incorporate the levator ani (levator plica- fect, which are grasped with forceps. The defect is repaired
tion), since this can result in vaginal distortion, constriction, with interrupted 0 polyglactin sutures (Vicryl); they are usu-
postoperative pain, and dyspareunia. The rectovaginal fascia is ally placed cranial to caudal, as opposed to the side-to-side
plicated to the midline using a series of interrupted size 0 placement in a posterior repair. Again, care is taken to avoid
polyglactin sutures (Fig. 51.5) that are initially tagged and then
tied in succession. The distal end of the rectovaginal septum
(imbricated rectovaginal fascia) is then attached to the recon-
structed perineal body (perineorrhaphy) if this is performed.
Any redundant vaginal epithelium that crosses the midline is
excised, and the vaginal epithelium is closed with 3-0 poligle-
caprone 25 (M onocryl) absorbable sutures (Fig. 51.6).
FIGURE 51.3 The proximal end of the rectocele is grasped with an

Allis clamp and the midline and transverse incisions are marked. FIGURE 51.5 The rectovaginal fascia is identified lateral to the recto-
Injection of local anesthetic with epinephrine can help with develop- cele. Absorbable interrupted sutures are placed in the rectovaginal fas-
ing a plane. cia bilateral. The sutures are tagged and then tied down in succession.
represent the lower edges of the reconstructed introitus. Care

must be taken not to overly narrow the introitus especially be-
cause the relaxation of the pelvic floor during anesthesia can
often lead to miscalculations in the resulting introitus. A trian-
gular piece of vaginal epithelium is removed so as not to
damage the underlying superficial transverse perineal muscles
(Fig. 51.8). The bulbocavernosus muscles are plicated with
midline interrupted size 0 polyglactin sutures (Fig. 51.9) and
the epithelium is closed with a running absorbable suture.
Preservation of the size of the genital hiatus is important for
women who wish to remain sexually active.
Po st e rio r Re p air w it h Bio lo g ic and

Synt he t ic Mat e rials
FIGURE 51.6 Examination of the posterior vaginal wall following
the posterior repair.
In an attempt to improve the anatomic cure rates, several vari-
ations have been used for correcting the posterior prolapse.
The use of synthetic or biologic material as reinforcement or
the incorporation of any healthy muscle that could result in replacement of weak fascia was derived originally from gen-
dyspareunia. If indicated, the perineal body is reconstructed. eral surgery and has been advocated in gynecologic surgery.
The vaginal epithelium is closed as previously described. The most widely used biologic materials are human freeze-
dried cadaveric fascia lata, solvent-dehydrated fascia lata
(Tutoplast), porcine dermal graft (Pelvicol), and decellularized
Re co nst ruct io n o f t he Pe rine al Bo d y human cadaveric dermis (Alloderm, Repliform).
Synthetic materials can be classified as absorbable or perma-
The perineal body is located between the vaginal introitus and nent. Their use has increased since they were first described in
the anus, and attached to it are the following structures: bulbo- 1995 for the management of stress urinary incontinence and
cavernosus muscles, superficial transverse perineal muscles, PO P. The most commonly used absorbable synthetic graft is
levator ani muscles, the external anal sphincter, and the recto- polyglactin 910, while polypropylene is commonly used as a
vaginal fascia (Fig. 51.7). Due to its lateral and superior sup- nonabsorbable material. M ost published data on graft mate-
port there is limited downward movement of the perineal rials are related to incontinence surgery and abdominal
body. Rectoceles that recur or are symptomatic with defecatory colpopexy. There is no standardized method to place the graft.
disorders may actually be disorders of exaggerated perineal The graft is placed through the vaginal incision as another layer
descent due to the detachment of the perineal body to the rec- of support after plication of the rectovaginal fascia. Transverse
tovaginal septum. and anteroposterior dimensions of the prolapsed segment are
Reconstruction of the perineal body starts with placement measured. A graft of similar size is placed and secured by de-
of Allis clamps on the lateral edges of the posterior commis- layed absorbable or nonabsorbable 0 sutures. The redundant
sure of the vagina that also grasp the underlying bulbocaver- vaginal mucosa is then excised and the mucosa is closed using
nosus muscles. When brought together in the midline, they an absorbable continuous suture with no tension.
FIGURE 51.7 Inferior view of the pelvic

floor. Superficial perineal muscles and per-
ineal membrane have been removed on the
left to show attachments of the levator ani
(LA) muscles to the distal vagina, anus, and
perineal body.
FIGURE 51.8 Perineorrhapy incision. The perineorrhapy incision is

diamond-shaped and only the epithelium is removed. With a finger in
the rectum, interrupted sutures are placed lateral to medial (1) with
the first pass and then medial to lateral (2) and then tied down.
Po st o p e rat ive Care

In our practice, women who have undergone a repair of a FIGURE 51.10 Following the reconstruction of the perineal body, the
epithelium is closed using a running absorbable suture. The genital
posterior vaginal wall defect are admitted to the hospital hiatus demonstrated has been constructed for a non-sexually active
overnight for pain management and observation. An ice woman.
pack to the perineum every couple hours can reduce postop-
erative edema and pain in women who have had a perineor- trial is performed by a visiting nurse 3 or 4 days later in the
rhaphy. A voiding trial is typically performed the day of patient’s home for those who fail initially. Women are dis-
discharge (most often postoperative day 1). A repeat voiding charged home, to return in 2 weeks, with a bowel regimen
consisting of fiber, stool softeners, and a “ plan” if they have
not had a bowel movement for a couple of days. O ral pain
medications, including anti-inflammatory agents and nar-
cotics, may be prescribed. We instruct all women that they
are limited to no lifting over 10 pounds and “ nothing in the
vagina” for 6 weeks.
O UTCO MES
Re sult s
Despite the fact that transvaginal colporrhaphies have been
the preferred surgical procedure for rectocele repair among
gynecologic surgeons for over 100 years, there are few data
regarding the long-term anatomic success. In different case
series, the anatomic cure rate ranges from 76% to 96% for
posterior and from 56% to 100% for site-specific defects (10).
A recent Cochrane review of surgical management for pro-
lapse reported that transvaginal repair is superior to a
transanal approach for posterior vaginal wall prolapse, with a
lower recurrence rate (RR 0.28; 95% CI, 0.009–0.64) (11).
Posterior colporrhaphy was found to be effective in allevi-
ating symptoms of vaginal bulge (4–64% ), constipation
(22–100% ), and fecal incontinence (4–36% ). Thus, the func-
tional improvement is not always correlated with anatomic
success.
FIGURE 51.9 The perineum after three sutures are placed. The geni- O ver the past 20 years there have been several case series
tal hiatus has decreased in size and the perineal body is reconstructed. reporting on the anatomic success of posterior repair with
Chap t e r 52: Ab d ominal Sacral Colp op e xy 349
graft material, with cure rates ranging from 89% to 100% for Dyspareunia rates of 21% to 27% have been reported fol-
a follow-up period of 3 to 60 months. Variability of the cure lowing posterior repair (12) and are linked to the levator ani
rate can be partially explained by the different definitions and plication that is commonly done. Weber et al. (5) reported
tools used to assess anatomic cure. similar rates without a plication. Rectocele repairs using syn-
thetic mesh may result in both dyspareunia and hispareunia.
H ispareunia or partner dyspareunia is a term we use to de-
Co mp licat io ns scribe the pain resulting from penile exposure to the eroded
mesh during intercourse. The extent of this phenomenon is
The most common immediate complications associated with unknown.
repair of rectocele are injury to the rectum, constipation, According to the literature, the rate of erosion via the vagi-
infection, perirectal hematoma, and inclusion cyst. When the nal route varies from 12% to 30% (13). The true rates of ero-
rectal lumen is inadvertently opened during dissection of the sion may be higher than reported due to the short follow-up in
rectum from the vaginal mucosa, the defect must be closed most studies. The type of mesh used affects erosion rates;
during surgery. The most important factor is recognition at however, no synthetic mesh seems to be completely spared
the time of the injury, as neglected cases may result eventually from this phenomenon.
in rectovaginal fistula. The risk of passing suture through the Typically, women with mesh erosion present with persis-
rectal mucosa is diminished by placing a finger in the rectum tent vaginal discharge or bleeding and possible dyspareunia
at the time of suturing. If a stitch is felt on rectal examination and require transvaginal trimming of the exposed portion of
it should be removed transvaginally, not through the rectum. the mesh. Successful treatment of vaginal mesh erosion with
Constipation should be avoided and is one of the major estrogen cream has been reported (13), but in our experience
threats to the success of the surgery; therefore, the problem is estrogen has not been effective.
best addressed prior to undergoing surgical repair.
References
1. O lsen AL, Smith VJ, Bergstrom JO , et al. Epidemiology of surgically man- 8. Guiahi M , Kenton K, Brubaker L. Sacrocolpopexy without concomitant
aged pelvic organ prolapse and urinary incontinence. O bstet G ynecol posterior repair improves posterior compartment defects. Int Urogynecol J
1997;89:501–506. Pelvic Floor D ysfunct 2008;19(9):1267–1270.
2. Luber KM , Boero S, Choe JY. The demographics of pelvic floor disorders: 9. Richardson AC, Lyon JB, Williams N L. A new look at pelvic relaxation.
current observations and future projections. A m J O bstet G ynecol 2001; A m J O bstet G ynecol 1976;126:568–573.
184:1493–1501. 10. Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele:
3. Swift SE. The distribution of pelvic organ support in a population of focus on associated defecatory and sexual dysfunction. O bstet G ynecol
female subjects seen for routine gynecologic health care. A m J O bstet 2004;104:1403–1421.
G ynecol 2000;183:277–285. 11. M aher C, Baessler K, Glazener CM , et al. Surgical management of pelvic
4. H endrix SL, Clark A, N ygaard I, et al. Pelvic organ prolapse in the organ prolapse in women. Cochrane D atabase Syst R ev 2007:CD004014.
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bowel function. A m J O bstet G ynecol 1998;179:1446–1450. 659–661.
6. Bradley CS, Brown M B, Cundiff GW, et al. Bowel symptoms in women 13. Dwyer PL, O ’Reilly BA. Transvaginal repair of anterior and posterior com-
planning surgery for pelvic organ prolapse. A m J O bstet G ynecol 2006; partment prolapse with ATrium polypropylene mesh. Br J O bstet G ynecol
195:1814–1819. 2004;111:831–836.
7. Rooney K, M ueller E, Kenton K, et al. Isolated anterior vaginal wall re-
pairs is highly correlated with apical prolapse. A m J O bstet G ynecol 2006;
195:1837–1840.
CHAPTER 52 ■ ABDO MINAL SACRAL

CO LPO PEXY
J. CHRISTIAN WINTERS AND SCO TT DELACRO IX, JR.
Pelvic organ prolapse (PO P) is a common yet complex medical descensus of the anterior compartment near the hymenal ring
condition that can significantly impair a woman’s quality of or beyond is associated with VVP. VVP usually occurs as a re-
life. PO P can occur at multiple sites, and therefore the effect sult of multifactorial muscular and connective tissue disorders
of these defects on a woman’s symptoms may vary. O ne of that result in weakening of the supporting structures of
the more complex types of PO P is vaginal vault prolapse the vaginal apex—the cardinal and uterosacral ligaments. In
(VVP), and its incidence is reported to be 18.2% of all women most cases this is accompanied by defects elsewhere on the
with prolapse (1). In fact, many would suggest that any pelvic floor, such as central or lateral cystocele, high or low
rectocele, enterocele, or perineal body laxity. Up to 72% of The pelvic examination begins with the patient in the litho-
patients with VVP have been shown to have other pelvic floor tomy position, utilizing a Valsalva maneuver. If all areas of the
defects in some combination (2). For any patient undergoing pelvic floor can be assessed in this position, the examination is
surgical correction for prolapse, it is paramount to recognize completed. Urethral mobility can almost always be assessed
all potential defects prior to surgery. Undiagnosed and un- visually, but in rare equivocal cases, a cotton-tipped applicator
treated vault prolapse will almost always ensure recurrence of test can be performed. In many cases, it will be difficult to as-
a surgically corrected cystocele (1). It has also been demon- sess low-grade or moderate VVP, especially in posthysterec-
strated that an isolated abdominal repair of VVP without ad- tomy patients without the cervix as an anatomic landmark.
dressing concomitant pelvic floor defects may lead to “ Dimples” at the lateral apex of the vagina can sometimes be
decreased patient satisfaction and the need for secondary vagi- used to locate the cuff. These dimples usually represent the
nal repair. point of attachment of the uterosacral ligaments. The exam-
Finally, there are numerous reports of occult stress urinary iner’s fingers are placed at the vaginal apex. If the fingers de-
incontinence manifesting after vaginal vault prolapse repair scend halfway to the hymeneal ring or further on Valsalva,
(3). There is evidence to support the use of prophylactic anti- significant vault prolapse is present. O nce again in the supine
incontinence procedures at the time of VVP repair in women position, the anterior and posterior compartments are assessed
with occult stress urinary incontinence (3). independently. H alf of a vaginal speculum is initially used to
This chapter will discuss the abdominal sacral colpopexy compress the posterior compartment while the examiner as-
(ASC) for the correction of VVP. O ne must consider incorpo- sesses the anterior compartment for abnormal descent. The
rating ancillary vaginal or anti-incontinence procedures with posterior compartment can then be assessed by replacing the
ASC because an untreated symptomatic secondary defect or speculum to support the anterior vaginal wall. It is important
undiagnosed occult stress urinary incontinence (3) will signifi- to distinguish prolapse high along the posterior vaginal wall
cantly impair overall patient satisfaction. as either a high rectocele or an enterocele. This can be accom-
plished by bimanual rectovaginal examination in the supine or
standing position to detect enterocele. In an enterocele, there
DIAGNO SIS is a defect between the pubocervical fascia and rectovaginal
fascia that allows predominantly small intestine to press
Patients with VVP will often complain of pelvic pressure, vagi- against the vaginal epithelium. If no enterocele sac is palpated
nal protrusion, dyspareunia, difficulty walking, and back between the rectum and vagina (examiner’s fingers), the defect
pain. Bowel and genitourinary symptoms vary from urinary is most likely a high rectocele. The perineal body should pro-
and fecal incontinence to difficult elimination or sexual dys- vide definition between the anterior and posterior perineal tri-
function. Patients with severe prolapse may need to manually angles. Prior episiotomy scars and defects in this area should
reduce the prolapse to evacuate the rectum or void. Women be noted. In equivocal or difficult examinations where the full
with severe prolapse or uterine procidentia may develop recur- extent of the prolapse may not be appreciated, the patient
rent urinary tract infections or hydronephrosis due to angula- can be evaluated while standing. The Pelvic O rgan Prolapse
tion of the ureters. Q uantification (PO P-Q ) can be used as an adjunct to the ex-
A thorough physical examination is needed to establish the amination, particularly when performing serial examinations
diagnosis of VVP and to demonstrate other pelvic floor de- or exchanging data (4).
fects and/or occult stress urinary incontinence. During the Lower urinary tract function should be assessed in all
examination every segment of the pelvic floor should be eval- patients, whether symptomatic or not. As previously noted,
uated in a systematic manner—the anterior vaginal wall, the stress urinary incontinence can be unmasked by correction of
vaginal apex (or cervix), the posterior vaginal wall, and the PO P of any type. After reduction of the PO P by vaginal pack-
perineum (Table 52.1). ing or pessary, a Valsalva stress test with a full bladder is per-
formed in the standing position. Care should be taken not to
TA B LE 5 2 . 1 falsely support and occlude a hypermobile urethra and thus
obtain a false-negative result.
COMPARTMEN T-SPECIFIC DEFECTS AN D FEMALE Urodynamic testing is strongly advised to delineate bladder
PELVIC ORGAN S COMMON LY AFFECTED and urethral function. With the prolapse reduced, the exam-
iner assesses for the presence of stress urinary incontinence.
LOCATION DEFECT
If present, the degree of sphincteric deficiency is quantified us-
Urethra O ccult stress incontinence ing abdominal leak point pressures. In addition, urodynamic
H ypermobility testing allows the examiner to assess the quality of bladder
Anterior vaginal wall Lateral cystocele storage and quantify the contractility of the bladder during
and/or emptying. Women with impaired contractility or those who
central cystocele void by abdominal straining may have more difficulty voiding
Vaginal apex Vaginal vault prolapse after surgery. These women may need counseling regarding
this issue, particularly if an anti-incontinence procedure is per-
Posterior superior vaginal wall Enterocele formed. These voiding dynamics are easily diagnosed with
and/or
urodynamic evaluation. Patients with fecal dysfunction, par-
high rectocele
ticularly incontinence, may be evaluated with additional stud-
Posterior inferior vaginal wall Rectocele ies such as anorectal manometry, transrectal ultrasonography,
Perineum Incompetent perineal body and an electromyographic latency study. An assessment of
sexual function should be performed; one may consider the
use of a validated questionnaire such as the Prolapse and same regardless of approach, and we will describe the open
Incontinence Sexual Q uestionnaire (PISQ -12) (5). technique of ASC. The critical elements of the operation
include:
■ Permanent mesh (type I macroporous, monofilament) as
INDICATIO NS graft material
■ Secure suture fixation of the graft to the sacral promontory
An individualized approach to patients with advanced PO P
and vaginal cuff
should be undertaken after consideration of multiple factors.
■ Complete enterocele reduction and culdoplasty
The surgeon must consider all site-specific defects present as
■ Anti-incontinence procedure as indicated
well as the patient’s urinary, bowel, and sexual function. It is
of paramount importance to determine the most bothersome The patient is positioned in the low lithotomy position,
symptoms for the patient and to highlight the patient’s goals providing both transvaginal and transabdominal access. A
and expectations of treatment. Following this, the patient’s low midline abdominal incision is preferred by the authors
general medical condition and other factors are considered to allow exposure of the sacral promontory. A Pfannenstiel
when deciding on a management plan. incision may also be chosen in younger patients, although
There is no panacea for PO P, as each procedure has advan- exposure may be slightly more difficult. The following is a de-
tages, disadvantages, and risks. ASC should be considered an scription of the operative technique of ASC and abdominal
excellent treatment option in the following cases: failed previ- enterocele repair.
ous vaginal repair; recurrent enterocele and/or VVP; isolated O nce the incision is made and the peritoneal cavity entered,
high-grade apical prolapse and/or enterocele; and a younger it is essential to achieve excellent exposure by freeing all adhe-
woman with an active lifestyle who desires to continue sexual sions in the pelvis and packing the bowel out of the pelvis above
intercourse. the level of the sacral promontory. N ext, an incision is made in
In these patients ASC is an excellent choice because it max- the posterior peritoneum over the sacral promontory, extend-
imizes functional vaginal length and provides a near-normal ing inferiorly along the right lateral aspect of the rectum
vaginal axis. As discussed above, other pelvic floor defects and (Fig. 52.1). Electrocautery is used when dividing the fatty tissue
occult stress urinary incontinence can be addressed at the over the promontory. Diathermy cautery forceps are useful in
same time. this dissection. Excessive blunt dissection is avoided in this area
as shearing of presacral veins with severe bleeding may occur.
Care is taken to avoid the middle sacral vein traversing over the
ALTERNATIVE THERAPY promontory. As the fatty tissue is dissected free, the anterior
surface of the sacral promontory is visualized, usually by iden-
Pessary placement is a nonsurgical option that is often unsatis- tification of the anterior longitudinal ligament.
factory in severe cases of prolapse. In cases of total vaginal Two or three sutures of no. 0 Ethibond (Ethibond Excel
prolapse, pessary placement can be impossible. The need for polyester suture; Ethicon Inc., Johnson & Johnson, Somerville,
daily cleansing, replacement, discomfort, and vaginal erosion N J), using a M O -7 needle, or no. 0 Prolene (polypropylene su-
are some of the disadvantages to long-term pessary placement. ture material; Ethicon Inc.), using a M O -6 needle, are placed
A colpocleisis is a safe and effective alternative treatment into the periosteum over the sacral promontory (Fig. 52.1).
of PO P, especially in elderly patients. It does not preserve nor-
mal anatomy and is an option only in a patient not desiring
future sexual activity.
Vaginal methods of prolapse repair, including unilateral
or bilateral sacrospinous ligament fixation, plication of the
uterosacral ligament (M cCall) with culdoplasty, or iliococ-
cygeus fascial fixation, are also alternatives to abdominal
sacral colpopexy. Sacrospinous ligament fixation will result in
significant changes in the vaginal axis and has a higher inci-
dence of anterior compartment defect recurrence and rectal,
vascular, or neural complications. Plication of the uterosacral
ligament with culdoplasty is difficult in posthysterectomy pa-
tients, with a higher potential for ureteral injury. In addition,
there is concern regarding the functional integrity of the
uterosacral remnant (6). Iliococcygeus fascial fixation will re-
sult in vaginal shortening.
SURGICAL TECHNIQ UE
All patients are administered a mechanical bowel preparation
preoperatively. Thromboembolic elimination stockings and
sequential compression devices are used. O pen, robotic- FIGURE 52.1 Incision of posterior peritoneum extending into pelvis
assisted laparoscopic and pure laparoscopic approaches have lateral to rectum. N ote secure suture placement into the sacral
all been described. The principles of the operation remain the promontory.
FIGURE 52.4 Final graft position. Inset shows different methods of

graft attachment. Long extension of graft secured posteriorly.
FIGURE 52.2 Peritoneum over vaginal cuff incised. N ote: Dissection

is made easier by use of EEA sizer. placed into the enterocele sac to obliterate it (Fig. 52.5). This
will reduce the cul-de-sac and facilitate the culdeplasty.
A H alban culdoplasty is performed by placing linear su-
These sutures are safely secured for later placement into the
tures (2-0 Ethibond) through the posterior peritoneum and on
graft. Alternatively, commercially available tacking devices
the outer surface of rectum up to the vaginal cuff (Fig. 52.6).
may be used for securing the graft to the sacral promontory.
The central sutures are placed through the obliterated entero-
The peritoneum over the vaginal cuff is excised, and the
cele sac to prevent recurrence of enterocele. Upward retraction
peritoneum is dissected off the cuff of the vagina (Fig. 52.2).
of the graft will assist in exposing the cul-de-sac. Usually four
A 2.0-cm-wide segment of graft is sutured to the exposed
to six sutures are used to complete adequate cul-de-sac clo-
vaginal cuff using six sutures of 2-0 Ethibond (Fig. 52.3).
sure. (At this step, the central sutures from the culdoplasty are
M onofilament nonabsorbable mesh is recommended (see
placed through the long arm of the T, if used.)
O utcomes later). The graft is secured to the vagina by folding
Using the preplaced sutures on the sacral promontory, the
over the cuff of the vagina and allowing the long end of the
graft is secured to the promontory. Care must be taken to
graft to exit posteriorly and extend to the sacrum.
avoid excessive tension. Placing the obturator all the way into
Alternatively, a T-shaped configuration of the graft may be
the vagina but not pushing the vagina upward establishes the
created. The short arm of the T is placed on the top of the
proper length of the graft. The graft is placed around the right
vagina, and the long arm of the T is secured to the lower end
lateral aspect of the rectum. A space of two fingerbreadths
of the vagina. The enterocele sutures (Fig. 52.4) are placed
between the graft and the rectum prevents compression of the
into the long arm of the T on the lower side of the vagina.
rectum over the graft (Fig. 52.7). The excessive length of the
After placing an obturator in the vagina (large end-to-end
graft is trimmed after fixation to the sacrum.
anastomosis sizers are useful), the enterocele sac is identified
The graft is positioned in the retroperitoneal space by clos-
and secured with an Allis clamp. If the enterocele is large,
ing the presacral peritoneum over the graft and covering the
several pursestring sutures or linear 2-0 Ethibond sutures are
FIGURE 52.5 Isolation of enterocele from above. If enterocele is

FIGURE 52.3 Intraoperative view: Permanent graft secured to vagi- large, it may be reduced by plicating with pursestring sutures prior to
nal apex. cul-de-sac closure.
FIGURE 52.6 H alban cul-de-plasty: longitudinal sutures placed to close

cul-de-sac.
FIGURE 52.8 Final result. Graft positioned below posterior peritoneum

by closing the previously incised peritoneum over the mesh.
complication rate, minimal morbidity, and a low recurrence

rate. ASC maintains a functional vagina and restores maximal
vaginal length and support by securing the vaginal apex to the
periosteum of the sacrum (7). In a comparative study, the vagi-
nal length was longer after ASC compared to sacrospinous
fixation (7). The abdominal approach allows excellent expo-
sure to the pelvis and allows complete obliteration of the
pouch of Douglass (H alban culdoplasty).
A nonabsorbable monofilament synthetic mesh should be
used for fixation during the ASC. In a study by Culligan et al.
(8), patients undergoing ASC using either absorbable cadav-
eric fascia lata graft (Tutoplast) or nonabsorbable monofila-
ment polypropylene were randomized. The objective failure
rate for recurrence at any other vaginal site was 14 out of 44
in the fascial group and 4 out of 45 in the mesh group (RR
3.58, 95% CI 1.28–10.03) (9).
There are numerous reports by multiple authors that con-
firm the success of ASC. Success rates 90% have been re-
ported and the durability of this procedure has also been
documented (10–12). There are several randomized, prospec-
tive trials comparing sacrospinous ligament fixation (SSLF)
with abdominal sacral colpopexy (13). In a comparative study
FIGURE 52.7 Intraoperative view: graft in final position. N ote mini- between ASC versus vaginal repair, Benson et al. (11) reported
mal tension placed on graft material. Incised peritoneum will be a lower success rate with vaginal repair and an equivalent hos-
closed over graft after securing graft.
pital stay between the two groups. Lo and Wang (12) reported
on their results of ASC versus SSLF at a duration of 2.1 years:
graft on the vagina with the superior edge of the peritoneum 94.2% success with ASC compared to 80% with SSLF. M aher
over the vagina (Fig. 52.8). Stress incontinence procedures (if et al. (10) reported on a comparative study between ASC and
indicated) are then performed. The patient is then examined SSLF. At 2 years of follow-up, symptoms and anatomic suc-
to determine if any ancillary prolapse repairs are needed. cess were equivalent, but asymptomatic failures to introitus
and recurrent cystoceles were less after ASC. O verall, vaginal
procedures have a higher rate of recurrent anterior defects
O UTCO MES even when performed in the setting of a concomitant anterior
repair (colporrhaphy).
Re sult s The assessment, determination, and treatment (if present)
of occult stress urinary incontinence should be the standard by
In the indicated patient, the goal of pelvic reconstruction is to which patients with significant PO P warranting surgical cor-
preserve vaginal depth and normal vaginal axis while repair- rection are addressed. Brubaker et al. (3) reported the impor-
ing PO P. This should be done through a procedure with a low tance of performing simultaneous Burch culposuspension in
women undergoing ASC. In a prospective, controlled trial, (3.1% ), enterotomy (1.6% ), and ureteral injury (1.0% ).
23.8% of women who underwent Burch procedures at the Postoperative complications included urinary tract infection
time of ASC reported bothersome stress urinary incontinence (10.9% ), wound infection (4.6% ), ileus (3.6% ), deep venous
compared to 44.1% of women who underwent ASC alone. thrombosis or pulmonary embolism (3.3% ), and small bowel
These findings occurred in women regardless of the presence obstruction (1.1% ). The risk of significant bleeding has been
or absence of occult stress urinary incontinence. This study reported from 1.6% to 4.4% and may be controlled with the
clearly demonstrates that women undergoing ASC are at sig- use of stainless steel thumbtacks (14). Significant hemorrhage
nificant risk for developing stress urinary incontinence post- can occur from disruption of the presacral vessels. This com-
operatively, even in the absence of preoperative symptoms. plication may be reduced when fixation of the graft is per-
The implications of these findings should be discussed with formed high on the sacral promontory. M esh erosion into the
patients in advance of surgery. H owever, some patients may sigmoid colon has been reported (15) and is avoided by metic-
have significant obstructive voiding symptoms and no evi- ulous placement of the mesh while ensuring an adequate space
dence of stress urinary incontinence on preoperative evalua- between it and the sigmoid colon. Erosions are heralded by
tion. A selective approach may be warranted in these patients, persistent pain, discharge, irritative voiding symptoms, or in-
with the caveat that a midurethral sling can be placed at a fections, and clinicians must be vigilant in follow-up (16). In a
later date with minimal difficulty. In patients who have symp- recently reported meta-analysis, the rate of mesh erosion into
tomatic or occult stress urinary incontinence, the authors pre- the vagina was reported at 3.4% to 5.4% ; the rate may vary
fer midurethral sling placement at the time of ASC, due to the depending on the type of mesh used (13,17). Erosions are
common coexistence of intrinsic sphincter deficiency. more prevalent with Teflon or Gore-Tex type of materials and
O ther advantages of ASC include consistent anatomy that are rare with macroporous, monofilament meshes. The inci-
is less reliant on deficient pelvic connective tissue, the ability dence of mesh erosion is increased when performing a sacral
to perform the most definitive enterocele repair via abdominal colpoperineopexy (15). Concurrent hysterectomy has a theo-
culdoplasty, and the fact that urologists are comfortable with retical risk of increasing infection or erosion of the graft, given
pelvic surgery. The ASC is a procedure that should be easily the chance of contamination from vaginal microbes; however,
incorporated into the surgical repertoire of urologists, provid- current evidence is contradictory, and no randomized trials
ing excellent correction of VVP. have addressed this issue (13). In 60 patients undergoing con-
comitant hysterectomy using a two-layer closure of the vagi-
nal cuff followed by ASC with synthetic nonabsorbable
Co mp licat io ns monofilament mesh, the erosion rate was 0.8% compared to
0% in the 64 patients with a prior hysterectomy (18). In
Complications can be divided into intraoperative complica- patients undergoing a combined operation, supracervical hys-
tions and postoperative complications. In a comprehensive re- terectomy or a meticulous two-layer imbricated closure of the
view by N ygaard et al. (13), intraoperative complications vaginal cuff can be performed to reduce the risk of mesh ero-
included hemorrhage or transfusion (4.4% ), cystotomy sion at the vaginal cuff.
References
1. Winters J, Cespedes R, Vanlangendonk R. Abdominal sacral colpopexy 10. M aher CF, Q atawneh AM , Dwyer PL, et al. Abdominal sacrocolpopexy or
and abdominal enterocele repair in the management of vaginal vault pro- vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective
lapse. Urology 2000;56:55–63. randomized study. A m J O bstet G ynecol 2004;190:20–26.
2. Richter K. M assive eversion of the vagina: pathogenesis, diagnosis and 11. Benson JT, Lucente V, M cClellan E. Vaginal versus abdominal reconstruc-
therapy of the true prolapse of the vaginal stump. Clin O bstet G ynecol tive surgery for the treatment of pelvic support defects: a prospective ran-
1982;25:897–912. domized study with long-term outcome evaluation. A m J O bstet G ynecol
3. Brubaker L, Cundiff G, Weber A, et al. Abdominal sacral colpopexy 1996;175:1418–1422.
with Burch colposuspension to reduce stress urinary incontinence. N Engl 12. Lo T-S, Wang AC. Abdominal colposacropexy and sacrospinous ligament
J M ed 2006;354:1557–1566. suspension for severe uterovaginal prolapse: a comparison. J G ynecol Surg
4. Bump RC, M attiasson A, Bo K, et al. The standardization of terminology 1998;14:59–64.
of female pelvic organ prolapse and pelvic floor dysfunction. A m J O bstet 13. N ygaard I, M cCreery R, Brubaker L, et al. Abdominal sacral colpopexy: a
G ynecol 1996;175:10–17. comprehensive review. O bstet G ynecol 2004;104:805–823.
5. Rogers RG, Coates KW, Kammerer-Doak D, et al. A short form of the 14. Timmons M C, Kohler M F, Addison WA. Thumbtack use for control of
Pelvic Organ Prolapse/Urinary Incontinence Sexual Q uestionnaire (PISQ-12). presacral bleeding with description of an instrument for thumbtack appli-
Int Urogynecol J 2003;14(3):164–168. cation. O bstet G ynecol 1991;78:313–315.
6. Cole EE, Leu PB, Gomelsky A, et al. H istopathological evaluation of the 15. Rose S, Bunten CE, Geisler JP, et al. Polypropylene mesh erosion into the
uterosacral ligament: is this a dependable structure for pelvic reconstruc- bowel and vagina after abdominal sacral colpopexy. J Pelvic M ed Surg
tion? BJU Int 2006;97(2):345–348. 2006;12(1):45–47.
7. Given FT. Vaginal length and sexual function after colpopexy for complete 16. Karlovsky M , Thakre A, Badlani G, et al. Biomaterial for pelvic floor
uterovaginal eversion. A m J O bstet G ynecol 1993;169:284–287. reconstruction. Urology 2005;66:469–475.
8. Culligan PJ, M urphy M , Blackwell L, et al. Long-term success of abdomi- 17. Wu JM , Wells EC, H undley AF, et al. M esh erosion in abdominal sacral
nal sacral colpopexy using synthetic mesh. A m J O bstet G ynecol 2002; colpopexy with and without concomitant hysterectomy. A m J O bstet
187(6):1473–1482. G ynecol 2006;194(5):1418–1422.
9. M aher C, Baessler K, Glazener CM , et al. Surgical management of pelvic 18. Brizzolara S, Pillai-Allen A. Risk of mesh erosion with sacral colpopexy
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(O nline) 2007;3:CD004014.
SECTIO N V ■ VAS DEFERENS, SEMINAL
VESICLE, TESTIS
MARC GO LDSTEIN
CHAPTER 53 ■ ANATO MY O F THE EPIDIDYMIS,

VAS DEFERENS, AND SEMINAL VESICLE
HO WARD H. KIM AND MARC GO LDSTEIN
The formation of a spermatozoan from precursor cells does suited for nurturing and educating sperm also make it vul-
not signify its readiness to fertilize an oocyte. It must travel a nerable to injury and malfunction; imagine how easily the
vast distance and learn fundamentals such as swimming be- elongated single duct of the epididymis is injured or blocked.
fore debuting in the world and laying claim to its female The components of the excurrent ductal system (Fig. 53.1)
counterpart. Fortunately, the excurrent ductal system of the can be organized into a logical order, the epic journey of a
male reproductive tract provides specialized facilities for this spermatozoan from its origin at the germinal epithelium to its
journey, as a nursery, dormitory, finishing school, and test track. dramatic exit at the ejaculatory duct with assorted encounters
The anatomic features that make this system so exquisitely in between.
FIGURE 53.1 A: Front overview of the male excurrent ductal system. B: Side overview.
355
356 Se ct io n V: Vas De fe re ns, Se minal Ve sicle , Te stis
mesonephric tubules degenerate along with the mesonephros,

EPIDIDYMIS except the vasa efferentia, which become highly convoluted
tubules (11). In humans, the epididymis is well developed by
Physical Examinat io n 16 weeks of gestation, and secretory activity of the epididymal
cells has been observed by 25 weeks of gestation (12).
Careful assessment of the epididymides during the physical ex-
amination of an infertile patient is as important as the testicu-
lar evaluation. The consistency of the epididymis can help Anat o my
differentiate obstructive from nonobstructive causes of
azoospermia. A large and turgid feel to the epididymis implies The epididymis is a single tubule 6 to 7 m in length with the
obstruction of sperm outflow, whereas a small and flaccid cauda forming half of the length (Fig. 53.2); the long distance
epididymis indicates a likely problem of spermatogenesis. provides gametes both time and resources to mature during
Tenderness to palpation can indicate the presence of inflam- their travel down the tract (32,34). The rete testis gives rise to
mation or infection. Palpation of a cystic structure originating 8 to 12 ductuli efferentes that penetrate the tunica albuginea
from the epididymis indicates the presence of a spermatocele; and form the lobules that comprise the caput of the epi-
aspiration of the cyst fluid revealing sperm confirms the diag- didymis (34). Anatomically, the epididymis is divided in three
nosis. In patients presenting with acute scrotal pain, the pres- parts, the caput (head), the corpus (body), and the cauda
ence of a paratesticular or epididymal nodule or “ blue dot” (tail). M ore specifically, the epididymis is composed of the ter-
and absence of testicular pain help to distinguish testicular minal part of the ductuli efferentes, the ductus epididymis,
torsion from torsion of the testicular appendages. and the initial portion of the vas deferens (34). Each segment
of the epididymis features the characteristic size and shape of
the ducts, epithelial lining, contractile elements, innervation,
De ve lo p me nt and vascularization (34).
The luminal shape on transverse section of the epididymis
The epididymis develops from the portion of the mesonephric varies from the irregular stellate shape in the ductuli efferentes
duct that was directly associated with the mesonephros; all to the regular, round, or oval shape in the ductus epididymis to
FIGURE 53.2 Epididymis and vas deferens.

Chap t e r 53: Anatomy of the Ep id id ymis, Vas De fe re ns, and Se minal Ve sicle 357
the wide irregularity of the cauda epididymis (34). The duct blood supply, the epididymis is generally independent of the
constricts at the caudal section before it widens considerably testicular vascular network, and there is little direct hormonal
(34). The luminal shape and size reflect the different function of exchange by this route, although the direct linkage of the lym-
each segment as well as the different cellular components con- phatic drainage of the testis and epididymis allows for passage
tained within. The epithelium of the ductuli efferentes is pris- of testicular hormones into the epididymis (7). The capillary
matic; at least two cell types, some with cilia and others with network of the epididymis is much more extensive than that of
microvilli, are gathered according to size in a single layer with the testis, with the density of microvessels reflecting the con-
their apical poles joined by junctional complexes (34). As vari- centration and demands of the specialized epithelial cells (7).
ant cell morphologies may reflect adaptations of the same cell,
different investigators report different numbers of cell types. Inne rvat io n
The epithelium of the ductus epididymis is a prismatic pseudo- Sympathetic nerve endings are concentrated in the corpus and
stratified type with basal and chief cells, among other cell types cauda of the epididymis with progressive density approaching
(34). The epithelial transition from the cauda to the initial por- the vas deferens, consistent with their contractile role during
tion of the vas deferens is progressive, without striking changes ejaculation (34). In the ductuli efferentes and proximal epi-
in the cellular organization (34). The sheath enclosing the en- didymis, the sympathetic nerves form a loose peritubular
tire epididymis contains a continuous layer of contractile cells, plexus without penetrating between the cells (34). The distal
organized circularly or in a light spiral, with rare longitudinal portion of the epididymis demonstrates intermittent contrac-
bundles outside the circular layers (34). In the cauda, the con- tions during ejaculation, in contrast to the peristaltic activity
tractile cells are replaced by smooth muscle cells forming three of the proximal epididymis (34). M ean transit time of sperm
layers, inner and outer longitudinal and intermediate circular, in the epididymis of humans is 12 days (26).
that thicken and continue into the vas deferens (34).
The delicate structure of the epididymis makes it vulnera-
ble to iatrogenic injury. The epididymis may be violated dur- Funct io n
ing procedures such as hydrocelectomy, spermatocelectomy,
and orchiopexy, especially if the epididymis is adherent to the In addition to the transport of spermatozoa with smooth mus-
tunica vaginalis. Furthermore, unlike vascular injuries, which cle contractions, the epididymis stores and facilitates matura-
declare themselves immediately with hematoma or ecchymosis tion of the spermatozoa. Fluid resorption at the caput
formation, epididymal injury may not be evident until the epididymis concentrates sperm by 20-fold (9). Turner et al.
patient later presents for fertility evaluation. H opps and (33) hypothesized that the dilution of epididymal fluid on
Goldstein (16) reported the restoration of spermatozoa in the ejaculation along with the addition of electrolytes promote
ejaculate in five of six patients following microsurgical repair sperm motility. Acott et al. (1,4) presented evidence that
of iatrogenic epididymal injury from hydrocelectomy. sperm motility may depend on changes in intrasperm cyclic
Blockage of the epididymis is not limited to iatrogenic injuries; adenosine monophosphate (cAM P) levels and the binding of a
trauma, infection, inflammation, and even blockage of the vas forward motility protein of epididymal origin. The epididymis
deferens (i.e., vasectomy) and subsequent increase in intralu- also synthesizes and secretes proteins thought to be involved
minal pressure can result in epididymal obstruction. in the development of motility and fertilizing capacity (18).
Studies in rats have demonstrated reconstruction of mem-
Blo o d Sup p ly brane glycoproteins of spermatozoa resulting from interactions
The epididymis is supplied by the spermatic and funicular vas- with epididymal secretory proteins as part of the maturation
cular pedicles (7). An intra-abdominal branch of the spermatic process (5). The maturation process within the epididymis is
artery divides to feed the corpus, and an inguinal branch di- dependent on androgens. In a study of the rat epididymis,
vides to feed the caput (7). The funicular pedicle consists of castration resulted in changes in the ultrastructural organiza-
the deferential artery, which is a branch of the internal iliac tion of the epididymal epithelium and inhibition of secretory
artery or from a branch of the internal iliac artery, usually the function (22). Fertilization with spermatozoa from the caput
superior vesical artery, and runs along the vas deferens onto epididymis is possible, however. Silber (30) performed vasoe-
the cauda; and the funicular artery, which starts at the vesicu- pididymostomy in 51 patients with blockage at the caput epi-
lar artery and supplies the vas deferens and the cauda; the didymis; pregnancy rates with spermatozoa from the proximal
funicular artery is thought to be the most important contribu- and distal caput were 33% and 50% , respectively.
tion to the main muscular epithelium of the cauda (7). Just as
the hypogastric artery is now referred to as the internal iliac
artery, the funicular vessel has fallen out of favor and is rarely VAS DEFERENS
referenced outside of historical anatomy texts. A more recent
description of epididymal blood supply attributes the testicu- Physical Examinat io n
lar (internal spermatic) artery as the source of the superior epi-
didymal artery of the globus major of the epididymis and the The most important aspect of the physical examination of the
cremasteric artery as the origin of the inferior epididymal vasa deferentia is to simply confirm their presence (Fig. 53.3).
artery of the globus minor of the epididymis (17). About 95% of men with cystic fibrosis have congenital bilat-
In humans, the testicular vascular and epididymal vascular eral absence of the vasa deferentia (CBAVD) (6). As over 70%
systems form anastomoses (7); this redundancy is helpful to mi- of men with CBAVD have mutations in at least one allele of the
crosurgeons performing vasectomy reversals and other scrotal cystic fibrosis transmembrane conductance regulator (CFTR)
procedures that can potentially interrupt blood supply to the gene detectable by routine testing methods, couples with
testis or epididymis. Despite this contact with the testicular CBAVD wanting to conceive should undergo genetic testing (6).
It is composed of three layers: mucosa, musculosa, and ad-

ventitia. The mucosa (60 m thickness) is lined by a tall
columnar epithelium containing chief cells, dark or pencil cells,
mitochondrion-rich cells, and basal cells (35). The muscular
layer forms 80% of the wall thickness, and the component
large smooth muscle cells are arranged in an outer and inner
longitudinal orientation with a thick middle circular or spiral
layer (35). The adventitia contains blood vessels and nerves (35).
The vas deferens is vulnerable to injury, especially in its
course through the inguinal canal. Inguinal hernia repair in
both adults and children is an important cause of vasal obstruc-
tion. In adults, the vas deferens can become entangled in the
synthetic mesh of the hernia repair. In children, the vas deferens
can be ligated inadvertently with the hernia sac. The vas is only
1 mm in external diameter before puberty and 2 mm after mid-
puberty (24). In a report by Sheynkin et al. (29), 7.2% of 472
men surgically explored for obstructive azoospermia had an ia-
trogenic injury to the vas deferens. Twenty patients had under-
gone pediatric inguinal hernia repair, and 10 patients had
undergone adult inguinal hernia repair, the two most common
etiologies of vasal injury. O verall, vasal injury was secondary to
bilateral inguinal hernia repair in 19 patients, to unilateral in-
guinal hernia repair in 11, to renal transplantation in 2, to ap-
pendectomy in 1, and to spermatocelectomy in 1 (29).
FIGURE 53.3 Palpation of the vas deferens on physical examination.
(From Goldstein M . Surgical management of male infertility and
other scrotal disorders. In: Cam pbell’s urology, 8th ed. Philadelphia:
Blo o d Sup p ly
WB Saunders, 2002:1532–1587, with permission.) The blood supply to the vas deferens is derived from the defer-
ential artery, which originates from the internal iliac artery
(28). The vas deferens features two distinct vascular networks:
In addition, abdominal ultrasonography should be performed the larger vessels of the adventitia provide branches that pene-
to assess the man for associated renal anomalies. Schlegel et trate the musculosa centripetally to the lamina propria, where
al. (27) reported 26% of men with unilateral congenital a dense capillary network resides in the subepithelium (28). In
absence of the vas deferens and 11% of men with CBAVD to rat studies, a distinct subepithelial sinusoidal network is seen,
have renal agenesis. Scrotal ultrasonography is helpful in and the sinusoidal network is thought to function during ejac-
detecting other urogenital anomalies, such as contralateral ulation in increasing intraluminal pressure (14,23,28,31). The
ejaculatory duct and epididymal or vasal obstruction in men deferential artery is surrounded by a dense adrenergic net-
with unilateral congenital absence of the vas deferens (13). work, and it contracts and relaxes in response to different ag-
onists, demonstrating that it plays an active role in regulating
the vasal blood supply (21). Venous drainage occurs via the
De ve lo p me nt deferential vein, which travels along the vas deferens to empty
into the hypogastric vein (28).
The vas deferens is formed by the portion of the mesonephric
duct from the mesonephros to the urogenital sinus (11). The Inne rvat io n
vas deferens is taken along with the testis during its descent
The high density of the adrenergic nerve endings of the distal
and inguinal passage; the vas deferens is progressively
epididymis continues into the three layers of the vas deferens
stretched during this process (11).
(28), although it has been noted that adrenergic innervation in
humans is less extensive than in other species (2). Cholinergic
neurons have also been demonstrated in the vas deferens (28).
Anat o my
The vas deferens stretches about 45 cm in length as it travels
from the cauda epididymis through the inguinal canal to join SEMINAL VESICLE
the seminal vesicle behind the bladder and form the ejacula-
tory duct that empties into the prostatic urethra (35). The lu- Physical Examinat io n
men of the scrotal portion averages about 330 m in diameter.
Two distinct histologies divide the vas deferens into the vasal Palpation of the seminal vesicles provides important informa-
portion, comprising the proximal 40 cm of length, and the tion for urologic specialists in oncology or fertility. Ideally, the
ampullary portion, comprising the distal 5 cm (35). The cylin- former group uses the digital rectal examination of the seminal
drical vasal portion is 2 to 4 mm in diameter and resembles vesicles to feel for their involvement in prostate cancer and the
the cauda epididymis (35). In contrast, the ampulla is dilated latter group to collect evidence for ejaculatory duct obstruc-
and fusiform and resembles the seminal vesicle (35). tion in men with azoospermia and low-volume ejaculate.
The thick, muscular wall ( 1 mm thickness) of the vas In reality, unless the examiner is blessed with long, slender
deferens contrasts with its narrow lumen (0.5 mm) (35). digits, the seminal vesicles are difficult to reach for adequate
Chap t e r 53: Anatomy of the Ep id id ymis, Vas De fe re ns, and Se minal Ve sicle 359
palpation. Although transrectal ultrasonography cannot sub-

stitute for the tactile assessment of cancer, infertility specialists
fortunately can use this noninvasive test to help diagnose ejac-
ulatory duct obstruction when the seminal vesicles elude the
reach of their index fingers. Seminal vesicle dilatation 1.5
cm and other signs, including dilatation of the ejaculatory
duct, calcifications within the duct, and the presence of mid-
line cysts on transrectal ultrasonography, suggest the diagno-
sis of ejaculatory duct obstruction. H owever, transrectal
ultrasonography is less accurate than the traditional diagnos-
tic combination of testicular biopsy and vasography (Fig.
53.4).
De ve lo p me nt
The caudal end of the Wolffian duct develops into the seminal
vesicle, first as a dilatation, then as an evagination (15).
This simple tube branches into a lobular structure during its
development, organizing into ducts draining into a principal FIGURE 53.4 Left vasogram demonstrating contrast in the vas defer-
ens, seminal vesicle, and bladder, indicating patency of the left excur-
excretory duct (15). The few differentiated cuboidal cells that rent ductal system. Residual contrast seen in right seminal vesicle
line the Wolffian duct during fetal life undergo several modifi- from previously performed right vasogram.
cations with the production of androgens by the fetal testis
and are eventually replaced at puberty by a glandular epithe-
lium (15). In humans, the seminal vesicles are relatively undif- three layers of the seminal vesicle wall include villous mucosa,
ferentiated during infancy and adolescence and develop their smooth muscle, and external sheath (10). The mucosa consists of
secretory activity between 16 and 18 years of age (3,15). a pseudo-stratified epithelium containing granular columnar
cells and ovoid basal cells resting on a basement membrane sur-
rounded by loose connective tissue replete with elastic fibers
Anat o my (10). The histology of the seminal vesicle is identical to that of the
ampulla of the vas deferens (10). The epithelium is composed of
The seminal vesicles (Fig. 53.5) are exocrine glands that empty principal secretory cells, basal cells, and duct cells, which are
into the ejaculatory ducts (Fig. 53.6). They enrich the sperm with considered variants of principal cells (3,10). The principal cells
proteins, enzymes, fructose, and other substances, contributing metabolize the secretory components of seminal vesicle plasma
46% to 80% of the total ejaculate volume (20). As such, the sem- and are dependent on androgens and other hormones such as
inal vesicles are designed to optimize their secretory function. The prolactin for growth and activation (10).
FIGURE 53.5 Seminal vesicles, posterior view.

FIGURE 53.6 Ejaculatory ducts. (Adapted from Goldstein

M . Surgical management of male infertility and other scrotal
disorders. In: Cam pbell’s urology, 8th ed. Philadelphia: WB
Saunders, 2002:1532–1587.)
Blo o d Sup p ly
Bulb o ure t hral (Co w p e r) Gland s and
The seminal vesicle receives its blood supply from the inter-
nal iliac artery via the vesiculodeferential artery (28). Venous
Ure t hral Gland s
outflow is provided by the prostatic plexus and the inferior
Bulbourethral glands are paired multilobular glands that are
vesical plexus, which in turn drain into the internal iliac
located at the penile bulb and empty into the urethra (28). A
vein (28).
fibroelastic capsule and a thick striated compressor muscle
surround a network of elastic and muscle fibers separated by
connective tissue septa (28). A single layer of cuboidal or
Funct io n squamous cells lines the ducts, while mucuslike cells line the
glandular alveoli (25,28). The bulbourethral glands receive
The seminal plasma, composed of fluid from the seminal vesi-
their blood supply from the artery to the bulb of the penis as
cles, prostate, and accessory glands, contains a wide range of
well as the internal pudendal artery, the urethral artery, the
substances, including inorganic ions, low-molecular-weight
perineal artery, and the anastomosis of the cystic inferior and
organic molecules such as citrate, reducing sugars, amino
internal pudendal arteries (19,28). M otor nerves control the
acids, and prostaglandins (28). Using a rat model system,
smooth muscle contraction, vascular tone, and secretory activ-
Clavert et al. (8) examined the role of the seminal vesicle fluid
ity of the accessory glands (28). Primary innervation of the
on fertility. They concluded that seminal plasma prevents ag-
smooth muscle of the accessory glands is provided by adrener-
glutination of sperm, stabilizes the sperm cytoplasmic mem-
gic fibers arising from the ipsilateral pelvic plexus (28). The
brane, coats antigens on the sperm surface, forms a coagulum
vasculature is innervated by a separate system of nerves travel-
to prevent loss of deposited sperm, and in the female genital
ing with the blood vessels (28). Urethral glands or the glands
tract stimulates smooth muscle activity and inhibits lympho-
of Littre open into the urethra and, similar to bulbourethral
cytic reactions (8).
glands, secrete mucus during intercourse.
ACCESSO RY GLANDS SUMMARY

Pro st at e The anatomic features of the epididymis, vas deferens, and
seminal vesicle reflect their function. An understanding of the
Although an important organ of the male reproductive tract, anatomy of the excurrent ductal system facilitates the diagnos-
the prostate is featured in its own chapters and will not be re- tic workup and physical examination as well as the surgical
viewed here. management of male fertility disorders.
Chap t e r 54: Se minal Ve sicle and Ejaculatory Duct Surg e ry 361
References
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247–252. Totowa, N .J.: H umana Press, 2005;71–93.
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Bull 1982;9:673–677. synthesis in the rat epididymis. Characterization of androgen-dependent
3. Aumüller G. Prostate gland and sem inal vesicles. Berlin: Springer, 1979. and testicular fluid-dependent proteins. Biochem J 1980;188:667–676.
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1983;96:256–264. 21. M edina P, Chuan P, N oguera R, et al. Reactivity of human deferential
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1995;332:1475–1480. structure of different epithelial cells in the rat epididymis. A nat R ec
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1985:80–94. mission electron microscopy and scanning electron microscopy study. J
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1981:67–79. 27. Schlegel PN , Shin D, Goldstein M . Urogenital anomalies in men with con-
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CHAPTER 54 ■ SEMINAL VESICLE AND

EJACULATO RY DUCT SURGERY
JAY I. SANDLO W
the pelvic nerve and the hypogastric nerve. The hypogastric

SEMINAL VESICLE SURGERY nerve sends both adrenergic and cholinergic fibers to the seminal
vesicles. Lymphatic drainage is via the internal iliac nodes (1).
The seminal vesicles are paired male organs with no female Primary pathology within the seminal vesicles is rare; sec-
homologue. They develop as a dorsolateral bulbous swelling ondary lesions are more common. In the past, insufficient
of the distal mesonephric duct at approximately 12 fetal imaging methods led to infrequent definition of either primary
weeks. The blood supply to the seminal vesicle is from the or secondary seminal vesicle pathology. The use of transrectal
vesiculodeferential artery, a branch of the umbilical artery. ultrasonography (TRUS), computerized tomography (CT),
Venous drainage is from the vesiculodeferential veins and the and magnetic resonance imaging (M RI) has improved diag-
inferior vesical plexus. The seminal vesicles are innervated by nostic visibility and facilitated the diagnosis and treatment of
seminal vesicle pathology. The necessity of surgical interven- If a solid lesion identified in the seminal vesicle shows no
tion is rare, but indications include congenital cysts with infec- evidence of local spread and is benign on biopsy, treatment is
tion and/or obstruction causing infertility, ureteral ectopy into dependent on symptoms. If the patient is asymptomatic, close
a seminal vesicle with resultant obstruction or dysplasia of the follow-up consisting of repeat rectal examination and TRUS
ipsilateral kidney, and primary tumors, either benign or malig- to determine subsequent growth of the tumor is reasonable. If
nant. Surgical access to the seminal vesicles is mostly via the mass enlarges or if the patient has symptoms referable to
routes familiar to the urologic surgeon, but surgery on the the mass, simple seminal vesiculectomy is advisable. This may
seminal vesicles alone (without adjacent organ removal) is a be accomplished through one of several routes described
unique challenge. below. If the mass is quite large and solid and demonstrates
questionable margins, or if the biopsy shows malignant cells,
the treatment of choice is quite different. Because fewer than
10 cases of primary tumors of the seminal vesicles have been
Diag no sis treated at any one institution, it is difficult to define optimal
The normal seminal vesicle on TRUS is an elongated, flat, treatment with any degree of certainty. Radical excision,
paired structure between the rectum and the bladder just supe- which usually includes a cystoprostatectomy with pelvic lym-
rior to the prostate and is typically not palpable on digital rec- phadenectomy, is the treatment of choice unless the tumor is
tal examination. The diagnosis of seminal vesicle neoplasms extremely small. This recommendation is based on the exten-
can be difficult because they often do not cause symptoms sive nature of the majority of the cancers when detected. The
until late in their course. General symptoms that may occur excision may include the rectum (total pelvic exenteration) if
include urinary retention, dysuria, hematuria, or hematosper- it is thought to be invading the surrounding structures.
mia. A mass is often palpable above the prostate and is usually Adjuvant therapy has no proven efficacy, although the only
not tender. TRUS is usually the next step in diagnosis and may long-term survivors in the literature received radical surgery
be accompanied by needle aspiration or biopsy for diagnosis. with subsequent pelvic radiation therapy or androgen depriva-
CT or M RI would then be appropriate to stage the patient and tion therapy. N o chemotherapeutic regimen is known to be
may also be used to stage solid lesions within the pelvis, as efficacious.
well as to confirm the hemorrhagic nature of suspicious
masses. Because prostate cancer may be mistaken for primary
seminal vesicle cancer, serum prostate-specific antigen (PSA), Surg e ry
as well as tissue immunohistochemical stains for PSA, should,
if positive, help define the prostate as the site of primary ma- The most useful open surgical methods include transperineal,
lignancy. In infertile patients who present with azoospermia, similar to radical perineal prostatectomy; transvesical,
or in patients with hematospermia or coital pain, TRUS is the achieved by incising through the posterior bladder wall; par-
initial imaging study. Contrast vasography accurately images avesical; retrovesical; or transcoccygeal. O ver the past decade,
the vas deferens and ampullary–seminal vesicle junction but is the laparoscopic or robotically assisted approaches to benign
less reliable than TRUS for seminal vesicle pathology. seminal vesicle lesions have been found to be remarkably di-
rect and associated with much less postoperative morbidity
than the open surgical approach (2). The choice of surgical ap-
proach, of course, depends partly on the characteristics of the
Alt e rnat ive The rap y lesion to be treated but probably more on the experience and
There are relatively few alternatives to treatment of seminal expertise of the surgeon. For the most part, congenital lesions
vesicle masses, unless they are infected. Antibiotics may be uti- require an abdominal approach so that the ipsilateral kidney
lized in this case. M any of the benign masses are asympto- can be dealt with concomitantly, if necessary. Such lesions may
matic and may be observed. Ejaculatory duct obstruction can be dealt with by laparoscopic or open surgical intervention.
also be observed if fertility is not an issue or if the couple de- Benign lesions may be approached perineally; however, the
sires sperm acquisition with in vitro fertilization. risk of impotence is high even if a nerve-sparing approach is
attempted. Larger benign tumors or cysts are best handled by an
anterior abdominal approach, although a transcoccygeal method
may be as useful. Again, the transperitoneal or retroperitoneal
Ind icat io ns fo r Surg e ry laparoscopic approach has great merit for such lesions.
Patients with malignancy require radical extirpation, which
Treatments of conditions of the seminal vesicles alone are lim- commonly includes cystoprostatoseminal vesiculectomy and
ited to (i) transperineal/transvesical aspiration of seminal vesicle pelvic lymphadenectomy. This operation is no different from a
cysts or abscesses, (ii) transurethral unroofing of seminal vesi- routine procedure for bladder cancer and, thus, is not de-
cle cysts or abscesses, (iii) laparoscopic or robotic dissection, scribed here.
and (iv) open resection of one or both seminal vesicles.
M ost procedures performed on the seminal vesicles are re-
lated to radical surgery for the treatment of urethral, prostate, Pre o p e rat ive Pre p arat io n
bladder, or rectal cancer. Treatments specific to the seminal Preoperative preparation for laparoscopic, robotic, or open
vesicle include transrectal aspiration of cysts or abscesses, seminal vesicle surgery depends on the extent of the pathology
transurethral unroofing of abscesses and obstructing cysts, and the planned incision. Transperineal, transcoccygeal, and
and open resection for refractory infections, to excise an ectopic transvesical approaches should be prefaced by a complete
ureter, or to remove benign or malignant masses. bowel preparation. M ost surgeons use a mechanical preparation
with GoLytely orally the evening before surgery, followed by and the ampullae of the vas should be recognized directly
the standard antibiotic bowel regimen. Some method to pre- beneath the bladder neck. They can be dissected by scissors
vent phlebothrombosis in the legs, such as use of intermittent down to their entrance into the prostate and then either lig-
compression stockings during and immediately after surgery, ated and divided or left intact, depending on the pathology, as
is advisable. described in the perineal approach. Just lateral to the ampul-
lae on the prostate base, the seminal vesicles should be identi-
fied and the plane surrounding them entered easily unless
there has been prior inflammatory disease (Fig 54.1B). The
Surg ical Te chniq ue seminal vesicles should be encircled and dissected completely
A variety of open surgical approaches to the seminal vesicles free. M etal clips should be placed on the vascular pedicle and
have been described, of which the most useful are the trans- a 2-0 chromic tie on the distal end at the prostate. A clip is
vesical, transperineal, and laparoscopic. placed across the proximal end of the vas to prevent seminal
vesicle contents from obscuring the field, and then the vesicle
is transected and removed. If there is a moderate-sized cyst,
Transve sical Ap p ro ach the dissection is more involved but is usually made simple be-
The transvesical approach to the seminal vesicle has been de- cause the perivesical plane is usually more pronounced. The
scribed by numerous authors (3). A midline extraperitoneal plane may be very difficult to establish if there was prior vesi-
suprapubic incision is made up to the umbilicus, and the rec- culitis, and in this instance the ureteral catheters are a wel-
tus muscles are separated on the midline. The space of Retzius come safeguard—care must be taken not to dissect completely
is opened by downward displacement of the transverse fascia through Denonvilliers fascia posteriorly and into the rectum.
on the pubis, and an O mni retractor is placed to expose the The posterior bladder incision is then closed with a running 2-0
anterior bladder wall. Care is taken during this dissection not absorbable suture in the muscle layer, followed by a running
to injure the epigastric vessels on either side of the pubis. The 4-0 absorbable suture in the mucosal layer. The ureteral stents
bladder is opened longitudinally approximately 7 to 10 cm, and 4 8 sponges are removed, a 20Fr urethral catheter is
ending 2 to 3 cm away from the bladder neck. M oist 4 8 placed, and the anterior bladder wall is closed as the posterior
sponges are placed on the bladder wall laterally and at the wall was. Suprapubic tube placement is an option but is not
dome of the bladder, and specialized blades are placed to put necessary. A suction drain is placed through a separate stab
the open bladder on stretch. Although it is not necessary, it is incision and positioned in the prevesical space away from the
preferable to place long 8Fr feeding tubes in the ureters at this suture line. The urethral catheter is typically removed in 5 to 7
point to define the orifices and to help with identification of days. This approach is more prone to blood loss and ureteral
the subtrigonal ureters to prevent their injury later in the dis- injury than the perineal approach, but a rectal laceration is
section. Using a Bovie cutting stylet, a vertical incision is made much less likely.
through the trigone on the posterior midline approximately 5 cm
in length (Fig. 54.1A). Alternatively, a transverse incision just Transp e rine al Ap p ro ach
above the bladder neck can be used, but it is not preferred. The transperineal approach to seminal vesiculectomy is virtu-
The vertical incision is deepened through the bladder muscle, ally identical to radical perineal prostatectomy, described in
A B
FIGURE 54.1 The transvesical approach to the seminal vesicle. A: Vertical incision in the trigone to
expose the retrovesical seminal vesicle. B: Dissection of the vas ampullae and seminal vesicles.
FIGURE 54.2 The transperineal approach.

A: U-shaped incision in the perineum with
takedown of the central tendon. B: Exposure
and ligation of the seminal vesicles after incising
B Denonvilliers fascia.
Chapter 29. An exaggerated dorsal lithotomy position is used noted. This approach is well tolerated, and patients are usu-
to elevate the perineum so that it is parallel to the floor. An ally discharged within 24 to 48 hours of surgery.
inverted-U incision is made in the perineum and the central
tendon is divided (Fig. 54.2A). An anterior retractor stretches Parave sical and Re t ro ve sical Ap p ro ache s
the rectal sphincter superiorly, allowing visualization of the The paravesical incision is used in children, when there is a
glistening anterior rectal fascia fibers. The rectourethralis is large unilateral cyst that lies lateral to and above the bladder,
divided near the prostatic apex and a weighted speculum is and when nephroureterectomy is required. A midline or
placed, dropping the tented rectum. To adequately expose the Pfannenstiel extraperitoneal suprapubic incision is made. The
seminal vesicle, the rectum should be dissected off the poste- bladder is finger-dissected away from the lateral pelvic side-
rior surface of the prostate to a point higher than that needed wall on the affected side. The vas deferens is identified, placed
for perineal prostatectomy. Denonvilliers fascia is then incised on tension, and dissected down toward the base of the blad-
transversely or in the midline (if nerve-sparing) on the prostate der. If the seminal vesicle mass is distended, it should be visible
near the base of the seminal vesicles. rather quickly as the vas comes close to the bladder posteri-
Seminal vesicle dissection is facilitated by posterior traction orly. Placing a catheter in the bladder and emptying it usually
on the prostate provided by placement of a Lowsley retractor allows the plane between the bladder and the cyst to be read-
in the bladder. M edially, the ampullae and seminal vesicles are ily identified. The plane is incised with scissors, and the semi-
apparent after Denonvilliers fascia is incised (Fig. 54.2B). The nal vesicle cyst is carefully dissected away sharply. When the
ampullae can be spared for the excision of a simple seminal tip of the cyst is clearly identified, a 1-0 chromic suture is
vesicle cyst or small tumor but may need to be resected in the placed into it to provide traction, making further dissection
setting of cancer or infection. After dissection of the seminal easier. As the dissection proceeds, it must be remembered that
vesicle at the prostatic base, an absorbable tie of 2-0 suture is the ureter crosses the vas and must be identified to prevent its
used to ligate the gland (Fig. 54.2B). Before division of the injury. In addition, the superior vesicle artery and perhaps the
seminal vesicle, a clip is placed on the cut end of the organ to inferior vesicle artery may be sacrificed to gain access to the
minimize spillage. An Allis or Babcock clamp is then placed base of the seminal vesicle. This will cause no harm and
on the freed base of the seminal vesicle to ease the apical dis- should be done without major concern. As the dissection pro-
section. The vascular pedicle at the apex of the gland is usually ceeds, the bladder is progressively rolled over medially, and
observed within 1 cm of the tip and is ligated with small metal the mass is dissected away from the bladder laterally. The
clips, allowing gland removal. The wound is closed in layers plane is easily maintained with sharp dissection. Any vessels
as outlined for perineal prostatectomy. A Penrose drain is left feeding the seminal vesicles should be suture-ligated or metal-
in the area of dissection for 24 hours or until no drainage is clipped. As the prostate is approached, caution must be used
FIGURE 54.3 The retrovesical approach. A:

M idline infraumbilical incision. B: Incision of
the posterior peritoneum over the rectum in
the cul-de-sac. C: Exposure of the vas ampulla
C and seminal vesicle behind the bladder.
to stay directly on the mass so as not to injure the neurovascu- The retrovesical approach should be considered in patients
lar bundle lying just lateral to the seminal vesicle. At the requiring bilateral excision of small seminal vesicle cysts or
prostate base, the neck of the seminal vesicle is encircled and benign masses (4). A midline suprapubic incision is made into
ligated with a 2-0 absorbable suture. A clamp is placed across the peritoneal space (Fig. 54.3A). A catheter is placed, and the
just distal to the tie, and the seminal vesicle is severed. There urine is evacuated. The reflection of the peritoneum over the
may be no need to clip the vas. A suction drain is placed in the rectum at the posterior bladder wall is incised transversely,
bed of the seminal vesicle and brought out through a separate with care taken not to incise into the rectum (Fig. 54.3B). The
stab incision. The wound is then closed in layers. bladder is peeled back from the rectum progressively with
Postoperative care is as previously described, except with this sharp dissection until the ampullae of the vasa and the tips of
approach, the drain can be removed within 24 hours if there is the seminal vesicles come into view (Fig. 54.3C). The seminal
no drainage, and the urethral catheter can be removed within vesicles are dissected down to the base of the prostate, much
24 hours. The patient may be discharged within 2 to 3 days. as described in the transvesical approach, and the neck of the
Complications include ureteral injury and excessive blood seminal vesicle is ligated and divided bilaterally. The ampullae
loss. If the principles outlined earlier are followed, these are are usually not taken unless necessary. A suction drain is left
unlikely events. in the area posterior to the bladder and brought out as before.
FIGURE 54.4 The transcoccygeal approach.

A: The incision is made over the coccyx and
curved along the gluteal cleft. B: Denonvilliers
fascia is incised deep to the rectum to expose
the prostate and seminal vesicles.
Postoperative care is as per the description for a paravesical prostate is encountered. It is possible that the neurovascular
resection. Complications include rectal injury, bladder lacera- bundle will be recognized from this approach. O nce the
tion, and hemorrhage. In this situation, a rectal injury would prostate is palpated, dissection of the tissue directly superior
be within the peritoneum well above the levator ani muscles. to the base on the midline should reveal the ampulla of the vas
After a two-layer closure as before, strong consideration and, lateral to it, the seminal vesicle (Fig. 54.4B). If difficulty
should be given to placement of omentum over the closure be- dissecting the rectum away from the prostate is encountered, a
tween the bladder base and the rectum, as well as to a tempo- finger in the anus via an O ’Connor sheath will allow the cor-
rary colostomy. rect plane to be determined. Dissection and removal of the
seminal vesicles should follow the principles outlined previ-
Transco ccyg e al Ap p ro ach ously. A Penrose drain should be left in the area, exiting
through a separate stab incision at closure. The rectum should
The transcoccygeal approach may not be familiar to most uro-
be carefully scrutinized for injury; if any injury is found, it is
logic surgeons and is unlikely to be a common choice owing to
closed in two layers. The wound is closed in layers as well.
fear of rectal injury and impotence. In individuals for whom
Postoperative care does not differ from that previously de-
the perineal or supine position may be difficult to maintain, or
scribed; similar to the perineal approach, the patient should
who have had multiple suprapubic or perineal surgeries, the
have a rapid and easy recovery. The drain should be removed
transcoccygeal approach may be very useful. The patient is
within 2 to 3 days if there is no drainage.
placed on the table, ventral side down (prone) and in a relative
jackknife position (5). The incision is made in an L shape from
midway on the sacrum (10 cm from the tip of the coccyx) and Lap aro sco p ic Te chniq ue
angled at the tip of the coccyx down the gluteal cleft within M ost laparoscopic surgery performed on the seminal vesicles
3 cm of the anus (Fig. 54.4A). The incision is carried down to has been in conjunction with radical prostatectomy. It is
the lateral side of the coccyx, which is dissected free from the known that dissection of the ampulla of the vas and seminal
underlying rectum and eventually totally removed. The gluteus vesicles is a challenging part of a perineal prostatectomy, and
maximus muscle layers are moved aside, and the rectosigmoid thus prior mobilization of these structures made this easier. Its
is encountered and dissected carefully from the underside application for benign seminal vesicle pathology is limited to
of the sacrum. With careful dissection, the lateral wall of the case reports or small series (2).
rectum on the side of the lesion is dissected medially from Patients are placed supine with the arms carefully padded
the levator ani muscle and surrounding tissue until the and tucked in by the sides. Access to the perineum is usually
FIGURE 54.5 O ptimal sites (black spots) of access for

transabdominal laparoscopic seminal vesicle excision.
N umbers represent trocar size in millimeters.
not necessary for benign seminal vesicle pathology, whereas if a laparoscopic clip is also a good choice. The seminal vesicle
a laparoscopic or robotic prostatectomy will be performed in should be dissected caudally down to its juncture with the
addition, the legs are abducted but left straight with the use ampulla of vas and then clipped en bloc. With completion of
of an operating table that allows a split-leg arrangement. If the dissection, the specimen is placed in an entrapment device
possible the low lithotomy position is avoided so as to mini- (LapSac, Cook Urological Inc., Spencer, IN ) or an Endocatch
mize the risk of lower extremity thrombosis or neuromuscular bag (US Surgical, Tyco H ealthcare, N orwalk, CT) and ex-
injury. Patients are carefully strapped to the operating table tracted through one of the larger laparoscopic ports. Large
with wide cloth tape across the chest and thighs as steep cysts may be aspirated prior to extraction so as to minimize the
Trendelenburg (approximately 20 degrees) is required for specimen size and obviate the need for enlarging the incision.
deep pelvic laparoscopic visualization. After the patient is pre- H emostasis and surrounding visceral integrity are assured and
pared and draped, a Foley catheter is inserted into the bladder then the laparoscopic ports are closed in the usual fashion.
under sterile conditions. An orogastric tube placed in the In select cases, a concomitant ipsilateral nephroureterec-
stomach is optional. tomy may be required should an atrophic kidney have an
A transperitoneal approach is preferred for benign seminal ectopic ureter draining into the seminal vesicle. It is recom-
vesicle lesions. After establishing a suitable pneumoperi- mended that the laparoscopic nephroureterectomy be per-
toneum up to 15 mm H g with the Veress needle placed at the formed prior to the seminal vesicle dissection. Thus, the
inferior or superior umbilical crease, four laparoscopic ports patient would begin the procedure in a modified lateral decu-
are usually adequate for seminal vesicle benign pathology ex- bitus position and then the operating table would be rotated
cision. These ports, varying from 5 to 12 mm in size, may be so as to bring the patient into a relative supine and
placed in a diamond shape (Fig. 54.5) or a horseshoe shape. Trendelenburg direction. The operative details of laparoscopic
With the patient in steep Trendelenburg, the peritoneum just nephrectomy for benign disease are described in Chapter 124.
anterior to the rectum in the rectovesical pouch (pouch of Laparoscopic robotic assistance for surgery of the seminal
Douglas) is incised transversely between the two obliterated vesicles has usually been performed in conjunction with radi-
umbilical ligaments. Large seminal vesicle cysts are usually cal prostatectomy. The technique, with respect to port place-
easily visualized and the dissection is carried close to the sem- ment and approach, is almost identical to the standard
inal vesicles so as to avoid injury to surrounding viscera and laparoscopic route described (6).
the neurovascular bundle. Use of bipolar coagulation is highly Although the transperitoneal laparoscopic/robotic ap-
recommended over monopolar energy so as to minimize injury proach to the seminal vesicles offers improved visualization to
to these surrounding structures. The dissection can be completed the seminal vesicles, the latter’s close proximity to bladder,
using laparoscopic scissors and curved graspers using blunt rectum, ureter, and neurovascular bundle must be appreciated
and sharp dissection. The main arterial branch to the tip of the by the surgeon. Transperitoneal incision in the pouch of
seminal vesicle is easily handled with bipolar coagulation, but Douglas, which is too anterior, may lead to perforation of the
posterior bladder wall. Subtle hints that the surgeon may be transurethral resection into the prostatic substance, just distal
dissecting too anterior would be the appearance of the detru- to the bladder neck at the 5 or 7 o’clock position. H owever,
sor musculature, which is quite vascular and tends to bleed urinary reflux, with resultant postvoid dribbling, and infec-
easily. Should a hole be made in the bladder, it can be repaired tion are potential complications (7). Previous reports have
laparoscopically or robotically without undue difficulty. detailed endoscopic treatment of seminal vesicle abscesses
Similarly, the rectal wall may be incised at any point in using semirigid ureteroscopes, as well as drainage of a seminal
the seminal vesicle mobilization. Assuming the patient has vesicle cyst cystoscopically with an incision using a Collins
received a satisfactory bowel preparation, such rectal lacera- knife (1).
tions may be laparoscopically or robotically repaired in two
layers. The anal sphincter is dilated at the termination of
the procedure and the patient’s diet is advanced slowly. O ut co me s
Electrocautery must be used judiciously when in close prox-
imity to the rectum. Use of precise bipolar coagulation is Re sult s
recommended. Resection of the seminal vesicles for cystic and inflammatory
The distal ureter runs close to the tip of the seminal vesicle. diseases is in general successful, although large case series are
Any tubular structure that is lateral to the seminal vesicle may rare. Seminal vesicle extirpation for cancer has also been suc-
be the vas arching upwards towards the internal ring, but it cessful, but the rarity of this indication prohibits an accurate
also could be the ureter. The surgeon may easily become dis- assessment of survival and cure rates. Strict categorization of
oriented to which ampulla of the vas is being dissected, lead- the 100 reported cases of primary seminal vesicle cancer re-
ing to the dissection shifting too far lateral and possibly veals that fewer than 50% are truly primary to the seminal
injuring or transecting the ureter. Injection of intravenous vesicle (8). In general, reconstructive surgery in children using
methylene blue quickly confirms the ureteral injury. Should these approaches has resulted in satisfactory outcomes.
this unfortunate complication occur, the ureter could possibly
be repaired by laparoscopic or robotic suturing. H owever, a
ureterovesical reimplantation may be required and necessitate Co mp licat io ns
open surgical conversion. Placement of a double-J ureteral Each approach to seminal vesicle surgery is associated with
stent following repair is wise, and a pelvic drain is strongly unique complications. The relative complication rates with
advised in the presence of any bladder, rectal, or ureteral injury these approaches are outlined in Table 54.1. Limited ex-
that may have occurred during the course of laparoscopic or traperitoneal rectal injuries can be handled with formal two-
robotic seminal vesicle dissection. layer closure. Rectal injury with the retrovesical approach is
Finally, the neurovascular bundle is just lateral to the tips intra-abdominal, however, and may require the placement of
of the seminal vesicles. Injury to this structure will impair omentum over the repair or even temporary colostomy. M ost
erectile function and create a serious problem, especially to bladder injuries can be closed primarily. The most important
the potent patient who may be undergoing seminal vesicle point about ureteral injuries is their recognition. M ost ureteral
excision for benign disease. injuries can be treated adequately with stents for 7 to 10 days.
Although data are limited for laparoscopic and robotic
excision of benign seminal vesicle pathology alone, this ap-
proach appears to afford superb visualization with minimal
postoperative morbidity and shorter hospitalization compared
EJ ACULATO RY DUCT SURGERY
to the open surgical alternatives (2). In most cases, the seminal The ejaculatory ducts are paired, collagenous, tubular struc-
vesicle is excised laparoscopically or robotically in conjunc- tures that commence at the junction of the vas deferens and
tion with radical prostatectomy or cystoprostatectomy. seminal vesicle, course through the prostate, and empty into
the prostatic urethra at the verumontanum. There are three
End o sco p ic Tre at me nt distinct anatomic regions to the ejaculatory duct: the proximal
Transurethral Resection. If the cyst or abscess is adjacent to and largely extraprostatic portion, the middle intraprostatic
the prostate (not in the middle or distal end of the seminal segment, and a distal segment that is incorporated into the lat-
vesicle), it may be possible to unroof the cavity with a deep eral aspect of the verumontanum in the prostatic urethra (9).
TA B LE 5 4 . 1
RELATIVE COMPLICATION RATES OF THE DIFFEREN T SURGICAL APPROACHES TO THE SEMIN AL VESICLE
Bladder or Risk for Blood

Approach Rectal Injury Impotence Ureteral Injury Transfusion Other Risks
O ther M oderate H igh M oderate M oderate Thromboembolic

Transvesical Low Low H igh Low Fistula
Transperineal H igh H igh M oderate M oderate Thromboembolic
Para/Retrovesical M oderate Low M oderate Low Low
Transcoccygeal H igh H igh Low Low Low
Laparoscopic Low Low Unclear Low Air Embolism
The duct consists of three histologic layers: an outer mus- N ot all patients with ejaculatory duct obstruction have di-
cular layer, a collagenous middle layer, and an inner mucosal lated seminal vesicles, and not all patients with dilated seminal
layer (10). The muscular layer is absent in the distal segment. vesicles have ejaculatory duct obstruction. This has led to
refinements in diagnostic techniques. Jarow (9) found that
seminal vesicle sperm aspiration with TRUS more accurately
Ind icat io ns fo r Surg e ry defined affected patients. With a 30-cm, 21-gauge needle
(Williams, Chiba, or oocyte retrieval needle), the seminal vesi-
Patients with ejaculatory duct obstruction sufficient to cause cles are aspirated transrectally or transperineally during TRUS
coital discomfort, recurrent hematospermia, or infertility (Fig. 54.6A). The aspirate is then examined under 400 phase
should be considered candidates for transurethral treatment. microscopy for sperm. The finding of more than three sperm
Infertility with duct obstruction can present with low ejaculate per high-power field is considered positive and suggestive of
volume and azoospermia or low ejaculate volume with de- obstruction. Importantly, the duration of sexual abstinence
creased sperm density ( 20 10 6 sperm per mL) or impaired prior to aspiration can influence the findings. Seminal vesicle
sperm motility ( 30% motility). Anatomic findings sugges- aspiration should be performed with 24 hours of sexual ab-
tive of obstruction and lesions located within approximately 1 stinence. Despite the fact that aspiration does not anatomically
to 1.5 cm of the verumontanum are usually amenable to localize the site of blockage or differentiate between physical
transurethral management. blockage and functional obstruction, it confirms that spermato-
genesis is ongoing and that epididymal obstruction is unlikely.
Injection of nonionic contrast (50% Renografin) into the
Diag no sis seminal vesicles after seminal vesicle aspiration, followed by
formal radiographic imaging, can be a useful retrograde study
Ejaculatory duct obstruction causes infertility in 5% of of seminal vesicle and vasal anatomy in suspected obstruction
azoospermia cases. Duct obstruction can result from seminal (Fig. 54.6B). Also, a good-quality pelvic and inguinal vaso-
vesicle calculi, mullerian duct (utricular) or wolffian duct gram can be obtained in most patients (Fig. 54.6B).
(diverticular) cysts, postsurgical or postinflammatory scar tis- Fluoroscopy or a kidney-ureter-bladder (KUB) plain film is
sue, calcification near the verumontanum, or congenital atresia taken after the injection of 5, 10, and 20 mL of contrast to
(7). Classically, this condition presents as hematospermia, delineate excurrent duct anatomy. H elpful maneuvers include
painful ejaculation, or infertility with azoospermia. Associated (i) having the patient in the 15- to 30-degree reverse
risk factors include evidence of prior urinary tract infection or Trendelenburg position for radiographs to “ open up” the
trauma and perineal pain or discomfort. It is important to pelvic outlet and minimize overlying pelvic bone density and
discontinue medications that may impair ejaculation. An ab- (ii) placing a Foley catheter with 5 mL of water in the balloon
breviated list of these medications is found in Table 54.2. on slight traction during contrast injection to reduce the
Ejaculatory duct obstruction is suggested by finding enlarged, spillage of contrast into the bladder that “ clouds” the radi-
palpable seminal vesicles on rectal examination. The diagnosis ograph. As seminal vesiculography is more invasive than sim-
is confirmed by a combination of findings: ple aspiration, it may require mild intravenous sedation and is
1. An ejaculate volume 1.0 mL and a pH 7.0 that con- best performed at the time of transurethral surgery.
tains no sperm or fructose Injection of diluted indigo carmine or methylene blue (1:5
2. A TRUS demonstration of dilated seminal vesicles ( 1.5 dilution with saline) into the seminal vesicle with TRUS in-
cm in width) or dilated ejaculatory ducts ( 2.3 mm) in stead of contrast is termed seminal vesicle chromotubation.
association with a cyst, calcification, or stones along the When performed with cystoscopy it can assess whether or not
duct there is antegrade flow of dye from the seminal vesicle into the
Recently, high-resolution TRUS has virtually replaced the prostatic urethra (Fig. 54.6C). In fact, “ patency,” with chro-
more invasive vasography for this diagnosis. M RI with en- motubation, defined by the presence of dye egressing from the
dorectal coil is recommended in suspicious cases without ejaculatory duct orifices after seminal vesicle injection, may be
TRUS findings as it is excellent for the detection of small cysts. the most accurate way to diagnose complete ejaculatory duct
To complete the evaluation for infertility, it is important that obstruction, unilateral or bilateral (11).
the serum follicle-stimulating hormone (FSH ) and testosterone
levels be normal. Testicular volume should also be normal. A
testis biopsy confirming ongoing sperm production may be Surg ical Te chniq ue
helpful but is not always necessary.
Transurethral resection of the ejaculatory ducts (TURED) is
performed in the outpatient setting. Following the administra-
tion of light general or regional anesthesia and a single dose of
TA B LE 5 4 . 2 a broad-spectrum antibiotic, the patient is placed in the dorsal
MEDICATION S ASSOCIATED WITH IMPAIRED lithotomy position with a rectal drape (O ’Connor). Formal
EJACULATION cystourethroscopy is performed. Careful examination is made
of the areas lateral to the verumontanum within the prostatic
Antihypertensive agents urethra to visualize either ejaculatory duct orifice. A small re-
-Adrenergic blockers (prazosin, phentolamine) sectoscope (24Fr) and electrocautery loop are inserted and the
Thiazides verumontanum is resected in the midline (Fig. 54.7). The re-
Antipsychotic agents section is performed with pure cutting current to minimize
cauterization of the delicate ejaculatory ducts. O ften several
A B
FIGURE 54.6 A: Working setup for transrectal ul-

trasound (TRUS) aspiration of seminal vesicles.
L arge black dot points out the TRUS probe inserted
into the rectum and sm all gray dot is placed on the
syringe and needle used for aspiration. B: N ormal
TRUS seminovesiculogram showing seminal vesicle
and ejaculatory ducts with contrast. A rrow s show
the pelvic and inguinal vas deferens. C: N ormal
TRUS chromotubation. Cytoscopic view of methyl-
ene blue egressing from both ejaculatory duct ori-
C fices (w hite X s) after injecting the seminal vesicles.
passes of the cutting loop are required to visualize the ejacula- Several useful aids can ensure that the resection is per-
tory duct openings within the prostate. This can mean rela- formed safely and completely. With an endoscopic needle, the
tively deep dissection in a small prostate gland, a situation milky ejaculatory duct fluid can be sampled transurethrally
that can make even an experienced transurethral surgeon feel during the procedure and inspected with microscopy for sperm.
uneasy. At the correct level of resection, cloudy, milky fluid The use of simultaneous, real-time TRUS during the resection
can usually be seen effluxing from the opened ducts. After is a valuable addition to this procedure. The exact location of
resection, large bleeding blood vessels are lightly cauterized, the lesion to be resected can be determined by TRUS and the
with care taken to avoid fulguration of the duct openings. depth of resection continuously assessed during the resection.
Because the area of resection is at the prostatic apex, near Similarly, TRUS can be used to guide the instillation of indigo
both the external urethral sphincter and the rectum, careful carmine or methylene blue into the seminal vesicles with a
and constant positioning of the resectoscope is essential. A long, 20-gauge Chiba needle before the resection. The dye is
finger placed in the rectum can help avoid rectal injuries and subsequently visualized on relief of obstruction.
assist in keeping the resectoscope tip proximal to the external
sphincter. A small Foley catheter is placed for 24 to 48 hours
and removed on an outpatient basis. O ral antibiotics are given O ut co me s
while the catheter is in place. After such treatment for infertil-
ity, intercourse is resumed after 7 days, and a formal semen Re sult s
analysis is checked as early as 2 weeks and then at regular in- Long-term relief of postcoital and perineal pain after TURED
tervals thereafter, until semen quality stabilizes. can be expected in 60% of patients (12). H ematospermia has
FIGURE 54.7 Transurethral resection for ejaculatory

duct obstruction. M idline resection of the verumon-
tanum is shown. Lateral and deeper resection may be
necessary depending on the site and reason for duct
obstruction. (Conceptualized by Paul Stempen)
also been effectively treated with TURED, but the literature

on this indication remains anecdotal. There is convincing evi- Co mp licat io ns
dence from several large series of patients treated for infertility
The expected complication rate from TURED surgery is approx-
that a 20% to 30% pregnancy rate can be expected from
imately 20% (7). The most common complications are self-
TURED (13,14). In one series, men treated for either low-
limited hematospermia, hematuria requiring recatheterization,
volume azoospermia or low-volume oligoasthenospermia
and urinary tract infection. M ore concerning, but less frequent,
were equally likely (65% to 70% ) to show improvements in
are epididymitis and a “ watery” ejaculate. H igh-volume watery
semen quality after TURED (14). From a recent series, it ap-
ejaculate is presumed secondary to the reflux of urine retrograde
pears that obstruction due to cysts responds better to TURED
through the ejaculatory ducts into the seminal vesicles or into
than that due to calcification (15).
opened cysts, as suggested by the finding of creatinine in the ejac-
Several caveats of TURED surgery should be emphasized
ulates of TURED patients. In addition to the social implications
to the patient preoperatively. Roughly 13% of men treated by
of this, the exposure of sperm to urine may impair fertility po-
TURED for low-volume azoospermia will convert to normal-
tential. Several potentially major but rarely reported complica-
volume azoospermia. Among these patients, some have evi-
tions include retrograde ejaculation, rectal perforation, urinary
dence of secondary obstruction at the level of the epididymis
incontinence, and recurrent seminal vesicle infection.
that requires epididymovasostomy. Epididymal obstruction
may reflect the effects of time and blockage on other portions
of the delicate male ductal system. N otably, 4% of patients ACKNO WLEDGMENTS
treated for low-volume oligoasthenospermia may become
azoospermic after TURED, presumably from scar tissue for- The author would like to thank Drs. Paul Turek and H oward
mation. We now recommend preoperative sperm cryopreser- Winfield for their previous works that contributed to this
vation if TURED is planned for this indication. chapter.
References
1. Sandlow JI, Winfield H N , Goldstein M . Surgery of the scrotum and seminal 9. Jarow JP. Seminal vesicle aspiration in the management of patients with
vesicles. In: Cam pbell-Walsh Urology, 9th ed. Philadelphia: WB Saunders, ejaculatory duct obstruction. J Urol 1994;152:899–901.
2007;1098–1127. 10. N guyen H T, Etzell J, Turek PJ. N ormal human ejaculatory duct anatomy: a
2. M cDougall EM , Afane JS, Dunn M D, et al. Laparoscopic management of study of cadaveric and surgical specimens. J Urol 1996;155:1639–1642.
retrovesical cystic disease: Washington University experience and review of 11. Wu DS, Shinohara K, Turek PJ. Ejaculatory duct chromotubation as a
the literature. J Endourol 2001;15:815–819. functional diagnostic test in ejaculatory duct obstruction. J Urol 1999;
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seminal vesiculectomy: a case report. J Urol 1975;113:385–388. 12. Farley S, Barnes R. Stenosis of ejaculatory ducts treated by endoscopic re-
4. Silva DeAssis J. Seminal vesiculectomy. J Urol 1952;68:747–753. section. J Urol 1973;109:664–666.
5. Kreager JA, Jordan WP. Transcoccygeal approach to the seminal vesicles. 13. Pryor JP, H endry WF. Ejaculatory duct obstruction in subfertile males:
A m Surg 1965;31:126–127. analysis of 87 patients. Fertil Steril 1991;56:725–730.
6. M enon M , Tewari A, Peabody J. The VIP Team. Vattikuti Institute prosta- 14. Turek PJ, M agana JO , Lipshultz LI. Semen parameters before and after
tectomy: technique. J Urol 2003;169:2289–2292. transurethral surgery for ejaculatory duct obstruction. J Urol 1996;
7. Fisch H , Lambert SM , Goluboff ET. M anagement of ejaculatory duct 155:1291–1293.
obstruction: etiology, diagnosis, and treatment. World J Urol 2006;24(6): 15. Kadioglu A, Cayan S, Tefekli A, et al. Does response to treatment of ejacu-
604–610. latory duct obstruction in infertile men vary with pathology? Fertil Steril
8. Benson RC Jr, Clark WR, Farrow GM . Carcinoma of the seminal vesicle. 2001;76:138–142.
J Urol 1984;132:483–485.
CHAPTER 55 ■ VASECTO MY
DO UGLAS G. STEIN
As the most dependable method of contraception and one that

requires virtually no compliance, vasectomy is an ideal choice ALTERNATIVE THERAPY
for those men who have made a mature, informed decision to
have no more children, and especially for men who have diffi- Especially because vasectomy should always be presented as a
culty with compliance. As a result, 11% of the U.S. popula- permanent form of contraception, a full disclosure of alterna-
tion relies on vasectomy as their primary method of birth tive contraceptive methods must be a part of informed consent.
control, and the incidence of vasectomy is approximately While condoms are the only other alternative available to men,
500,000 per year in the United States. While it has been noted men should have a thorough understanding of the options
that vasectomy is the “ most common procedure involved in available to women, even though these provide less control for
malpractice claims against urologists” (1), vasectomy accounted the male. When features of the male anatomy (obesity, tight
for only 8 of 469 (1.7% ) urology malpractice claims closed scrotum, thin vasa, or scarring from prior scrotal surgery)
with indemnity payment between 1985 and 2004 for one lia- would make vasectomy difficult for the vasectomist at his or
bility carrier in N ew York (2). So, while urologists need not her skill level, couples considering permanent contraception
avoid vasectomy to decrease perceived high liability, they need should be asked to consider tubal ligation for the woman or
to be thoroughly versed in the management of men seeking the opinion of a vasectomist with more experience, as compli-
vasectomy. cation rates are lower for vasectomies performed by more ex-
perienced vasectomists. While not guaranteed successful,
sperm storage should also be considered by vasectomy candi-
dates as an insurance policy that may enable paternity after va-
DIAGNO SIS sectomy, if vasectomy reversal fails to restore fertility.
In most practices, a “ consultation visit” includes counseling
about vasectomy and a brief physical examination to help
determine whether the surgeon and the patient feel comfort-
SURGICAL TECHNIQ UE
able with office vasectomy under local anesthesia or whether, N early all surgical procedures involve three steps: (i) anesthe-
in rare circumstances, general anesthesia in an operating room sia, to allow the procedure to proceed without pain, (ii) access,
is indicated for reasons of patient anxiety or features on physi- or how the surgeon gets to the target organ, and (iii) technique,
cal examination that could make vasectomy more difficult in how one manages the target organ, the actual vasectomy.
an office setting. Such features include incomplete testicular
descent (either untreated or status post orchiopexy); scarring
due to prior scrotal surgery; a small tight scrotum; obesity with Ane st he sia
thick spermatic cords; very thin vasa; large hydrocele, sperma-
tocele, or varicocele; or extreme scrotal hypersensitivity. In this For vasectomy, general anesthesia or heavy intravenous seda-
practice of about 2,000 vasectomies per year, general anesthe- tion in an operating room setting may be preferred by anxious
sia is never utilized. Counseling is accomplished online by a patients and by surgeons who simply find it easier than using
personal counseling video, a very informative web page, and a local anesthesia for anxious or technically challenging patients.
written consent that includes alternatives, potential complica- For young healthy men, the risks are minimal, but the costs may
tions, and pre- and postprocedure instructions. M edical and make it prohibitive for men without health insurance coverage.
surgical (prior scrotal conditions and surgeries) histories are M ost vasectomies are performed in an office setting under
reviewed by the physician. Sedatives are not routinely used. local anesthesia. Administration with a needle is the most
common and traditional technique, but since 2002, no-needle
anesthesia has made vasectomy much more acceptable, espe-
INDICATIO NS FO R SURGERY cially for men who “ just hate needles.”
N eedle local anesthesia is accomplished after the scrotum is
While no strict criteria exist for determining which patient prepped and draped. A 27-gauge 1.5-inch needle is commonly
should be offered vasectomy, the Electronic Code of Federal used to create a skin wheal over the point at which the vas is
Regulations for sterilization of persons in federally assisted held beneath the skin (Fig. 55.1). Then the needle is advanced
family planning projects (Title 42 CFR, Part 50, subpart B) proximally its full length adjacent to the vas in the direction of
specifies that the individual be at least 21 years of age and the external ring. Two mL of anesthetic is injected into the vas
mentally competent when consent is obtained, that consent sheath as the needle is withdrawn. (A 30-gauge 1-inch needle
be obtained with certain procedures, and that 30 days pass causes less of a poke but requires more time and strength for
between the date of consent and the date of vasectomy. injection. The anesthetic can be lidocaine without epinephrine
372
Chap t e r 55: Vase ctomy 373
FIGURE 55.1 The right vas deferens is manipu-

lated to the midline raphe and anesthetized.
[1% burns a bit 2% ] or a mixture of lidocaine and bupiva- skin and underlying tissue to a depth of 2 to 5 mm, depending
caine to delay the onset of the mild discomfort that usually oc- on the factory setting of the particular M adaJet. N o-needle
curs on the day of the procedure.) The surgeon then either lifts anesthesia is administered after the scrotal wall is shaved but
and injects the other vas or proceeds with the vasectomy on before the formal scrotal preparation with povidone-iodine.
this side, employing the traditional incisional technique or the The vas is lifted into position beneath the skin at the preferred
no-scalpel technique (see below). The contralateral vas sheath access site (anterior midline or lateral scrotal wall), the overly-
is injected similarly, either through the same skin wheal if the ing skin is prepared with alcohol, the fluted tip of the M adaJet
vasectomy is to be performed through a single midline open- is positioned over the vas (Fig. 55.3), and the release button is
ing (preferred) or through a second skin wheal if the surgeon pressed to discharge the anesthetic through the skin and
is more comfortable with accessing the vas through separate around the vas. The procedure is repeated one or two times
lateral wall openings. along the path of the vas at 4- to 5-mm intervals. M edication
N o-needle local anesthesia for vasectomy involves the use entry sites are barely visible as minute dots, surrounding which
of a jet injector, the most popular of which is the M adaJet are 2- to 3-mm areas of anesthetized skin. If the right vas is
(M ADA, Inc., Carlstadt, N J). Use of no-needle local anesthesia lifted to the midline and injected 2 mm to the left of the median
has become more widespread, popularized by Weiss and Li (3). raphe, and if the left vas is then lifted to the midline and
The M adaJet (Fig. 55.2) emits an extremely thin 0.1- to 0.2 mL injected 2 mm to the right of the median raphe, the patient
stream of anesthetic (a 50:50 mixture of 2% lidocaine and develops a square of anesthetized skin about 4 to 5 mm on each
0.5% bupivacaine is preferred) strong enough to penetrate the side centered on the midline and the scrotal septum receives
four to six doses of the anesthetic. Through the anesthetized
square, the no-scalpel vasectomy (N SV) is performed.
For the occasional vasectomy, needle anesthesia is more
convenient unless the surgeon wishes to appeal to those men
who “ just hate needles.”
FIGURE 55.3 Positioning a M adaJet with a straight head over the

FIGURE 55.2 Cocking a M adaJet with an angled head. The release right vas, while it is held beneath the median raphe using a three-finger
button is at the top. technique.
Acce ss
Using the traditional approach, access to the vas is accom-
plished through a 1- to 1.5-cm horizontal or vertical incision
in each lateral scrotal wall or through a single incision in the
midline, wherever the vas was previously anesthetized using
needle or M adaJet. The vas, held beneath the incision and still
within its sheath, is grasped with an Allis or small towel
clamp. Then the fibrous tissue around the vas is incised longi-
tudinally with the scalpel, exposing the vas itself, which is
then grasped with an Adson forceps, and a section is lifted
through the sheath. Surgeons familiar with N SV instruments
but more comfortable with an incisional approach often pre-
fer to use the N SV ringed forceps to both secure the vas and
lift it from its sheath.
The no-scalpel approach utilizes two special instruments FIGURE 55.5 H eld using the three-finger technique, the right vas is
and a three-finger technique (Fig. 55.4). Access to both vasa is grasped with the no-scalpel vasectomy (N SV) ringed forceps.
via a single small opening in the anterior midline of the scrotal
wall (anesthetized with needle- or M adaJet-applied lidocaine), tip of the pointy N SV hemostat is then introduced into the lu-
but there is no reason why the same instruments could not be men of the vas and removed. The N SV hemostat is then closed
used with lateral wall incisions for surgeons more comfortable and both tips are introduced into the lumen of the vas at the
with that approach. After the scrotum is prepared with same spot. The tips are spread to a width twice that of the vas,
povidone-iodine and draped, needle anesthesia is utilized (see splitting the vas open longitudinally and spreading all overly-
above) or the pinpoint marks in the skin made by the M adaJet ing layers. O ne tip of the N SV hemostat is then used to
are located and the site marked by inserting and gently spread- “ hook” the vas (Fig. 55.6) and lift it from its sheath as the
ing the tips of the pointy N SV hemostat. Locating the pinpoint ringed forceps is removed. The ringed forceps is then used to
M adaJet injection application sites can be difficult, especially grasp one wall of the vas and deliver a 1- to 3-cm loop of it
in dark-skinned men, so this step and the remainder of the from its sheath (Fig. 55.7).
vasectomy may be much easier with the magnification provided
by 2 optical loupes. The vas, most commonly located on the
posterior aspect of the spermatic cord, is swept medially and O cclusio n
lifted into position beneath the anesthetized site using a three-
finger technique. While the vas is draped over the middle fin- N umerous methods for establishing vasal obstruction have
ger and stabilized with the thumb of the nondominant hand, been described, and most surgeons employ a combination of
the skin is drawn tightly over it with the index finger of the luminal cauterization, ligation, division, excision, and fascial
same hand. The vas is grasped with the N SV ringed forceps interposition with either a suture ligature or hemoclip (4)
(Fig. 55.5). When the overlying skin is thin, the initial grasp (Figs. 55.8, 55.9, 55.10, and 55.11). The objective should be
incorporates the skin. When the overlying skin is very thick, very low failure and low complication rates, without removing
some surgeons will find it easier to spread the skin and under- so much vas, especially in young patients, that vasectomy
lying fascia enough to introduce the N SV ringed forceps reversal is rendered extremely difficult. “ Early” failure is said
through this opening and grasp the vas within its sheath. O ne to occur when the postvasectomy patient has motile sperm or
FIGURE 55.4 The three-finger technique for

isolating the (A) right and (B) left vas deferens.
FIGURE 55.6 After the vas and overlying layers are split by spread-
ing with the pointy hemostat, the pointy hemostat is used to hook the
vas as the no-scalpel vasectomy (N SV) ringed clamp is released.
FIGURE 55.9 Cauterization of both ends with excision of a segment

but no fascial interposition. (Copyright and courtesy of Barone M A,
Irsula B, Chen-M ok M , et al., and the Investigator Study Group.
Effectiveness of vasectomy using cautery. BM C Urol. 2004;4:10,
http://www.biomedcentral.com/1471-2490/4/10)
FIGURE 55.7 A loop of vas is delivered.
FIGURE 55.10 Cauterization of both ends with fascial interposition

over the testicular end (abdominal end left outside sheath) using su-
ture. (Copyright and courtesy of Barone M A, Irsula B, Chen-M ok M ,
et al., and the Investigator Study Group. Effectiveness of vasectomy
using cautery. BM C Urol 2004;4:10., http://www.biomedcentral.
com/1471-2490/4/10)
significant numbers ( 100,000/mL) of nonmotile sperm in the

semen 6 months after vasectomy. Recanalization within the tis-
sue between the two severed ends occurs frequently during the
1 to 2 months following vasectomy but usually scars off. Early
failure occurs when recanalization does not scar off but rather
FIGURE 55.8 Cauterization of both ends without excision of a seg-
persists. “ Late” failure is the return of motile sperm to the se-
ment or fascial interposition. (Copyright and courtesy of Barone M A,
Irsula B, Chen-M ok M , et al., and the Investigator Study Group. men of a patient previously diagnosed as azoospermic, an
Effectiveness of vasectomy using cautery. BM C Urol 2004;4:10, event caused by delayed recanalization and usually discovered
http://www.biomedcentral.com/1471-2490/4/10) as a result of a surprise pregnancy.
FIGURE 55.12 The no-scalpel vasectomy (N SV) pointy hemostat is

used to spread vessels away from a 1- to 2-cm length of vas.
FIGURE 55.11 Cauterization of the abdominal end only (open-ended
technique) with fascial interposition over the abdominal end (testicu-
lar end left outside sheath) using a hemoclips. (Copyright and cour-
tesy of Barone M A, Irsula B, Chen-M ok M , et al., and the Investigator (Fig. 55.12). At the prostatic end of the segment, a small vaso-
Study Group. Effectiveness of vasectomy using cautery. BM C Urol tomy opening is made with one tip of the pointy N SV hemo-
2004;4:10, http://www.biomedcentral.com/1471-2490/4/10) stat (Fig. 55.13). A battery-powered wire loop thermocautery
tip is introduced into the upper end and advanced 5 to 10 mm
toward the prostate (Fig. 55.14). It is activated just long
There are numerous reviews of surgical techniques (5,6).
enough to sear the mucosal lining of the vas so that it will seal
Ligation without division has a high early failure rate, even
off by scarring. If applied too long, causing the full thickness
when employing a specially designed clip rather than a suture
of the wall to blanch, the cauterized segment may slough,
ligature or hemoclip (7). Cauterization without division might
negating the effectiveness of cautery in contributing to
be expected to create adequate obstruction by scarring in
obstruction of the vas. Then the thermocautery unit or a scis-
some patients but is not routinely used because of an antici-
sors is used to divide the vas where the vasotomy was made.
pated high failure rate, given that cautery and division (with-
The prostatic end slips up into the vas sheath and the margins
out excision of a segment or fascial interposition) resulted in
of the sheath are brought together and tented over the buried
the only failures in a study of the effectiveness of various
end with a conventional H alsted hemostat (Fig. 55.15). If
cautery techniques (4). Early recanalization and failure rates
there are any bleeding vessels near the sheath margins, these
are highest for ligation and excision without fascial interposi-
can be included in the hemostat to provide hemostasis. At this
tion and lowest for thermal cautery with fascial interposition
point, the testicular end is still secured with the ringed clamp.
(4,8). This is the rationale for the following technique.
The hemostat is now brought down to a position below the
ringed clamp (toward the foot of the table) and transferred to
the nondominant hand. A medium hemoclip is applied to the
Pre fe rre d Ane st he sia, Acce ss, and tissue in the hemostat alongside the testicular end of the vas,
O cclusio n Te chniq ue s drawing the sheath around the testicular end so that it cannot
slip back inside. When the hemostat is removed, the clip rotates
The no-needle, no-scalpel vasectomy with thermal cauterization back cephalad and sits parallel to the testicular end (Fig. 55.16)
and hemoclip fascial interposition is performed as follows. An
elastic lasso is applied at the coronal sulcus and an attached
hemostat is snapped onto the shirt to keep the penis elevated.
Most patients, coached by online instructions and telephone staff,
shave the night before so that the skin is not so sensitive to the
alcohol used to prepare it for application of the no-needle anes-
thesia. If needed, the anterior scrotal wall is shaved with a single-
edge shaver. N o-needle local anesthesia is applied to each vas in
turn at a midline location as described previously. The scrotum
is then formally prepped with povidone-iodine and draped with
a fenestrated 18 24-inch drape. If no-needle anesthesia is not
used, needle anesthesia is applied as described previously.
After local anesthesia, the no-scalpel technique described
previously is utilized to deliver a loop of vas from its sheath
(see Fig. 55.7). It is very important that the vas be opened a few
millimeters lengthwise to confirm complete penetration of the
sheath and to allow grasping of the vas wall with the ringed
forceps. The N SV pointy hemostat is passed along theunder-
surface of the vas at the apex of the loop and gently spread to FIGURE 55.13 The no-scalpel vasectomy (N SV) pointy hemostat is
push the vasal vessels away from a 1- to 2-cm segment of vas used to make a small vasotomy opening in the abdominal end.
FIGURE 55.16 When the hemostat is removed, the hemoclipped sheath

FIGURE 55.14 The tip of a thermocautery unit is introduced into the over the buried abdominal end rotates back to its original position.
abdominal end.
Fo llo w -Up Se me n Analysis

If a fresh specimen contains fewer than 100,000 nonmotile
sperm per milliliter (1 sperm per 400 high-power field with
many light microscopes), as will be the case for 95% at 12
weeks, no further testing is necessary, as 99.7% of these cases
will achieve azoospermia or rare nonmotile sperm by 24 weeks
(4) and the risk of pregnancy with fewer than 100,000 non-
motile sperm per milliliter is extremely low (9,10). If a sample
older than 2 hours (motility evaluation not reliable) shows no
sperm in 10 high-power fields, which would be fewer than
10,000 sperm per milliliter, no further testing is necessary. If
any sperm are seen in 10 high-power fields at 8 weeks, another
container or mailer is provided. If sperm are seen at 12 weeks
in a second unfresh specimen, evaluation of a fresh specimen is
required. Labrecque et al. (8,10) propose a nomogram suggest-
ing that testing be repeated every 4 to 6 weeks and that failure
due to “ persistent” recanalization (some cases will scar closed)
be considered probable only if motile sperm persist over
FIGURE 55.15 After the abdominal end is divided, it slips up into the 6 months. When 100,000 or more non-motile sperm per milli-
vas sheath and a H alsted hemostat is used to close the sheath margins
over the now-buried abdominal end. liter persist for over 6 months, failure should be considered,
but even this is considered overly cautious by some (11,12).
so that it will not hang up on scrotal wall fascia as it released

back into the scrotum. Be careful that the sheath is not drawn
so tightly around the lower end that it indents the surface, O UTCO MES
compromising blood flow to the segment outside the sheath.
Should that end slough, the remaining stump would be inside Re sult s
the sheath, defeating the intent of fascial interposition. An ad-
ditional hemoclip can be applied for hemostasis if necessary. Using fascial interposition with a hemoclip to bury the testicu-
The ringed clamp on the testicular end is opened and the divided lar end, over the past 16 years and approximately 10,800 va-
vas ends fall back into the scrotum. The testicular end is not sectomies, four patients (0.04% ) experienced early failure
ligated or cauterized, making this an open-ended technique. (motile sperm at 4 months) and required repeat vasectomies,
The same procedure is repeated on the other side. and four patients (of whom we are aware), again 0.04% ,
The patient is instructed to recline on the day of the surgery. experienced late failure (pregnancy and confirmation of
Ice packs are recommended by many surgeons to decrease the motile seminal sperm or paternity 1 year after azoospermia).
risk of hematoma formation. On the day after surgery, patients Since February 2007, the author has buried the prostatic end
may walk and drive ad lib but should avoid yard work, sports, of the vas, hoping for an even lower failure rate. As of M ay
and heavy lifting. They may shower, then continue use of scrotal 2008 and 2,465 vasectomies with burial of the prostatic end,
supports for 2 more days. Two days after the vasectomy, patients there has been one early failure (again 0.04% ) and no late fail-
may return to normal activities and sex but should limit aggres- ures. It is still too early to present a rate of late failures and to
sive athletic workouts to half of the normal routine to see if determine whether abdominal-end fascial interposition is su-
they are ready for normal routines thereafter. perior to testicular-end fascial interposition.
upstream in the proximal vas and epididymis and may en-

Co mp licat io ns hance the prognosis for success with a future vasovasostomy.
O pen-ended vasectomy expectedly reduces the risk of pain
Early due to congestive epididymitis, but paradoxically does not in-
Three levels of hematoma are possible: small (2–3 cm) inci- crease the risk of tender sperm granuloma (14) and actually
dental hematomas following needle or no-needle anesthesia reduces it. For granulomas that are exquisitely tender, most
will usually resolve within a few days; medium (3–5 cm) patients will respond to nonsteroidal anti-inflammatories.
hematomas due to delayed bleeding of a weakened small Some may also respond to an injection of a steroid near the
vessel may take 2–3 weeks to resolve; for large ( 5 cm) granuloma, but some will require surgical excision.
hematomas, surgical drainage should be considered to de- Chronic pain of the scrotal contents after vasectomy is a
crease the duration of morbidity. Reported rates average syndrome with various names: postvasectomy pain syndrome
about 2% but are higher (4.6% ) for surgeons who perform (PVPS), congestive epididymitis, postvasectomy orchalgia, and
few vasectomies (1 to 10 per year) and lower (1.6% ) for sur- chronic testicular pain (15). In two studies conducted 7 to
geons who perform many vasectomies ( 50 per year). The in- 12 months following vasectomy, 14.7% of men described some
cidence is lower with N SV (0.3% versus 1.4% ), during which degree of chronic discomfort of the scrotal contents; approxi-
tissue is spread for exposure of the vas, than with traditional mately 1% described the pain as “ quite severe and noticeably
vasectomy. affecting quality of life” (16), and 1% to 2% expressed regret
Postvasectomy inflammation can occur anywhere from over having had the vasectomy because of pain. Rates were
3 days to years following vasectomy. Patients who have had about the same at 10 years following vasectomy, indicating
little discomfort following vasectomy may “ out of the blue” that the incidence does not increase or decrease with time.
develop swelling and tenderness at the vasectomy site or PVPS is thus defined as intermittent or constant unilateral or
within the epididymis and convoluted vas “ upstream” from bilateral testicular pain for 3 months following vasectomy,
the vasectomy site. M ost cases are unilateral and respond severe enough to interfere with daily activities and cause the
quickly to nonsteroidal anti-inflammatories. patient to seek medical attention. There are no predictors as to
Infection with conventional incisional vasectomy has been which patients will develop it, there is no clear-cut etiology,
reported to occur in 1.4% of cases compared with a rate of and there is no best treatment. The syndrome is not due to in-
0.1% with N SV (13). The most severe and obvious cases fection, so antibiotics are not helpful. M edical treatment op-
develop into scrotal abscesses that require surgical drainage. tions include nonsteroidal anti-inflammatories, scrotal
There is one published report of lethal gangrene due to beta- support, nerve blocks, and tricyclic antidepressants. Surgical
hemolytic strep with onset 2 days after vasectomy in a previ- treatments include conversion to open-ended vasectomy, vasec-
ously healthy young man. tomy reversal, epididymectomy, and orchiectomy (15).
Prolonged sexual dysfunction following vasectomy is rare.
Lat e Through the years questions have been raised about an
Sperm granulomas form at the vasectomy site to varying de- association between vasectomy and a variety of subsequently
grees in up to 60% of patients. A granuloma probably forms diagnosed disease states, including atherosclerosis, prostate
when sperm leak from the testicular end of the divided vas and cancer, glomerulonephritis, and primary progressive aphasia.
cause the inflammation needed for their absorption, typically So far, reviews of the initial studies point out methodologic fac-
in the second or third week following vasectomy. This actually tors, and subsequent studies have not been able to support any
vents the congestion and inflammation that often occurs association between vasectomy and any disease states (17).
References
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CHAPTER 56 ■ VASO EPIDIDYMO STO MY
PETER T. K. CHAN
Azoospermia may be due to bilateral obstruction at any point of

the male excurrent ductal system, which comprises the efferent
ductules, epididymis, vas deferens, and the ejaculatory ducts.
Primary obstructive azoospermia is most commonly due to bi-
lateral obstruction of the epididymides, if the iatrogenic cause of
vasal obstruction postvasectomy is excluded. Obstructive
azoospermia due to epididymal obstruction can be corrected by
microsurgical reconstruction with vasoepididymostomy.
Vasoepididymostomy is considered the most technically
challenging operation in male reproductive microsurgery. With
the introduction of optical enhancement, microsurgical end-
to-end single-tubule anastomosis was introduced by Silber (9)
in 1978, and end-to-side anastomosis by Wagenknecht et al.
(10) Berger (1) described a tubular intussusception using three
double-armed microsutures placed to an epididymal tubule in
a triangular fashion (Fig. 56.1). Subsequently, M armar (7)
modified this technique, using only two microsutures placed
perpendicularly to the epididymal tubule for the anastomosis
(Fig. 56.2). Chan et al. (2,3) reported placing the two micro-
sutures longitudinally to the epididymal tubules, allowing the
incision on the tubules to be made longitudinally (longitudinal FIGURE 56.2 Two-needle intussusception vasoepididymostomy. This
technique allows the use of two double-armed sutures to provide a
intussusception vasoepididymostomy [LIVE]) and resulting in four-point fixation on the vasal end for the anastomosis.
a larger lumen of epididymal inflow to the anastomosis.
of epididymal obstruction is prolonged vasal obstruction after

DIAGNO SIS vasectomy. Besides a vasectomy, other history that may sug-
gest an obstruction include previous surgeries, instrumenta-
A thorough history and physical examination often provide tion, or trauma in the groin, pelvis, scrotum, prostate, or
important clues that can lead to the diagnosis of epididymal urethra or prior epididymoorchitis. A family history of cystic
obstruction. In N orth America, by far the most common cause fibrosis suggests that the patient may be a carrier of mutations
in the cystic fibrosis transmembrane conductance regulator
gene (congenital bilateral absence of vas deferens with epi-
didymal obstruction).
The physical examination should include a complete exam-
ination of the scrotum, vas deferens, testes, and epididymides.
Findings suggestive of epididymal obstruction include a vasec-
tomy performed in the proximal convoluted vas, a full epi-
didymis or epididymal cysts with normal testicular volume
and texture, and the time since the vasectomy. The presence of
a vasal sperm granuloma reduces the risk of epididymal ob-
struction. Congenital bilateral absence of the vas deferens on
scrotal examination represents another finding consistent with
obstruction of the excurrent ductal system. Semen analyses
demonstrating azoospermia with normal ejaculation volume,
pH , and fructose level are consistent with isolated bilateral
epididymal obstruction.
The diagnoses of unilateral obstruction and partial epi-
FIGURE 56.1 Triangulation intussusception end-to-side vasoepididy- didymal obstruction are difficult to make or confirm, as these
mostomy. Three double-armed microsutures are placed in a triangula-
tion fashion on the epididymal tubule, which is opened in the center of
patients generally do not present with azoospermia, but rather
the triangle formed. The ends of the sutures are placed on the vasal with infertility with a combination of oligo-, astheno-, and
end to complete the anastomosis. teratospermia. If unilateral or partial epididymal obstruction
379
is suspected clinically and vasoepididymostomy or other sur- can be an effective alternative to allow them to conceive as
gical reconstruction of the excurrent ductal system is contem- early as possible.
plated, cryopreservation of sperm preoperatively should be
considered as it is possible that the semen profile may decline
significantly postoperatively if the reconstructive surgery fails.
Epididymal obstruction is generally an intraoperative
SURGICAL TECHNIQ UE
diagnosis, as suggested by the presence of active spermato- A light general anesthesia is preferred. Slight movements are
genesis within the testis and the absence of sperm in a patent greatly magnified by the operating microscope and may dis-
vas deferens. Although additional evaluations, including turb performance of the anastomosis. In the absence of any
cystoscopy and various imaging studies, including scrotal clinical evidence of complicated obstruction (e.g., multiple
and transrectal ultrasound, computerized tomography, and previous failure of reconstruction attempts, large vasal gap,
magnetic resonance imaging, may provide information significant fibrosis in scrotal structure on physical examina-
that is consistent with epididymal obstruction, they are tion), regional anesthesia with sedation can be employed in
neither sensitive nor specific enough to diagnose epididymal cooperative and motivated patients. Appropriate intraopera-
obstruction and are generally not required prior to vasoepi- tive intravenous antibiotics should be considered, particularly
didymostomy. in cases with a significant past history of infection in the geni-
Active spermatogenesis must be confirmed prior to attempt- tourinary tract.
ing reconstruction of the excurrent ductal system. Confirmation
of active spermatogenesis can be obtained through bilateral tes-
ticular biopsy performed as an isolated procedure ahead of
time. H istologically, the cross section of each seminiferous Pre p arat io n o f t he Vas
tubule should have over 20 mature spermatids. Alternatively,
cytologic examination of testicular aspiration for spermatozoa A high scrotal incision (Fig. 56.3) is preferred to allow ade-
intraoperatively prior to vasoepididymostomy may confirm the quate mobilization of the inguinal portion of the vas to anas-
presence of active spermatogenesis. tomose to the epididymis without any tension. When isolating
the vas, its periadventitial sheath should not be stripped off to
preserve its blood supply. As the epididymis lies laterally in the
posterior aspect of the testis, the vas should be mobilized and
INDICATIO NS isolated lateral to the rest of the spermatic cord to allow a
more direct contact with the epididymis for the anastomosis.
Vasoepididymostomy is indicated in cases of obstructive In patients who had a previous vasectomy, the vas should be
azoospermia due to epididymal obstruction. Vasoepididy- transected at the vasectomy site to evaluate whether the testic-
mostomy should be performed in epididymal tubules that con- ular vas contains sperm and whether a vasoepididymostomy is
tain abundant sperm (motile or immotile) or sperm parts indicated. The cut surface of the testicular end of the vas def-
(heads and tails). Absence of abundant sperm or sperm parts erens is inspected with the operating microscope under 15 to
indicates that the level of epididymal obstruction is located 25 magnification. A healthy, white mucosal ring should be
more proximally, where the anastomosis should be per- seen that springs back immediately after gentle dilation with a
formed. Vasoepididymostomy should not be attempted in the 2- to 3-mm microvessel dilator. The muscularis should appear
absence of vasa, when the vasal gap is too big to be bridged smooth and soft. A gritty-looking muscularis layer indicates
despite appropriate surgical maneuvers for tissue mobiliza- the presence of scar/fibrotic tissues. H ealthy bleeding should
tion, or in case of azoospermia due to testicular failure be noted from both the cut edge of the mucosa as well as the
(nonobstructive azoospermia). surface of the muscularis. If the blood supply is poor or the
ALTERNATIVE THERAPY
Besides microsurgical reconstruction with vasoepididy-
mostomy, men with azoospermia due to epididymal obstruc-
tion may have sperm retrieved surgically from the
epididymides (microscopic [M ESA] or percutaneous [PESA]
epididymal sperm aspiration) or from the testes (testicular
sperm aspiration [TESA] or testicular sperm extraction
[TESE]) for intracytoplasmic sperm injection (ICSI) to
achieve pregnancy with their partners. With the increasing
popularity and availability of assisted reproductive technolo-
gies such as in vitro fertilization and ICSI, the safety and effi-
cacy of these technologies have improved significantly in
FIGURE 56.3 A high scrotal incision (solid lines) for vasoepididy-
recent years. Particularly for couples in whom the female mostomy allows to option to extend the incision (dotted lines)
partners are of advanced reproductive age or have significant towards the external inguinal ring (marked by X ) for mobilization of
female-factor infertility, sperm retrieval combined with ICSI the abdominal vas to bridge a larger gap for the anastomosis.
Chap t e r 56: Vasoe p id id ymostomy 381
muscularis is gritty, the vas should be recut until healthy tissue fashion proximally. O nce sperm are identified, seal the punc-
is found. ture with a bipolar cautery and begin the anastomosis a few
In patients with primary epididymal obstruction with no millimeters proximally along the epididymal tubule. Since the
previous vasectomy, the vas is isolated at the junction of the microsutures are to be placed longitudinally, a straight seg-
straight and convoluted vas, where it is hemitransected with a ment of the tubule is more preferable than one that is curved.
15-degree ophthalmic knife. Transection of the vas at this This would allow the needle bites to run further along the
area will allow the maximal length of straight vas to be pre- tubule and a longer incision to be made longitudinally be-
served to allow a tension-free vasoepididymostomy to be per- tween the two needles.
formed. The vasal fluid is sampled and evaluated under light
microscopy. The absence of sperm and sperm parts in the
vasal fluid indicates epididymal obstruction. O n the other
hand, the presence of abundant motile sperm indicates the Pre p arat io n o f t he Ep id id ymal Tub ule
absence of epididymal obstruction, and evaluation of vasal
patency distally is essential to identify the location of the ob- The epididymal tunic covering the tubule is thick and tough.
struction. In this case, the hemitransected vas can be reap- O n the other hand, the bare epididymal tubule underneath is
proximated with interrupted 10-0 and 9-0 microsutures in thin and delicate, and extra care should be taken to avoid ac-
two layers. cidentally puncturing it, resulting in leakage of epididymal
Patency of the abdominal end of the vas should be con- fluid and collapse of the tubule. After the initial cut on the epi-
firmed by saline vasogram in which a 24G soft angiocatheter didymal tunic, there is often still a thin layer of residual tunic
connecting to a syringe containing 1 to 3 cc of saline is used to covering the epididymal tubule. Use of indigo carmine on the
cannulate the vas. Easy injection of saline towards the abdom- tissue may enhance visualization of the residual overlying
inal vas confirms patency. If patency is not certain, a dye vaso- tunic. The residual tunica should be dissected off fully with a
gram using 1 to 3 cc of 1:10 diluted indigo carmine should be combination of sharp and blunt dissection to expose the bare
performed. After injection of dye, bladder catheterization epididymal tubule underneath and to facilitate its intussuscep-
should review blue or green dye in the urine to confirm pa- tion into the vasal lumen when completing the anastomosis.
tency. If patency is not confirmed, formal vasography with di- The vas deferens is drawn up through an opening in the
luted water-soluble radiographic contrast medium can be used tunica vaginalis and secured in proximity to the anastomotic
to locate the obstruction. site with two to four interrupted sutures of 6-0 polypropylene
placed through the vasal adventitia and the tunica vaginalis.
Care should be taken to avoid taking too deep a bite with the
suture; this may result in accidental closure of the vasal lumen,
Id e nt ificat io n o f t he Ap p ro p riat e rendering failure of the surgery. The vasal lumen should reach
Ep id id ymal Tub ule the opening in the epididymal tunica easily, with length to
spare. To avoid tension or kinking of the vas, the surgeon
After confirming that a vasoepididymostomy is necessary should inspect the position and orientation of the vas not only
and that the abdominal vas is patent and of adequate length, when the testicle is delivered outside, but also when the testi-
the testis within the tunica vaginalis is delivered outside the cle is placed back into the scrotum. The posterior edge of the
wound. A longitudinal incision is made on the anterior as- epididymal tunica is then approximated to the posterior edge
pect of the tunica vaginalis. In long-term epididymal obstruc- of the vas muscularis and adventitia with two or three inter-
tion, a small hydrocele is often noted when opening the rupted sutures of 9-0 nylon (Fig. 56.4). This is done in such a
tunica vaginalis. The epididymis is then inspected under the way as to bring the vasal lumen in close approximation to the
operating microscope at 16 to 25 magnification to select epididymal tubule selected for anastomosis. Adequate hemo-
an anastomotic site above the area of suspected obstruction. stasis of the vas and the epididymal tunic is essential, as the
O ften, a discrete yellow sperm granuloma is noted, above fluid in the epididymis cannot dissolve blood clot, which may
which there is indurated epididymis and dilated tubules, obstruct the anastomosis.
and below which the epididymis is soft and the tubules are
collapsed.
Selection of the correct level of the epididymal tubule for
anastomosis should not be a random event. The diameter of Lo ng it ud inal Int ussusce p t io n
the epididymal tubule increases gradually from caput to Vaso e p id id ymo st o my
cauda. Anastomosing to the larger tubule may result in a
higher patency rate. O nce a potential epididymal tubule for The LIVE procedure is our preferred method of microsurgical
the anastomosis is identified, a relatively avascular area of the vasoepididymostomy as it greatly simplifies the procedure
epididymal tunica is grasped with sharp jeweler’s forceps and while yielding the highest patency rate among the various al-
tented upward. A 3- to 4-mm buttonhole is made in the tunica ternative techniques that we have employed (4–6). To allow
with microscissors to create a round opening that matches the even distribution of the suture points, four microdots are
outer diameter of the prepared vas deferens. placed with a micro marking pen on the vasal ends to demar-
If the level of obstruction in the epididymis is not clearly cate the exit points of the suture needles to be placed on the
demarcated, choose a tubule distally and puncture it with a vas (Fig. 56.4A). For the anastomosis, we prefer to use 1-inch
10-0 needle to aspirate epididymal fluid and examine it micro- monofilament 10-0 nylon sutures, double-armed with 70-
scopically. If sperm are not found, proceed in an identical micron-diameter taper-point needles. Double-armed sutures
A B
D
C
E F
FIGURE 56.4 Longitudinal intussusception vasoepididymostomy

(LIVE). A: The vas is secured on the edge of the tunica epididymis
with two or three 9-0 sutures with its lumen opposing the midportion
of the isolated epididymal tubule. B: Placement of the two double-
armed 10-0 mucosal sutures in a longitudinal fashion on the tubule
that is opening with a longitudinal incision between the needles. C
and D: The sutures are pulled through and placed in an inside-out
fashion on the vasal ends. E and F: A 9-0 tension-reducing suture is
placed to position the vasal lumen in direct opposition with the epi-
didymal lumen prior to tying the mucosal sutures. G: When the epi-
didymal tubule is aligned in parallel with the vasal lumen, both
mucosal sutures can be tied to their own ends to complete the anasto-
G mosis.
allow inside-out placement of the needles on the mucosa, prior to tying. When setting up the anastomosis, in order to
eliminating the need for manipulation of the mucosa and the achieve the lowest tension possible without kinking the vas,
possibility of back walling. M odification of the LIVE tech- the vasal lumen usually may end up lying parallel (Fig. 56.4)
nique for the use of longer double-armed needles or single- or perpendicular (Fig. 56.5) to the direction of the epididy-
armed needles will be described later. mal tubule. The ends of sutures for tying should be chosen
The vas is secured with 9-0 nylon sutures on the edge of the carefully according to the orientation of the vas with respect
tunica epididymis opening, with the vasal lumen positioned at to the direction of the epididymal tubule. In the setting
the center of the selected epididymal tubule. Under the highest when the vas and the epididymal tubules are parallel to each
magnification of the operating microscope (25 to 40 ), the other, the two sutures are tied with their own ends on either
needles of two double-armed 10-0 microsutures are placed side of the stay suture (Figs. 56.4F, 56.4G). In the setting
longitudinally on the epididymal tubule (Fig. 56.4B). Leave when the vas and the epididymal tubules are perpendicular
the microneedles in the epididymal tubule until it is ready to to each other, it is not necessary to push the ends of the 10-0
be incised longitudinally. Since the diameter of the needle sutures on the same side of the 9-0 tension-reducing suture
(70 microns) is significantly larger than the suture diameter to tie. Instead, the two 10-0 sutures can simply be cross-tied
(17 microns), pulling through the needle will result in leakage to each other (Figs. 56.5B, 56.5C).
of the epididymal fluid. The collapse of the epididymal tubule, The advantages of LIVE include providing a four-point fix-
along with the impaired visibility from the cloudy epididymal ation at the mucosal anastomosis using two double-armed mi-
fluid, makes it difficult to place an additional suture or to crosutures and allowing a larger epididymal lumen to be
make a precise opening in the tubule for the anastomosis. created with a longitudinal incision on the tubule. A water-
Using a 15-degree ophthalmic knife, the tubule is incised tight outer-layer anastomosis between the vasal sheath and
longitudinally between the two needles of the 10-0 sutures the epididymal tunic is crucial to avoid leakage of fluid, which
(Fig. 54.4B). The epididymal fluid is then aspirated with a can lead to formation of sperm granuloma. We recommend
5-microliter micropipette or with a 24G angiocatheter con- placing 10 to 12 interrupted sutures of 9-0 nylon for the outer
nected to a syringe for aspiration. The fluid is examined for layer closure (Fig. 56.5D). Care should be taken to avoid in-
sperm under light microscopy. We generally recommend that jury to the peripheral epididymal tubules during the placement
the surgeon evaluate the epididymal fluid himself or herself of needles on the epididymal tunic.
with a bench-top light microscope intraoperatively. This al- LIVE is a delicate procedure. Errors can occur at several
lows a quicker and more accurate answer to be obtained and crucial points of the surgery, requiring the anastomosis to be
avoids drying of the slide during transit to a pathologist/cytol- performed more proximally. Examples may include absence of
ogist outside the operating room, which may compromise the sperm or sperm parts in the epididymal fluid, tearing of the
interpretation. epididymal tubule, or breakage of a mucosal suture. In any of
If motile sperm are found, cryopreservation of the sample these cases, a new spot more proximally in the epididymis
should be considered for future use with ICSI should the anasto- should be identified to redo the anastomosis. The surgeon
mosis fail. Generally, if the level of the epididymal tubule is care- should not feel frustrated when it is necessary to take down
fully selected, the fluid inside is likely to contain sperm or sperm the setup and redo the procedure at a more proximal site.
parts. Absence of abundant sperm or sperm parts in the fluid in- Although it is time-consuming to redo an anastomosis, the ex-
dicates that obstruction is still proximal to the selected segment tra time is well worth it. Vasoepididymostomy is a delicate op-
of tubule and anastomosis should not be performed there. eration where the outcome is highly dependant on technical
The needles of the two double-armed 10-0 sutures are then perfection.
pulled through and placed to the mucosa in the vasal ends in
an inside-out fashion through the four microdots (Figs. 56.4C,
56.4D). Depending on whether the selected epididymal tubule
for the anastomosis lies parallel (Fig. 56.4) or perpendicular
Clo sure
(Fig. 56.5) to the vas, the placement of the needles on the vas After careful hemostasis and copious irrigation of the tissue,
may vary. the tunica vaginalis should be closed with absorbable sutures
and the testis returned intrascrotally in the correct orientation.
Care should be taken to avoid any tension when manipulating
Co mp le t ing t he Anast o mo sis the testis and spermatic cord after a delicate anastomosis is
completed. With careful control of hemostasis, the risk of
To avoid tearing the 10-0 sutures out of the epididymal tubule scrotal edema or hematoma can be minimized and drainage is
during tying, it is necessary to position the vas to allow the generally not necessary.
vasal and epididymal lumina to be in direct opposition to each
other. This is achieved by placing a 9-0 tension-reducing su-
ture approximating the epididymal tunic to the vasal sheath
prior to tying the 10-0 microsutures (Figs. 56.4E, 56.4F). This Mane uve rs t o Gain Ext ra Le ng t h
9-0 suture is tied loosely to allow visualization of the anasto- t o Brid g e a Larg e r Gap
mosis during tying of the 10-0 sutures. Just prior to tying, the
ends of each of the 10-0 sutures should be gently pulled until The simplest maneuver that should be attempted first to gain
the opposite end just begins to move. This prevents having a length to bridge a larger gap for the anastomosis is to mobilize
loose loop of suture in the anastomosis and ensures that the the abdominal vas superiorly towards the external inguinal
epididymal mucosa is plastered against the vasal mucosa ring. The skin incision may be extended towards the external
C D
FIGURE 56.5 Longitudinal intussusception vasoepididymostomy (LIVE) when the epididymal tubule lies per-
pendicular to the vasal lumen. A: After pulling through the 10-0 mucosal sutures from the epididymal tubules,
they are placed on the vasal end according to the plan for tying. B: A 9-0 tension-reducing suture is placed to po-
sition the vasal lumen in direct opposition with the epididymal lumen prior to tying the mucosal sutures. C: In
this scenario, the mucosal sutures can be cross-tied with the end of the other mucosal suture to complete the
anastomosis. D: Ten to 12 9-0 sutures are placed on the vasal sheath and the tunica epididymis to complete the
outer layer of the anastomosis.
inguinal ring to facilitate this maneuver. Care should be taken

to avoid stripping the periadventitial sheath to compromise
the vasal blood supply. When there is still inadequate length of
the vas deferens to reach the dilated epididymal tubule with-
out tension, the cauda and corpus epididymis can be dissected
off the testis and flipped up to obtain additional length (Fig.
56.6). To do this, the full depth of the epididymis is encircled
with a small Penrose drain at the level of obstruction and, un-
der 8 to 16 magnification, it is dissected distally off the
testis, yielding sufficient length to perform the anastomosis
(4). Usually, a surgical plane can be developed between the
epididymis and testis, and injury to the epididymal blood sup-
ply can be minimized by staying right on the tunica albuginea
of the testis. The inferior and if necessary the middle epididy-
mal branches of the testicular artery are doubly ligated and
divided to free an adequate length of epididymis. The superior
epididymal branches entering the epididymis at the caput
are always preserved and can provide adequate blood supply
to the entire epididymis. The tunica vaginalis in then closed
over the testis with absorbable suture, which prevents drying
of the testis and thrombosis of the surface testicular vessels FIGURE 56.6 The corpus and caudal epididymis can be dissected off
during the anastomosis. The dissected epididymis can remain from the testis tunica albuginea and brought superiorly to bridge a
outside the tunica vaginalis for the anastomosis. massive vasal gap.
complete the anastomosis. Tying of the two single-armed sutures

Use o f Sing le -Arme d Micro sut ure s fo r can follow the same principle as described previously.
Lo ng it ud inal Int ussusce p t io n
Vaso e p id id ymo st o my
LIVE can be performed using 10-0 single-armed sutures, which Use o f Lo ng Do ub le -Arme d Micro sut ure s
are less costly than the double-armed ones (8). The disadvantage fo r Lo ng it ud inal Int ussusce p t io n
is that two of the four needle placements on the vasal end have Vaso e p id id ymo st o my
to be done in an outside-in fashion. Two 10-0 sutures are first
placed on the vas in an outside-in fashion. If the selected epi- LIVE can be performed using a single long (6-inch) double-
didymal tubule lies perpendicularly to the vasal lumen, it is rec- armed microsuture. Similar to the use of single-armed micro-
ommended to place the two needles on the two dots on the same sutures, the disadvantage is that two of the four needle
side as the dominant hand of the surgeon (Fig. 56.7A). If the se- placements on the vasal end have to be done in an outside-in
lected tubule lies in parallel to the vas, the sutures can be first fashion. The two needles at each end are first placed in the vas
placed on the two upper microdots and then pulled through the in an outside-in fashion. If the selected epididymal tubule lies
vasal lumen (Fig. 56.7B). Insertion of a 2- to 3-mm microvessel perpendicularly to the vasal lumen, it is recommended to place
dilated during the outside-in placement of the needle may fur- the two needles on the two dots on the same side as the domi-
ther decrease the risks of back walling of the vasal lumen mu- nant hand of the surgeon (Fig. 56.8A). If the selected tubule
cosa. The LIVE procedure can then be performed in a similar lies in parallel to the vas, the sutures can be first placed on the
fashion, with the two needles placed on the epididymal tubules two upper microdots and then pulled through the vasal lumen
where a longitudinal incision is made between the needles. The (Fig. 56.8B). Insertion of a 2- to 3-mm microvessel dilated
sutures are then pulled through and placed to the remaining two during the outside-in placement of the needle may further de-
microdots marked on the vasal end in an inside-out fashion to crease the risks of back walling of the vasal lumen mucosa.
A
A
B B
FIGURE 56.7. A: Placement of single-armed microsutures for longi- FIGURE 56.8. A: Placement of a long double-armed microsuture for
tudinal intussusception vasoepididymostomy (LIVE) when the epi- longitudinal intussusception vasoepididymostomy (LIVE) when the
didymal tubule is in parallel to the vasal lumen. The arrow s indicate epididymal tubule is in parallel to the vasal lumen. The arrow s indi-
the placement of the first bites of the two sutures. B: Same technique cate the placement of the first bites of the two needles. B: Same tech-
when the epididymal tubule is perpendicular to the vasal lumen. The nique when the epididymal tubule is perpendicular to the vasal lumen.
arrow s indicate the placement of the first bites of the two sutures The arrow s indicate the placement of the first bites of the two needles
when the surgeon is right-handed. of the suture when the surgeon is right-handed.
The LIVE procedure can then be performed in a similar fash- achieved pregnancy with assisted reproduction, all using fresh
ion, with the two needles first placed on the epididymal ejaculated sperm.
tubules where a longitudinal incision is made between the nee-
dles. The sutures are then pulled through and placed to the re-
maining two microdots marked on the vasal end in an Co mp licat io ns
inside-out fashion to complete the anastomosis. Since a single
double-armed suture is used in this case, suture tying needs to Potential surgical complications associated with vasoepididy-
be done only once. Care must be taken to ensure there is no mostomy include wound infection, scrotal edema, hematoma,
loose loop of suture before tying; otherwise, leakage of epi- orchalgia, and persistent epididymal obstruction (surgical fail-
didymal fluid may occur. ure). M ost of these complications are self-limiting and can be
managed conservatively. M ore devastating complications such
as ischemic epididymal fibrosis and testicular atrophy may be
encountered rarely. The risk of complications increases in pa-
O UTCO MES tients who have multiple previous unsuccessful reconstruction
attempts with a significant extent of tissue fibrosis in the scro-
Re sult s tal contents, or in cases where additional dissection is required
to mobilize the vas or the epididymis to bridge a larger gap for
We recently reported our clinical experience of microsurgical the anastomosis.
LIVE in a series of 72 men with azoospermia due to epididy- Patients should also be instructed on the various preventive
mal obstruction (3). The mean age of the subjects was 39.3 measures, such as avoidance of strenuous physical activities im-
years. The etiologies of obstruction were postvasectomy mediately postoperatively, use of an ice pack for wound or scro-
(69% ), infection (22% ), iatrogenic (5% ), trauma (1% ), and tal compression to prevent the development of hematoma or
idiopathic (3% ). The median duration of obstruction was edema, and avoidance of ejaculation for up to 4 weeks to mini-
18.7 years. Previous failed attempts at reconstruction were mize the risks of disruption of the anastomosis due to the force
noted in 38% of patients. M ean follow-up period was 16.3 of propulsion of the excurrent ductal system from orgasm.
months. Postoperatively, semen analyses may be performed at 1
The patency rate, defined as 10,000 sperm per milliliter of month and subsequently every 2 to 3 months. Patients who
semen at any time postoperatively, was 92% . Early patency have motile sperm return to the ejaculate should consider cry-
was achieved in 73% of subjects at 4 to 6 weeks postopera- opreserving sperm, as initially patent anastomoses may even-
tively. The median best sperm count was 12.9 10 6 /mL, with tually shut down. From our experience with LIVE, the great
a 23% rate of forward motility. The late “ shut-down” rate, majority of patients who have a patent anastomosis will have
defined as the percentage of subjects who had sperm postoper- sperm in the ejaculate in the first 6 months. It is rare for
atively but later became persistently azoospermic, was 4% at patients who have been persistently azoospermic in the first
1 year postoperatively. The median duration of the procedure 6 months postoperatively to have the anastomoses open up.
was 55 minutes per anastomosis. Persistently azoospermic men without cryopreserved sperm
Among patients with follow-up over 1 year, the natural can opt for a redo vasoepididymostomy or surgical sperm re-
pregnancy rate was 31% . M edian time to achieve natural trieval by various techniques combined with ICSI to achieve
pregnancy was 15.3 months. An additional 39% of patients pregnancy with their partner.
References
1. Berger RE. Triangulation end-to-side vasoepididymostomy. Journal of 6. Chan PT, Brandell RA, Goldstein M . Prospective analysis of outcomes after
Urology, 1998;159:1951–1953. microsurgical intussusception vasoepididymostomy. BJU Int 2005; 96(4):
2. Chan PT, Li PS, Goldstein M . M icrosurgical vasoepididymostomy: a 598–601.
prospective randomized study of 3 intussusception techniques in rats. 7. M armar JL. M odified vasoepididymostomy with simultaneous double nee-
J Urol 2003;169:1924–1929. dle placement, tubulotomy and tubular invagination. Journal of Urology
3. Chan PT, Lee R, Li PS, et al. Six Years of Ex perience w ith M icrosurgical 2000;163:483–486.
L ongitudinal Intussusception Vasoepididym ostom y (L IV E): A Prospective 8. M onoski M A, Schiff J, Li PS, et al. Innovative single-armed suture tech-
A nalysis. Abstract presented at the 2008 Annual M eeting of the American nique for microsurgical vasoepididymostomy. Urology 2007;69(4):
Urological Association. 800–804.
4. Chan PTK, Goldstein M . Vasectomy and vasectomy reversal. In: Kandeel 9. Silber SJ. M icroscopic vasoepididymostomy: specific microanastomosis to
FR, ed. M ale R eproductive D ysfunction. N ew York: Informa H ealthcare, the epididymal tubule. Fertility and Sterility 1978;30:565–571.
2007:385–405. 10. Wagenknecht LV, Klosterhalfen H , Schirren C. M icrosurgery in andrologic
5. Chan PTK, Goldstein M . Reproductive tract reconstruction and vasectomy urology. I. Refertilization. Journal of M icrosurgery 1980;1:370–376.
reversal. In: Chan PTK, Goldstein M , Rosenwaks Z , eds. R eproductive
M edicine Secrets. Philadelphia: H anley & Belfus, 2004:112–135.
CHAPTER 57 ■ VASO VASO STO MY
MARC GO LDSTEIN AND HO WARD H. KIM
Of the 500,000 men undergoing vasectomy each year in the Physical findings specific to the vasectomy site include the
United States, an estimated 2% to 6% will ultimately seek rever- presence of a sperm granuloma and the length of the vasal
sal (1). Despite the proven safety and efficacy of reversal surgery, gap. Sperm granulomas are found in 10% to 30% of men un-
vasovasostomy is not universally accepted. A significant draw- dergoing reversal surgery (7). The presence of a sperm granu-
back to vasovasostomy is the variable time interval to recovery loma can serve as a pop-off valve for the efferent ductile
of fertile sperm from the ejaculate, which is especially problem- system, protecting the epididymis from the detrimental effects
atic for patients with partners of advanced maternal age. The of increased intratubular pressure, and increases the likeli-
lack of access to a microsurgeon trained in the vasovasostomy hood of vasovasostomy being required instead of vasoepididy-
and vasoepididymostomy procedures is another potential limita- mostomy. A large gap between the obstructed vasal ends may
tion. With the widespread availability of assisted reproductive require inguinal extension of the scrotal incision and addi-
techniques (ART), some have questioned the need for complex tional dissection to ensure a tension-free anastomosis.
reconstructive procedures for postvasectomy infertility.
M icrosurgical vasovasostomy was first described in the
1970s by Earl O wen and Sherman Silber. O wen reported a pa- Lab o rat o ry Evaluat io n
tency rate of 98% in his series of 50 patients (2). Silber noted
that normal sperm counts can be achieved in up to 95% of pa- A semen analysis with examination of the centrifuged pellet is
tients (3). This technique has been refined even further since its the primary laboratory test obtained prior to reversal surgery.
introduction, and similar, if not better, success rates have been Up to 10% of patients will have sperm with tails in the cen-
reported recently by dedicated urologic microsurgeons (4). trifuged pellet at a mean of 10 years after vasectomy (8), a
Most cost-benefit analyses have found that reversal procedures finding indicative of likely sperm in at least one has deferens,
are the most efficacious and economical management of post- meaning a vasovasostomy will almost certainly be possible
vasectomy infertility (5), even in men with previous failed on at least one side with a good overall prognosis for return
vasectomy reversal (6), demonstrating that microsurgical recon- of sperm to the ejaculate. An elevated level of serum follicle-
struction is an important treatment option in appropriately stimulating hormone (FSH ) suggests poor spermatogenesis in
selected patients. men with small, soft testes, which may precipitate further
diagnostic workup. In men with elevated serum FSH levels or
in men without prior fertility, the serum antisperm antibody
DIAGNO SIS assay helps to make a case for obstructive azoospermia with
active spermatogenesis (9).
The preoperative workup for men requesting vasectomy reversal
is straightforward. Confirmation of previous natural fertility is
often sufficient documentation of spermatogenesis. H owever, INDICATIO NS FO R SURGERY
if the patient has never fathered children in the past or if he
has obstructive azoospermia without a history of prior vasec- Although an overwhelming majority of vasovasostomies are
tomy, further workup is necessary. The workup includes a full performed in men with postvasectomy infertility, a significant
history, physical examination, and basic laboratory tests, in- number of men undergo repair for iatrogenic injury to the vas
cluding a semen analysis, and should be performed in con- deferens. In a series of 472 patients surgically explored for
junction with evaluation of the female partner. An obstructive obstructive azoospermia, 7.2% had an iatrogenic injury (10).
etiology such as complications from a previous hernia repair M ode of injury included inguinal hernia repair (more frequently
may be revealed in the medical history. pediatric hernia surgery), renal transplantation, appendec-
tomy, and spermatocelectomy (10). Because these patients
often have longer vasal defects, impaired blood supply, and
Physical Exam longer obstructive intervals, surgery is usually more challeng-
ing technically and outcomes are worse.
The physical examination provides important clues about the
likelihood for successful reversal surgery. Testicular volume
and consistency mirror the spermatogenesis status; soft, small Pro g no st ic Fact o rs
testes suggest impaired spermatogenesis, and a testicular biopsy
may be necessary prior to reconstruction. An indurated epi- Several patient and partner factors influence the outcome of re-
didymis or an ipsilateral hydrocele may predict the presence of versal surgery and should be considered during the preoperative
a secondary epididymal obstruction, which would necessitate evaluation. These factors include prior fertility, age at vasec-
a vasoepididymostomy. tomy, medical and surgical history subsequent to vasectomy,
387
obstruction interval, and partner’s age and fertility status. The

chance for successful pregnancy following vasectomy reversal
decreases from 56% in patients whose partners are 20 to 39
years of age to 14% in those whose partners are age 40 or older
(11). M en with the same partners from before the vasectomy
procedure also fare better, perhaps due to proven previous
fecundity together and shorter time interval since vasectomy
(12). Regarding time interval between the initial vasectomy and
subsequent reversal surgery, we found patency and pregnancy
rates of 91% and 89% , respectively, for obstruction interval of
5 years and 89% and 44% , respectively, for obstruction inter-
val of 15 years (13). The Vasovasostomy Study Group had
similar results: they reported patency and pregnancy rates of
97% and 76% , respectively, for obstruction interval of 3
years, which fell to 71% and 30% for obstruction interval of 15
years or more (14). Finally, as a significant number of reversals
FIGURE 57.2 The specially designed microsurgical chair adjusts for
actually require vasoepididymostomy on one or both sides, the optimal support of the chest and arms.
surgeon must be comfortable with performing both surgeries.
position, the use of specially designed microsurgical chairs

increases the stability of the surgeon’s chest and arms (Fig. 57.2).
ALTERNATIVE THERAPY By standing or sitting on the patient’s right side, the right-
handed surgeon is in position to place the more difficult
Alternatives to vasovasostomy include in vitro fertilization abdominal end vasal sutures with the forehand.
(IVF) with intracytoplasmic sperm injection (ICSI) using re-
trieved sperm, donor sperm insemination, and adoption.
Selecting between vasovasostomy and vasoepididymostomy Ane st he sia
based on intraoperative vasal fluid findings will be discussed
later in this chapter. With the availability of IVF/ICSI, the use of Although regional anesthesia can be used for uncomplicated
donor sperm or adoption for postvasectomy infertility is rare. vasovasostomies, general anesthesia is preferred to minimize
disruptive motion when placing the delicate anastomotic
sutures, especially during complex or prolonged reconstruc-
SURGICAL TECHNIQ UE tive procedures. The patient’s ability to remain still and the
surgeon’s experience and comfort level should be considered
in selecting the type of anesthesia.
O p e rat ing Ro o m Se t -up
A two-headed operating microscope with 6 to 32 power Incisio n
magnification is used (Fig. 57.1). Foot pedal controls allow
the surgeon to zoom and focus the field of view without inter- After a dose of intravenous cefazolin and standard surgical
rupting the surgery. The microscope is used for most of the preparation of the groin and genitalia in the supine position,
procedure, with the exception of the opening incision and clo- the external inguinal ring is marked on both sides (Fig. 57.3).
sure. Although the operation can be performed in the standing Careful palpation of the vasectomy site helps to determine the
level of the incisions, usually high vertical scrotal incisions at
FIGURE 57.1 The operating microscope has two heads for the sur-
geon and the assistant. M icroscope settings are checked before start- FIGURE 57.3 A: The right surgical incision is marked over the scro-
ing the procedure. (All photos courtesy of M arc Goldstein, M D and tal skin. The external inguinal ring is marked with an X . The incision
Philip S. Li, M D) is at least 1 cm away from the penis.
Chap t e r 57: Vasovasostomy 389
FIGURE 57.3 B: The skin incisions for both sides are marked. FIGURE 57.6 The testis is delivered into the field, with the tunica
vaginalis intact.
least 1 cm lateral to the base of the penis for optimal cosmetic

preferred. Incision through the scar from the previous surgery
results. The incision should be long enough to allow delivery of
usually leads directly to the obstruction. Even if the epididymis
the testis; the tunica vaginalis should be kept intact to optimize
needs to be exposed, the testis can be delivered through the
exposure of the vas deferens (Figs. 57.4–6). The incision may
inguinal incision or through a separate scrotal incision.
be extended toward the external ring if a high vasectomy or
large vasal gap is encountered. Alternatively, if the site of vasal
disruption is even higher, such as in the case of inguinal Exp o sure o f t he Vasa De fe re nt ia
obstruction secondary to herniorrhaphy, an inguinal incision is
Adequate exposure of the vas deferens is critical for achieving a
tension-free anastomosis (Fig. 57.7). To preserve the blood sup-
ply of the vas deferens, the correct dissection plane must be
achieved along the vasal sheath; venturing too close to the
sheath endangers the periadventitial vasal blood supply,
whereas straying too far away from the sheath jeopardizes the
testicular artery. Injury to the testicular artery can result in tes-
ticular atrophy, as the deferential artery likely has been dis-
rupted during the previous vasectomy. The operating
microscope should be used for this dissection with at least 10
power magnification to provide adequate visualization and to
minimize risk of injury to the vessels. After gentle blunt dissec-
tion of the vas deferens, two Babcock clamps are placed above
and below the obstructed segment (Fig. 57.8). Finding the
proper dissection plane can be facilitated by transilluminating the
sheath with the operating light (Fig. 57.9). A curved mosquito
clamp is used to puncture this space at two points on either side
FIGURE 57.4 The skin incision is made with a #15 blade. of the vasectomy site (Fig. 57.10), and two quarter-inch Penrose
FIGURE 57.7 Blunt dissection with a gauze-covered finger releases

FIGURE 57.5 Electrocautery is used for the underlying dartos layer. the vas deferens from the surrounding tissue.
FIGURE 57.8 Two Babcock clamps are placed along the length of the A
vas deferens.
B
FIGURE 57.11 A: Q uarter-inch Penrose drains are brought through
the two openings made by transillumination. B: Using traction on the
FIGURE 57.9 Transilluminating the tissue surrounding the vas defer- Penrose drains, the vas deferens is released using both blunt and sharp
ens by bringing the operating light low helps to identify the correct dissection.
dissection plane.
additional length when a long vasal gap is encountered. Blunt
dissection with the index finger through the external inguinal
ring can release the abdominal vas deferens almost to the level
of the internal inguinal ring without opening the external
oblique aponeurosis. Distally, the convoluted vas deferens can
be dissected from the epididymal tunica (Figs. 57.12 and
57.13). Up to 6 cm of additional length can be achieved with
FIGURE 57.10 The plane between the vas deferens and the surround-
ing tissue is pierced with a Crile clamp.
drains are pulled through to serve as handles to traction the vas

deferens while gently separating the surrounding tissue with
both blunt and sharp dissection with small fine M etzenbaum
scissors (Fig. 57.11).
Length is more difficult to achieve on the abdominal portion FIGURE 57.12 The vas deferens is freed distally to the level of the
of the vas deferens. Several maneuvers can be used to achieve convolutions.
FIGURE 57.13 The convoluted vas deferens is fully exposed. A
these techniques. Another 4 to 6 cm can be released by further

dissection of the epididymis from the testis, up to the level of the
caput epididymis. Again, the blood supply must be carefully
preserved. Finally, the Prentiss maneuver can provide up to
10 cm of vasal length when used in combination with the other
techniques.
Pre p arat io n o f t he Vasa De fe re nt ia

The obstructed segment, along with any associated vasectomy
clips or sperm granuloma, is excised, first on the testicular side
using an ultrasharp knife and a slotted 2-mm, 2.5-mm, or
3-mm-diameter nerve-holding clamp (Accurate Surgical &
Scientific Instruments Corp., Westbury, N Y). The slotted nerve- B
holding clamp allows for a perfect 90-degree transection
FIGURE 57.15 A: Sperm granulomas are found in 10% to 30% of
(Figs. 57.14 and 57.15). Under 15 to 25 magnification, men undergoing vasovasostomy. B: The initial cut is made on the tes-
three distinct layers—the mucosa, muscularis, and adventitia— ticular side of the obstructed segment or sperm granuloma.
can be visualized. The mucosa should be white and elastic and
the muscularis smooth and supple. Evidence of bleeding at each
layer demonstrates a healthy blood supply. If the blood supply
is in question, or if the muscularis appears gritty and fibrotic,
additional transections should be made until the appearance of
healthy tissue (Fig. 57.16). The deferential artery and vein are
ligated with 6-0 Vicryl. The micro-bipolar coagulation forceps,
set at 2.5 to 3.5 watts, help control the smaller bleeders, but
care should be taken to avoid thermal injury to the mucosa.
FIGURE 57.16 An unhealthy segment of vas deferens demonstrates

white, avascular vasal layers surrounded by fibrotic scar tissue.
Examinat io n o f Vasal Fluid

The testicular end of the vas deferens is milked and a touch-
prep is made using a glass slide (Fig. 57.17). The fluid is mixed
with a drop of lactated Ringer’s solution and a cover slip is
FIGURE 57.14 The slotted nerve-holding clamp and the ultrasharp placed. The slide is immediately examined under 40 power
knife help to make perfect 90-degree transections of the vas deferens. magnification using a separate microscope setup (Fig. 57.18).
good option for grades 1 through 4. If no sperm are found in

the vasal fluid (grade 5), the gross appearance of the vasal
fluid can help in deciding between vasovasostomy and vaso-
epididymostomy (Table 57.1). Cloudy, water-soluble fluid in-
dicates the best chance for the eventual return of sperm to the
semen, and thick, white, greasy toothpaste-like material indi-
cates the worst prognosis (Fig. 57.19). Although a standard
algorithm has not been established, the general recommenda-
tion is to proceed with vasovasostomy if sperm are identified
in the vasal fluid or if the quantity of the fluid is copious and
watery. Vasoepididymostomy should be considered if the vasal
fluid is absent or if the quality of the fluid is thick, white, and
creamy. If no fluid can be expressed for evaluation, the testic-
ular end of the vas deferens is barbitaged with 0.1 mL of saline
using a 24-gauge angiocatheter sheath, and the resultant fluid
FIGURE 57.17 A touch-prep of the vasal fluid is made by blotting the is examined (Fig. 57.20). In the presence of large sperm gran-
freshly cut testicular portion of the vas deferens onto a glass slide. ulomas, the testicular end of the vas is minimally dilated with
very little or no luminal fluid; barbitage with milking often
expresses a small amount of fluid with sperm.
The abdominal end of the vas deferens is similarly tran-
sected and inspected. The lumen is gently dilated with a mi-
crovessel dilator and about 1 mL of saline is injected with a
24-gauge angiocatheter sheath to confirm patency. In assess-
ing patency of the testicular and abdominal ends of the vasa
deferentia, the surgeon must consider the left and right sides
FIGURE 57.18 A separate microscope setup should be used to

examine the vasal fluid under 40 magnification.
In its review of vasectomy reversal, the Practice Committee of

the American Society for Reproductive M edicine (ASRM
Guidelines) graded the sperm quality of vasal fluid as follows:
grade 1, mainly normal motile sperm; grade 2, mainly normal
nonmotile sperm; grade 3, mainly sperm heads; grade 4, only FIGURE 57.19 A thick, greasy, “ toothpaste” consistency indicates a
sperm heads; and grade 5, no sperm (15). Vasovasostomy is a poor prognosis for sperm in the vasal fluid.
TA B LE 5 7 . 1
EVALUATION OF VASAL FLUID
Gross Microscopic Indicated

appearance appearance Grade surgery
Copious, cloudy, thin, water soluble Sperm with tails 1, 2 Vasovasostomy

Copious, creamy M any sperm heads, occasional 3, 4 Vasovasostomy
yellow, water-soluble sperm with short tails
Scant fluid, sperm granuloma present Barbitage fluid with sperm 1–5 Vasovasostomy
Copious, crystal clear, watery N o sperm 5 Vasovasostomy
Scant, white, thin fluid N o sperm 5 Vasoepididymostomy
Copious, thick, white, toothpaste-like, N o sperm 5 Vasoepididymostomy
water-insoluble
Dry N o sperm 5 Vasoepididymostomy
Typical intraoperative findings on vasal fluid evaluation and the recommended procedure for each finding are listed.
FIGURE 57.20 If the vas deferens is “ dry,” a 24-gauge angiocatheter FIGURE 57.22 A tongue blade wrapped with 1-inch Penrose drain
sheath is used to barbitage the lumen with saline. provides a platform for suture placement.
together, with the fundamental principle that one good anas-

tomosis is superior to two tenuous connections. For exam-
ple, if a right epididymal obstruction and a left abdominal
vas blockage are encountered, a single crossed vasovasos-
tomy should be performed. Specifically, crossed vasovasos-
tomy should be considered in the following circumstances:
(i) unilateral inguinal obstruction of the vas deferens with an
atrophic contralateral testis, or (ii) obstruction or aplasia of
the inguinal vas or ejaculatory duct with a contralateral epi-
didymal obstruction. Although this technique requires open-
ing of the scrotal septum, it is much easier than an inguinal
vasovasostomy.
Anast o mo sis o f t he Vasa De fe re nt ia

FIGURE 57.23 A rubber dam prevents sutures from sticking and get-
In preparation for the anastomosis, the two ends of the vas ting lost in the surrounding tissue.
deferens are stabilized without tension using a microspike ap-
proximating clamp (Fig. 57.21) (16). A tongue blade encased
in a 1-inch Penrose drain serves as a platform for suturing
(Fig. 57.22). The entire setup is brought up through a slit in a The Micro d o t Te chniq ue fo r Mult ilaye r
rubber dam (Fig. 57.23); the rubber dam provides a contrast- Micro surg ical Vaso vaso st o my
ing field for the black sutures and prevents the sutures from
adhering to tissue. A microtip marking pen (Devon Skinmarker Extra Fine #151,
Devon Industries, Buffalo, N Y) is used to make six equidistant
dots on the face of each transected vas deferens; the dots of one
vasal end should mirror those of the other end to prevent twist-
ing or distortion of the anastomosis (Fig. 57.24). The dots are
made at the 1, 3, 5, 7, 9, and 11 o’clock positions on the muscu-
laris, roughly halfway between the adventitia and the mucosa.
This blueprint ensures precise suture placement and a water-
tight closure even with markedly discrepant luminal diameters.
Six monofilament 10-0 nylon double-armed sutures with
70-micron-diameter taper-point needles (Sharpoint, Surgical
Specialties Corp., Reading, PA, or Ethicon, Inc., Somerville,
N J) are placed, starting with the three anterior positions (Figs.
57.25 and 57.26). Each suture begins within the lumen and
exits at the dot; this inside-out placement of the sutures mini-
mizes mucosal manipulation and reduces the risk of back-
walling. The mucosal lumen can be stained with indigo carmine
and gently dilated with the microvessel dilator as needed to fa-
FIGURE 57.21 The microspike approximating clamp stabilizes the cilitate suture placement (Fig. 57.27). Although methylene
two ends of the vas deferens for suturing. blue causes an immediate reduction in sperm motility and
A FIGURE 57.26 Three anterior mucosal sutures are placed and tied.
B
FIGURE 57.24 A: The microdots are made on the clock face of each FIGURE 57.27 Visualization of the mucosal edge is improved with
cut vasal end using a microtip marking pen. B: The microdots should the application of indigo carmine.
be symmetrical and mirror the corresponding side. N ote the size dis-
crepancy of the two vasal ends, with the larger dilated testicular end
resulting from occlusive pressure.
FIGURE 57.28 M onofilament 9-0 nylon deep muscularis sutures are

placed in between the three anterior mucosal sutures.
FIGURE 57.25 The placement of the 10-0 nylon mucosal sutures is nylon deep muscularis sutures are placed in between these
guided by the microdots. Additional fine-tuning of the suture place- three, without including the mucosa, and tied (Fig. 57.28).
ments can be made at the surgeon’s discretion. The vas deferens is rotated 180 degrees and the remaining
three mucosal sutures are placed in a similar fashion (Fig.
should be avoided in reversal surgery, indigo carmine may be 57.29). Before the final mucosal suture is tied, the vasal lumen
used (17). Each suture should include a small amount of mu- is irrigated with heparinized lactated Ringer’s solution to dis-
cosa and one third to one half of the muscularis, and the same courage clot formation. Four deep muscularis sutures are
amount of tissue should be included on each side. After the placed between the recently placed mucosal sutures for a cir-
three anterior mucosal sutures are tied, two monofilament 9-0 cumferential two-layer closure. Four to six monofilament 9-0
with minimal handling using atraumatic technique. The anas-

tomosis should be leak-proof and tension-free. As sperm are
highly antigenic, leakage at the anastomosis can develop into a
sperm granuloma and provoke an inflammatory reaction, po-
tentially leading to failure of the vasovasostomy (18). Tension
on the anastomosis may result in late stricture and failure after
an initial period of sperm in the ejaculate.
Sp e cial Circumst ance s

If unhealthy tissue or blood supply results in cutback of the
testicular portion of the vas deferens to the convoluted seg-
ment (Fig. 57.31), anastomosis to the convoluted portion of
the vas deferens follows the same principles as for the stan-
A dard anastomosis, with a few additional considerations. A
perfect 90-degree transection must be achieved; the convo-
luted segment is even more vulnerable to an oblique cut, re-
sulting in insufficient mucosa and muscularis on one side. The
surgeon must resist the temptation to unravel the convoluted
segment lest the maneuver compromise the blood supply.
Instead, additional length can be achieved with careful dissec-
tion of the vas deferens away from the epididymal tunica.
During the suturing, taking too-large bites of the convoluted
segment increases the risk for perforation of adjacent convolu-
tions. In a series of 48 patients undergoing vasectomy reversal
B
FIGURE 57.29 A: The vas deferens is rotated 180 degrees for place-
ment of the remaining sutures. B: The sutures are placed in the same
sequence as on the other side.
nylon sutures placed between the deep muscularis sutures

within the adventitia constitute the third closure layer. Finally,
the vasal sheath is reapproximated with six interrupted 8-0 ny-
lon sutures, which protects the anastomosis from tension and
enhances vascularization across the anastomosis (Fig. 57.30).
Chances for a successful operation are optimized by following
the basic principles of anastomotic surgery, including mucosa- A
to-mucosa approximation of healthy well-vascularized tissue
B
FIGURE 57.31 A: If additional length is necessary, the convoluted
FIGURE 57.30 The vasal sheath is reapproximated with 8-0 nylon segment is carefully dissected free. B: The vasal cut is made at the
sutures, covering and protecting the anastomotic sutures. juncture of the straight and convoluted portions.
athletic supporter. The supporter should be worn at all times,

even at nighttime, for 6 weeks. Thereafter, the supporter is
worn during athletic activity until pregnancy is achieved.
Light activity may be resumed in 3 days and heavy activity in
3 weeks. The patient is instructed to avoid sexual activity and
ejaculation for 4 weeks. H ydrocodone with acetaminophen
and a nonsteroidal anti-inflammatory drug are used for post-
operative pain management. Semen analyses are obtained at 1,
3, and 6 months after surgery and every 6 months thereafter.
O UTCO MES
Re sult s
FIGURE 57.32 After closure, the nonscrotal portion of the incision is
reinforced with adhesive skin-closure strips. In our published series of 194 consecutive cases, patency was
achieved in 99.5% of cases when sperm were found in the
vasal fluid on at least one side at the time of surgery (4). The
involving the convoluted vas deferens, the patency and natural
pregnancy rate in the first 100 cases was 54% , which in-
pregnancy rates were 88% and 48% , respectively, comparable
creased to 64% when female factor infertility was excluded
to outcomes with the standard technique (19).
(4). Pregnancy rates were 82% to 89% for obstructive inter-
In a less frequently encountered scenario, significant short-
vals of 0 to 15 years but significantly lower, 44% , with ob-
age of vasal length during a crossed vasovasostomy may war-
structive intervals 15 years (13). Persistent azoospermia
rant a testicular transposition. This maneuver takes advantage
beyond 6 months after surgery is an indication of likely imme-
of the superior length of the spermatic cord to the vas defer-
diate surgical failure. Late failure after initial patency were ob-
ens. Tension on the vas deferens is relieved by simply moving
served in 12% of men by 14 months after surgery, an event
the testes to the contralateral hemiscrotum through an open-
usually preceded by progressive loss of motility on semen
ing in the septum.
analyses, followed by decreasing sperm counts (20). Because
of the possibility for late stricture formation, we recommend
Clo sure cryopreservation of semen specimens when motile sperm are
found in the ejaculate.
After the four-layer anastomosis, the dartos layer is approxi- Failure of vasectomy reversal may be due to unrecognized
mated with interrupted 4-0 M onocryl followed by a subcutic- epididymal obstruction and compromised anastomosis, among
ular skin closure with 5-0 M onocryl (Fig. 57.32). Penrose other causes. With patency and pregnancy rates of 67% and
drains may be necessary with extensive dissection (Fig. 57.33); 30% , respectively, repeat vasectomy reversal surgery remains
as reversal surgery is performed on an ambulatory basis, ex- a viable option (21). Prognostic factors for successful initial
plicit instructions are given to the patient for self-removal the vasectomy reversal also apply to repeat procedures.
following day.
Po st o p e rat ive Care and Fo llo w -Up Co mp licat io ns

Bacitracin ointment and sterile gauze dressing are applied to Vasovasostomy is a safe procedure with a low risk for signifi-
the closure, followed with fluff-type gauze and a snug-fitting cant complications. Although hematoma formation is the
most common acute complication of vasectomy reversal
surgery, only seven small hematomas occurred in our series of
2,100 cases (unpublished data). All resolved in 6 to 12 weeks
without intervention. N o wound infections occurred. Sperm
granulomas, which often precede eventual obstruction,
formed in about 5% of our patients (unpublished data). In an
animal study, sperm granulomas were present in 99% of failed
anastomoses in rats undergoing vasovasostomy (18).
Co st -Be ne fit Analyse s

To address the comparative utility of reversal surgery and
ART, several cost-benefit analyses have been performed.
Pavlovich and Schlegel (5) reported a cost per delivery after
vasectomy reversal of $25,475 with a delivery rate of 47% ,
FIGURE 57.33 Penrose drains exiting the dependent portion of whereas the cost per delivery after sperm retrieval and ICSI
the scrotum provide wound drainage for cases involving extensive was $72,521 with a delivery rate after one cycle of ART with
dissection. sperm retrieval of 33% . Furthermore, a systematic review of
Chap t e r 58: Microsurg ical Varicoce le ctomy 397
four cost-benefit analyses comparing these two approaches subsequent children are possible without the need for fur-
also reported results favoring vasectomy reversal surgery (22). ther intervention. The ASRM Guidelines recommend the
Another study found the cost of microsurgical epididymal use of microsurgical reconstruction if the obstructive interval
sperm aspiration with ICSI/IVF to be 2.4 times higher than following a vasectomy is 15 years and no female fertility
vasectomy reversal, even in men with previous failed vasec- risk factors are present (15). The use of ICSI with sperm re-
tomy reversal (6). trieval is recommended if advanced female age ( 37 years
Vasovasostomy is a safe and cost-effective management of age) or fertility factors requiring IVF (e.g., tubal disease)
option for postvasectomy infertility. Although the average are present, if the chance for success is greater with this tech-
interval until pregnancy after successful microsurgical recon- nique, or if the couple prefers this method for financial or
struction is 12 months, reversal surgery has significant advan- other reasons (15).
tages over ART: the normal partner avoids treatment and
References
1. Goldstein M . Vasectomy reversal. Com pr T her 1993;19:37–41. 13. Boorjian S, Lipkin M , Goldstein M . The impact of obstructive interval
2. O wen ER. M icrosurgical vasovasostomy: a reliable vasectomy reversal. and sperm granuloma on outcome of vasectomy reversal. J Urol 2004;
J Urol 2002;167:1205. 171:304–306.
3. Silber SJ. Perfect anatomical reconstruction of vas deferens with a new mi- 14. Belker AM , Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical
croscopic surgical technique. Fertil Steril 1977;28:72–77. vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991;
4. Goldstein M , Li PS, M atthews GJ. M icrosurgical vasovasostomy: the mi- 145:505–511.
crodot technique of precision suture placement. J Urol 1998;159:188–190. 15. Practice Committee of the American Society for Reproductive M edicine.
5. Pavlovich CP, Schlegel PN . Fertility options after vasectomy: a cost- Vasectomy reversal. Fertil Steril 2006;86:S268–271.
effectiveness analysis. Fertil Steril 1997;67:133–141. 16. Goldstein M . M icrospike approximator for vasovasostomy. J Urol 1985;
6. Donovan JF Jr, DiBaise M , Sparks AE, et al. Comparison of microscopic 134:74.
epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro 17. Sheynkin YR, Starr C, Li PS, et al. Effect of methylene blue, indigo
fertilization with repeat microscopic reconstruction following vasectomy: carmine, and Renografin on human sperm motility. Urology 1999;53:
is second attempt vas reversal worth the effort? H um R eprod 1998;13: 214–217.
387–393. 18. H agan KF, Coffey DS. The adverse effects of sperm during vasovasostomy.
7. Goldstein M . Surgical management of male infertility and other scrotal dis- J Urol 1977;118:269–273.
orders. In Walsh PC, Retik AB, Vaughan DE, et al., eds. Cam pbell’s 19. Sandlow JI, Kolettis PN . Vasovasostomy in the convoluted vas deferens:
Urology, Vol. 2. Philadelphia: WB Saunders, 1997:1331–1377. indications and outcomes. J Urol 2005;173:540–542.
8. Lemack GE, Goldstein M . Presence of sperm in the pre-vasectomy reversal 20. M atthews GJ, Schlegel PN , Goldstein M . Patency following microsurgical
semen analysis: incidence and implications. J Urol 1996;155:167–169. vasoepididymostomy and vasovasostomy: temporal considerations. J Urol
9. Lee R, Ullery BW, Ehrlich JR, et al. Value of serum antisperm antibodies in 1995;154:2070–2073.
diagnosing obstructive azoospermia. J Urol 2007;639(suppl. 177): abstract 21. M atthews GJ, M cGee KE, Goldstein M . M icrosurgical reconstruction fol-
1927. lowing failed vasectomy reversal. J Urol 1997;157:844–846.
10. Sheynkin YR, H endin BN , Schlegel PN , et al. M icrosurgical repair of iatro- 22. Garceau L, H enderson J, Davis LJ, et al. Economic implications of assisted
genic injury to the vas deferens. J Urol 1998;159:139–141. reproductive techniques: a systematic review. H um R eprod 2002;17:
11. Gerrard ER Jr, Sandlow JI, O ster RA, et al. Effect of female partner age on 3090–3109.
pregnancy rates after vasectomy reversal. Fertil Steril 2007;87:1340–1344.
12. Chan PT, Goldstein M . Superior outcomes of microsurgical vasectomy
reversal in men with the same female partners. Fertil Steril 2004;81:
1371–1374.
CHAPTER 58 ■ MICRO SURGICAL

VARICO CELECTO MY
ARMAND ZINI AND ZIV MAIANSKI
A varicocele is an abnormal dilation of the pampiniform plexus The effect of varicocelectomy on male fertility is also contro-
of the testis. It is reported that 35% to 40% of infertile men versial (3,4). Uncontrolled studies have generally shown im-
have a palpable varicocele (dilated testicular veins), whereas proved semen quality and pregnancy outcome after surgery
the prevalence of a varicocele in the general male population is (3). O n the other hand, the results of randomized, controlled
about 15% (1,2). Despite extensive study, the exact mechanism studies of varicocelectomy for clinical varicocele are equivocal
by which varicocele influences fertility remains unclear. (4,5). N onetheless, varicocelectomy remains a commonly
Various theories continue to be discussed, such as abnormal treated condition in men with infertility in N orth America (6).
testicular temperature regulation with elevated scrotal temper- The benefit of varicocele repair must be balanced by the risk
ature, reduced perfusion of the affected testicle due to venous associated with the procedure itself. Therefore, it is important
stasis and backflow of toxic substances of either adrenal or re- to select the procedure with the highest success and lowest
nal origin, and changes in the testicular endocrine milieu (2). complication rate.
In addition, testicular pain associated with varicocele (in the

DIAGNO SIS absence of other pathology), psychological concern regarding
future fertility, and cosmetic reasons are all relative indica-
Varicoceles develop during early adolescence, at which time tions. Varicocele repair is not indicated in men with normal
they usually produce no symptoms. Therefore, in the adoles- semen analyses or a subclinical (nonpalpable) varicocele.
cent, the detection of a varicocele is by routine physical exam-
ination of healthy individuals. In contrast, in the majority of
adult cases, the patient is referred to the urologist following a ALTERNATIVE THERAPY
poor semen analysis. O n occasion the patient may provide a
history of dull scrotal ache or heaviness upon prolonged Several approaches exist for varicocelectomy, including
standing or exertion. retroperitoneal and inguinal open techniques, microsurgical
The physical examination should be performed in a warm inguinal and subinguinal approaches, laparoscopic repairs,
room. The patient should be examined in the standing and and radiographic embolization. The microsurgical varico-
supine positions, before and after a Valsalva maneuver. celectomy, low inguinal or subinguinal, as first described by
Careful palpation of the pampiniform plexus and measure- M armar et al. (7), is preferred by many urologist and male in-
ment of testicular size (preferably by a standard orchidometer) fertility experts because it is associated with a higher success
are essential. The Valsalva maneuver can provoke engorge- rate and lower morbidity than nonmicrosurgical techniques
ment of the plexus. Long-standing varicocele can induce a re- (8,9).
duction in volume of the affected testis, usually the left one. The subinguinal approach is associated with less operative
Varicoceles can be classified into one of three grades based and postoperative pain than the inguinal approach because,
on physical examination: with the former technique, the external oblique aponeurosis is
1. Grade I: small, palpable, following Valsalva maneuver only not opened. H owever, the subinguinal approach is more chal-
2. Grade II: moderate, clearly palpable but not visible lenging owing to the greater number of vessels (arteries and
3. Grade III: large, visible enlargement of the pampiniform veins) encountered at the subinguinal level compared to the
plexus inguinal canal.
Scrotal ultrasound including Doppler is a valuable tool to con-

firm the physical findings when the clinical exam is difficult SURGICAL TECHNIQ UE
(e.g., in obese men, when there has been prior scrotal surgery,
or when the testicle has a high scrotal position) and for objec- For the subinguinal approach, optical magnification is manda-
tive measurement of testicular size. tory to avoid injury to the testicular artery and lymphatic ves-
Abnormalities in semen analysis include a decrease in sperm sels. For a better cosmetic result in the case of bilateral
concentration and motility and an increase in abnormal morpho- varicocelectomy, we recommend marking the incision sites
logic forms classically described as “stress pattern.” However, (Fig. 58.1). The inguinal area is prepared and draped in the
none of these seminal findings are specific to varicocele. standard sterile way.
We start with a 2- to 3-cm oblique skin incision centered
over the external inguinal ring, as previously described (Fig.
INDICATIO NS 58.2) (8). The incision is deepened through the Camper and
Scarpa fasciae by lifting these layers with a mosquito clamp
The indications for repairing varicoceles in adolescents in- and dividing the tissue with monopolar electrocautery. The
clude the following: spermatic cord is exposed by placing two small Richardson
1. Palpable left varicocele with associated ipsilateral testicu- retractors at the extremities of the incision and by sliding a
lar atrophy (with the volume of the left testis being at least finger along the course of the spermatic cord, starting at the
20% less than that of the right)
2. Palpable varicocele with abnormal semen analysis results
3. Large symptomatic (painful) varicocele
4. Bilaterally palpable varicocele with testicular atrophy
Although prophylactic treatment of adolescent varicocele (for
prevention of future infertility) is not recommended, it is im-
portant to follow untreated patients, since no test can predict
whether an adolescent will be fertile or infertile.
Based on the Best Practice Policies for M ale Infertility of
the American Urological Society (5), varicocele treatment
should be offered to the male partner of a couple attempting
to conceive when all of the following are present:
1. A varicocele is palpable.
2. The male partner has one or more abnormal semen para-
meters or sperm function test results.
3. The couple has documented infertility. FIGURE 58.1 The position of the right and left subinguinal incisions
4. The female partner has normal fertility or potentially cor- (approximately 2.5 cm long) for microsurgical varicocelectomy. The
rectable infertility. arrow head points to the location of the right external inguinal ring.
Chap t e r 58: Microsurg ical Varicoce le ctomy 399
FIGURE 58.4 The testicle is delivered through the subinguinal inci-

sion. The spermatic cord (sm all arrow head) and the gubernaculum
(large arrow head) are depicted.
FIGURE 58.2 Illustration demonstrating the location of the inguinal

(A ) and subinguinal (B) incisions for microsurgical varicocelectomy
(the position of the external inguinal ring is shown).
FIGURE 58.5 The external spermatic fascia is lifted with two smooth
forceps in preparation for longitudinal incision of this fascia.
FIGURE 58.3 The spermatic cord is grasped with the Babcock clamp
and delivered through the incision.
external ring and ending at the upper scrotum. The cord is

then grasped with a Babcock clamp (Fig. 58.3), delivered, and
placed over a large (1-in.) Penrose drain. During this maneu-
ver, care is taken to spare the ilioinguinal nerve and the genital
branches of the genitofemoral nerve. The testicle is then deliv-
ered through the wound by gently pulling on the cord and
FIGURE 58.6 Illustration demonstrating the spermatic cord after
pushing the testicle cephalad. O nce the testicle is delivered, the longitudinal incision of the external (large arrow ) and internal sper-
gubernacular veins and external spermatic perforators are ex- matic fasciae (sm all arrow ).
posed, clipped, and divided (Fig. 58.4).
The testicle is returned to the scrotum, and the spermatic The internal spermatic vessels are exposed and examined
cord is elevated on a large Penrose drain. The microscope is (Fig. 58.6).
then brought into the operating field and the cord examined To simplify the procedure and protect the vas deferens and
under 8 to 15 magnification. The external and internal its vessels from potential injury during subsequent cord dissec-
spermatic fasciae are gently lifted (Fig. 58.5) and incised in the tion, we first create a window between the internal spermatic
direction of the fibers using the monopolar electrocautery. vessels and the external spermatic fascia such that the internal
parameters and with pregnancy rates in the range of 40% to

60% (3). H owever, most of these studies are retrospective,
nonrandomized, and heterogeneous (3). Several recent reviews
have critically examined the results of randomized, controlled
trials of varicocelectomy. When all randomized trials are eval-
uated (including studies of subclinical varicocele and those of
men with normal semen parameters), the data do not support
the practice of varicocelectomy for male infertility (4).
H owever, in N orth America, it is not common practice to treat
subclinical varicoceles and/or men with normal semen para-
meters (6). In a recent analysis including only randomized
studies of clinical varicoceles with abnormal semen parame-
ters, the data support the practice of varicocelectomy for male
infertility (5).
M ost studies of adolescents with varicocele indicate that
varicocelectomy has a beneficial effect on testicular function.
FIGURE 58.7 The spermatic cord is divided into two packages with a In general, surgery is indicated in boys with testicular atrophy
1-in. Penrose drain between (a) the contents of the internal spermatic and/or abnormal semen parameters. Controlled studies indi-
fascia (large arrow head) and (b) the remainder of the cord, including cate that at follow-up evaluation (1 to 15 years), varicocelec-
the vas deferens and cremasteric fibers (sm all arrow head).
tomy is associated with higher sperm parameters and higher
testicular volumes than no treatment (11,12).
spermatic vessels are separate from the external spermatic fas-

cia and its associated structures (cremasteric fibers, external CO MPLICATIO NS
spermatic vessels, vas deferens and its vessels) (10). A second
Penrose drain is then introduced between the internal sper- There are three complications specific to varicocelectomy:
matic vessels and the external spermatic fascia and its associ- 1. H ydrocele formation. This complication is believed to be
ated structures (Fig. 58.7). due to ligation of lymphatic channels. The postoperative
We first dissect the contents of the internal spermatic fascia incidence of hydrocele is significantly lower with micro-
(lying on top of the most superficial Penrose drain). Subtle scopic surgery (0% to 0.69% ) than it is with the retroperi-
pulsations will usually reveal the location of the underlying in- toneal approach (7% to 9% ), laparoscopic ligation (12% ),
ternal spermatic artery(ies). O nce identified, the artery is dis- or conventional inguinal varicocelectomy (3% to 30% )
sected free of all surrounding veins by blunt dissection using a (8,9). H ydrocele repair (hydrocelectomy) is indicated for
microsurgical needle driver and is then encircled with a 2-0 the management of a large, symptomatic (painful) hydrocele.
silk ligature for identification. Care is taken to also identify 2. Recurrence. This generally results from incomplete liga-
and isolate a number of lymphatics (usually three to six chan- tion of collateral venous channels. The recurrence rate as-
nels), and these are also encircled with a 2-0 silk ligature. All sociated with microsurgery ( 2% ) is significantly lower
internal spermatic veins are clipped or ligated (with 4-0 silk) than that with the retroperitoneal (15% to 25% ), inguinal
and divided. At the end of the first dissection, the cord is skele- (5% to 15% ), and laparoscopic approaches (5% to 15% )
tonized such that only the identified artery(ies) and lymphatics (8,9). This complication can be corrected by a repeat sur-
are preserved. gical procedure or by radiographic embolization. H owever,
We then elevate and dissect the contents of the external a redo varicocelectomy is often technically challenging and
spermatic fascia (lying between the two Penrose drains). The may pose a greater risk of complications (e.g., testicular
vas deferens and its associated vessels are readily identified atrophy, hydrocele).
and preserved. Any cremasteric artery is also preserved. The 3. Testicular ischemia and atrophy. These are a result of in-
remaining cremasteric fibers and veins are ligated and cut, jury to the testicular artery. The incidence is likely very low
thus skeletonizing the cord. At the completion of varicocelec- owing to the collateral vasculature (vasal and external
tomy, the cord should contain only the testicular artery or ar- spermatic arteries) supplying the testicle.
teries, vas deferens and associated vessels, and spermatic cord
lymphatics. The wound is irrigated with 1% N eomycin irriga-
tion, and the Scarpa and Camper fasciae are closed with a sin- SUMMARY
gle 3-0 chromic catgut suture. The incision is infiltrated with
0.5% M arcaine solution with epinephrine, and the skin is The use of the operating microscope during varicocelectomy
closed with a running 4-0 Vicryl subcuticular closure rein- allows for better identification (and preservation) of the testic-
forced with Steri-Strips. A dry sterile dressing is applied. ular artery and lymphatic channels and for complete ligation
of small collateral venous branches. Therefore, microsurgical
varicocelectomy reduces the potential for complications to a
O UTCO ME minimum and, as such, is considered superior to nonmicro-
surgical varicocelectomy (inguinal or subinguinal). H owever,
Several publications have addressed the efficacy of varico- microsurgical varicocelectomy, particularly the subinguinal
celectomy as a treatment for male infertility. In general, varico- approach, remains a technically challenging procedure that
celectomy is associated with an improvement in several sperm requires microsurgical expertise.
Chap t e r 59: Te stis Biop sy and Te sticular Sp e rm Extraction (TESE) 401
References
1. N agler H M , Luntz RK, M artinis FG. Varicocele. In: Lipshultz LI, H oward 8. Goldstein M , Gilbert BR, Dicker AP. M icrosurgical inguinal varicocelec-
SS, eds. Infertility in the m ale, 3rd ed. St. Louis, M O : M osby–Year Book, tomy with delivery of the testis: an artery and lymphatic sparing technique.
1997:336–359. J Urol 1992;148:1808–1811.
2. Fretz PC, Sandlow JI. Varicocele: current concepts in pathophysiology, di- 9. Cayan S, Kadioglu TC, Tefekli A, et al. Comparison of results and compli-
agnosis, and treatment. Urol Clin N orth A m 2002;29:921–937. cations of high ligation surgery and microsurgical high inguinal varico-
3. Schlesinger M H , Wilets IF, N agler H M . Treatment outcome after varicocelectomy in the treatment of varicocele. Urology 2000;55(5):750–754.
celectomy: a critical analysis. Urol Clin N orth A m 1994;21:517–529. 10. Z ini A, Fischer M A, Bellack D, et al. Technical modification of microsurgi-
4. Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male cal varicocelectomy can reduce operating time. Urology 2006;67:803–806.
subfertility: a systematic review. L ancet 2003;361:1849–1852. 11. Sayfan J, Siplovich L, Koltun L, et al. Varicocele treatment in pubertal boys
5. Ficarra V, Cerruto M A, Liguori G, et al. Treatment of varicocele in subfer- prevents testicular growth arrest. J Urol 1997;157:1456–1457.
tile men: the Cochrane Review—a contrary opinion. Eur Urol 2006; 12. Paduch DA, N iedzielski J. Repair versus observation in adolescent varico-
49:258–263. cele: a prospective study. J Urol 1997;158:1128–1132.
6. Sharlip ID, Jarow JP, Belker AM , et al. Best Practice policies for male infer-
tility. J Urol 2002;167:2138–2144.
7. M armar JL, DeBenedictis TJ, Praiss D. The management of varicoceles by
microdissection of the spermatic cord at the external inguinal ring. Fertil
Steril 1985;43:583–588.
CHAPTER 59 ■ TESTIS BIO PSY AND

TESTICULAR SPERM EXTRACTIO N (TESE)
PETER N. SCHLEGEL
Testicular biopsy may serve as a diagnostic or therapeutic but some of these men have limited foci of spermatogenesis
procedure, or both. Testicular biopsy is indicated for the that can provide sperm for assisted reproduction. All men (that
classification of azoospermia as obstructive (where normal we have evaluated) with congenital absence of the vas defer-
sperm production is documented on biopsy) or nonobstructive ens, normal serum FSH levels, and normal-volume ( 15-cc)
(where sperm production is markedly abnormal). For testes had sperm production, obviating the need for biopsy.
azoospermic men, testicular sperm extraction (TESE), a surgi- If performed for diagnostic purposes, biopsy should be per-
cal procedure involving retrieval of one or more samples of formed on both testes, since substantial differences in sperm
testicular tissue, may procure spermatozoa that can be used production may be present without a palpable difference in
for successful treatment with assisted reproduction. Whereas the testes. Up to 10% to 15% of men will have a substantial
testicular biopsy was previously used only to document nor- difference in sperm production in the two different testes.
mal sperm production prior to possible reconstruction of A second relative indication for testis biopsy is for the eval-
reproductive tract obstruction, men with impaired sperm pro- uation of azoospermic men with presumed abnormal produc-
duction (serum follicle stimulating hormone [FSH ] more than tion. These men with nonobstructive azoospermia (N O A) will
three times normal levels) may be candidates for testis biopsy typically have soft or small testes and an elevated FSH level.
or TESE. Although these patients are not expected to have completely
normal production and reproductive tract obstruction, in se-
lected cases sperm may be retrieved from the testis and used
TESTIS BIO PSY with assisted reproduction (intracytoplasmic sperm injection;
ICSI). A biopsy may be of value in providing some prognostic
A testis biopsy is performed to document the level of sperm information on which patients are candidates for ICSI.
production. It is used to determine whether obstruction is pre- Unfortunately, a diagnostic biopsy is performed randomly and
sent for an azoospermic man with palpable vasa deferentia. evaluates only a limited number of the hundreds of highly
Testis biopsy can also provide some diagnostic information coiled seminiferous tubules within the testis. Subsequent at-
for men with nonobstructive azoospermia. Since a single tempts at sperm retrieval are dependent on finding the most
biopsy samples very little of the testis, it may not definitively advanced spermatogenic pattern of production in the 600 to
determine if sperm are present in any area of the testis for men 800 tubules present within each entire testis. An initial, ran-
with nonobstructive azoospermia. O nly men with a serum dom diagnostic biopsy that demonstrates at least one sperma-
FSH less than three times the upper limit of normal levels will tozoon predicts the subsequent finding of sperm on attempted
have normal sperm production. Azoospermic men with small TESE in 80% to 95% of patients. The observation of at least
or soft testes are highly unlikely to have sperm production, germ cells (spermatogonia or spermatocytes) on diagnostic
biopsy predicts subsequent sperm retrieval with TESE for specimen. The sample should be cut off sharply and placed di-
about 50% of patients. In all cases, the chance of sperm re- rectly into Bouin solution or buffered glutaraldehyde. The use
trieval is determined by the most advanced pattern of sperm of formalin is avoided because of the deleterious effects that it
production on diagnostic biopsy, not the predominant pat- has on tubular architecture. A “ wet prep” of the cut semini-
tern. For men who have only tubules with Sertoli cells in their ferous tubular surface or a “ squash prep” of a separate piece of
lumen, the chance of sperm retrieval from another area of the tubules on a glass slide, bathed with lactated Ringer solution
testis is at least 35% to 40% . Therefore, the prognostic value and compressed with a cover slip, can be immediately exam-
of a diagnostic biopsy in N O A is limited. ined under the microscope. The presence of sperm alone does
Diagnostic information on the status of spermatogenesis is not guarantee obstruction; however, only men with motile
most reliably determined on evaluation of a thin-sectioned sperm are highly likely to have distal obstruction.
stained fixed tissue specimen. Specimens for tissue evaluation The tunical levels and the skin should both be closed to en-
can be obtained by open biopsy, needle biopsy, or, occasionally, courage hemostasis. Generous injection of 0.25% bupivacaine
fine needle aspiration. Given the potential inadequacy of needle into the tunica vaginalis space and the subcutaneous areas
biopsy or fine needle aspiration, with its attendant risks to the provides excellent local anesthesia postoperatively.
vasculature of the testis, the open biopsy technique is prefer-
able. The biopsy should be performed prior to reconstruction
(rather than simultaneous to vasoepididymostomy) in most ”Q uick Pre p ” Cyt o lo g ic Evaluat io ns fo r
cases, so that a definitive analysis of sperm production is possi- Me n w it h Pre sume d O b st ruct io n
ble on fixed sections prior to further exploration. In addition,
vasography is superfluous at the time of biopsy and should be Since introduction of the testis biopsy as a diagnostic tool by
avoided because of the risk of vasal injury or stricture. H otchkiss (3) and Charney (4), a variety of refinements in
technique have been proposed to improve its usefulness. The
role of a testis biopsy is to evaluate spermatozoal production
Te chniq ue and, indirectly, the presence or absence of reproductive tract
obstruction. Since formal testis biopsy requires fixation, em-
For open biopsy, the procedure may be done under local or bedding, and staining of specimens for interpretation, biopsy
general anesthesia. The testis must be accurately positioned and reproductive tract reconstruction must occur at different
with the scrotal skin tightly stretched over the testis, and the times. Q uantitative analysis of testicular sperm production is
epididymis must be secured in a posterior position. A 1-cm in- possible by counting the number of mature spermatids per
cision is made transversely over the midportion of the testis round tubule, as described by Silber and Rodriguez-Rigau (5).
(Fig. 59.1). The incision is carried out down to the tunica vagi- Several techniques have attempted to provide additional infor-
nalis. Cutting through this tunic is confirmed intraoperatively mation or “ quick analysis” from testis biopsy specimens.
by the release of a small amount of clear fluid, expressed from
within the space of the tunica vaginalis. A stay suture is placed Te chniq ue : To uch Pre p
through a nonvascularized region of the testis, preferably in a The touch prep (testicular touch imprint) is a cytologic smear of
superior, medial, or lateral position. N onreactive suture such fluid from the cut surface of testicular parenchyma. The touch
as nylon or polypropylene is preferred. O ptical loupes or an prep is performed during testis biopsy by taking a clean glass
operating microscope may help identify vessels under the tu- slide and placing it on the cut surface of seminiferous tubules
nica albuginea, limiting the risk of injury to the testicular after obtaining a specimen for permanent section. The slide is
blood supply. A 0.5-cm incision is made through the tunica al- applied to the cut surface in several areas and immediately
buginea with a sharp no. 11 blade or a fine ophthalmic knife. cytofixed with a commercial spray or 95% ethyl alcohol. The
A small sample of seminiferous tubules should extrude easily smear is subsequently stained via the Papanicolaou technique.
through this incision. If a sample is not easily delivered, the in- Identification of individual spermatogenic cells as well as ma-
cision may not be long or deep enough. Excessive pressure to ture spermatozoa is possible. The most important role of the
extrude tubules may adversely affect the architecture of the touch prep is to differentiate between late maturation arrest and
complete spermatogenesis. Late maturation arrest may be diffi-
cult to assess on biopsy, since mature sperm with tails are
uncommonly seen on the thin slice of a histologic slide, and
quantitation of spermatozoal production is usually inferred
from the number of mature spermatids present on fixed testis
biopsy specimens. Q uantitation of spermatozoa on touch prep
allows direct evaluation of whether late maturation arrest may
be present. Detection of fully formed testicular sperm morphol-
ogy is also possible. A diagnosis of late maturation arrest spares
the patient unnecessary scrotal exploration and even possible
partial epididymectomy in a futile attempt at reconstruction.
Little published data exist regarding the frequency of late
maturation arrest or the sensitivity (or specificity) of the touch
prep technique. If late maturation arrest is very uncommon
and false-positive results occur with the touch prep, then it is
possible that more patients may be denied reconstructive
FIGURE 59.1 Technique for open testicular biopsy. microsurgery than are benefited by diagnosis of late maturation
arrest. Certainly, the touch prep can be of great value when features. ICSI has changed our view of the functional capacity
late maturation arrest is suspected. of testicular spermatozoa; these sperm are now routinely used
to effect pregnancies using in vitro fertilization (IVF) with
Te chniq ue : We t Pre p ICSI. In the unobstructed setting, sperm quality improves as
A wet prep is performed after the standard biopsy specimen the spermatozoa travel from caput to cauda epididymis; how-
has been atraumatically transferred into Bouin solution. For ever, this is not true in the obstructed setting. In reproductive
the wet prep, a small additional piece of testis is placed on a tract obstruction, improved motility is seen in sperm retrieved
clean glass side with Ringer lactate, and the tissue is com- from the areas of the epididymis closer to the testis (caput)
pressed under a glass cover slip. Analysis of this specimen can compared to the distal end of the epididymis (cauda). In con-
be performed immediately in the operating room. The pres- trast, sperm from the cauda region of an obstructed epi-
ence or absence of sperm is documented, and the motility of didymis are in advanced stages of degeneration and necrosis.
sperm can also be evaluated. N ormal sperm are absent or rare, whereas macrophages filled
The presence or absence of sperm is not very predictive of with phagocytized sperm remnants or sperm with blunt or
the findings on fixed permanent sections, but the presence of coiled tails are seen in abundance. This finding is often re-
sperm motility may be of importance. A review of 100 consecu- ferred to as “ inverted motility.” Therefore, in some cases, it is
tive testis biopsy and wet prep evaluations at Cornell indicated possible that better sperm quality can be found in the testis.
that histology (complete spermatogenesis) and cytology (pres- Although it has long been thought that sperm exiting the
ence of sperm on wet prep) were concordant in only 81% of testis are immature and incapable of fertilization, this holds true
biopsies. H owever, the presence of motile sperm had a 100% only in the unobstructed system. In obstruction, better-quality
positive predictive value for the presence of reproductive tract sperm can be found proximally, in the rete testis, vasa efferen-
obstruction. For the 18 cases where motile sperm were present, tia, or caput epididymis, and the more distal (cauda) epididymis
it would have been safe to proceed with microsurgical recon- is the site of sperm degeneration. These factors should be taken
struction of the reproductive tract. The converse is not applica- into account during any attempt at sperm retrieval.
ble; the absence of motile sperm did not predict the absence of
obstruction. In fact, 47 out of 65 men (72% ) with obstruction
did not have motile sperm present on wet prep. No no b st ruct ive Azo o sp e rmia:
Further data collection will be helpful to fully evaluate the He t e ro g e ne it y o f Sp e rm Pro d uct io n
relevance of sperm motility on wet prep examination during
testis biopsy. Based on the data available, the presence of It has previously been shown that human testicular histology is
motile testicular sperm is highly suggestive of the presence heterogeneous; that is, there can be small foci of abnormal
of distal obstruction. spermatogenesis adjacent to normal seminiferous tubules. The
converse of this previously casual observation is now the cor-
nerstone of treatment for men with nonobstructive azoosper-
Summary: Te st is Bio p sy mia. Successful sperm retrieval is possible in most TESE
attempts in men with nonobstructive azoospermia, despite di-
Testis biopsy is a diagnostic technique to assess spermatogenesis. agnostic testis biopsy specimens showing predominantly matu-
It is most useful to determine whether obstruction is the cause ration arrest or Sertoli cell-only. The ability to retrieve sperm
of azoospermia. It is possible to take additional tissue during from the testes of men with nonobstructive azoospermia is in-
this diagnostic procedure that can be frozen for subsequent dependent of testicular size and FSH level but dependent on the
therapeutic trials of assisted reproduction. Cytologic evaluation, most advanced level of spermatogenesis identified. All stan-
performed concurrently with standard testicular biopsy, may dard parameters of testicular evaluation (testicular volume,
provide important adjunctive information. Touch prep tech- FSH , inhibin B levels) evaluate overall function of the testis.
niques allow for the detection of late maturation arrest, not Since sperm retrieval and pregnancy are dependent on finding
evaluable on fixed permanent sections. Touch prep techniques sperm in just one small focu of the testis, the only predictor of
allow for evaluation of the presence of sperm within the seminif- successful treatment is the most developed region of the testis,
erous tubule, without removing an additional piece of testicular not the predominant pattern of testicular histology, overall tes-
parenchyma. The wet prep technique allows an evaluation of ticular volume, or FSH . These observations suggest that nearly
sperm motility. The presence of sperm motility appears to be all cases of male factor infertility can potentially be treated.
highly indicative of the presence of obstruction. Further infor-
mation regarding the frequency of late maturation arrest and the
endurance of the predictive value of wet prep sperm motility is Int racyt o p lasmic Sp e rm Inje ct io n
needed. At present, cytologic techniques should best be consid-
ered adjuncts to, not a replacement for, careful evaluation of Without question the most significant advance in the treat-
fixed permanent testicular biopsy specimens. ment of male infertility has been the technique of intracyto-
plasmic sperm injection or ICSI. The procedure involves the
deposition of a single sperm directly into the oocyte cytoplasm
SPERM RETRIEVAL FO R with a micropipette. The advantages of this technique are that
ASSISTED REPRO DUCTIO N it bypasses all oocyte barriers so that even severely abnormal
spermatozoa can successfully fertilize as long as the spermato-
It had long been thought that sperm exiting the testis lack ma- zoon is viable. At this point, ICSI has been applied successfully
turity, motility, and fertilizing capability and that transit to obstructive and nonobstructive azoospermia with fresh and
through the epididymis is essential to the acquisition of these thawed spermatozoa obtained from the epididymis and testis.
FIGURE 59.2 Technique of fine needle aspiration of testis.
As ICSI has been more widely applied, it has become evident men. In this procedure, the testis is stabilized between the
that female factors, not male, present the primary limitations surgeon’s thumb and forefinger and a needle is inserted along
to ICSI success in couples unable to achieve a pregnancy. the long axis of the testis. The needle is withdrawn slightly
and redirected in order to disrupt the testicular architecture.
The procedure is repeated until adequate testicular material
Pe rcut ane o us Te st icular Sp e rm Asp irat io n has been aspirated. A Franzen needle holder can be used to
provide negative pressure for needle aspiration (Fig. 59.2).
As mentioned above, it was previously thought that sperm
retrieved from the testis were incapable of fertilization.
H owever, it is now well established that testicular sperm can Pe rcut ane o us Te st icular
be used effectively with ICSI, although the cytogenetic abnor- Bio p sy (Pe rcBio p sy)
mality rate is higher in testicular than in epididymal or ejacu-
lated sperm. Although testicular sperm retrieval has been A technique of percutaneous biopsy of the testis has also been
reported in cases of obstructive azoospermia after epididymal described. A 15-gauge biopsy gun with a short (1-cm) excur-
aspiration attempts failed, the primary indication for open tes- sion is used to retrieve testicular tissue (Fig. 59.3). Anesthesia is
ticular sperm retrieval today should be for sperm acquisition achieved with a spermatic cord block, and multiple biopsies
in nonobstructive azoospermia. can be obtained through a single entry site. The patient may be
Testicular sperm can be recovered using fine needle aspira- prepared for this procedure by the topical application of local
tion (FN A), percutaneous biopsy, or an open technique. The anesthetic as EM LA cream (Astra-Z eneca Pharmaceuticals,
technique of percutaneous fine needle aspiration of the testis Worcester, M A). The core needle provides better sperm yield
was initially described as a diagnostic procedure in azoospermic than fine needle aspiration and is relatively simple to use.
FIGURE 59.3 Technique of percutaneous testicular biopsy

(PercBiopsy).
region near the midportion of the medial, lateral, or anterior

Te st icular Sp e rm Ext ract io n surface of the testis is chosen, and a generous incision in the
tunica albuginea is created with a 15-degree ultrasharp knife,
Testicular sperm retrieval using an open biopsy technique
avoiding any capsular testicular vessels. With this approach,
(TESE) is rarely, if ever, indicated for men with obstructive
direct visualization of large areas of the testis can be achieved,
azoospermia. The procedure is more invasive and is not needed
which allows for either large sample biopsies or microdissec-
in obstructive azoospermia to allow sperm retrieval. If an open
tion. Since the incision is directed at an avascular region, the
procedure is performed, then our experience is that over 99%
sperm retrieval procedure is less traumatic than multiple
of men (184 out of 185) with obstructive azoospermia will have
“ blind” biopsies. The testis is opened widely to allow direct
approximately 100 10 6 or more sperm retrieved from the
examination of all areas of testicular parenchyma. Dissection
epididymis with microsurgical epididymal sperm aspiration
between the tubules is also needed to view tubules that are not
(M ESA). Sperm retrieval from the epididymis is far more
exposed with the initial approach (Fig. 59.4). The microdis-
efficient than testicular biopsy extraction in that it provides bet-
section technique that we have applied allows the removal of
ter sperm yield and motility when compared to that obtained
tiny (2 to 3 mm; 3- to 5-mg volumes) of testicular tissue with
with TESE in obstructive azoospermia. This provides sperm
improved sperm yield (1). The tubules containing sperm can
quantities sufficient for a virtually unlimited number of ICSI
often be identified visually under an operating microscope
attempts. If testicular sperm retrieval is planned because of
after opening the testis, when approximately 10 to 15
patient preference or if microsurgical expertise is not available,
magnification is used to assist the biopsies. The tubules con-
then PercBiopsy is the recommended approach.
taining sperm production are directly identified based on their
large size and white color. If all tubules appear uniform at high
No no b st ruct ive Azo o sp e rmia power magnification, then dissection is performed to allow
access to other regions of the testis. Finally, if no sperm have
Testicular access is required for sperm retrieval in nonobstruc- been seen in microdissected samples, additional searching
tive azoospermia since pockets of sperm production are lim- throughout testicular tissue is done, avoiding the centrifugal
ited and evaluation of large areas of the testis or multiple testicular vessels that course parallel to and between the
biopsies are usually needed to retrieve sperm. Although testi- septae that separate seminiferous tubules.
cular fine needle aspiration has been used to retrieve sperma- The excised testicular tubular segments are placed in
tozoa in azoospermic men, documentation of its effectiveness buffered human tubal fluid or a similar culture medium
is lacking for men with nonobstructive azoospermia. Two supplemented with 6% Plasmanate. Isolation of individual
controlled studies have shown that open biopsy has a substan- tubules from the mass of coiled testicular tissue is achieved by
tially higher yield of sperm for men with nonobstructive initial dispersal of the testis biopsy specimen using scissors,
azoospermia (1,2). An alternative approach is to perform preferably in a small Petri dish. Additional dispersion of
testis biopsies with intentional cryopreservation. H owever, tubules is achieved by passing the suspension of testicular tis-
this approach may lead to unnecessary biopsies, since up to sue through a 24-gauge angiocatheter. Individual tubules may
35% of “ azoospermic” men will have sperm found with care- also be evaluated directly in the embryology laboratory imme-
ful examination of the ejaculate on the day of planned simul- diately prior to ICSI, but the evaluation of sperm in the oper-
taneous TESE-ICSI. In addition, sperm “ retrieved” from the ating room during TESE provides critical information to the
testis and frozen may not survive the freeze-thaw process in surgeon to determine how much dissection and/or removal of
nonobstructive azoospermia. M oreover, multiple biopsies may tissue is necessary.
be needed to retrieve sperm in men with nonobstructive Intraoperatively, a “ wet prep” of the suspension is prefer-
azoospermia, and a simultaneous biopsy-by-biopsy analysis is ably examined under phase-contrast microscopy at 200
required with careful analysis by an experienced embryologist. power in the operating room. If no spermatozoa are seen, then
A microsurgical approach to TESE is presented herein. (a) additional samples of tissue are obtained through the same
tunical incision, (b) the remainder of the testis is examined by
evaluating the exposed regions of testicular tissue and (c) expo-
Micro d isse ct io n Te st icular sure of deeper tubules is effected by dissecting between the sep-
Sp e rm Ext ract io n (Micro TESE) tae and everting the testicular tissue, and then (d) examination
of the contralateral testis is performed if no sperm have been
M icrosurgical TESE offers the advantages of improved yield found. The sperm extraction process is complete when sperm
of spermatozoa per biopsy, less tissue removal (and less risk of are reliably identified in the wet preparation of a biopsy speci-
testicle loss), and improved identification of blood vessels men. O therwise sperm extraction attempts are stopped when
within the testicle, minimizing the risk of vascular injury and all areas of the testis have been examined. Care must be taken
loss of remaining functional areas of the testis. to preserve vessels between and within the septae of the testis
O n the day of, or preferably on the day before, oocyte re- that contain the tubules. Additional incisions beyond the initial
trieval, scrotal exploration is performed through a median wide incision should be avoided, as they could adversely affect
raphe incision under local or general anesthesia, and sperm the blood supply to the testis. O perating through a limited in-
are retrieved using an open technique. In order to confirm ac- cision may not allow the surgeon to adequately control bleed-
curate identification of the testis, observe all testicular vessels, ing within the testis. N ot only does this potentially obscure the
and avoid any injury to the epididymis, delivery of the testis is testicular tissue, but the scar tissue that develops within the
routinely performed. testis postoperatively is primarily caused by postoperative
Testicular blood vessels under the tunica albuginea are bleeding within the testicle. Therefore, meticulous hemostasis
identified with 6 to 8 optical magnification. An avascular with bipolar cautery during the procedure is important.
Centrifugal vessels
Extroversion of testicular
parenchyma for
microdissection
FIGURE 59.4 Exposure during

microdissection testicular sperm
extraction (TESE).
Subsequent processing of the testicular tissue suspension, commonly in men previously treated with platinum-based reg-
including mechanical disruption and/or additional enzymatic imens for germ cell tumor (73% ) than in men treated for lym-
digestion of the specimens, is performed in the IVF laboratory. phoma with cytoxan-based regimens (48% ). O f 91 attempts
Aliquots of tissue can also be processed for cryopreservation. at sperm retrieval for men who have Klinefelter syndrome
(47, XXY; nonmosaic), sperm were found for 68% of men,
and clinical pregnancy (fetal heartbeat on ultrasound) was
Re sult s o f TESE fo r achieved in 43% of cases once sperm were retrieved.
No no b st ruct ive Azo o sp e rmia
We have done microdissection TESE on over 865 men with Summary: Sp e rm Re t rie val
nonobstructive azoospermia. Sperm retrieval rates for
azoospermic men are 63% . O nce sperm are obtained, the Sperm retrieval for use with the advanced form of assisted re-
testicular sperm will fertilize 55% of oocytes injected using production, ICSI, is now possible for many men with non-
the ICSI technique. Clinical pregnancies (fetal heartbeat seen obstructive azoospermia. M en with azoospermia may have
on ultrasound) are obtained during 48% of successful sperm unique genetic defects, such as Y chromosome microdeletions,
retrieval attempts for couples with nonobstructive azoosper- that should be evaluated prior to an attempt at conception. In
mia. O ngoing or delivered pregnancies occurred for 43% of obstructive azoospermia, several options exist to allow for
successful attempts at sperm retrieval. sperm retrieval rates approaching 100% . In nonobstructive
N o etiology of azoospermia provided an absolute predictor azoospermia, TESE is required and sperm retrieval is less cer-
for the presence or absence of sperm within the testes, except tain. At the Weill Cornell M edical Center, 63% of couples with
for the presence of complete deletions of the AZ Fa or AZ Fb nonobstructive azoospermia have sperm retrieved from the
regions of the Y chromosome. (Testicular volume and serum testis with TESE, and 48% of couples achieved a clinical preg-
FSH levels did not predict sperm retrieval.) Sixty-four at- nancy using testicular sperm in nonobstructive azoospermia.
tempts at sperm retrieval-ICSI have been made where the man Since some couples will not have sperm retrieved with TESE,
had testicular failure because of prior chemotherapy treat- the use of frozen donor spermatozoa as backup should be dis-
ment. Sperm were obtained in 53% of attempts, slightly more cussed with couples prior to simultaneous TESE-ICSI attempts.
References
1. Schlegel PN . Testicular sperm extraction: microdissection improves sperm 4. Charney CW. Testicular biopsy: its value in male infertility. J A m M ed
yield with minimal tissue excision. H um R eprod 1999;14:131–135. A ssoc l940;115:1429–1432.
2. Amer M , Ateyah A, H any R, et al. Prospective comparative study between 5. Silber SJ, Rodriguez-Rigau LJ. Q uantitative analysis of testicle biopsy: de-
microsurgical and conventional testicular sperm extraction in non-obstructive termination of partial obstruction and prediction of sperm count after
azoospermia: follow-up by serial ultrasound examinations. H um R eprod surgery for obstruction. Fertil Steril 1981;36(4):480–485
2000;15(3):653–656.
3. H otchkiss RS. Testicular biopsy in the diagnosis and treatment of sterility
in the male. Bull N Y A cad M ed 1942;18:600–605.
CHAPTER 60A ■ EPIDIDYMAL SPERM
ASPIRATIO N
CIGDEM TANRIKUT AND MARC GO LDSTEIN
O bstructive azoospermia is the blockage of the male repro-

ductive tract resulting in complete absence of sperm in the INDICATIO NS FO R SURGERY
ejaculate. Up to 40% of azoospermic patients undergoing fer-
tility evaluation will have an obstructive etiology (4). Although many postvasectomy patients are candidates for mi-
Fortunately, cases of obstructive azoospermia now comprise crosurgical reconstruction via vasovasostomy or vasoepididy-
the most treatable of male factor problems owing to the devel- mostomy (see Chapters 56 and 57), not all such patients are
opment of advanced reproductive techniques: in vitro fertiliza- willing or able to undergo reconstruction. O bstructive
tion (IVF) and intracytoplasmic sperm injection (ICSI). azoospermia related to blockages of the epididymides or vasa
O bstruction may be either congenital or acquired, occur- deferentia, regardless of etiology, may be addressed via surgi-
ring along any point of the male excurrent ductal system: epi- cal sperm retrieval followed by IVF-ICSI.
didymis, vas deferens, or ejaculatory duct. Congenital causes
of obstructive azoospermia include congenital absence of the
vasa deferentia and idiopathic epididymal obstruction. ALTERNATIVE THERAPY
Acquired reasons for reproductive tract obstruction include
prior vasectomy, previous genitourinary tract infection, iatro- Surgical alternatives to epididymal sperm extraction in men
genic injury related to prior surgery, and a history of pelvic or with obstructive azoospermia include testicular sperm extrac-
scrotal trauma. This chapter focuses on common techniques tion via a variety of methods (see Chapter 59). Sperm ob-
used in the setting of obstructive azoospermia to surgically ex- tained from men with chronically obstructed reproductive
tract sperm from the epididymis for use with a concurrent tracts usually have poorer motility and decreased fertilizing
IVF-ICSI cycle or for purposes of cryopreservation for future capability as compared with ejaculated sperm. The use of ICSI
IVF-ICSI cycles. is essential to achieve optimal results with either epididymal
or testicular sperm; thus the female partner must be willing
and able to go through with an IVF cycle if surgically ex-
DIAGNO SIS tracted sperm are to be used. O ther alternatives about which
the couple should be counseled include the use of donor sperm
Azoospermia in a man with normal-volume testes ( 20 cc) or adoption.
and normal serum follicle stimulating hormone (FSH 8.0 U
per L) suggests an obstructive etiology. If neither vas deferens
is palpable on physical examination, obstructive azoospermia
is due to congenital bilateral absence of the vasa deferentia SURGICAL TECHNIQ UE
(CBAVD), a reproductive tract anomaly associated with cystic
fibrosis. M en with genetic mutations of the cystic fibrosis Sperm may be retrieved from the epididymis using either mi-
transmembrane conductance regulator (CFTR) gene may lack crosurgical or percutaneous techniques (Table 60A.1).
segments anywhere from the epididymis to the seminal vesicle, M icrosurgical epididymal sperm aspiration (M ESA) can be
with resultant obstructive azoospermia (2,11). Screening for performed on the same day as the partner’s oocyte retrieval or
the CFTR gene mutation should be performed in the patient at a separate time interval prior to oocyte retrieval with cryo-
as well as in his partner, and genetic counseling should be preservation of procured sperm. Percutaneous epididymal
provided. sperm aspiration (PESA) does not often yield numbers of
Patients with obstructive azoospermia due to vasectomy sperm sufficient to allow for cryopreservation and, therefore,
will be apparent upon obtaining patient history. If physical should be performed synchronously with egg retrieval.
examination reveals normal testicular volume and FSH is in Regardless of when sperm aspiration is performed relative to
the normal range, no further evaluation is warranted prior to oocyte retrieval, it is imperative that an intraoperative sample
proceeding with sperm extraction. be assessed under phase-contrast microscopy by a qualified
In patients with suspected or known obstructive azoosper- embryologist to assess the quality of the sample.
mia presenting with testis atrophy and/or elevated FSH , a In patients with obstructive azoospermia, sufficient quanti-
testis biopsy may be considered to confirm normal spermato- ties of sperm are generally obtained from aspiration on one
genesis, proceeding with concurrent epididymal or testicular side; however, the patient should be counseled that a bilateral
sperm extraction if sperm are identified. procedure may be necessary.
407
TA B LE 6 0 A . 1
COMPARISON OF MESA AN D PESA
ADVAN TAGES DISADVAN TAGES
Microsurgical • Lower risk for complications, less • General anesthesia preferred

epididymal sperm risk for spermatic cord or • Requires microsurgical skills
aspiration (MESA) epididymal damage • M ore expensive
• Large numbers of sperm may be • Longer recovery
obtained and cryopreserved
in multiple aliquots during
single procedure
Percutaneous epididymal • N o microsurgical skill required • H igher risk of complications,
sperm aspiration (PESA) • Local anesthesia sedation including hematoma, pain, and
• Can be done in office vascular injury to testes and
epididymis
• Variable success in obtaining sperm
• Smaller quantity of sperm obtained
than with M ESA
using the thumb and index finger or a smooth-tipped microfor-

Micro surg ical Ep id id ymal Sp e rm ceps enhances flow from the incised tubule. With patience, 25
Asp irat io n (MESA) to 50 L of highly concentrated epididymal fluid can be re-
covered, containing approximately 75 million sperm. This is
M ESA is most easily performed with the patient under general diluted in multiple aliquots of 2 to 3 mL of human tubal fluid
anesthesia, although spinal or local anesthesia may be used. medium, such that there are approximately 5 million sperm
The patient is supine on the operating table and anesthesia is per milliliter. Those specimens not used immediately for IVF-
induced. The scrotum is shaved and sterilely prepared and ICSI are cryopreserved for possible future use. If no sperm or
draped. A longitudinal median raphe or transverse hemiscro- immotile sperm are obtained at the initial incision site or the
tal incision is made. The testis is delivered through the incision quantities acquired are inadequate, additional incisions are
to gain direct access to the epididymis. The operating micro- made more proximally along the epididymis or even at the
scope is brought into the field at this time. The surgeon’s non- level of the efferent ductules until motile sperm are obtained.
dominant hand is used to hold the testicle while stabilizing the O nce adequate quality and quantity of sperm are attained,
epididymis between the thumb and index finger. Under the op- the tubular incisions may be closed using 10-0 Prolene or
erating microscope at 10 to 15 magnification, the mi- bipolar cautery. After ensuring meticulous hemostasis, the edges
crotipped bipolar forceps are used along the longitudinal of the epididymal tunic are reapproximated using a 6-0 or 8-0
plane of the epididymal tunic to create an avascular plane. nonabsorbing monofilament suture in a running fashion. The
The tunic is incised gently using a 15-degree ophthalmic mi- testis is reduced into the hemiscrotum, and the scrotal incision
croknife, taking care not to violate the underlying epididymal
tubules. H emostasis is attained using the bipolar cautery. A di-
lated epididymal tubule is selected and isolated, then incised
with the microknife (Fig. 60A.1A). In an obstructed epi-
didymis, sperm within the more caudal aspect tend to be of
poorer quality, and better-quality sperm are usually found
within the body or head of the epididymis, so the tubule
should be selected accordingly. The epididymal fluid is
touched to a sterile glass slide, a drop of saline is added, a
cover slip is placed, and then the fluid is immediately exam-
ined under a bench microscope. When motile sperm are iden-
tified, a dry micropipette (5 L; Drummond Scientific Co.,
Broomall, PA) or a standard hematocrit pipette is placed adja-
cent to the effluxing epididymal tubule (Fig. 60A.1B). Using
an in-line syringe for aspiration is not recommended, as the
negative pressure generated may disrupt the delicate epididy-
mal mucosa. Sperm-containing fluid will be drawn into the
pipette by simple capillary action (5). Two pipettes may be
used simultaneously in order to expedite sperm recovery. The
highest rate of flow is observed immediately after incising the FIGURE 60A.1 M icrosurgical epididymal sperm aspiration. A: Selec-
tubule. Sperm quality progressively improves after the initial tion and isolation of dilated tubule (10 magnification). B: Aspiration
washout. Gentle compression of the testis and epididymis of sperm into micropipette by capillary action (15 magnification).
Chap t e r 60A: Ep id id ymal Sp e rm Asp iration 409
is closed in layers in standard fashion. Fluffed gauze and an leading to testis atrophy and impaired testis function. Scrotal
athletic supporter are placed on the patient prior to waking exploration is rarely indicated for management of any of these
from anesthesia. complications. Given the blind nature of PESA, the risks of
hematoma, scarring, and spermatic cord injury are higher
than those associated with M ESA.
Pe rcut ane o us Ep id id ymal Sp e rm
Asp irat io n
Re sult s
Percutaneous epididymal sperm aspiration (PESA) is a simpler
method of obtaining epididymal sperm that does not require An experienced microsurgeon can retrieve sperm from the
microsurgical experience (1). It may be performed under local epididymis via M ESA in over 99% of patients with obstruc-
anesthesia via spermatic cord block, with or without the use tive azoospermia (7,10). Similar success rates are possible even
of intravenous sedation. After initiation of anesthesia and ster- if previous scrotal procedures have been performed or if
ile preparation and draping of the scrotum, the testis is stabi- extensive scarring is present. If the entire epididymis is obliter-
lized manually with the nondominant hand or by the ated from prior surgery or infection, the efferent ductules of
assistant. The surgeon grasps the epididymis between thumb the testis can still be exposed by reflection of the caput epi-
and index finger. A small (21- or 22-gauge) needle is percuta- didymis; one should be able to aspirate sperm from at least
neously inserted into the epididymis, and an attached syringe one of these tubules.
containing a small amount (approximately 0.1 cc) of human Reported sperm extraction rates via PESA are somewhat
tubal fluid is used to gently aspirate fluid from the epididymis. lower than those reported for M ESA, averaging about 80%
A small amount of this fluid is assessed under a bench micro- (3). The ability to cryopreserve sperm obtained from men with
scope to confirm the presence of sperm and ascertain motility. obstructive azoospermia can help alleviate concerns regarding
M ultiple punctures may be required to obtain sufficient coordination of sperm extraction with oocyte retrieval, as well
sperm-containing fluid. If no sperm are retrieved, as occurs in as offer the possibility of avoiding repeat sperm extraction if
at least 20% of sperm retrieval attempts (6), then one must good quantities of motile sperm are obtained at the initial ex-
proceed with M ESA, testis biopsy, or testicular aspiration. traction. N o clearly identified differences in outcomes be-
Given that the numbers of sperm retrieved with PESA are tween the use of fresh or cryopreserved and thawed sperm
often not sufficient to allow for cryopreservation, repeat pro- have been demonstrated (9).
cedures may be warranted for multiple IVF cycles. In addition, Using surgically extracted epididymal sperm warrants IVF
there is a risk for the development of scrotal hematoma or with ICSI to accomplish oocyte fertilization. Successful fertil-
injury to the epididymal or testicular vessels given the blind ization rates using ICSI in conjunction with surgically retrieved
nature of this procedure. epididymal sperm are approximately 72% (8). Fertilization
and pregnancy rates for both M ESA and PESA are compara-
ble. O f critical importance for successful outcomes, however,
O UTCO MES is the collaborative effort of the urologist along with the
embryology team and reproductive endocrinologist.
Co mp licat io ns
Complications after either procedure are infrequent and in-
clude wound infection, scrotal hematoma, epididymal scar-
ring, and injury to the spermatic cord vasculature, possibly
References
1. Craft IL, Khalifa Y, Boulos A, et al. Factors influencing the outcome of in- 7. N udell DM , Conaghan J, Pedersen RA, et al. The mini-micro-epididymal
vitro fertilization with percutaneous aspirated epididymal spermatozoa sperm aspiration for sperm retrieval: a study of urological outcomes. H um
and intracytoplasmic sperm injection in azoospermic men. H um R eprod R eprod 1998;13:1260–1265.
1995;10:1791–1794. 8. Palermo GD, Schlegel PN , H ariprashad JJ, et al. Fertilization and preg-
2. Daudin M , Bieth E, Bujan L, et al. Congenital bilateral absence of the vas nancy outcome with intracytoplasmic sperm injection for azoospermic
deferens: clinical characteristics, biological parameters, cystic fibrosis men. H um R eprod 1999;14:741–748.
transmembrane conductance regulator gene mutations, and implications 9. Prabakaran SA, Agarwal A, Sundaram A, et al. Cryosurvival of testicular
for genetic counseling. Fertil Steril 2000;74:1164–1174. spermatozoa from obstructive azoospermic patients: the Cleveland Clinic
3. Glina S, Fragoso JB, M artins FG, et al. Percutaneous epididymal sperm Experience. Fertil Steril 2006;86:1789–1791.
aspiration (PESA) in men with obstructive azoospermia. Int Braz J Urol 10. Schlegel PN , Palermo GD, Alikani M , et al. M icropuncture retrieval of epi-
2003;29:141–145. didymal sperm with in vitro fertilization: importance of in vitro microma-
4. Jarow JP, Espeland M A, Lipshultz LI. Evaluation of the azoospermic nipulation techniques. Urology 1995;46:238–241.
patient. J Urol 1989;142:162–165. 11. Stuhrmann M , Dörk T. CFTR gene mutations and male infertility.
5. M atthews GJ, Goldstein M . A simplified technique of epididymal sperm A ndrologia 2000;32:71–83.
aspiration. Urology 1996;47:123–125.
6. M eniru GI, Gorgy A, Batha S, et al. Studies of percutaneous epididymal
sperm aspiration (PESA) and intracytoplasmic sperm injection. H um
R eprod Update 1998;4:57–71.
CHAPTER 60B ■ EPIDIDYMECTO MY
DAVID M. NUDELL AND LARRY I. LIPSHULTZ
The epididymis is a complex tubular network that connects

the testicular efferent ducts to the vas deferens. In total, the DIAGNO SIS
single epididymal tubule measures 3 or 4 m. In its coiled form,
the epididymal tubule is contained within the tunica vaginalis This procedure is performed rarely, and the diagnostic steps
of the epididymis, creating a crescent-shaped organ intimately are individualized to each patient.
attached to the posterolateral aspect of the testis. The epi-
didymis is anatomically divided into caput, corpus, and cauda
regions (head, body, and tail, respectively) (Fig. 60B.1). While
there are histologic differences in the delicate epididymal
tubule between these regions, there are no gross and discrete
Currently, epididymectomy is done more commonly for com-
dividing lines between the regions. The blood supply to the
plex epididymal cystic disease, chronic scrotal pain, or postva-
caput and body of the epididymis arises from a division of
sectomy pain syndromes. O ther indications are for abscess or
the testicular artery. The cauda epididymis is usually supplied
chronic infections of the epididymis.
by a branch of the vasal artery, but rich anastomotic connec-
tions usually exist. The epididymis functions primarily in
sperm transport and maturation.
ALTERNATIVE THERAPY
Surgical removal of all or part of the epididymis is done un-
commonly, especially with the availability of broad-spectrum
antibiotics. In the past, most cases were performed for ab-
scess, chronic infection, or tuberculosis of the epididymis. In
cases of scrotal abscess, the epididymis may be removed in an
attempt to save the testis from overwhelming orchitis (1). If
tuberculosis is suspected, it is critical to obtain appropriate
cultures at the time of surgery.
SURGICAL TECHNIQ UE
After administration of appropriate antibiotics if necessary, ei-
ther general or local anesthesia is induced. If local anesthesia
is used, a generous cord block and infiltration of the skin over-
lying the incision will be adequate. A transverse scrotal inci-
sion is made that is just large enough to deliver the testis,
epididymis, and distal vas deferens. The initial incision may be
carried down through the tunica vaginalis without extensive
dissection of the plane between the tunica vaginalis and dartos
muscle layer. This will allow delivery of the intravaginal con-
tents. O ften, the distal vas deferens can be accessed in this way
as well. If extensive scarring or infection has occurred, it may
be necessary to dissect the tunica vaginalis free of the dartos
muscle layer due to dense adhesions. In these cases, sharp dis-
section of the testis and epididymis from the undersurface of
FIGURE 60B.1. Sagittal section of the testis and epididymis. The epi- the tunica vaginalis will usually be necessary as well. In cases
didymis is seen attached to the posterolateral aspect of the testis. The performed for postvasectomy pain, it is important to remove
efferent ducts (vasa efferentia) of the testis consist of 10 to 20 chan- the epididymis and vas all the way up to and including the va-
nels draining individual lobes of the testis into the globus major of the
sectomy site or sperm granuloma (2). If performed for other
epididymis. The epididymal tubule gradually gains more smooth mus-
cle components as it progresses toward the vas deferens, which is seen reasons, the vas may be divided and ligated at the junction of
exiting the inferior, most distal aspects of the epididymis. the convoluted and straight vas with an absorbable suture. In
410
Chap t e r 60B: Ep id id yme ctomy 411
Vas
Epididymis
Epididymal
artery and
vein
Testicular
artery and vein FIGURE 60B.2. Drawing demonstrating the correct
plane of dissection during epididymectomy. The main
spermatic cord structures are seen posterior and medial
as they enter the testis. Injury to these structures can be
avoided by dissecting only the plane between the epi-
didymis and testis, which will usually contain only epi-
didymal blood supply. The vascular pedicle to the
epididymis may be encountered in the dissection plane
between the testis and epididymis. The exact location of
this blood supply can be variable.
patients with complex cystic disease, it is critical to ascertain dissection has been performed or purulent material was en-
the desire for future fertility. If fertility is still desired, epi- countered, a drain should be left in place that exits in a depen-
didymectomy should be avoided. If surgery is necessary in this dent fashion. O therwise, the tunica vaginalis is closed with a
situation, the larger cysts should be removed from the epi- running absorbable suture followed by closing the dartos
didymis individually with the use of an operating microscope layer and skin with interrupted or running absorbable sutures.
to avoid epididymal tubular obstruction.
After the vas is divided, it is dissected back to the vasoepi-
didymal junction and dissection begun in the plane between
the epididymis and the testis (Fig. 60B.2). O ptical loupe mag- O UTCO MES
nification can be helpful in maintaining the correct plane and
avoiding injury to the testis or spermatic cord vessels. The dis- Co mp licat io ns
section is done sharply with fine Iris-type scissors and Bovie
cauterization. The epididymis is grasped between the thumb Complications of epididymectomy include hematoma forma-
and index finger of the nondominant hand and elevated off tion, orchitis, skin infection, chronic pain, and infertility.
the testis as the dissection progresses from inferior to superior. Inadvertent injury to the spermatic cord during a difficult dis-
The epididymal artery may be encountered midway up the section may lead to testis atrophy.
dissection of the epididymis, but its exact location may be
variable. If encountered, the artery should be ligated. The
main spermatic cord blood supply containing the testicular Re sult s
artery will usually be found medial and posterior to the dissec-
tion in the region of the head or proximal body of the epi- The results of epididymectomy vary with the indications for
didymis (Fig. 60B.2). In cases where the normal anatomy is surgery. In patients with complex, symptomatic cystic disease,
distorted, it is important to avoid dissection into the spermatic patient satisfaction is usually high following surgical removal
cord, as this will lead to testicular infarction and subsequent (3). In patients with chronic orchalgia, epididymectomy has
atrophy. The most superior attachment of the epididymis to produced poor results, with around 50% improvement rates
the testis consists of the testicular efferent ducts. These can be in several series (3–5). This may not be surprising given the
ligated with a single absorbable suture or cauterized. At this high incidence of perineural fibrosis found in the pathology
point, the specimen can usually be removed intact. specimens from patients undergoing epididymectomy for pain
After the area is irrigated, the epididymal bed is inspected syndromes (2). H owever, in well-selected patients, satisfaction
closely for bleeding. Vessels can be cauterized or ligated with as high as 90% has been obtained (5). Poor predictors of suc-
small, absorbable sutures. The edges of the tunica along the cess include pain extending into the groin region, failure to al-
bed of the epididymis should be approximated with several leviate pain following a well-placed spermatic cord block, and
absorbable sutures for further hemostasis and to prevent leak- normal appearance of the epididymis on preoperative ultra-
age of testicular sperm from the efferent ducts. If extensive sound (5). Selective denervation of the spermatic cord may be
another alternative to epididymectomy for chronic pain syn- Epididymectomy is performed most commonly for complex
dromes (6). This technique involves skeletonizing the sper- cystic disease, chronic pain syndromes, postvasectomy pain
matic cord surgically, leaving only the vas deferens, a few syndromes, and nonhealing infections. There are slight but im-
lymphatic channels, and the testicular artery intact. This pro- portant differences in the technique used for each of these in-
cedure is best accomplished through a subinguinal incision dications. For example, during epididymectomy performed
with the use of an operating microscope. The long-term re- for postvasectomy pain syndromes, excision of the proximal
sults of this relatively new approach remain to be determined. vas up to and including the vasectomy site is necessary. This is
For patients with postvasectomy pain syndromes, epi- not necessary in patients with cystic disease or with idiopathic
didymectomy results have been mixed. In general, about 50% orchalgia. In patients with cystic disease who desire fertility,
of patients report long-term satisfaction and prevention of on- epididymectomy should be avoided and the larger cysts, if
going pain following epididymectomy (2). As mentioned, it is necessary, should be removed microsurgically. In patients with
important in these cases to include the vas deferens up to and infection, it is important to obtain appropriate intraoperative
including the vasectomy site in the surgical specimen. cultures and insert a dependently directed drain.
References
1. Chen TF, Ball RY. Epididymectomy for post-vasectomy pain: histological 4. Sweeney P, Tan J, Butler M R, et al. Epididymectomy in the management of
review. Br J Urol 1991;6:407–413. intrascrotal disease: a critical reappraisal. Br J Urol 1998;81:753–755.
2. H eidenreich A, O lbert P, Engelmann UH . M anagement of chronic testalgia 5. West AF, Leung H Y, Powell PH . Epididymectomy is an effective treatment
by microsurgical testicular denervation. Eur Urol 2002;41:392–397. for scrotal pain after vasectomy. BJU Int 2000;85:1097–1099.
3. Padmore DE, N orman RW, M illard O H . Analyses of indications for and 6. Witherington R, H arper WM IV. The surgical management of acute bacterial
outcomes of epididymectomy. J Urol 1996;156:95–96. epididymitis with emphasis on epididymotomy. J Urol 1982;128:722–725.
CHAPTER 61 ■ EJACULATIO N INDUCTIO N

PRO CEDURES: PENILE VIBRATO RY
STIMULATIO N AND ELECTRO EJACULATIO N
DANA A. OHL, SUSANNE A. QUALLICH, JENS SØNKSEN, NANCY L. BRACKETT, AND CHARLES M. LYNNE
Anejaculatory infertility is a relatively uncommon etiology of periurethral muscle against a tightly closed bladder neck,
failure to conceive, but in certain patient populations, this resulting in projectile expulsion of semen from the urethra.
condition may be the most common cause of infertility. M en There are several types of ejaculatory dysfunction, includ-
with anejaculatory infertility have dysfunction of some por- ing premature ejaculation, retrograde ejaculation, and anejac-
tion of the normal ejaculatory reflex system, preventing the ulation. M en with premature ejaculation and retrograde
emission of semen during normal sexual activity. These neuro- ejaculation are not appropriate for penile vibratory stimula-
anatomic components of the ejaculatory response include (a) tion (PVS) and electroejaculation (EEJ), favoring other treat-
penile dorsal nerves carrying efferent sensory stimuli to the ment algorithms. Candidates for ejaculation induction
spinal cord at S2–4; (b) descending pathways from the brain procedures are those men who are unable to initiate a normal
to carry cerebral input down to the ejaculatory center at ejaculatory reflex due to neurologic conditions. The most
T10–L2; (c) ascending pathways from S2–4 to coordinate sen- common cause seen in practice is spinal cord injury (SCI), due
sory input at T10–L2; (d) sympathetic outflow at T10–L2, to the fact that SCI men are able to ejaculate only 10% to
carried via the sympathetic chain, the inferior mesenteric plexus, 20% with normal coitus (8). O ther etiologies include surgical
and pelvic sympathetics, ending in the walls of the ejaculatory sympathectomy from retroperitoneal lymph node dissection,
organs, the seminal vesicles, vas deferens, prostate, and blad- aortic surgery, or perirectal dissection, diabetic neuropathy,
der neck, to effect seminal emission and bladder neck closure; transverse myelitis, multiple sclerosis, and spinal bifida. In
and (e) pudendal nerves to stimulate the periurethral skeletal these neurologic conditions, segments of the normal neu-
muscle, to create the projectile phase of the reflex. Stimulation roanatomic structures are nonfunctioning, leading to absence
of the brain and genitalia results in a coordinated response of seminal emission. In uncommon cases, anorgasmia from a
culminating in emission of sperm and seminal plasma into psychogenic source may be a reason to utilize ejaculation in-
the urethra, followed shortly by rhythmic contractions of the duction procedures.
Chap t e r 61: Ejaculation Ind uction Proce d ure s: Pe nile Vib ratory Stimulation and Ele ctroe jaculation 413
that non-SCI men rarely should undergo EEJ (7). In men with
DIAGNO SIS normal sensation, a general anesthetic is needed to perform
EEJ, and the added cost of the anesthetic changes the cost-
The diagnosis of anejaculation is made primarily by history. effectiveness calculations. Although it may still be reasonable
Certainly in individuals with the profound neurologic condi- to utilize EEJ in the non-SCI population, the clinician needs to
tions mentioned previously, such as spinal cord injury, there is strongly consider the alternative procedures noted below.
little mystery as to the source of their infertility. The history
needs to capture other risk factors, such as prior surgery, a di-
agnosis of diabetes, and any neurologic symptoms that may
indicate an occult condition. In individuals who are relatively ALTERNATIVE THERAPIES
neurologically intact, such as a diabetic neuropath, a history
of normal orgasm sensation, without seminal fluid emitted per The goal in ejaculation induction procedures is to obtain
urethra, is key. O ne needs to inquire for signs of retrograde sperm to be used in ARTs. Therefore, the choice of ART is de-
ejaculation, such as cloudiness in the urine immediately after pendent on the sperm quality delivered by the ejaculation in-
ejaculation. In men with psychogenic anorgasmia, which duction procedure. For instance, if a procedure delivers sperm
tends to be lifelong, the history may be more problematic, as with 10 million total motile sperm (TM S), then a simple
these men may have never experienced a normal orgasm. The ART procedure, such as intrauterine insemination (IUI), will
clinician may need to have the man describe in detail the events have a reasonable chance of a pregnancy. H owever, if the TM S
that occur during sexual activity to determine if the man is is between 1 and 10 million, then standard in vitro fertiliza-
experiencing orgasm or not. tion (IVF) will be necessary to give reasonable pregnancy
There are few diagnostic tests necessary in most men prior rates. If the TM S drops below 1 million sperm, intracytoplas-
to a trial of an ejaculation induction procedure. Information mic sperm injection (ICSI) in conjunction with IVF is neces-
about spermatogenesis can be indirectly obtained with a sary to give reasonable pregnancy rates. Finally, in an SCI man
serum follicle stimulating hormone (FSH ) level and by finding who exhibits exceptional semen quality with PVS, patient-
a normal testicular volume on physical examination. If the directed PVS procedures in the home setting, followed by
FSH is elevated, a testis biopsy might be indicated. If there is a patient-directed vaginal insemination, may result in pregnancy.
question of retrograde ejaculation, postorgasm urine is exam- In general, ejaculation induction procedures are aimed at
ined to look for sperm. In men with retrograde ejaculation, or utilizing IUI in an attempt to optimize cost-effectiveness. If IUI
those with peripheral neuropathy (diabetic neuropathy or sur- is determined not to be cost-effective as compared to IVF, the
gical sympathectomy), a trial of sympathomimetic agents may advantage of ejaculation induction is lost. In fact, when ana-
induce antegrade ejaculation, thus preventing the need for lyzing the effectiveness of EEJ when coupled with IUI in men
ejaculation induction. Finally, prior to performing procedures without SCI, the increased cost of the required anesthetic
on men with anejaculation, a fertility evaluation of the female changes the analysis to favor proceeding directly to the more
partner ensures that a suitable recipient for assisted reproduc- costly IVF procedure, based on pregnancy rates and the cost
tive techniques (ARTs) is available. of the procedures (7). Since there are methods other than EEJ
to deliver adequate numbers of sperm for IVF, these proce-
dures merit discussion.
In men who require an anesthetic to perform EEJ, it is cost-
INDICATIO NS FO R EJ ACULATIO N effective to bypass the EEJ procedure and go directly to sperm
INDUCTIO N PRO CEDURES aspiration procedures (described elsewhere in this book), in
conjunction with IVF, and ICSI of the partner’s oocytes (7).
Men with anejaculation who wish to induce a pregnancy in their H owever, some IVF clinics proceed directly to sperm aspira-
female partners are candidates for PVS or EEJ. These proce- tion procedures in all men, without consideration of PVS or
dures are not aimed at restoring sexual function, but merely IUI, even for SCI subjects. The authors disagree with this algo-
serve as a method to retrieve sperm that might be used for rithm, based on cost-effectiveness analysis (5).
ARTs. Indeed, many men find these procedures uncomfort- Finally, a discussion of options in the anejaculatory patient
able. Therefore, the goal of using PVS and EEJ is procreation. would not be complete without mentioning the possibility of
Penile vibratory stimulation is useful in men who are an- donor artificial insemination and adoption. This information
ejaculatory from SCI. Since this procedure requires an intact is discussed with the couple, but the subjects themselves need
ejaculatory reflex arc, men with peripheral neuropathies and to decide whether to forego attempts at conception with the
those with incomplete lesions are suboptimal candidates. PVS male partner’s sperm and use these techniques.
has a higher success rate in SCI men with complete lesions, le-
sions above T8, upper motor neuron characteristics (spastic),
and intact bulbocavernosus and hip flexion reflexes. The suc-
cess rate markedly drops off with the lower levels of injury as- TECHNIQ UES
sociated with lower motor neuron injury characteristics.
H owever, because of the relative noninvasiveness of PVS com- Pe nile Vib rat o ry St imulat io n
pared to EEJ, it is reasonable to attempt PVS in all SCI men
prior to attempting EEJ. Penile vibratory stimulation depends on an intact reflex arc to
EEJ is utilized for SCI men who fail PVS and in all other be successful. The general idea is that the penis is overstimu-
etiologies of anejaculation. H owever, cost analysis of the lated with a carefully designed vibrator, overcoming the ejacu-
results of EEJ with ARTs has led to the recommendation latory reflex threshold. Sensory input is carried via the dorsal
nerves into the sacral cord. These impulses then ascend into
the ejaculatory center at the thoracolumbar cord, where sym-
pathetic fibers carry a signal to the ejaculatory organs, causing
them to contract. Since a complete ejaculatory reflex is
elicited, there is also coordination of bladder neck closure dur-
ing emission to prevent retrograde ejaculation, as well as pul-
satile rhythmic contraction of the periurethral muscles,
causing, in turn, pulsatile projectile ejaculation. The neuro-
physiologic events that occur during PVS are indistinguishable
from a normal ejaculatory reflex, other than the fact that it is
not associated with sexual activity, as well as the lack of sen-
sation and control of the SCI subject.
The choice of the vibrator directly impacts ejaculation suc-
cess rates. A study performed by Sønksen et al. (9) found that
ejaculation rates when utilizing a vibrator with amplitude of
1.0 mm was only 32% in a cohort of SCI men. When chal-
lenging the same group of men with a vibrator with peak-to-
peak amplitude of 2.5 mm, the ejaculation rate was 91% . In A
this study, amplitudes of commercially available vibrators
were measured, and it was found that manufacturers’ specifi-
cations were highly inaccurate and were not dependable
enough to make choices in the types of devices to be used for
patients. These observations led to development of a commer-
cially available device produced with medical indication stan-
dards and FDA approval for use in ejaculation induction
procedures in SCI men (Fig. 61.1). The authors recommend
that this FDA-approved device be used in clinical PVS.
The initial PVS should be done in the clinic setting to en-
sure that there are no complications. PVS can be performed on
a treatment table or with the patient remaining in his wheel-
chair. Although retrograde ejaculation is very uncommon with
PVS, it is prudent to catheterize the bladder prior to the first
procedure and again immediately after the procedure to check
for sperm in the bladder. Catheterization must be done with a
plastic catheter with nonspermicidal lubricant. If after the first
procedure it is determined that no retrograde ejaculation is B
present, subjects will characteristically not develop this over
FIGURE 61.2 Different SCI patients will respond to different stimu-
time, and the catheterization may be omitted from future lation positions. A: Placement of the vibrator head at the frenulum.
procedures. B: Placement of the vibrator head on the dorsum of the glans penis.
An automated blood pressure cuff is used to monitor

blood pressure during the procedure, in case autonomic dysre-
flexia with extreme blood pressure increase occurs in response
to the stimulation. SCI men with lesions above T6 are prone
to dysreflexia. In such patients, consideration must be given to
prophylactic administration of sublingual nifedipine 10 to
20 mg. Autonomic dysreflexia is discussed in more detail in
the “ Complications” section of this chapter.
The vibrator is placed on the patient’s penis to deliver the
stimulation. In most subjects, the stimulation area most likely
to result in a positive response is the frenulum, although there
is individual variation that can be sorted out with trial and
error (Fig. 61.2).
The vibrator is placed on the penis with an initial ampli-
tude of 2.5 mm and a frequency of 100 H z. Enough pressure
to get the device close to dampening is used to ensure delivery
of an adequate power of vibration. The stimulation is applied
until ejaculation occurs, or for a total of 3 minutes. If no ejac-
FIGURE 61.1 The FertiCare vibrator (M ulticept APS, Copenhagen,
Denmark) is the only device approved by the FDA for the purpose of ulation is reached within 3 minutes, there may be sensory fa-
penile vibratory ejaculation. tigue and a rest period is indicated. O ne can resume stimulation
again after a rest period of 1 minute, with consideration given consideration is given for a short course of prophylactic an-
to increasing the amplitude in half-centimeter increments up tibiotics. To clear the rectum of feces, SCI men are instructed
to 4.0 mm at maximum. to perform their normal bowel evacuation the night before the
During stimulation, characteristic muscular responses can procedure. N on-SCI men are instructed to empty the rectum
be seen and can give clues to the operator that ejaculation may with the assistance of an enema.
be imminent. With application of the vibrator, abdominal and Although most non-SCI men should not undergo EEJ,
periurethral muscle contractions are typical. Piloerection is there may be compelling reasons to proceed. These may in-
also common. When ejaculation is near, there is tonic contrac- clude evidence of very high sperm production, increasing the
tion of leg and abdominal muscles, followed by rapid release chance of an IUI success; or religious objections to IVF, neces-
and spastic, sometimes jerking, contractions of the muscles, sitating the use of IUI. In non-SCI men, EEJ is a very painful
coincident with the actual ejaculation process. If the vibration procedure and must be performed under anesthesia. General
is discontinued just prior to ejaculation when such premoni- anesthesia has been the most common modality in practice.
tory signs are seen, the complete reflex will continue without The discussion of the procedure that ensues will assume that
interruption. Discontinuation at this time may limit blood the subject is an SCI man, who does not require anesthesia.
pressure rise in those prone to dysreflexia and may also pre- There is only one device that is FDA-approved for EEJ of
vent overstimulation and sensory fatigue, allowing multiple SCI men. This is the Seager unit. Virtually all modern experi-
stimulations to be successful. If multiple attempts are made, ence with EEJ has been with this machine. The unit consists of
one can continue with another stimulation period after a rest a central power generator and cords that may be attached to a
period of 1 minute (2). variety of rectal probes. The central unit has a stimulation
An assistant is responsible for ensuring that the ejaculate is counter and a read-out of probe temperature so that overheat-
collected in a sterile specimen container. The assistant can also ing may be monitored. There is a heat sensor fail-safe that
be very helpful in ensuring the comfort of the patient and cuts power to the unit if temperature rises to unsafe levels.
watching for complications. Such assistance in monitoring for The EEJ equipment setup and additional supplies are shown
complications ensures having another set of eyes on the blood in Fig. 61.3.
pressure monitor and checking verbally with the patient for EEJ is performed on the treatment table. The patient begins
any symptoms of dysreflexia, such as headache. supine, and an automated blood pressure cuff is applied to
After the procedure, most patients feel quite well. There monitor for dysreflexia. In those prone to dysreflexia, consid-
may be a general reduction in reflex activity that may lead to eration is given for prophylactic sublingual nifedipine, 10 to
limitation of spasticity and bladder activity. The blood pres- 30 mg. Since EEJ is capable of providing a very noxious stim-
sure of those who have received prophylactic nifedipine ulus that can create a dysreflexia situation in prone individu-
should be measured after assuming the sitting position. als, subjects are instructed to inform the staff if a headache or
palpitations arise.
The bladder is catheterized in all EEJ cases, due to the
Ele ct ro e jaculat io n propensity for retrograde ejaculate (Fig. 61.4). Five to 20 mL
of a sperm-friendly medium from the assisted reproduction
Rectal probe EEJ has been used in animal husbandry quite lab is instilled into the bladder (Fig. 61.5). A plastic catheter
regularly for some time. The first use in men with spinal cord with nonspermicidal lubricant is used for the pre- and post-
injury was reported in 1948 (4), but no pregnancies from elec- procedure catheterizations to limit sperm toxicity.
troejaculated sperm were reported until the 1970s. Further The subject is then turned into the lateral decubitus posi-
isolated reports ensued for many years until Bennett refined tion (Fig. 61.6), and rectoscopy is performed to ensure that no
the procedure and presented a series of United States pregnan- lesions are seen (Fig. 61.7). If significant inflammation is seen
cies from EEJ of SCI men (1). due to bowel program activity or colitis, the procedure should
H istorically, it was assumed that EEJ worked via direct be canceled for the day and rescheduled. Any inflammatory
stimulation and contraction of the ejaculatory organs. condition of the colon will only be made worse by running
H owever, recent research has shown that the electrical stimu- electrical energy into the area.
lation appears to initially cause high-pressure contraction of The probe is inserted far enough into the rectum such
the pelvic floor and periurethral muscles, leading to a partially that the limit of the plastic is located just at the anal sphincter
coordinated reflex with seminal emission and contraction of (Fig. 61.8). The electrodes should be completely internalized
the bladder neck and rhythmic, although somewhat disorga- inside the rectum. The conductive characteristic of the rectal
nized, contractions of the periurethral muscles, leading to ex- mucosa allows efficient flow without much heat generation.
pulsion of semen (11). Although there are many components H owever, if the electrodes are applied externally to the skin,
of the reflex that are similar to PVS, the less organized reflex the very high resistance of the skin will cause significant heat
response leads to incomplete coordination and the likely pos- release and put the patient at risk for perineal burn. The elec-
sibility that some of the ejaculate will be emitted in a retro- trodes are positioned anteriorly, facing the ejaculatory organs.
grade fashion. Electricity is delivered in waves of increasing voltage. The
Since retrograde ejaculation is a distinct probability, it is first stimulation is 2.5 to 5.0 V and is increased by 2.5 to 5.0 V
important to prepare the patient to limit toxicity of the sperm- per stimulation. The degree of rectal contact and individual
urine contact. The authors favor limitation of fluid intake in characteristics lead to differences in resistance, such that with
order to limit urine production during the procedure. Subjects the same voltage, differences in electrical flow (milliamperes)
are instructed to take 1⁄2 teaspoon of sodium bicarbonate may be seen. In general, a guideline of a maximum delivery of
12 hours and 2 hours prior to the procedure to alkalinize 1,000 mA at peak stimulation should be used, and that is usu-
the urine. In SCI men with recurrent urinary tract infections, ally seen with a voltage delivery of 30 to 35 V (Fig. 61.9).
A FIGURE 61.4 The bladder is emptied prior to electroejaculation.
FIGURE 61.5 Sperm-friendly medium is instilled into the bladder in

anticipation of retrograde ejaculation.
C
FIGURE 61.3 Electroejaculation equipment. A: Sigmoidoscope and
rectal probe. B: Additional equipment, including plastic catheters, non-
spermicidal lubricant packets, media for instillation into the bladder,
basin for draining the urine, and specimen containers for the antegrade
and retrograde specimens. C: Seager M odel 14 Electroejaculator.
M eters give voltage and current delivery, stimulation count and time, FIGURE 61.6 The lateral decubitus position allows access for inser-
and probe temperature. The central rheostat is turned by the operator tion of the rectal probe and access to the penis for retrieving antegrade
to alter voltage. ejaculate.
FIGURE 61.7 Rectoscopy is performed before and after the electrical FIGURE 61.9 The operator is maintaining probe position with the
stimulation. right hand, while moving the rheostat on the machine to alter voltage
delivery.
Waves are delivered with a relatively rapid rise to the

chosen voltage for that stimulation, held for 5 seconds, and
then abruptly cut off. During the time of electrical silence,
the ejaculatory response develops over a few seconds, and
ejaculation actually occurs during the silent phase. In the
past the standard thinking was to leave an electrical baseline
of 100 mA, never reaching zero again. H owever, the change
from the older technique to the one described above has led
to a significant reduction in the percentage of retrograde
ejaculate (3,6).
During stimulation, there can be significant abdominal and
leg muscle contractions. Piloerection can be seen also, and this
also may indicate an adequate level of stimulation. In the elec-
trically silent period between contractions, and during ejacula-
tion, visible contraction of the perineal and periurethral
muscles may be seen, again attesting that adequate stimulation
is being given.
A An assistant holds a cup over the penis to ensure that any
antegrade ejaculate is collected (Fig. 61.10). Since ejaculate
B
FIGURE 61.8 Rectal probe insertion. A: The well-lubricated probe is
placed into the rectum. B: Final probe position with the electrodes FIGURE 61.10 The assistant is maintaining the position of the ure-
completely inside the sphincter. The electrodes are positioned facing thral meatus inside the specimen container to collect the antegrade
anteriorly. ejaculate.
O UTCO MES
In SCI men, PVS is approximately 60% successful in inducing
an ejaculatory response. The best results are seen in men with
spasticity, in those with lesions above T8, and in those with
intact bulbocavernosus and hip flexion reflexes, where ejacu-
lation rates can be as high as 90% . EEJ, however, is nearly
universally successful in causing seminal emission.
Unfortunately, the sperm quality from PVS and EEJ in SCI
men is poor. This includes abnormalities of gross semen para-
meters and abnormal sperm function. Typically, sperm num-
bers are high, but motility and viability are very low. O ther
abnormalities seen include poor overnight survival, decreased
ability to penetrate cervical mucus, and lower fertilizing capa-
bility, as compared to control sperm. This limits the success
rates in series of men attempting conception.
Sperm obtained from ejaculation induction procedures are
FIGURE 61.11 Following electrical stimulation, the subject is once
again catheterized to retrieve the retrograde fraction of the ejaculate. sent to the assisted reproductive laboratory for processing by
standard preparation techniques. The specimens can be uti-
lized for IUI or IVF, depending on the couple’s situation and
the sperm quality. The largest series of EEJ coupled with ARTs
may be retained in the urethra, gentle milking on the under- demonstrated an IUI cycle fecundity of 11% per cycle and
side of the urethra in an antegrade fashion may help in the ex- 35% per couple. A single attempt of EEJ coupled with IVF
pulsion. The assistant can also aid in monitoring the blood gave a 43% pregnancy rate (7).
pressure and any patient complaints of dysreflexia. In men with exceptional semen quality, couples may be
When no more fluid is expelled following a stimulation cy- taught to perform PVS at home and do vaginal insemination.
cle, or if probe temperature reaches 39.5ºC, the procedure is In a series of men in Germany, Denmark, and the United
terminated. The probe is removed and rectoscopy performed States, 73 of 169 couples had a pregnancy (43% ). N inety-nine
again to ensure that no burn, bleeding, or perforation is seen. pregnancies in these 169 couples were achieved (10).
The subject is then catheterized again to extract the postejacu-
lation urine (Fig. 61.11). A plastic catheter is used to avoid
sperm adhering to it, and nonspermicidal lubricant is used, for
obvious reasons. After extraction of bladder contents, the blad-
CO MPLICATIO NS
der is irrigated with the sperm-friendly medium for complete
Autonomic dysreflexia is a phenomenon seen in higher spinal
removal of retrograde ejaculate. Both specimens are submitted
cord lesions. When a noxious stimulus is delivered, such as
to the laboratory for analysis and processing (Fig. 61.12).
EEJ, the initial response is for the sympathetic nervous system
Similar to PVS, patients feel quite well after EEJ, and they
to raise the blood pressure. Regulatory mechanisms including
may also feel a reduction in skeletal muscle and bladder spas-
vascular baroreceptors give rise to modulation of the response
ticity for 12 to 24 hours after the procedure.
from brainstem centers. The sympathetic outflow responsible
for the blood pressure rise is located below T6. Therefore, in a
man with a spinal cord injury above T6, the brainstem centers
cannot communicate with the sympathetic outflow, leading to
an autonomous, and unchecked, response. Therefore, the pe-
riphery is responding to the noxious stimulus with extreme
rises in blood pressure, without normal control mechanisms
stopping this reflex response.
EEJ and PVS are efficient stimuli that can induce dysre-
flexia. In susceptible subjects, dangerous rises in blood pres-
sure can be seen, resulting in a risk for stroke. Blood pressure
monitoring is essential in men with T6 or above lesions.
Prophylactic nifedipine is highly successful in limiting the risk
of extreme blood pressure rise during the procedures (12).
Specific minor complications from PVS may include skin
swelling or bruising, discomfort from muscle contraction dur-
ing the procedure, and urinary retention in reflex voiders due
to limitation of reflex activity following the procedure.
There have been very rare reports of rectal injury or burn
from EEJ, which is obviously a major complication, but the
FIGURE 61.12 The specimens from a typical EEJ procedure include
incidence is extremely low. Patients may also experience some
a small-volume antegrade ejaculate and a larger-volume retrograde discomfort during the procedure and temporary urinary reten-
fraction. tion, as in PVS.
Chap t e r 62: Anatomy of the Te stis 419
References
1. Bennett CJ, Ayers JW, Randolph JF Jr, et al. Electroejaculation of para- 7. O hl DA, Wolf LJ, M enge AC, et al. Electroejaculation and assisted repro-
plegic males followed by pregnancies. Fertil Steril 1987;48:1070–1072. ductive technologies in the treatment of anejaculatory infertility. Fertil
2. Bird VG, Brackett N L, Lynne CM , et al. Reflexes and somatic responses as Steril 2001;76:1249–1255.
predictors of ejaculation by penile vibratory stimulation in men with spinal 8. Sønksen J, Biering-Sørensen F. Fertility in men with spinal cord or cauda
cord injury. Spinal Cord 2001;39:514–519. equina lesions. Sem in N eurol 1992;12:106–114.
3. Brackett N L, Ead DN , Aballa TC, et al. Semen retrieval in men with spinal 9. Sønksen J, Biering-Sørensen F, Kristensen JK. Ejaculation induced by penile
cord injury is improved by interrupting current delivery during electroejac- vibratory stimulation in men with spinal cord injuries. The importance of
ulation. J Urol 2002;167:201–203. the vibratory amplitude. Paraplegia 1994;32:651–660.
4. H orne H W, Paull DP, M unro D. Fertility studies in the human male with 10. Sønksen J, Lochner-Ernst D, Brackett N L, et al. Vibratory ejaculation in
traumatic injuries of the spinal cord and cauda equina. N Engl J M ed 169 spinal cord injured men and home insemination of their partners. J
1948;239:959–961. Urol 2008;175[Suppl]:656.
5. Kafetsoulis A, Brackett N L, Ibrahim E, et al. Current trends in the treat- 11. Sønksen J, O hl DA, Wedemeyer G. Sphincteric events during penile vibra-
ment of infertility in men with spinal cord injury. Fertil Steril 2006;86: tory ejaculation and electroejaculation in men with spinal cord injuries. J
781–789. Urol 2001;165:426–429.
6. O hl DA, Sønksen J, Bolling R. N ew stimulation pattern for electroejacula- 12. Steinberger RE, O hl DA, Bennett CJ, et al. N ifedipine pretreatment for au-
tion based on physiological studies. J Urol 2000;163[Suppl]:1522. tonomic dysreflexia during electroejaculation. Urology 1990;36:228–231.
CHAPTER 62 ■ ANATO MY O F THE TESTIS

HO WARD H. KIM AND MARC GO LDSTEIN
A working knowledge of anatomy is vital for all surgeons, but O ther disorders, such as androgen-insensitivity syndromes,
it is perhaps especially critical for male reproductive urolo- can present with impaired secondary sex development or
gists. In addition to knowing which nerves and lymphatics to infertility.
avoid injuring during surgery and which collateral blood sup-
ply to depend on when a particular blood vessel is transected,
the infertility specialist must understand the surgical anatomy Hyp o t halamic-Pit uit ary-Go nad al Axis
in the context of spermatogenesis and reproductive physiol-
ogy. Fortunately, the male reproductive anatomy has clinically Reproductive hormones are controlled by the hypothalamus,
relevant physical examination findings that facilitate the com- which releases GnRH in a pulsatile fashion, on average every
mitment of major principles to memory. 90 to 120 minutes from its preoptic and arcuate nuclei
(Fig. 62.1). GnRH stimulates the anterior pituitary to release
luteinizing hormone (LH ) and follicle stimulating hormone
INTRO DUCTIO N TO MALE (FSH ). LH in turn stimulates the production of testosterone by
REPRO DUCTIVE SYSTEM Leydig cells, while FSH supports spermatogenesis in Sertoli
cells. Both androgens and estrogens feed back to inhibit LH
release, and inhibin, produced by the Sertoli cells, decreases
Physical Examinat io n FSH release.
Although representing only a minor subset of infertile men,

endocrine disorders are often associated with characteristic
findings on physical examination and are generally treatable TESTIS
with hormonal manipulation. Physical assessment of the
hypothalamic-pituitary-gonadal (H PG) axis begins as soon as Physical Examinat io n
the infertile patient disrobes for the examination. Body habi-
tus and secondary sex characteristics such as body hair distri- The physical examination of an infertile man reveals a
bution provide clues to disruption of the H PG axis and its wealth of information. Body habitus is assessed. Late
potential role in the fertility status of the patient. For example, closure of the epiphyses due to lack of adequate testosterone
men with Kallmann syndrome or hypogonadotropic hypogo- results in an arm span that exceeds height, or a pubis-to-foot
nadism (H H ) can present with delayed pubertal development distance that exceeds pubis-to-crown distance by 5 cm.
or midline defects such as anosmia and cleft palate. In Gynecomastia, feminized body habitus, and sparse male hair
Kallmann syndrome, the olfactory axons fail to establish con- distribution complete the picture characteristic of either H H
nections with the developing olfactory bulb during develop- or Klinefelter syndrome. Evaluation of the scrotal contents
ment, resulting in problems with gonadotropin-releasing is the centerpiece of the examination. A scrotum warmed
hormone (GnRH ) secretion. GnRH neurons use olfactory with a heating pad to relax the dartos muscle and a securely
nerve migration for their own travel to the forebrain (12). private room optimize patient comfort and subsequently yield
FIGURE 62.1 H ypothalamic-pituitary-gonadal

axis. G nR H , gonadotropin-releasing hormone;
L H , luteinizing hormone; FSH , follicle stimulat-
ing hormone.
a superior examination. The testes should be checked for size inhibiting substance/antimüllerian hormone (M IS/AM H ),
and consistency. Testes measure 15 to 25 cu cm in volume (45) respectively (65). AM H transcription is regulated by many
and 4.5 to 5.1 cm in longitudinal length (60) in young healthy transcription factors, including steroidogenic factor 1 (SF-1),
men. Testes decrease in size with age (27). Size directly corre- SRY H M G box related gene 9 (SO X9), Wilms tumor 1
lates to spermatogenesis, as seminiferous tubules comprises (WT1), and a zinc finger transcription factor (GATA-4) (11).
80% of testicular volume (5). Although a variety of devices Testosterone preserves the wolffian duct, and M IS/AM H in-
are available for testis size measurement, including calipers, duces degeneration of the adjacent müllerian duct (23). The
punched-out orchidometers, and scrotal ultrasonography, we wolffian duct of the regressing mesonephros combines with
prefer the standard Prader orchidometer for quick and easy the developing gonad to form the epididymis, ductus deferens,
assessment of testis volume. Assessment of testis consistency is ampulla, and seminal vesicles (55).
equally important. A soft, mushy feel to the testis implies di-
minished spermatogenic capacity. Taken together, size and
consistency help differentiate nonobstructive from obstructive De sce nt
causes of azoospermia.
The developing testis is anchored by two ligaments, the cranial
suspensory ligament and the caudal genitoinguinal ligament
De ve lo p me nt or gubernaculum (23). Although we have an incomplete un-
derstanding of the mechanism of testicular descent, the
Primordial germ cells migrate from the yolk sac to the genital process can be conceptualized as occurring in three simplified
ridge of the mesonephros, where they join somatic cells to steps: nephric displacement, transabdominal movement, and
form the primary epithelial or medullary cords (55). The testes inguinal passage. In the first stage, occurring about gestation
arise from the primordial germ cells at 7 to 8 weeks of devel- day 55, the gubernaculum and the wolffian and müllerian
opment (25) under the direction of the SRY gene of the Y ducts pull the gonad posteriorly as the metanephros moves
chromosome (58). The component cells of the testis, Leydig and anteriorly into the space recently vacated by the mesonephros
Sertoli cells, begin production of testosterone and müllerian (15). As the abdominal cavity of the fetus enlarges, the gonad
maintains its proximity to the inguinal canal by dynamic But not many know that the testicular capsule consists of more
changes to the suspensory ligaments. Under hormonal control, than just the tunica albuginea. The testicular capsule is dis-
the gubernaculum enlarges and the cranial suspensory liga- tinctly separate from the scrotal layers and is composed of its
ment regresses, facilitating descent (24) at 8 to 15 weeks of own three layers: the visceral layer of the tunica vaginalis (an
gestation (23). Testosterone induces regression of the cranial outer thin serous layer composed of attenuated mesothelial
suspension ligament (61), whereas gubernacular development cells), the tunica albuginea (a fibrous membrane, composed of
depends on insulinlike hormone 3 (Insl3) produced by the collagen fibers and fibroblasts, that forms the bulk of the cap-
Leydig cell (13,43). At 25 to 35 weeks of gestation (23), the sule), and the tunica vasculosa (a thin, delicate areolar layer
gubernaculum pushes through the inguinal canal, leading with occasional networks of tiny blood vessels) (9). The tunica
the testis outward into its final position (55). Calcitonin gene- albuginea forms septations that separate the testis into lobules;
related peptide (CGRP), found in the sensory branches of the the blood supply travels along these septations (9). Along the
genitofemoral nerve, appears to control gubernacular growth posterior border of the testis, the tunica albuginea thickens to
and direction of migration (23,68). The process ends with the form the mediastinum testis, which houses the channels of
regression of the gubernaculum (66). the rete testis and the initial portions of the vasa efferentia
(Fig. 62.3) (9). Contractility of the testicular capsule (49) may
Cap sule be involved in the regulation of blood flow into the testis (53).
M edical students are all too familiar with the seven layers of the
scrotal wall: skin, dartos muscle, superficial perineal fascia, ex- Blo o d Sup p ly
ternal spermatic fascia, cremasteric fascia, internal spermatic The internal spermatic or testicular, deferential, and external
fascia, and the parietal layer of the tunica vaginalis (Fig. 62.2). spermatic or cremasteric arteries are the major blood supply
FIGURE 62.2 Anatomic layers of the scrotal wall and testicular

capsule.
FIGURE 62.3 O verview of testicular anatomy.
to the testis (Fig. 62.4) (18). The internal spermatic artery The deferential artery branches from the inferior vesical
arises from the aorta at L2-3, just below the origin of the renal artery and travels along the vas deferens in the spermatic cord
arteries, and travels over the psoas major muscle, the ureter, to the convoluted portion of the epididymis at the cauda (34).
and the genitofemoral nerve (41). The right testicular artery The cremasteric artery forms off the inferior epigastric artery
also lies anterior to the inferior vena cava and posterior to the and travels superficially in the cremasteric fascia and tunica
third part of the duodenum, the right colic artery, the ileocolic vaginalis to widely cover the surface of the testis and sper-
artery, the root of the mesentery, and the terminal ileum; the matic cord (34). Large-caliber anastomotic channels between
left testicular artery lies posterior to the inferior mesenteric the testicular and deferential arteries have been demonstrated
vein, the left colic artery, and the lower descending colon (41). in 87% of human testes specimens (34). The deferential artery
The artery enters the spermatic cord as a single vessel before forms its anastomosis at the cauda epididymis, whereas the
branching several times, sometimes as high as the internal in- testicular artery forms its anastomosis by a branch anywhere
guinal ring (34). Studies have noted that the testicular artery from near the internal inguinal ring to the tunica albuginea
often has one to three branches supplying the upper and lower (34). The cremasteric artery has contributed to the anastomo-
poles of the testis (41). sis in 50% of the specimens studied (34). The relative contri-
Despite variant views on testicular blood supply, the pre- butions of each artery to the overall blood supply can be
dominant understanding is that the arteries supplying the estimated by noting their diameters; H arrison and Barclay
parenchyma arise on the free border and run up toward (18) and H arrison (17) reported that the sum of the cremas-
the mediastinum before turning and branching out into the teric and deferential diameters was equal to the diameter of
parenchyma (54). The testicular arteries penetrate the poste- the testicular artery in one third of the cases. The diameter
rior aspect of the tunica albuginea and send parenchymal of the testicular artery is equal to or greater than the sum of
branches anteriorly as they travel inferiorly. Large branches the deferential and cremasteric artery diameters in 57.5% of
also cover the inferior pole of the testis. The medial and lateral cases (47). Raman and Goldstein (47) point to the Poiseuille
aspects of the midtestis have relatively fewer arterial branches law (Q 4 P8 L ), in which the rate of blood flow through
compared to the anterior and inferior aspects (53). Color a vessel (Q ) is related to the fourth power of the radius ( ), the
Doppler ultrasonography with point spectral analysis has difference in blood pressure at the two ends (P), the viscosity
demonstrated the low vascular resistance of the testis, in con- of blood ( ), and the length of the vessel (L ); because of the
trast to the high vascular resistance of the epididymis and fourth power of the radius, blood flow of a large vessel is
peritesticular tissues (39). greater than that of two smaller vessels whose combined
FIGURE 62.5 Varicocelectomy. In addition to ligation of the internal

spermatic veins, external spermatic and gubernacular veins must be
identified and clipped to prevent varicocele recurrence. (From
Goldstein M . Surgical management of male infertility and other scro-
tal disorders. In: Cam pbell’s urology, 8th ed. Philadelphia: WB
Saunders, 2002:1532–1587, with permission.)
varicocelectomy (Fig. 62.5). If the patient simultaneously or

subsequently undergoes vasectomy, the deferential venous
drainage may be compromised. Lee et al. (35) advocate micro-
surgical technique to avoid this outcome of insufficient venous
drainage when performing both vasectomy and varicocelec-
tomy in the same patient. In another example of relevant
surgical venous anatomy, the importance of gubernacular
veins and their contribution to varicocele has been debated.
Although Ramasamy and Schlegel (48) reported no benefit of
testicular delivery and ligation of gubernacular veins when
performing varicocelectomy, M urray et al. (42) found pre-
sumed scrotal collaterals in 7% of recurrent varicoceles.
Knowledge of the layout of the testicular blood supply
FIGURE 62.4 Testicular blood supply. N ot pictured: cremasteric artery.
minimizes the risk for significant bleeding and compromise of
the arterial supply during surgical sperm retrieval (51). The
branches of the testicular artery are vulnerable to injury with
diameter equals that of the larger vessel. Raman and their superficial course beneath the tunica albuginea. In one
Goldstein (47) concluded that the testicular artery contributes study, significant arterial blockage resulted from placement of
significantly more to the testicular blood supply than the com- a traction suture through the lower pole of the testis (26).
bined flow of the deferential and cremasteric arteries. This Each septal compartment created by the tunica albuginea en-
fact may be relevant in procedures involving ligation of the capsulates at least one centrifugal artery with surrounding
testicular artery with dependence on collateral blood flow, seminiferous tubules (53). M ostafa et al. (41) divided the testis
such as non–artery-sparing laparoscopic varicocelectomy. into three vascular zones: the rich vascular areas comprising
Although several studies have reported no testicular atrophy the upper pole, mediastinum testis, and posterolateral seg-
in adults and adolescents who had their testicular arteries lig- ments; the moderate vascular area of the middle third of the
ated during varicocelectomy (29,38,59), other studies have lateral surfaces; and the poor vascular areas of the anterior
demonstrated significant sequelae of testicular artery ligation border and anterolateral surfaces.
(30,44,57). The location of the testes outside the main body cavity
The layout of the testicular blood supply has important im- makes them vulnerable to traumatic injury and torsion.
plications for several urologic procedures. In the surgical man- Within the body, the long distance of travel across several
agement of cryptorchidism with intentional ligation of the anatomic planes by the internal spermatic artery and the other
testicular artery, manipulation of the vas deferens should be structures of the spermatic cord, as well as their delicate na-
minimized to preserve the deferential artery (34). Also, the tes- ture, exposes them to iatrogenic injury. Spermatic cord struc-
ticular artery must be ligated above the origin of its anasto- tures, including the testicular artery, may be injured during an
motic branch to take advantage of collateral circulation from inguinal hernia repair. In adults, the use of mesh for hernia
the other arteries (34). Even venous drainage plays a signifi- repair can involve the spermatic cord with inflammation or di-
cant role in the surgical anatomy of the testis. Deferential rect obstruction. In children, the fine structures of the sper-
veins provide the only outlet for venous drainage following matic cord can be ligated inadvertently along with the hernia
sac. The testicular artery and lymphatics may be compromised during the course of spermatogenesis. In the “ zipper” theory,
during varicocelectomy. Even with microsurgical technique, tight junctions at the basal domain of Sertoli cells break down
accidental artery ligation has occurred in approximately 1% to allow passage of spermatocytes as new tight junctions are
of 2,102 cases (4). O f these, 5% resulted in testicular atrophy; formed behind them (37). In the “ repetitive removal of mem-
the low incidence of morbidity was attributed to the preserva- brane segments” theory, stress created by spermatocytes alters
tion of the cremasteric and/or secondary testicular arteries (4). tight junction fibrils (37).
Venous channels run independent of arteries, draining into
surface veins of the tunica albuginea or into a central vein near
the mediastinum; these veins feed the pampiniform plexus
Inne rvat io n
(54). Lymph fluid of the testis and epididymis travels in the
spermatic cord to the lumbar or para-aortic lymph nodes N o somatic nerves supply the testis. Scrotal and spermatic
(40,55). branches of the genitofemoral and ilioinguinal nerves as well
as sympathetic fibers along the testicular artery mediate testic-
ular pain (19). The genital branch of the genitofemoral nerve
Co unt e rcurre nt He at Exchang e innervates the cremaster muscle and scrotal skin, and a branch
of the ilioinguinal nerve innervates the skin of the upper scro-
The control of blood flow to the testis is a complex collabora- tum and base of the penis. Spermatic cord traction during
tion of many factors, including nervous and hormonal con- scrotal surgery may even activate peritoneal stimulation (62).
trol, temperature, and posture (54). As for all organ systems, Autonomic innervation is provided by the superior spermatic
blood flow is critical for testicular function and its effects on nerve and the inferior spermatic nerve (14). The superior sper-
the system as a whole. Beyond the importance of flow rate to matic nerve originates from the celiac and aortic plexuses and
the inflow of oxygen and nutrients, the delivery of androgens travels along the testicular vessels to form the major nerve
to the body relies on testicular blood flow (54). Furthermore, supply of the testis (14). Sympathetic fibers originate in tho-
the countercurrent heat exchange system of the testicular vas- racic segments 10 and 11, whereas the parasympathetic fibers
culature has been widely discussed in the context of varicocele come from the vagus nerve (14). The inferior spermatic nerve
pathophysiology. The arteries are intimately intermingled with travels with the ductus deferens and through the epididymis to
the veins along the spermatic cord with the surrounding innervate the lower pole of the testis (14). Sympathetic fibers
pampiniform plexus (64), allowing for efficient heat exchange originate in the inferior mesenteric and hypogastric plexuses,
and cooling of the testis. As a result of this mechanism, the and parasympathetic fibers branch from the pelvic nerve (14).
blood entering the testis is 2ºC to 4ºC lower than rectal tem- Evidence from animal models indicates that the nerve supply
perature (1), and intratesticular temperatures are 3ºC to 4ºC to the testis helps regulate its endocrine function. H owever,
lower than rectal temperature (32). the precise function of testicular innervation in humans
remains unclear.
Testicular pain is a common referral for urologists and can
be secondary to infection, inflammation, trauma, varicoceles,
Blo o d –Te st is Barrie r hydroceles, and other causes. O rchialgia can be acute or
The relative isolation of the testis fluid is attributed to the chronic, and it is best treated by addressing the underlying dis-
blood–testis barrier formed by inter–Sertoli cell tight junctions order, such as varicoceles. As another example, vasectomy re-
(63). Lipid solubility, not molecular size, is the main determi- versal can alleviate postvasectomy pain syndrome. H owever,
nant of substance entry into the testis fluid, although glucose the etiology of chronic testicular pain remains unknown in up
and testosterone are two substances that enter more rapidly to 25% of patients even after extensive workup (8). For these
than expected (55). The barrier is established at puberty, and men, treatment ranges from psychological support to medica-
once formed is resistant to disruption (55). Efferent duct ligation, from regional nerve blocks to surgery (36). Inguinal or-
tion and subsequent distention of the seminiferous tubules is chiectomy is one option, providing complete pain relief in
one way to disrupt the barrier (55). The blood–testis barrier 75% of patients in one study (8). In another study, however,
may serve to optimize tubular conditions for meiosis, and the orchiectomy failed in 80% of patients (6). Understanding the
immunological isolation of the testis fluid may be a secondary innervation of the testes and scrotum can help to target surgi-
benefit (55). M en with failure of the barrier (i.e., men having cal management. Levine and M atkov (36) reported microsur-
undergone vasectomy) can form antibodies against their own gical denervation of the spermatic cord, including branches of
spermatozoa (55). H olash et al. (21) hypothesized that testicu- the ilioinguinal and genitofemoral nerves and autonomic
lar microvessels form part of the blood–testis barrier. They re- fibers, to provide complete pain relief in 76% and partial re-
ported several markers of barrier properties, such as glucose lief in 9% . H eidenreich et al. (19) reported a 96% complete
transporter and P-glycoprotein, in testicular microvessels response rate.
analogous to brain microvessels. They also found intertubular
Leydig cells adjacent to microvessels to express the astrocyte
markers glial fibrillary acidic protein, glutamine synthetase, Se minife ro us Tub ule s
and S-100 protein; astrocytes help to maintain barrier features
in brain microvessels (21). The seminiferous tubules contain the germinal epithelium.
Sperm cells must travel from the basal compartment to They form the bulk of the testis, with 15 to 25 m of length
the adluminal and luminal compartments. Two theories exist per gram of tissue in humans (3,55). As the testis declines
to explain how spermatocytes cross the blood–testis barrier in size with age, there is a corresponding shortening of the
FIGURE 62.6 N ormal spermatogenesis showing several cellular associations (stages) in a seminiferous
tubular cross section. Sb1, round spermatid; Sc and Sd2, elongated spermatids; II, secondary spermato-
cyte; P, pachytene spermatocyte; Z , zygotene spermatocyte; G , spermatogonia; S, Sertoli cells (hema-
toxylin and eosin, magnification 1,000 ). (From Jow WW. Testis biopsy. In: Goldstein M , ed. Surgery of
m ale infertility. Philadelphia: WB Saunders, 1995:15, with permission.) Inset: Exaggerated, schematic
illustration of the blood–testis barrier formed by tight junctions of Sertoli cells.
seminiferous tubules (33,55). The tubules are a series of con- which has duplicated its DN A, forms two haploid secondary
voluted loops with their two ends opening into the rete testis; spermatocytes (2N ). In meiosis II, the chromatids of each
they are further organized into about 300 lobules, with one to chromosome of the secondary spermatocyte divide to form
four tubules per lobule (55). The tubular wall has four layers: spermatids (1N ). In transforming the spermatid into a sperma-
an internal noncellular layer or basement membrane, an inter- tozoan, spermiogenesis involves multiple steps, including
nal cellular or intralamellar layer containing smooth muscle acrosome formation, nuclear changes, neck and tail forma-
cells, an external noncellular layer similar to the internal non- tion, and reorganization of the cytoplasm (10).
cellular layer, and an external cellular layer organized from
cells of the intertubular mesenchyme (7). This flexible wall Sup p o rt ing Ce lls
regulates the entry of fluid and substances and may contribute In addition to the germ cells, supporting cells, also called fol-
to the transport of spermatozoa with rhythmic peristaltic con- liculous cells, small epithelial cells, or indifferent cells, reside
tractions (7). in the seminiferous tubules (7). These somatic elements origi-
nate from the coelomic cells of the gonadic crests and organize
into sex cords shortly after sexual differentiation (7). The sup-
Ge rminal Ep it he lium porting cells increase their numbers by mitosis prior to sper-
matogenesis, and they gradually convert to Sertoli cells with
Ge rm Ce lls and Sp e rmat o g e ne sis the onset of spermatogenesis (7).
A cross-sectional view of a seminiferous tubule demonstrates
the wall with basement membrane enclosing Sertoli cells and Se rt o li Ce lls
sperm cells at various stages of development. Spermatogenesis Sertoli cells are polymorphous and highly cohesive (7). The
involves three distinct processes: mitotic renewal of con- size and shape of Sertoli cells vary over the course of the sem-
stituent stem cells, called spermatogonia; meiotic halving of iniferous epithelial cycle (7). The shape has been described as
the chromosomal number of the sperm product; and struc- a short body adjacent to the basement membrane with multi-
tural development of the mature spermatozoan (10). ple sheetlike cytoplasmic projections extending toward the lu-
Spermatogenesis begins near the basement membrane, and the men, the form of these projections altered by surrounding germ
cells migrate toward the lumen as they develop, a process fa- cells (10). Each Sertoli cell spans the basement membrane to
cilitated by the Sertoli cells (10). the tubular lumen and encloses clusters of germ cells (Fig. 62.6).
Spermatogonia (2N ) have significant contact with the base- The seminiferous epithelial cycle refers to the simultaneous
ment membrane of the seminiferous tubule. They are classified development of several germ cell generations within the semi-
as type A dark, type A pale, and type B based on their appear- niferous tubule, in which the cycles of different generations
ance on electron microscopy (10). Cells undergoing meiosis are coordinated (7). In humans, the duration of the seminifer-
are identified as spermatocytes. In meiosis I, the diploid pri- ous epithelial cycle is 64 days (20), and the duration of sper-
mary spermatocyte (2N becomes 4N with DN A replication), matogenesis is 74 to 76 days (56).
The Sertoli cell has many functions. The Sertoli-Sertoli involved in steroidogenesis and augmentation of cholesterol
tight junctional complexes effectively separate the exterior transport to and within the mitochondria (16). Leydig cells
and interior compartments of the seminiferous epithelium (2). communicate extensively with Sertoli cells and germ cells via
The Sertoli cell also secretes numerous products, including in- paracrine regulation of testicular function (50). There are two
hibin, androgen-binding protein (ABP), testicular transferrin generations of Leydig cells in humans: fetal and adult. Fetal
and ceruloplasmin (iron and copper transport proteins), plas- Leydig cells originate from undifferentiated mesenchymal cells
minogen activators, and growth factors (2). It even produces at 8 weeks of gestation and regress starting at 14 weeks (5).
and metabolizes steroid hormones, although on a much Adult Leydig cells are evident at puberty (5). The gradual de-
smaller scale than Leydig cells (2). The secretory capacity of cline in plasma testosterone with advancing age correlates
the Sertoli cell is bidirectional, which means it can secrete into with age-related attrition of Leydig cells (28) or may possibly
both the tubular lumen and the interstitium and systemic cir- be due to alterations in LH function and oxidative damage to
culation (67). In addition to supplying nutrition, adhesion, proteins involved in steroidogenesis (69).
and transport functions to cells undergoing spermatogenesis,
Sertoli cells may regulate apoptosis of germ cells (46). Sertoli Re t e Te st is and Effe re nt Duct s
cell function is regulated primarily by FSH and testosterone, The rete testis is a network of anastomosing channels lo-
although other substances, such as insulin, glucagon, calcitonin, cated at the testicular hilum along the epididymal edge of
estrogens, other steroid hormones, and vitamins, play a sup- the testis (55). Cells lining the rete testis vary from squa-
porting role (2). Surrounding cells such as germ cells, Leydig cells, mous to columnar and are joined near the lumen by special-
and myoid cells interact with the Sertoli cell by cell-cell contacts ized junctions (55). The rete testis is closely associated with
and paracrine factors (2). The Sertoli cell population is a ma- the testicular artery at the surface of the testis (55). Sperm
jor determinant of testicular size along with germ cells (2). The and fluid flow from the rete testis and travel through effer-
ratio of germ cells to Sertoli cells is estimated at 16:1 (2,67). ent ducts to reach the epididymis (55). These ducts are lined
with principal and ciliated cells (55). Although these cells
have minimal secretory capacity, the ciliated cells may be in-
Int e rst it ial Tissue volved with fluid resorption (55). In contrast to the rete
testis, the efferent ducts are bathed by a dense subepithelial
The interstitium surrounding the seminiferous tubules is com- capillary bed (31).
posed of loose fibrous connective tissue and a network of
blood vessels, nerves, and lymphatics. The interstitial tissue
also contains cells including fibroblasts, reticular cells, SUMMARY
macrophages, plasma cells, lymphocytes, mast cells, and
epithelioid cells called Leydig cells (22). O ur current knowledge of male reproductive anatomy and
physiology is a culmination of research spanning more than a
Le yd ig Ce lls century. Recent advances in molecular techniques have re-
O rganization of the Leydig cell within the interstitium varies vealed some of the underlying mechanisms, such as cell signal-
by species, but in humans Leydig cells form small aggregations ing, involved in spermatogenesis and development of the
near blood and lymphatic vessels (10). LH stimulates the pro- reproductive tract. This chapter reviewed the basic anatomy
duction of androgens by the Leydig cell through several mech- of the testis, a simplified framework that can be filled in with
anisms, including acceleration of synthesis of the proteins future developments in the field.
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CHAPTER 63 ■ SIMPLE O RCHIECTO MY
BRETT S. CARVER AND SHERRI M. DO NAT
Simple orchiectomy involves the removal of one or both testes

at the distal spermatic cord, usually through an anterior INDICATIO NS FO R SURGERY
transscrotal approach, although it has also been described
through a suprapubic approach (9). It is used in the treatment The primary indication for bilateral scrotal orchiectomy is ad-
of benign intrascrotal processes and as a method of androgen vanced prostate cancer requiring hormonal ablation as treat-
ablative therapy in patients with advanced prostate cancer. ment. O ther indications for simple orchiectomy include benign
Among men in the United States, prostate cancer is the intrascrotal disorders such as a traumatic injury to the testis
most commonly diagnosed malignancy, with 186,320 new requiring partial or complete removal of the devitalized tissue,
cases projected to be diagnosed in 2008 and approximately testicular necrosis following prolonged torsion, and severe
28,660 deaths attributed to it (1). Since H uggins and H odges epididymal orchitis that is refractory to antimicrobial therapy.
(7) first demonstrated the therapeutic benefit of hormonal ab- M alignant diseases of the testes, such as suspected germ
lation in the treatment of advanced prostate cancer, bilateral cell tumor, should never be managed with a simple orchiec-
scrotal orchiectomy has been commonly utilized as a means of tomy through a transcrotal approach. Suboptimal approaches
removing the testosterone-producing tissue, thereby bringing to testicular neoplasms, including scrotal orchiectomy and
serum levels to castrate levels. Although it has been by tradi- transscrotal biopsy, can alter the normal lymphatic drainage
tion used only for treatment in patients with advanced or of the testis and increase the burden of therapy for the patient
metastatic disease, it is currently being evaluated for patients (3). A meta-analysis of 206 cases of scrotal violation reported
with presumed localized disease in both neoadjuvant and ad- a local recurrence rate of 2.9% , compared to 0.4% for pa-
juvant settings to determine if it has any benefit in decreasing tients treated with inguinal orchiectomy, but no difference in
the chance of local or systemic recurrence and improving sur- systemic relapse or survival were appreciated (3). Therefore, if
vival when used in combination with the traditional there is any suspicion of testicular cancer, a radical orchiec-
monotherapies of surgery or radiation (4). tomy through an inguinal incision should be performed.
ALTERNATIVE THERAPY
DIAGNO SIS
There are now several agonist analogues of gonadotropin-
The initial diagnosis of prostate cancer is usually made through releasing hormone that inhibit the pituitary gonadal axis, result-
a combination of digital rectal exam, prostate-specific antigen ing in the downregulation of luteinizing hormone–releasing
level, patient symptoms, and transrectal ultrasound-directed hormone receptors and subsequent decrease in gonadotropin
biopsy, although it is on occasion found incidentally on secretion. These are equally effective in achieving hormonal
transurethral resection for obstructive benign disease. Advanced ablation and provide an alternative to orchiectomy in patients
disease may involve lymph nodes, bone, or, less commonly, vis- for whom the psychological implications of the surgery are
ceral or soft tissue lesions and may be documented by physical too great (4); however, the cost effectiveness of surgery is cer-
examination, elevated prostatic acid phosphatase levels, ab- tainly superior to that of chemical castration. While the use of
normal bone scan, computerized tomography scan, magnetic bilateral orchiectomy for the management of metastatic
resonance imaging, plain film bone survey, or chest X-ray. prostate cancer has declined with the implementation of go-
Lymph node involvement may be determined by biopsy of en- nadotropin-relasing hormone agonists or antagonists, a recent
larged nodes seen on imaging studies or unexpectedly during study demonstrated that, with changes in M edicare reim-
the pelvic lymph node dissection for a radical prostatectomy. bursement, the rates of surgical castration have increased over
Benign intrascrotal processes such as epididymal orchitis or recent years (14).
devitalization of testicular tissue by trauma or torsion are di- Alternatives to the total removal of the testis and epi-
agnosed by physical examination, patient symptoms, nuclear didymis have been explored and include subcapsular orchiec-
testicular examinations, color Doppler ultrasonic examina- tomy and subepididymal orchiectomy (2,6,8,12). These give
tions, and/or surgical exploration. In general, inflammatory the cosmetic effect of a testis being present but also achieve the
processes show increased flow on both nuclear scans and therapeutic goal of androgen ablation. There has been some
Doppler flow studies and processes causing devascularization controversy (10) over the efficacy of subcapsular orchiectomy
show decreased or no flow on nuclear and Doppler flow stud- since it was first described in 1942 by Riba (12); however,
ies. H owever, if there is any question as to whether an acute multiple modern studies have demonstrated its efficacy and
scrotum represents a testicular torsion versus an epididymal suggest that any residual testosterone production is most
orchitis, it should be surgically explored immediately to an- likely a result of incomplete removal of the intratesticular con-
swer the question and render the appropriate treatment. tents (2). Testicular prostheses are also available for use in
428
Chap t e r 63: Simp le O rchie ctomy 429
patients who desire a better cosmetic result, and these may be

placed in either the tunica vaginalis or within the tunica al-
buginea (13). Kihara and O shima (8) have also described an
epididymal-sparing orchiectomy with insertion of a pedicled
fibrofatty tissue graft to preserve scrotal cosmesis after bilat-
eral orchiectomy. This type of procedure may be complicated
by epididymitis, which can be minimized by performing a va-
sectomy at the time of the procedure (6). Advantages of a fi-
brofatty tissue graft over implants or prostheses are that there
are no risks of developing autoimmune disorders and rupture
or migration complications.
SURGICAL TECHNIQ UE
Simp le O rchie ct o my
This procedure may be performed with local, regional, or gen-
eral anesthesia. Local anesthetic sensory blockade is obtained FIGURE 63.2 The vas deferens is ligated separately from the vascular
by infiltrating the spermatic cord in the region of the vas def- structures of the cord. The vascular structures are double ligated with
erens in the high scrotum just below the pubic tubercle with a both a free tie proximally and a suture ligature distally using 0 Vicryl.
0.5% bupivacaine solution. Care must be taken to ensure that
the block is not injected intravascularly by drawing back on
the dartos and cremasteric layers until the parietal portion of
the syringe prior to injecting the medication. The same solu-
the tunica vaginalis is incised directly over the testis. This is
tion is then injected subcutaneously at the site of the anterior
usually evidence by a gush of fluid from the peritesticular
scrotal incision. Sensory blockade should then be tested by
space. The incision in the tunica vaginalis is lengthened in
pinprick before the beginning of the procedure.
both directions far enough to allow exposure of the entire tes-
ticle through the wound. The surrounding tunics are freed
Scro t al Ap p ro ach from the spermatic cord by a combination of blunt and sharp
dissection. M eticulous hemostasis may be obtained in each
The anterior scrotal wall is shaved to remove existing hair, layer as it is entered with electrocautery. O nce the spermatic
and the scrotum and genitalia are prepared in a sterile manner. cord is isolated, the vas deferens is separated, doubly clamped,
A 2.5- to 3.0-cm midline incision is made just through the skin divided, and ligated with 2-0 Vicryl ties (Fig. 63.2). The re-
along the median raphe in the anterior scrotal wall using a mainder of the cord structures may be divided into one or
no. 15 blade scalpel while the assistant pushes a testicle to- more bundles and are doubly clamped on the proximal side
ward the incision between his or her thumb and index finger and singly clamped on the distal side. O nce divided, the prox-
so that the testicle lies directly under the incision (Fig. 63.1). imal portion of the cord is ligated with a 0 Vicryl free tie be-
By electrocautery, the incision is then carried down through hind the most proximal clamp, which is then removed, and a
0 Vicryl suture ligature is placed just distal to the free tie
(Fig. 63.2). Before the cord is released to retract proximally,
the tunics, dartos, and subcutaneous areas are again inspected
for hemostasis. O nce this is felt to be adequate, the cord is
allowed to retract and attention is turned to the opposite testi-
cle. It is then removed through the same midline incision in the
same manner. This leaves two openings in the tunica vaginalis
and dartos layers, which are separated by a median septum.
These deep layers are then closed in one layer using a 3-0
Vicryl running suture. Allis clamps are placed at either end of
the median septum to facilitate the exposure (Fig. 63.3). The
skin is then closed with interrupted 3-0 chromic sutures and a
gauze dressing is applied. Drains are not required but can be
considered if there is doubt about hemostasis. Compression or
turban dressings may also be used if there is concern over
postoperative hemostasis or edema.
Sup rap ub ic Ap p ro ach

This approach is advantageous in patients in whom one wants
to avoid a scrotal incision and/or place testicular prostheses
FIGURE 63.1 A midline scrotal incision over the median raphe at the time of the orchiectomy. The patient again is placed
allows access to both testes. in the supine position and the suprapubic area is shaved. A
FIGURE 63.5 Isolation of the cord with a Penrose drain. Division of

the gubernaculum allows complete mobilization of the testis from the
scrotum.
testicle is delivered into the wound by placing upward pressure

on the scrotum and testicle, with simultaneous upward traction
on the cord with the Penrose drain. The gubernaculum is then
divided, which mobilizes the testicle (Fig. 63.5). The vas defer-
FIGURE 63.3 Closure of the deep layers of the scrotum, including the
dartos musculature and testicular tunics laterally and the midline sep-
ens and spermatic cord are then divided as previously described.
tum in one running layer. If testicular prostheses are desired, they are then placed into
the empty scrotum after adequate hemostasis is ensured, and a
pursestring suture of 3-0 silk is used to close the neck of each
4- to 5-cm transverse incision is made in the midline approxi- hemiscrotum (Fig. 63.6). The Scarpa fascia is closed with 3-0
mately 2 to 3 cm above the pubic symphysis (Fig. 63.4). This Vicryl suture, and the skin is closed with a 4-0 Vicryl subcutic-
is extended down through the subcutaneous tissues to the ular suture reinforced with benzoin and Steri-Strips.
level of the rectus fascia using electrocautery. The subcuta-
neous tissue is then swept bluntly toward the external inguinal
ring, exposing the distal spermatic cord, which is then isolated
just distal to the ring in the upper scrotum (Fig. 63.5). Right-
angle retractors are helpful to obtain exposure during this dis-
section by moving the incision toward the side being worked
on. The spermatic cord is looped with a Penrose drain and the
FIGURE 63.6 If a prosthesis is desired, it is placed into the empty

hemiscrotum. To prevent migration, a pursestring suture is used to
FIGURE 63.4 A midline suprapubic incision 2 to 3 cm above the pu- close the neck of the hemiscrotum, eliminating the need for an
bis allows access to both testes at a level just below the external ring. anchoring suture.
Chap t e r 63: Simp le O rchie ctomy 431
FIGURE 63.8 The parenchymal tissue is then removed at its midline

attachment with electrocautery and the internal surface of the capsule
is cauterized.
FIGURE 63.7 The tunica albuginea is opened in midline opposite the

epididymis and the contents are swept bluntly to the midline attachment.
Sub cap sular O rchie ct o my

This approach is used in patients who desire the cosmetic ef-
fect of testicles being present without the use of testicular
prostheses. The operation is approached through the anterior
scrotum as previously described (Fig. 63.1). O nce the testicle
is delivered to the wound, the tunica albuginea is opened in
midline in a cephalad-to-caudad fashion. H emostats are placed
on the edges of the capsule to provide traction, and an index
finger is placed behind the capsule to invert it (Fig. 63.7).
This maneuver facilitates the removal of the parenchymal con-
tents, which are swept to the midline using a gauze sponge.
The midline attachment of the parenchyma is divided using
electrocautery, and the remainder of the interior capsule is
cauterized to ensure hemostasis and complete destruction of
all testicular parenchyma (Fig. 63.8). This technique has also
FIGURE 63.9 The tunica albuginea is reapproximated with a running
been described using a CO 2 laser (15). The tunica albuginea is 3-0 Vicryl suture.
then closed using a running 3-0 Vicryl suture (Fig. 63.9) and
the residual testicular tunics, adnexa, and cord are returned to
the scrotum. The deep layers of the scrotum are closed in one
layer as previously described, as is the skin (Fig. 63.3).
Sub e p id id ymal O rchie ct o my

This is another procedure offered as an alternative to simple
scrotal orchiectomy for a more acceptable cosmetic result.
Again, the initial exposure to the testicles is the same as previ-
ously described for the anterior scrotal approach (Fig. 63.1).
O nce the testicle is delivered to the wound, a vasectomy is per-
formed including double ligation and division to minimize the
possibility of postoperative epididymitis (6). A line of dissection
between the cleavage plane of the testis and the epididymis is
utilized (Fig. 63.10). Dissection is started at the head of the
epididymis, and the epididymal tissue is clamped for hemosta-
sis. Care must be taken to secure the spermatic artery entering
the testis at a point between the midportion and the tail of the FIGURE 63.10 Dissection of the testis from the epididymis, ligating
epididymis. The clamped epididymal tissue is ligated using a the epididymal side over clamps with Vicryl suture.
which prevents any tamponade effect. Re-exploration with

evacuation of the hematoma and placement of a drain may be
required but can be ineffective when the bleeding dissects sub-
cutaneously in the dartos layer. This has led to the develop-
ment of several preventative measures to achieve adequate
compression of the area postoperatively, including turban-
type dressings or compression of the scrotal wall over a gauze
bolster as described by O esterling (11). These techniques
should not be substituted for being meticulous in obtaining
hemostasis at the time of the procedure.
Infection, depending on the degree of severity, is managed
by incision and drainage of any abscess pockets. This is fol-
lowed by local wound care, which may include wet-to-dry
dressing changes, sitz baths, and whirlpool with debridement
of any devitalized tissue. Antibiotics can be used in cases
where there is induration only and no abscess to drain or in
combination with the incision and drainage procedure if
needed. If antibiotics are used, they should be directed by the
results of wound cultures.
If a testicular neoplasm has been inadvertently removed
through a scrotal approach, the remaining inguinal spermatic
cord should be removed, as well as a wide excision of the scro-
tal scar. The hemiscrotum should also be removed if there was
FIGURE 63.11 After removal of the testis and further hemostasis any known tumor spillage during the transscrotal procedure.
with electrocautery, the tunica of the epididymis is closed over the raw This usually results in cure rates similar to those for conven-
surface using a running suture. tional initial radical inguinal orchiectomy (5).
3-0 Vicryl suture. M eticulous hemostasis is then obtained us- Re sult s

ing electrocautery, and a running 3-0 Vicryl suture on a ta-
pered needle is used to approximate the edges of the tunica The effectiveness of scrotal orchiectomy in terms of achieving
albuginea over the raw surface of the epididymis (Fig. 63.11). adequate hormonal ablation in patients with prostate cancer
The remaining spermatic cord and epididymis are replaced can be easily determined by measuring serum testosterone lev-
into the scrotum, which is closed as previously described. els postcastration, which are reduced by approximately 90% .
Castrate levels of testosterone have reportedly been achieved
by 2 and 15 hours after surgery (2,4). Prostate-specific antigen
O UTCO MES levels, patient symptoms, and patient survival may be fol-
lowed to determine the procedure’s effectiveness in terms of
Co mp licat io ns disease control. Side-effects may include loss of libido, impo-
tence, and hot flashes.
Complications can include infection, hematoma, edema, and
the inadvertent removal of a testicular neoplasm through the For benign intrascrotal processes such as epididymal orchitis
scrotal approach. O f these, hematoma can be a significant unresponsive to antibiotics, or devitalized tissues secondary to
problem because of the distensible nature of the scrotum, torsion or trauma, simple orchiectomy is curative.
References
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics 2008. CA Cancer J Clin 8. Kihara K, O shima H . Cosmetic orchiectomy using pedicled fibrofatty tis-
2008;58(2):71–96. Epub 2008 Feb 20. sue graft for prostate cancer: a new approach. Eur Urol 1998;34:210.
2. Arcadi JA. Rapid drop in serum testosterone after bilateral subcapsular 9. Klein EA, H err H W. Suprapubic approach for bilateral orchiectomy and
orchiectomy. J Surg O ncol 1992;49:35. placement of testicular prosthesis. J Urol 1990;143:765.
3. Capelouto C, Clark P, Ransil B, et al. A review of scrotal violation in tes- 10. O ’Conor VJ, Chaing SP, Grayhack JT. Is subcapsular orchiectomy a defini-
ticular cancer: is adjuvant local therapy necessary? J Urol 1995;153: tive procedure? J Urol 1963;89:236.
1397–1401. 11. O esterling JE. Scrotal surgery: a reliable method for the prevention of post-
4. Cassady JR, H utter JJ, Whitesell LJ. Prostate cancer. In: Vogelzang N J, operative hematoma and edema. J Urol 1990;143:1201.
Scardino PT, Shipley WU, et al., eds. Com prehensive tex tbook of geni- 12. Riba LW. Subcapsular castration for carcinoma of the prostate. J Urol
tourinary oncology. Baltimore: Williams & Wilkins, 1996:557–828. 1942;48:384.
5. Giguere JK, Stablein DM , Spaulding JT, et al. The clinical significance of 13. Solomon AA. Testicular prosthesis: a new insertion operation. J Urol 1972;
unconventional orchiectomy approaches in testicular cancer. A report from 108:436.
the Testicular Cancer Intergroup Study. J Urol 1988;139:1225. 14. Weight CJ, Klein EA, Jones JS. Androgen deprivation falls as orchiectomy
6. Glenn JF. Subepididymal orchidectomy: the acceptable alternative. J Urol rates rise after changes in reimbursement in the US M edicare population.
1990;144:942. Cancer 2008;112:2195.
7. H uggins C, H odges CV. Studies on prostatic cancer: the effect of castra- 15. Wishnow KI, Johnson DE. Subcapsular orchiectomy using the CO 2 laser: a
tion, of estrogen, and of androgen injection on serum phosphatases in new technique. L asers Surg M ed 1988;8:604.
metastatic carcinoma of the prostate. Cancer R es 1941;1:293.
CHAPTER 64 ■ INGUINAL O RCHIECTO MY
DAVID A. SWANSO N
Testicular tumors are relatively rare (only 2 to 3 cases per although blood should always be drawn for these tests before
100,000 men; an estimated 8,090 new cases in the United orchiectomy (12).
States in 2008) (8). When they occur, 94% are germ cell tu-
mors and the rest are tumors of the gonadal stroma and sec-
ondary tumors of the testis. In black men throughout the
world, germ cell tumors occur infrequently, but because
they do occur, this diagnosis cannot be excluded on the ba- The presence of an intrascrotal mass that cannot be clearly lo-
sis of race alone. Although the etiology of testicular tumors calized to outside the tunica albuginea is sufficient indication
is not known, there is a relatively high association (reported for surgical exploration through an inguinal approach.
in up to 12% of tumors) with a history of cryptorchidism; Although a sense of urgency is appropriate, it is not necessary
in 20% of such cases, the tumor is in the normally de- to consider inguinal orchiectomy an emergency procedure; it
scended testis. O rchidopexy does not prevent the subse- can be scheduled during regular operating hours.
quent development of tumor; it simply makes the diagnosis
easier to establish. Carcinoma in situ (CIS) is also known to
be associated with cryptorchidism, and data support the hy-
pothesis that at least some, if not all, germ cell tumors orig- ALTERNATIVE THERAPY
inate as CIS (7).
For the patient who has equivocal findings on physical exami-
nation and ultrasound that make the diagnosis of epididymitis
tenable, a short course of antibiotics may be tried. If there is
DIAGNO SIS no prompt improvement ( 10 to 14 days), or if the serum
tumor markers are elevated, inguinal exploration should be
M ost testicular tumors present as a palpable nodule or pain-
performed. Although radical (inguinal) orchiectomy is stan-
less swelling of the testis, often discovered incidentally by the
dard therapy for a solid lesion within the tunica albuginea,
patient or his sex partner. The differential diagnosis of a testic-
partial orchiectomy might be appropriate in the patient with a
ular mass includes tumor, epididymitis, and epididymoorchitis
solitary testis or bilateral testicular masses or in the patient
(the two most common diagnoses other than cancer), torsion
whose preoperative evaluation makes the diagnosis of an
(the diagnosis of which also requires surgery), and, less com-
epidermoid cyst of the testis highly likely (3,5,6,11). The selec-
monly, hernia, hydrocele, spermatocele, varicocele, hematoma,
tion criteria, technique, and results of organ-sparing surgery
and hematocele. The patient with cancer may complain of a
of the testis are presented in Chapter 65.
dull ache or sense of heaviness. Acute onset of pain is relatively
rare and usually indicates bleeding within the tumor or associ-
ated epididymitis. Signs and symptoms may be secondary to
metastatic spread. SURGICAL TECHNIQ UE
When careful bimanual examination of the testis reveals an
intratesticular mass, with or without an associated epididymal Although regional anesthesia is acceptable, general anesthe-
mass or tenderness, testicular tumor must be suspected. A sia is preferred because of the short duration of the surgery
transscrotal ultrasound is a widely available, rapid, sensitive, and the possible reflex response to traction on the testicle
noninvasive, and inexpensive way to determine whether there and cord. With the patient in the supine position, and after
is a solid mass within the tunica albuginea (12). Color adequate anesthesia, the lower abdominal wall, penis, and
Doppler ultrasound might on occasion help differentiate tes- scrotum are cleaned with a surgical scrub and draped in a
ticular torsion. M agnetic resonance imaging can also demon- sterile fashion so that the palpable testicular mass and ipsi-
strate the presence of an intratesticular mass but has no lateral hemiscrotum are accessible in the surgical field. By
established advantage over a careful physical examination tradition, an oblique skin incision is made approximately
plus ultrasound exam. With rare exceptions, all solid masses 2 cm superior to the inguinal ligament and parallel to that
within the testis should be considered malignant until proven ligament, extending approximately 8–10 cm laterally from
otherwise, and all require surgical intervention. just above the pubic tubercle to a point overlying the external
Patients with testicular tumors commonly have elevated tu- inguinal ring. I prefer a more horizontal incision, extending
mor markers, in particular -human chorionic gonadotropin approximately 5 to 8 cm from one fingerbreadth above the
and -fetoprotein. H owever, the presence of normal marker superior aspect of the external inguinal ring laterally toward
levels does not exclude malignancy, and there is in general no the internal inguinal ring, which might be slightly more
advantage to waiting for the marker results before operating, cosmetic (Fig. 64.1).
433
scalpel is used to make a small incision in the external oblique

aponeurosis midway between the internal and external in-
guinal rings, in the direction of its fibers. M etzenbaum scissors
are inserted through this opening, and the closed scissors are
pushed with slight upward pressure underneath the aponeuro-
sis to the external inguinal ring and then laterally toward the
internal ring (Fig. 64.2A). This helps ensure that the ilioin-
guinal nerve will not be cut during the next step, which is to
push the partially opened M etzenbaum scissors from the point
of incision into the external inguinal ring and then laterally to-
ward the internal ring as required, thus splitting the aponeu-
rosis and opening the roof of the inguinal canal (Fig. 64.2B).
Careful inspection will usually reveal the ilioinguinal nerve,
which should be freed up carefully by blunt and sharp dissec-
tion for the length of the incision. It can then be retracted out
of the surgical field by passing two small hemostats under-
neath the nerve, grasping the superior edge of the aponeurosis,
and retracting it in a cephalad direction. It may also help to
FIGURE 64.1 An almost horizontal incision from just cephalad to grasp the inferior edge of the aponeurosis and retract it as well
the external inguinal ring laterally almost to the internal ring provides to fully expose the inguinal canal.
adequate exposure and an excellent cosmetic result. Alternatively, the
incision may be made parallel to the inguinal ligament. This will expose the spermatic cord, although it may not
appear distinct because of the cremasteric muscle fibers
surrounding the cord, which merge into the internal oblique
muscle. Using a gauze sponge wrapped around the fingertip
The incision with the knife or electrocautery should be (Fig. 64.3A) or a peanut (Kittner) sponge (Fig. 64.3B), the
deepened through the subcutaneous tissue until the external plane between the spermatic cord and the floor of the inguinal
oblique aponeurosis is reached. There are usually one or two canal is bluntly developed until it can be encircled with a
significant veins that traverse this incision. They should be iso- thumb and forefinger. It is usually easiest to both initiate the
lated and secured with hemoclips or 3-0 plain or chromic dissection and completely encircle the cord at the level of the
catgut sutures before being cut. When the external oblique pubic tubercle. O nce it is ascertained that all components of
aponeurosis is cleaned sufficiently to be well visualized, it is the cord are included, the operator should pass a 0.5-in.
helpful to place one or two small self-retaining Gelpi (or simi- Penrose drain around the cord (Fig. 64.3C), elevate it with
lar) retractors in the wound to improve exposure. N ext, the gentle traction, and free up the cord laterally to the internal
FIGURE 64.2 A: The external oblique fascia is entered and tented up over the length of the inguinal
canal before cutting to help ensure that the ilioinguinal nerve is not injured. B: The external oblique
fascia is incised over the spermatic cord, and the incision is extended into the external ring.
FIGURE 64.3 A: The spermatic cord is bluntly mobilized from the inguinal liga-
ment and floor of the inguinal canal with a finger wrapped with a gauze sponge,
starting near the pubic tubercle. B: The blunt dissection is performed superiorly and
inferiorly to the cord and may be facilitated by using a peanut sponge. C: When the
435
entire spermatic cord is free, a 0.5-in. Penrose drain is passed around the cord.
FIGURE 64.4 The Penrose drain is encircled twice around the cord
just distal to the internal ring and clamped to act as a tourniquet. A FIGURE 64.5 The spermatic cord is triple-clamped just distal to the
finger outside the scrotum helps push the testis into the surgical field. internal ring (two clamps proximal and one distal to the Penrose
The gubernaculum is clamped and cut, and the scrotal side of the tourniquet) and cut after careful inspection of the testis, which has
gubernaculum is tied. been isolated from the surgical field on a sterile towel.
ring using predominantly blunt dissection, although some proceed with radical orchiectomy rather than risk returning a
sharp dissection may be required. Care should be taken in ap- testis with tumor to the scrotum. I want to emphasize that it
proaching the internal ring that the inferior epigastric vessels is only rarely necessary to open even the tunica vaginalis and
are not injured, and the spermatic cord should be inspected far more rare to open the tunica albuginea or perform a
carefully to ensure that an indirect inguinal hernia, which biopsy.
could contain bowel or bladder, is not present. At this point, To complete the orchiectomy, the spermatic cord should be
the spermatic cord should be occluded firmly with either a soft double-clamped at the level of the internal ring and proximal
rubber-shod clamp or, as I prefer, a 0.5-in. Penrose drain en- to the Penrose tourniquet with two Kelly or heavy right-angle
circled twice around the cord, tightened in a tourniquet fash- clamps; a third clamp is added to occlude the cord just distal
ion, and secured with a Kelly or right-angle clamp (Fig. 64.4). to the Penrose tourniquet (Fig. 64.5). The surgeon then tran-
The operator should be sure to leave enough spermatic cord sects the cord and removes the testicle, with attached sper-
distal to the internal ring to permit it to be double-clamped matic cord, from the surgical field. The cord is tied behind the
later without first removing the tourniquet. most proximal clamp with a 0 silk tie, and a suture ligature of
It is now possible to mobilize the testis from the scrotum 0 silk is placed behind the most distal clamp. O ne of the two
and through the opened external inguinal ring into the in- sutures should be left long for later identification of the stump
guinal canal and surgical field. Upward pressure on the exter- of the cord if a retroperitoneal lymph node dissection is per-
nal skin of the hemiscrotum and testis, coupled with gentle formed. Some surgeons prefer to tie the cord in two portions,
traction on the spermatic cord, will in general define the cir- separating the spermatic vessels and the vas deferens, and
cumferential fibromuscular attachments that need to be cut double-tying both portions of the cord. In either case, after the
or, better, electrocoagulated to completely free up the testis cord is securely tied, it should be allowed to retract through
(Fig. 64.4). Great care should be taken not to rupture the mass the internal ring into the retroperitoneum.
and spill tumor contents. At the most inferior aspect of the N ext, the surgeon should carefully inspect the entire floor
testis, there may be a well-defined gubernaculum that needs to of the inguinal canal as well as the scrotal compartment by
be clamped and cut, being careful to exclude scrotal skin, and everting the scrotal wall into the surgical field with upward
tied with 2-0 or 3-0 chromic catgut. external pressure on the most dependent portion of the hemi-
At this point, the surgeon should isolate the testis and scrotum. All sites of bleeding, even tiny ones, should be con-
spermatic cord, now free to the level of the internal ring, trolled with electrocautery and then irrigated with sterile
with sterile towels and carefully inspect the testis. If the diag- water. It is prudent to perform a final inspection for complete
nosis is still in doubt, the surgeon may open the tunica vagi- hemostasis at this point before closure. Closure begins with
nalis and expose the tunica albuginea of the testis. If doubt careful inspection of the inguinal floor. If it seems weak, it can
still persists, which should happen only rarely, a small inci- be reinforced with several interrupted sutures in a standard
sion may be made in the tunica albuginea to permit insertion hernia repair. If not, the ilioinguinal nerve should be released
of a finger for palpation of the testicular parenchyma. If all and the external oblique aponeurosis closed with interrupted
of these maneuvers fail to exclude tumor, the surgeon should 2-0 silk or 2-0 Prolene sutures, placing the sutures at varying
Chap t e r 64: Ing uinal O rchie ctomy 437
of the scrotum (10), and may preclude consideration of

surveillance as a treatment option, although this has been
challenged (1).
The most common actual complication is probably an in-
trascrotal hematoma. Because the scrotum is such an expan-
sile organ with loose areolar tissue beneath the dermis,
bleeding may continue because of a lack of tamponade, and
the resulting hematoma may grow quite large. These scrotal
hematomas usually become organized and quite firm and may
even raise the question of residual or recurrent tumor.
N onetheless, if the hematoma does not become infected
(which would require surgical drainage), it can almost always
be followed expectantly and will eventually regress. Ideally,
this complication should be prevented. The depths of the in-
guinal canal and entire inner surface of the scrotal wall should
be thoroughly and compulsively inspected and electrocoagu-
lated to ensure hemostasis. The surgeon can facilitate this, as
described earlier, by everting the scrotal wall with a finger po-
sitioned on the most dependent portion of the external scrotal
FIGURE 64.6 The stump of the cord retracts back through the inter-
nal ring into the retroperitoneum; one suture is left long. The external wall. After hemostasis appears adequate, the surgeon should
oblique fascia is closed with interrupted sutures placed at varying dis- irrigate with sterile water and inspect again. Although the tur-
tances from the cut edge and completely closing the external ring. ban dressing used in bilateral orchiectomy, which completely
collapses the scrotum, is not possible, it is possible to use a
modified turban dressing that is wrapped firmly enough to
collapse the hemiscrotum ipsilateral to the orchiectomy but
distances from the aponeurotic edge to prevent a linear tear not so tight as to cause pain because of pressure on the
and taking care to exclude the ilioinguinal nerve (Fig. 64.6). remaining testis.
The closure should begin at the level of the internal ring and It is also possible to get a retroperitoneal hematoma if the
extend medially as close to the pubic tubercle as possible be- ligature(s) on the spermatic cord pull off or if there is an injury
cause there is no longer any reason to have an external in- to one of the inferior epigastric vessels. Although rare,
guinal ring. A drain is not necessary or advisable. The wound retroperitoneal hematoma and other potential complications
should be irrigated once again and the skin incision closed have prompted one team of clinicians to advocate orchidec-
with clips or with a running subcuticular suture of 4-0 Vicryl tomy at the external ring (low cord) instead of at the internal
or M onocryl. The wound is covered with a dry sterile dressing ring (high cord) (2). N onetheless, despite an absence of appar-
and the scrotum is gently compressed with either fluffed gauze ent increase in relapse rate with this alternate surgical ap-
sponges held in place with an athletic supporter or by gently proach, they present no data to show fewer complications and
wrapping the scrotum with a loosely applied turban dressing no proven advantage to a quicker operation or to leaving the
of Kling, Kerlix, or Coban. An ice pack should be avoided be- inguinal flooor intact. In the absence of such data, this ap-
cause it has little impact on swelling and is a source of consid- proach is not recommended (4). Retroperitoneal hematoma
erable discomfort. can be prevented virtually always by a properly tied ligature
Patients may resume a regular diet and ambulation when with adequate length of spermatic cord distal to it so it cannot
completely awake and may be discharged. M ost patients re- slip off. A suture ligature on the spermatic cord offers an addi-
quire oral narcotic analgesics for pain control for several days. tional measure of security. Injury to the epigastric vessels can
be avoided by careful dissection of the proximal spermatic
cord at the level of the internal inguinal ring. This complica-
tion is usually discovered incidentally at the time of further
O UTCO MES staging evaluation with a computed tomography scan, although
an unexplained and occult blood loss may prompt investiga-
Co mp licat io ns tion. If bleeding has stopped when the problem is discovered,
it does not require specific treatment; the hematoma should
M any would consider the most serious complication to be ultimately be reabsorbed.
scrotal violation, which in the past required hemiscrotectomy
and now requires irradiation to the scrotum (for seminoma).
In truth, little data demonstrate reduced survival following Re sult s
scrotal contamination (9,10). N onetheless, there is virtually
no reason why the testis should be approached transscrotally Properly performed inguinal orchiectomy with the spermatic
if the diagnosis of possible testicular tumor has been even con- cord taken at the level of the inguinal ring is potentially curative
sidered. At the least, a transscrotal approach prevents early if the tumor is still confined to the testis. Except for treatment
control of venous outflow in the cord before manipulation of of a complication, reoperation is virtually never required, al-
the tumor, leaves spermatic cord behind, potentially alters though additional surgical procedures may be performed later
lymphatic drainage of the testis, risks tumor contamination to remove regional lymph nodes.
References
1. Aki FT, Bilen CY, Tekin M I, et al. Is scrotal violation per se a risk factor for 7. H oei-H ansen CE, Rajpert-De M eyts E, Daugaard G, et al. Carcinoma in
local relapse and metastases in stage I nonseminomatous testicular cancer? situ testis, the progenitor of testicular germ cell tumours: a clinical review.
Urology 2000;56:459–462. A nn O ncol 2005;16: 863–869.
2. Ashdown DA, Bodiwala D, Liu S. Is high cord radical orchiectomy 8. Jemal A, Thomas A, Siegel R, et al. Cancer statistics, 2008. CA Cancer J
always necessary for testicular cancer? A nn R Coll Surg Engl 2004; Clin 2008;58:71–96.
86;289–291. 9. Leibovitch I, Baniel J, Foster RS, et al. The clinical implications of proce-
3. Atchley JT, Dewbury KC. Ultrasound appearances of testicular epidermoid dural deviations during orchiectomy for nonseminomatous testis cancer. J
cysts. Clin R adiol 2000;55:453–512. Urol 1995;154:935–939.
4. H ayes M , Smart CJ, M ead GM . Inguinal orchidectomy [Comment]. A nn R 10. Pizzocaro G. Editorial comment. J Urol 1995;154:939.
Coll Surg Engl 2005;87:488–492. 11. Sloan JC, Beck SDW, Bihrle R, et al. Bilateral testicular epidermoid cysts
5. H eidenreich A, Engelmann UH , Vietsch H V, et al. O rgan preserving managed by partial orchiectomy. J Urol 2002;167:255–256.
surgery in testicular epidermoid cysts. J Urol 1995;153:1147–1150. 12. Steele GS, Kantoff PW, Richie JP. Staging and imaging of testis cancer. In:
6. H eidenreich A, Weissbach L, H öltl W, et al., for the German Testicular Vogelzang N J, Scardino PT, Shipley WU, et al., eds. Com prehensive tex t-
Cancer Study Group. O rgan sparing surgery for malignant germ cell tumor book of genitourinary oncology, 3rd ed. Baltimore: Lippincott Williams &
of the testis. J Urol 2001;166:2161–2165. Wilkins, 2005:587–595.
CHAPTER 65 ■ O RGAN-PRESERVING SURGERY

IN TESTICULAR TUMO RS
AXEL HEIDENREICH
Testicular germ cell tumors (TGCTs) are the most common normal testosterone levels indicate compensated Leydig cell
neoplasms in young men, with bilateral simultaneous and se- insufficiency. These patients bear a high risk to develop hy-
quential tumors arising in 2% to 3% of patients. Bilateral or- pogonadism with the need for androgen substitution follow-
chiectomy is still recommended as the gold standard ing surgery. In addition, a semen analysis should be obtained
treatment; it results in infertility, lifelong dependency on an- to assess fertility and to discuss the option of cryopreservation
drogen substitution, and psychological distress due to castra- (3,5). Also, testicular ultrasonography must be performed
tion at a young age. Because most testicular cancer patients preoperatively because this usually represents the imaging
are going to be longtime survivors with modern therapeutic modality of choice to assess the intratesticular location and di-
approaches, long-term morbidity should be omitted whenever ameter of the tumor. Scrotal magnetic resonance imaging ap-
possible; cure of cancer might only be achieved if quality of pears only to be necessary if there is more than tumor
life following therapy can be restored to pretreatment levels. suspected or if there is a very high suspicion for a benign tes-
Considering these quality-of-life issues, organ-sparing surgical ticular lesion (6).
approaches have been developed in patients with bilateral tes-
ticular cancer or in selected patients with a germ cell tumor
arising in a solitary testicle. ALTERNATIVE THERAPY
The alternative to testicular-sparing surgery is bilateral or-
DIAGNO SIS chiectomy, which will require lifelong hormonal replacement.
O ther problems associated with bilateral orchiectomy include
The diagnosis of testicular cancer is usually made by the ap- infertility and the psychological impact of the procedure on
pearance of a mass in the testicle that on ultrasonography ap- the patient, who is usually a young male.
pears solid or appears to have some cystic components (2).
Serum markers, including -human chorionic gonadotropin
and -fetoprotein, are routinely drawn prior to surgery. SURGICAL TECHNIQ UE
An inguinal approach is chosen with the skin incision being
INDICATIO NS FO R SURGERY made about two fingerbreadths above and parallel to the in-
guinal ligament (Fig. 65.1). The incision extends from the ex-
Patients in whom preservation surgery is contemplated should ternal inguinal ring cephalad for about 5 cm and is carried
have enough testicular parenchyma for maintaining physio- down to the external oblique fascia (Fig. 65.2). Care is taken
logical testosterone synthesis, which requires that the diameter not to injure the ilioinguinal nerve, which runs laterally just
of the tumor should not exceed 2 cm (3,7). Preoperative serum underneath the fascia.
testosterone and serum luteinizing hormone (LH ) levels should The spermatic cord is identified and isolated at the level of
be in the normal range. Elevated LH levels in the presence of the pubic tubercle (Fig. 65.3), secured with a half-inch Penrose
Chap t e r 65: O rg an-Pre se rving Surg e ry in Te sticular Tumors 439
FIGURE 65.1 Inguinal incision for exploration of the testicle in

relation to anatomic landmarks of the groin.
FIGURE 65.2 Incision of the external oblique fascia and its

close relationship to the ilioinguinal nerve.
FIGURE 65.3 Delivery of the spermatic cord after the external

oblique fascia has been opened.
FIGURE 65.6 Incision of the tunica albuginea just above the testicular
tumor.
FIGURE 65.4 M obilization of the spermatic cord up to the internal The operating field is draped with laparotomy pads, and
inguinal ring; the cord may be cross-clamped if desired. the tunica vaginalis is opened anteriorly; depending on the size
and the intratesticular location of the tumor, it might be lo-
cated underneath the tunica albuginea by simple palpation. In
drain, and mobilized back to the internal inguinal ring (Fig.
the presence of small testicular lesions, intraoperative ultra-
65.4). As in the case of radical orchiectomy, the spermatic
sonography with a 7.5-M H z scanner might be used for visual-
cord might be cross-clamped with a rubber-shod clamp prior
ization and detection (1).
to delivering the testicle in the operating field. In this scenario,
The tunica albuginea is incised just above the tumor (Fig.
all following manipulations should be performed under cold
65.6); because small testicular lesions usually present with a
ischemia by placing the testicle in crushed ice.
pseudocapsule, the surrounding testicular parenchyma can be
O n the other hand, it is also possible to deliver the testicle
scraped away with the blade of a scalpel (Fig. 65.7).
into the operating field without cross-clamping the spermatic
Following the enucleation procedure, four additional biopsies
cord; we know that simple tumor cell shedding will not result
are taken from the tumor bed to exclude tumor infiltration
in an increased frequency of distant metastases unless the tu-
(Fig. 65.8), and all specimens are sent for frozen section ex-
mor cells harbor molecular characteristics enabling them to
amination (FSE). At least in our hands, FSE has turned out to
adhere to the vascular endothelium, invade adjacent organs,
represent a reliable technique to differentiate between benign
and induce neovascularization. The testicle is delivered by
and malignant tumors. Another biopsy is taken from the pe-
slight traction on the spermatic cord and inversion of the scro-
ripheral testicular parenchyma, fixed in Bouin or Stieve solu-
tum; the gubernaculum is divided between two clamps and
tion, and sent for pathohistologic analysis to exclude
suture-ligated with 3-0 silk ties (Fig. 65.5).
associated testicular intraepithelial neoplasia. After careful
bipolar coagulation of small intratesticular blood vessels, the
tunica albuginea is closed with a 4-0 Vicryl running suture
FIGURE 65.5 The testicle is delivered, and the gubernaculum may be

divided and suture-ligated. FIGURE 65.7 The tumor is surrounded by a firm pseudocapsule.
Chap t e r 65: O rg an-Pre se rving Surg e ry in Te sticular Tumors 441
O UTCO MES
Co mp licat io ns
Potential complications include hemorrhage and loss of the
testicle. Eight-five percent to 92% of patients have maintained
adequate androgen levels (5).
Re sult s
The initial study with a limited number of patients showed a
5-year survival rate of 92% and the maintenance of physio-
logical testosterone serum levels in 92% without the need for
androgen substitution (5). These findings resulted in the
FIGURE 65.8 Additional quadrant biopsies following the enucle- German Testicular Cancer Study Group criteria for proper pa-
ation procedure.
tient selection, surgical technique, and follow-up based on the
review of a large patient cohort with a median follow-up of
8 years. The disease-free survival rate was 99% , local recur-
rences developed in 5.5% , and normal testosterone serum lev-
els were maintained in 85% of the patients.
The use of testicular-sparing surgery in testicular cancer re-
quires that there be close follow-up for possible recurrence.
The best modality for local follow-up is transscrotal ultra-
sonography. We recommend the first ultrasound to be done 4
to 6 weeks postoperatively, a time when scar tissue has re-
placed the intraparenchymatous traumatic edema; thereafter,
scrotal imaging should be performed at 2-month intervals for
the first year to adequately document the developing scar tis-
sue for further follow-up studies (5). In patients who have un-
dergone local radiation therapy postoperatively, periodic
ultrasonography can be safely omitted and the patients should
be educated to self-palpate the testicle. In patients who have
not undergone adjuvant local radiation, periodic ultrasonog-
raphy should be performed twice annually due to the high risk
of local recurrence. In patients who develop a local recur-
rence, secondary orchiectomy has to be performed and andro-
FIGURE 65.9 Running suture of the tunica albuginea. gen substitution has to be initiated (3–5).
In summary, organ-preserving surgery in patients with tes-
ticular germ cell tumors is feasible in patients with bilateral
(Fig. 65.9), the tunica vaginalis is closed with a Vicryl 3-0 testis cancer or germ cell tumor in a solitary testicle. The pro-
running suture, and the testicle is replaced in the scrotum, cedure should be performed in conjunction with biopsies of
taking care not to twist the spermatic cord. A formal orchi- the tumor bed and the resection rim and frozen section analy-
dopexy for the testicle is not necessary. The skin is closed sis, as well as a biopsy of the peripheral parenchyma. Follow-
with an absorbable, intracutaneous running suture; usually, up in these patients should be either postoperative radiation of
no drains are placed. Postoperatively, the patient should re- the remaining testicle with 18 Gy or very close follow-up. As
ceive potent analgesics and antiphlogistics to reduce uncom- this is still a controversial procedure, it may be best performed
fortable testicular pain. in a center experienced in the management of testicular cancer.
References
1. Buckspan M B, Klotz PG, Goldfinger M , et al. Intraoperative ultrasound 5. H eidenreich A, Weissbach L, H öltl W, et al., for the German Testicular
in the conservative resection of testicular neoplasms. J Urol 1989;141: Cancer Study Group. O rgan sparing surgery in malignant germ cell tumors
326–327. of the testis. J Urol 2001;166:2161–2165.
2. Fuse H , Shimazaki J, Katayama T. Ultrasonography of testicular tumors. 6. M enzner A, Kujat C, König J, et al. M RI in testicular diagnosis: differenti-
Eur Urol 1990;17:273–275. ation of seminoma, teratoma and inflammation using a statistical score.
3. H eidenreich A, Bonfi R, Derschum W, et al. A conservative approach to R ofo Fortschr G eb R ontgenstr N euen Bilgeb Verfahr 1997;166:514.
bilateral testicular germ cell tumors. J Urol 1995;153:10–13. 7. Weissbach L. O rgan preserving surgery of malignant germ cell tumors.
4. H eidenreich A, H öllt W, Albrecht W, et al. Testis-preserving surgery in J Urol 1995;153:90–93.
bilateral testicular germ cell tumors. Br J Urol 1997;79:253–257.
CHAPTER 66 ■ RETRO PERITO NEAL
LYMPHADENECTO MY
MICHAEL LEVERIDGE AND MICHAEL A. S. JEWETT
Carcinoma of the testis is the most common malignancy oc- enlarged nodes, none 2 cm. N 2 disease involves more than
curring in men aged 20 to 35. M ost testicular malignancies are five nodal deposits, or disease between 2 and 5 cm, while N 3
germ cell in origin and are classified as seminoma or nonsemi- disease has a greatest diameter 5 cm.
nomatous germ cell tumors (N SGCT), with the latter includ- The retroperitoneum in patients with germ cell tumors is
ing embryonal carcinoma, teratoma and teratocarcinoma, best examined using CT. Coronal views can be particularly
choriocarcinoma, and yolk sac tumors. Treatment usually be- helpful in examining the presence of and extent of disease.
gins with radical inguinal orchiectomy to remove the primary Plain films or CT of the chest should be used to assess for
tumor and to make a tissue diagnosis. Lymphovascular inva- metastatic disease to the lungs or mediastinum.
sion (LVI) and embryonal carcinoma (EC) are the principal Serum tumor markers are important in the assessment of
risk factors for metastasis. A staging workup follows. This the patient before and after orchiectomy, as well as in disease
chapter discusses the indications for retroperitoneal lym- monitoring after retroperitoneal or systemic treatment. The
phadenectomy in testis cancer and describes the technique in serum alpha-fetoprotein (AFP) and beta-human chorionic
primary and postchemotherapy settings. gonadotropin (H CG) are elevated in up to 80% of patients
before orchiectomy, and their persistence after removal of the
primary tumor may be considered an indicator of metastatic
disease, even in the setting of a negative imaging workup. The
DIAGNO SIS serum half-lives of AFP and H CG are 5 to 7 days and 24 to
36 hours, respectively, and so serial measurements may be
The majority of testis cancers are diagnosed following radical needed until a nadir is reached before determining that mark-
inguinal orchiectomy for a painless testicular mass. Less fre- ers are persistently elevated.
quently, patients present with a symptomatic testis mass, or
signs or symptoms of metastatic disease that lead to a pre-
sumptive or pathologically confirmed diagnosis.
The propensity for and the patterns of metastasis in germ INDICATIO NS FO R SURGERY
cell tumors form the basis of the staging workup and the stag-
ing system used to describe the extent of disease. This infor- Primary retroperitoneal lymphadenectomy or lymph node
mation will dictate treatment. As the testes originate in utero dissection (RPLN D) is less widely practiced than it once was
as intra-abdominal structures, their primary lymphatic but is considered for patients with stage I N SGCT, especially
drainage, and therefore first metastatic tumor landing site, is in the setting of adverse pathologic risk factors (presence of
to the retroperitoneum. The primary landing zones differ for LVI and predominant or pure EC) in the primary tumor, as
each testis. Right-sided testis tumors metastasize first to in- an alternative to surveillance (3). Those without adverse risk
teraortocaval nodes along the route of the supplying vessels, factors have a low risk of progression and are generally
then with decreasing frequency to the precaval, para-aortic, managed by initial active surveillance. Persistently elevated
and paracaval nodes (crossover may occur from right to left in markers after orchiectomy, with or without nodal metas-
the retroperitoneum). Left-sided masses metastasize to the tases, are generally managed with chemotherapy due to a
para-aortic nodes, and with decreasing frequency to the pre- 50% or more risk of systemic metastatic disease beyond the
caval and interaortocaval nodal regions (1). Further lymphatic retroperitoneum.
metastasis occurs via the thoracic duct, which may lead to me- Patients with N 1 low-volume disease may also be managed
diastinal or supraclavicular adenopathy. H ematogenous with primary RPLN D if markers are very low or normal. If
metastatic disease is less common than lymphatic and can the nodal diameter is 5 cm in any dimension, or if there are
originate from the testis or can gain entry to the systemic cir- numerous small nodes, these patients have a high likelihood of
culation via the thoracic duct. The lungs are the most common systemic disease and are managed with primary chemother-
hematogenously seeded sites. apy. The management of nodal disease 2 to 5 cm in axial di-
Retroperitoneal nodal staging is based on the number and mension is controversial, and many centers recommend initial
size of metastatic nodal deposits (2). N 0 disease is when the primary chemotherapy as although RPLN D provides 50 %
retroperitoneal computerized tomography (CT) imaging is control if markers are low or normal.
clinically negative with no nodes 10 mm, although normal- The most common indication for retroperitoneal lym-
sized nodes along the gonadal drainage may be considered phadenectomy is in the postchemotherapy setting (pcRPLN D).
suspicious. N 1 disease is when there are fewer than five Patients with a residual retroperitoneal mass(es) after primary
442
Chap t e r 66: Re trop e ritone al Lymp had e ne ctomy 443
chemotherapy for N SGCT are candidates for surgery because Subfertility affects an increased proportion of testis cancer
of a 50% incidence of viable germ cell tumor or teratoma patients primarily, and it can be further compromised with
(which may expand) (4). H istology of the residual mass can any treatment of advanced disease. Consideration of sperm
determine future treatment, as residual carcinoma is usually banking should be encouraged.
an indication for further chemotherapy (5). Residual
retroperitoneal disease occurs infrequently after radiation
and/or chemotherapy for seminoma, but these patients should
be considered for RPLN D if resolution does not occur, partic- SURGICAL TECHNIQ UE
ularly if a PET scan is positive. These masses tend to disappear
slowly after radiation therapy, and so a retroperitoneal mass Primary Pro ce d ure
may be initially closely observed. (No Pre vio us Tre at me nt )
The patient is positioned supine, with central venous and
epidural lines placed at the discretion of the attendant anes-
ALTERNATIVE THERAPY thesiologist. A midline incision is made from the xiphisternum
to approximately midway between the umbilicus and pubis,
Surveillance remains a very reasonable alternative for testis and subcutaneous tissue and fascia are divided (Fig. 66.1A).
cancer patients with a negative staging workup. A recent The fascia adjacent to the xiphisternum is undermined and in-
systematic review of surveillance in stage I germ cell cancer cised. The falciform ligament may be ligated and divided. A
revealed a 28% relapse rate in patients with N SGCT (3), thoracoabdominal incision can also be used, particularly in
with the implication that RPLN D would represent overtreat- early-stage left-sided tumors whose primary dissection will be
ment in approximately 70% of cases. O ne percent of the in the para-aortic and interaortocaval areas, but this is rarely
patients in these studies died of testis cancer during follow- done today. The peritoneum is entered and thoroughly explored.
up. Recurrence outside of the retroperitoneum will not be The right colon is reflected medially following the plane
prevented by RPLN D. These studies of early-stage germ cell anterior to the perinephric fascia (Fig. 66.1B). This dissection
tumors have uncovered several prognostic factors relating to can be carried up to the hepatic flexure as needed. The right
the primary tumor that have predictive value regarding risk ureter is identified and protected during the mobilization of
of relapse. Vascular or lymphovascular invasion is consis- the right colon, and it will later constitute the lateral limit of
tently related to increased risk of relapse, as are an increased the node dissection. The incision is carried around the cecum,
proportion of embryonal histology, the absence of yolk sac and the posterior peritoneum is incised medially along the
elements, higher local stage (particularly involvement of root of the small bowel mesentery, ending at the ligament of
spermatic cord tissue), and the presence of mature teratoma Treitz (Fig. 66.1C). The right colon and small bowel are then
(3). In patients without adverse risk factors, a stringent sur- dissected off the retroperitoneum until the left renal vein is
veillance protocol can be followed with 10% to 15% risk of visualized and accessible superiorly and the perinephric fascia
progression, sometimes treatable by RPLN D alone. H igh- is evident laterally. The small intestine and right colon are
risk patients, in our experience, have about a 50% chance of placed in a bowel bag and rotated onto the patient’s chest. The
progression, so any treatment will be unnecessary in about inferior mesenteric vein may be ligated and divided to facili-
50% . N onrisk adapted surveillance can be practiced, reserv- tate outward rotation of the pancreas for optimal retroperi-
ing treatment for those who clearly need it. Surveillance toneal exposure, although the left colon can also be taken
requires frequent assessments with history, physical exami- down. The left renal vein is mobilized and the tissue overlying
nation, serum marker measurement, and chest and abdomi- it is divided, with care to identify and ligate or clip larger lym-
nal imaging. As the majority of relapses occur in the first phatic channels as they may be encountered. The superior
year of surveillance, visits are undertaken at 2-month inter- margin must be carefully controlled to avoid chylous ascites,
vals for the first 2 years (CT of the abdomen can be done as with all superior borders of dissection around the hilum
every 4 months), with increasing intervals between assess- and behind the crura of the diaphragm. The retroperitoneum
ments afterwards. is now fully exposed to begin the dissection with a clear field
There is also evidence for primary chemotherapy for clini- of view.
cal stage I N SGCT, with a relapse rate of 1.5% to 7.0% in the
retroperitoneum (6). Indeed, a recent German clinical trial of
382 men randomized to RPLN D versus a single cycle of Te mp lat e s fo r Disse ct io n
bleomycin, etoposide, and cisplatin suggested an increase in
relapse-free survival in the chemotherapy cohort at a median Dissection templates in the retroperitoneum are based on the
follow-up of 4.7 years (7). The incidence of late relapse and lymphatic drainage patterns of the involved testis. M any sur-
long-term toxicity has not been described. geons do a full bilateral dissection for all cases, but the initial
Chemotherapy and RPLN D each have a role in low- efforts to achieve nerve sparing without necessarily identifying
volume retroperitoneal adenopathy. False-positive imaging the nerves intraoperatively lead to defining templates to
can occur in up to 30% of patients, but with increased size include the most likely nodes to be involved. For right-sided
of the retroperitoneal mass there is an increased likelihood testis tumors, the upper border of the renal veins marks the
that adenopathy represents active tumor. O ur practice is to superior extent of dissection (Fig. 66.2A). Suprahilar dissec-
advise primary chemotherapy in those patients with a tions are no longer performed unless there is gross adenopathy
retroperitoneal mass 5 cm in any dimension, or with ele- in the renal hilum, but in fact, much of the suprahilar tissue is
vated markers. pulled down and removed during a thorough dissection.
A B C
FIGURE 66.1 A: M idline incision from xiphoid to symphysis. B: Incision of the line of Toldt to allow
reflection of the right colon and exposure of the retroperitoneum. C: Continuation of line of peritoneal
incision around the root of the bowel mesentery.
Paracaval and interaortocaval nodes are removed, as are para- lymphadenectomy extends laterally to the ureters, posteriorly
aortic nodes to the level of the takeoff of the inferior mesen- to the psoas muscle and the anterior spinal ligament, and
teric artery. The nodes along the right common iliac artery are inferiorly to the ipsilateral midexternal iliac artery and
removed to the bifurcation of the common iliac artery. The contralateral common iliac artery bifurcation.
dissection extends laterally to the right ureter. The upper bor-
der of the renal veins is the superior limit of dissection in the
left-sided template as well (Fig. 66.2B). Para-aortic nodes are Ne rve -Sp aring Re t ro p e rit o ne al Lymp h
removed with the left ureter as the lateral limit and the bifur- No d e Disse ct io n
cation of the left common iliac artery as the inferior limit of
dissection. Interaortocaval nodes are removed above the take- The postganglionic sympathetic nerves arising from the lum-
off of the inferior mesenteric artery. In either case, suspicious bar sympathetic chains are responsible for seminal emission.
or enlarged nodes are indications for a full bilateral dissection Until 1988, they were routinely sacrificed, and many patients
(Fig. 66.2C). lost antegrade ejaculation and therefore fertility. The modifi-
In the presence of clinically positive nodes that number less cation of RPLN D allows identification and preservation of
than five, with none larger than 2 cm, similar templates as these nerves (9). The sympathetic fibers innervating the semi-
outlined above may be used. Caveats include the potential for nal vesicles and vasa deferentia arise as postganglionic fibers
left para-aortic (17% ) and left iliac (7% ) nodal disease in from T12-L3. The sympathetic trunks lie on the medial bor-
right-sided tumors, which would not be included in a strict ders of the psoas muscles bilaterally, lateral to the lumbar ver-
template dissection (8). Two percent of patients will have tebral bodies. The right trunk lies posterior to the middle of
suprahilar nodal disease in the interaortocaval region. These the inferior vena cava (IVC), and the lateral border of the
may be recognized and removed if grossly abnormal, but rou- aorta conceals the left trunk (Fig. 66.3). Their ganglia are
tine dissection here is not necessary given the low incidence of rounded or fusiform and of variable size (up to 10 mm). The
disease. This additional dissection does not contribute to addi- postganglionic nerves course anteromedially over the aorta,
tional patient morbidity, unless more lumbar vessels are lig- whereupon they form a network of fibers (Fig. 66.4). These
ated, which may incur a greater incidence of postoperative nerve fibers condense to form the inferior mesenteric and
back pain. hypogastric plexuses, which can exhibit variable location de-
In the setting of more extensive nodal disease, a full bilat- spite names approximating adjacent aortic branches. The
eral template is indicated (Fig. 66.2C). In this case the supe- nerves that connect these plexuses are termed intermesenteric
rior extent of dissection lies at the origin of the superior nerves. O ne rationale for limiting the inferior dissection in a
mesenteric artery, 1 to 2 cm superior to the renal arteries. The unilateral template to the inferior mesenteric artery origin is to
FIGURE 66.2 A: Template for right-sided tumor accounting for

crossover to left side. B: Template for left-sided tumor. C: Full
retroperitoneal dissection.
avoid the ipsilateral hypogastric plexus, which commonly iliac vein, with care taken to ligate or cauterize small vessels as
overlies the aortic bifurcation and interiliac angle. The hy- they are encountered (Fig. 66.5A). Careful lateral mobiliza-
pogastric and pelvic nerves emanate from these ganglia to tion of the cava is performed, with ligation of lumbar veins as
course inferiorly and supply the prostate, bladder, urethra, needed (Fig. 66.5B). The right sympathetic chain is encoun-
periurethral glands, seminal vesicles, and vasa deferentia. tered posterior to the midline of the IVC (Fig. 66.3). The lum-
Dissection begins by incising the tissue on the anterior sur- bar veins tend to run medial to the sympathetic chain but
face of the IVC in its midline, avoiding transection of obvious may be found lateral to it, or occasionally branching around
nodes. The adipose tissue is dissected medially to expose the it. The individual nerves running anteromedially from the
left side of the IVC from the left renal vein to the common ganglia of the chain pass above and medial to the lumbar
The left ureter is identified across the midline under the

inferior mesenteric vessels posterior to the mesocolon. A
plane is developed between the inferior mesenteric vessels an-
teriorly and the retroperitoneal lymphatic and adipose tissue
posteriorly. The inferior mesenteric artery occasionally must
be sacrificed, and if done should be ligated and cut several
centimeters from its origin at the aorta. This allows direct ac-
cess to the left side. The left ureter is identified in this plane
and is mobilized to the perinephric tissue, which can be re-
flected laterally to identify the psoas muscle. The tissue me-
dial to the ureters and perinephric tissue represents the
para-aortic nodal bed (Fig. 66.6). It can be seen above at the
level of the left renal vein as well as from below. For right-
sided tumors, the left gonadal vein is a marker of the lateral
limit of dissection at the renal hilum, but some surgeons
sacrifice it and go more laterally to be sure that retrograde
tumor cell spread to nodes in this area is removed if present.
This tissue is carefully reflected medially to identify the gan-
glia of the left sympathetic chain, and the postganglionic
nerves can be seen coming off to run anteromedially
(Fig. 66.3). Fibers from a higher ganglion may be encoun-
tered anterior to either renal artery, and they can be difficult
to preserve. It is not clear that they are necessary to preserve
FIGURE 66.3 Relationship between the great vessels and sympathetic
antegrade ejaculation. Similarly, nerves running along the
trunks. inferior mesenteric artery are clearly seen but not always
preserved with no obvious detriment.
At this point the patient’s sympathetic anatomy has been
elucidated, and anteromedially coursing fibers from the sym-
pathetic chains are preserved lateral to the aorta. The aorta
can now be exposed. Careful dissection along the aorta is then
undertaken. The previously identified sympathetic nerves are
followed from the side and preserved as they cross in front of
the aorta and coalesce into plexuses. The plexuses that con-
dense at and below the inferior mesenteric artery origin form
the hypogastric nerves that provide sympathetic innervation
to pelvic structures. Careful skeletonization and preservation
of these structures allow the complete removal of para-aortic
and interaortocaval nodal tissue, as well as tissue overlying
the aortic bifurcation, common iliac veins, and sacral promon-
tory, with maintenance of emission and ejaculation. It is our
practice to limit inferior dissection to the common iliac artery
bifurcation, taking care to preserve the genitofemoral nerves.
The remnant ipsilateral spermatic cord is removed, along with
as much vas deferens as possible and the spermatic vessels in
their attachments to the retroperitoneum.
It is not always possible to preserve all postganglionic
nerves, as nodal metastases or tumor masses may involve or
lie immediately adjacent to them. Ejaculation does not rely on
the preservation of all nerves, and so there should be no hesi-
tation to sacrifice ipsilateral (or even in a limited manner
bilateral) nerves to ensure complete removal of disease. The
right-sided nerves are generally more prominent and easier to
preserve.
At this point the retroperitoneum as defined by the limits
FIGURE 66.4 Anatomy of the lumbar sympathetic nerves. of dissection should be clear of all lymphatic and adipose tis-
sue surrounding the aorta and IVC, and postganglionic nerves
should be intact beside and overlying the aorta. The contents
veins, which serve as good landmarks. They can be individu- of the bowel bag are returned to the abdomen. The peri-
ally skeletonized from the underlying tissue, which is ulti- toneum can be reapproximated with absorbable suture. The
mately mobilized posteriorly and removed superiorly or fascial incision is closed with a running no. 1 suture, with
inferiorly. Dissection may be helped with the use of the occasional interrupted figure-of-eight sutures. The skin is
H ydro-Jet dissector. closed as per the surgeon’s preference. Drains and nasogastric
A B
FIGURE 66.5 A: Dissection between the vena cava and aorta. B: Retraction of the great vessels allows
exposure of the lumbar vessels, which may be ligated.
the mass and the template as above. Removing the mass alone
is not recommended due to the frequent micrometastases in
adjacent nodes (10). Recent case series, however, have demon-
strated a low retroperitoneal recurrence rate in patients
treated with unilateral template postchemotherapy proce-
dures, with excellent maintenance of antegrade ejaculation
(11). The postchemotherapy procedure can be complicated by
large tumor masses outside of typical templates, which may
mandate en bloc nephrectomy, or occasionally resection of
significant portions of the aorta or IVC. This has become less
common with the reduction in the proportion of cases with
active cancer to 10% in current series. Vascular surgery ex-
pertise may be required. Small lacerations of great vessels can
be repaired with monofilament 5-0 or 6-0 sutures.
It is important to clear the nodal and lymphatic tissue at
the upper limits of dissection in particular. The lymphatics are
FIGURE 66.6 Reflection of the left ureter and adipose tissue. often prominent anterior and behind the right crus of the
diaphragm. N odal tissue may be present behind the right crus
and can be removed from below if not overly bulky, sparing
the patient a thoracotomy. Similarly, nodal tissue may be pre-
suction are not routinely used. A urethral catheter is left in if sent along the course of the ipsilateral gonadal vessels and vas;
there is an epidural. these structures should be carefully inspected and removed
along with any nodal tissue along their lengths.
If the mass is confined and permits, nerve-sparing dissec-
Po st che mo t he rap y Re t ro p e rit o ne al tion can be performed in up to 50% of patients. This is partic-
Lymp had e ne ct o my ularly difficult where the tumor is adherent to the great
vessels, when skeletonization of the nerves is difficult and dis-
There is debate regarding whether patients with a post- section can appear to be subadventitial. N ormal vascular and
chemotherapy mass warranting resection should undergo a retroperitoneal anatomy can be distorted, and blood loss can
full bilateral template dissection or if oncologic control with be sudden; therefore, the surgeon and the anesthetist must be
fewer adverse outcomes can be obtained through excision of experienced.
pneumonia. Patients who have received bleomycin as part of

O UTCO MES their chemotherapy regimen are at particular risk of pul-
monary complications.
Co mp licat io ns Careful and successful sympathetic nerve preservation is
effective in preserving antegrade ejaculation and seminal
Intraoperative complications in primary RPLN D are generally emission.
confined to damage of the renal vasculature and great vessels.
Complication rates are increased in postchemotherapy proce-
dures. If an appropriate plane cannot be developed between the Re sult s
mass and the aorta or IVC, it may be more prudent to resect part
of the vessel and primarily close it or employ a vascular graft. Retroperitoneal lymphadenectomy provides pathologic stag-
Chylous ascites and lymphocele represent infrequent but ing. Patients with low-volume germ cell metastasis in the spec-
potentially serious complications that stress the importance of imen progress in approximately 30% of cases without
careful identification and obliteration of lymphatic vessels in- adjuvant chemotherapy. Chemotherapy in these patients may
traoperatively. M ost lymphoceles resolve spontaneously, while be avoided and can be given in the salvage setting in the case
some will require percutaneous drainage. They may occasion- of relapse. Alternatively, all patients with pathologically
ally exert a mass effect and cause gastrointestinal symptoms, proven retroperitoneal carcinoma may be given adjuvant
flank pain, or ureteric obstruction. chemotherapy with excellent cure rates, but 50% or more are
Pulmonary physiotherapy and early mobilization will limit treated unnecessarily.
the incidence of lung complications such as atelectasis and
References
1. Donohue JP, Z achary JM , M aynard BR. Distribution of nodal metastases chemotherapy in the adjuvant treatment of clinical stage I nonseminoma-
in nonseminomatous testis cancer. J Urol 1982;128:315–320. tous testicular germ cell tumors: AUO Trial AH 01/94 by the German
2. Greene FL, Page DL, Fleming ID, eds. A JCC cancer staging m anual, 6th ed. Testicular Cancer Study Group. J Clin O ncol 2008;26(18):2966–2972.
Lippincott-Raven Publishers, 2002. 8. Donohue JP, Thornhill JA, Foster RS, et al. The role of retroperitoneal lym-
3. Groll RJ, Warde P, Jewett M A. A comprehensive systematic review of tes- phadenectomy in clinical stage B testis cancer: the Indiana University expe-
ticular germ cell tumor surveillance. Crit R ev O ncol H em atol 2007;64(3): rience (1965 to 1989). J Urol 1995;153:85–89.
182–197. 9. Jewett M A, Kong YS, Goldberg SD, et al. Retroperitoneal lymphadenec-
4. Sim H G, Lange P, Lin DW. Role of post-chemotherapy surgery in germ cell tomy for testis tumor with nerve sparing for ejaculation. J Urol 1988;
tumors. Urol Clin N orth A m 2007;34:199–217. 139(6):1220–1224.
5. Steyerberg EW, Gerl A, Fossa SD, et al. Validity of predictions of residual 10. Carver BS, Shayegan B, Eggener S, et al. Incidence of metastatic nonsemi-
retroperitoneal mass histology in nonseminomatous testicular cancer. nomatous germ cell tumor outside the boundaries of a modified
J Clin O ncol 1998;16(1):269–274. postchemotherapy retroperitoneal lymph node dissection. J Clin O ncol
6. Stephenson AJ, Sheinfeld J. M anagement of patients with low-stage non- 2007;25(28):4365–4369.
seminomatous germ cell testicular cancer. Curr Treat O ptions O ncol 2005; 11. Steiner H , Peschel R, Bartsch G. Retroperitoneal lymph node dissection
6:367–377. after chemotherapy for germ cell tumors: is a full bilateral template always
7. Albers P, Siener R, Krege S, et al. and the German Testicular Cancer Study necessary? BJU Int 2008;102(3):310–314.
Group. Randomized phase III trial comparing retroperitoneal lymph node
dissection with one course of bleomycin and etoposide plus cisplatin
CHAPTER 67 ■ TO RSIO N O F THE TESTICLE

BLAKE W. MO O RE AND HARRY P. KO O
Testicular torsion is a surgical emergency that demands examination consistent with acute testicular torsion are often
prompt recognition and treatment to preserve testicular func- sufficient to warrant immediate surgical exploration.
tion. This condition occurs when the spermatic cord twists Torsion of the spermatic cord has been recognized in all
upon itself, leading to vascular compromise and a possible tes- age groups, with the majority of patients presenting during
ticular loss from prolonged ischemia. The need for timely as- adolescence. The annual incidence of testicular torsion in men
sessment and intervention is heightened by the fact that hours under the age of 25 years is estimated to be 1 in 4,000 (1). The
often elapse between the onset of symptoms and the urolo- peak incidence has uniformly been seen in the 12- to 18-year-
gist’s evaluation. Despite the continuing advancements in radi- old age range (accounting for 65% of all torsions), with a sec-
ologic imaging of the acute scrotum, history and physical ond, much smaller peak in the perinatal period (1,2). A large
Chap t e r 67: Torsion of the Te sticle 449
DIAGNO SIS
Pe rinat al To rsio n
In the newborn, local and systemic symptoms of torsion may
be scarce, delaying presentation and diagnosis. The patient
with antenatal torsion may present with a large, firm, painless
scrotal mass. Parents may report a swollen scrotum with dis-
colored skin. In postnatal torsion, similar symptoms develop
in a newborn with a previously normal scrotal examination.
H owever, torsion that occurs after birth is more likely to cause
systemic symptoms such as irritability or lack of appetite.
Parents may also note an acute onset of redness and swelling
of the scrotum.
In newborns, the physical exam may be the only indicator
of testicular torsion. The neonate is usually in no acute dis-
tress, though a postnatal onset is more likely to cause general
discomfort. An abdominal or inguinal mass may be found in
the case of an undescended testis. The scrotal skin may be dis-
A B
colored, ranging from erythematous to blue-black, depending
FIGURE 67.1 A: Extravaginal torsion, typical of a neonatal testicular on the degree and duration of torsion. Chronic changes are
torsion. The tunica vaginalis is involved with the twist of the sper- more frequently seen with antenatal torsion.
matic cord. B: Intravaginal torsion, usually seen after the neonatal pe-
riod, involves the spermatic cord below the reflection of the tunica
vaginalis onto the spermatic cord.
To rsio n o f t he Te st icle in Child re n,
Ad o le sce nt s, and Ad ult s
study found that 7% of the cases involved an undescended tes-
ticle, and it was speculated that testicular torsion was 10 times Torsion outside of the perinatal population is usually associ-
more common in patients with undescended testes (3). ated with a more acute symptomatology. The classical presen-
Curiously, a number of investigations have demonstrated tation is described as a sudden onset of severe, unilateral
unequal laterality, with the left testicle being affected more fre- testicular pain, with swelling of the testicle. With time, the pa-
quently. Bilateral torsion is said to account for fewer than 5% tient may complain of swelling and redness of the scrotum.
of all cases (3,4). The most common etiologies of scrotal pain are testicular
Testicular torsion can be classified as extravaginal or in- torsion, torsion of testicular appendage, and epididymitis.
travaginal based on whether the twisting is above or below the Differentiating these disease processes can sometimes be prob-
reflection of the tunica vaginalis onto the spermatic cord lematic. In general, historical features (fever, nausea/vomiting,
(Fig. 67.1). Extravaginal torsion occurs when the tunica vagi- dysuria, sexual activity, history of trauma) were not helpful in
nalis is not securely attached to the scrotum, allowing the tes- differentiating testicular torsion from other conditions. In a
ticle and the tunica vaginalis to rotate as a unit along the retrospective review of 90 patients presenting with acute scro-
longitudinal axis. This variant is virtually always limited to tum, the only statistically significant finding from history was
the perinatal population and may take place antenally or post- that patients with testicular torsion or torsion of testicular ap-
natally, a distinction that has important prognostic and thera- pendage had a shorter duration of symptoms ( 12 hours)
peutic implications. A review by Das and Singer (5) found that when compared with patients with epididymitis (7).
72% of perinatal torsions occur in utero. With intravaginal O lder patients typically have more acute findings on physi-
torsion, twisting of the spermatic cord occurs entirely within, cal exam. Almost invariably, the testicle will be swollen and
but does not involve, the tunica vaginalis. This type of torsion exquisitely tender. Scrotal edema and erythema are usually
affects patients outside of the perinatal age group, although it present. In many cases the affected testicle assumes a re-
has been reported on rare occasion in newborns. tracted, horizontal lie. A detectable secondary hydrocele could
Several anatomic factors contribute to intravaginal torsion. be found in up to 50% of patients. Loss of the cremasteric re-
The tunica vaginalis normally covers the anterior surface of flex is suggestive of testicular torsion, and in several series it
the testis and extends varying distances over the epididymis was universally absent (6,7). These characteristic findings all
and the spermatic cord. In the “ bell clapper” variant, the tu- point toward an etiology of testicular torsion, but it must be
nica vaginalis inserts at an abnormally high location on the remembered that no single finding is pathognomonic.
spermatic cord, causing the testis to be suspended freely
within the tunical cavity. The “ bell clapper” variant has been
seen in 12% of testes at postmortem (6). In addition, the To rsio n o f Te st icular Ap p e nd ag e s
mesorchium may have a narrow attachment onto the testicle,
allowing the testis to assume a more horizontal position Four testicular appendages have been identified: the appendix
within the scrotum. These factors contribute to increased tes- testis (hydatid of M orgagni), the appendix epididymis, the
ticular motility within the tunica vaginalis and facilitate rota- paradidymis (organ of Giraldés), and the vas aberrans of H aller.
tion of the testis about the spermatic cord. Each of these is susceptible to torsion, but the overwhelming
of 97% to 100% in diagnosing testicular torsion (7,9). Lack

of intratesticular blood flow and testicular enlargement are
characteristic findings. Gunther et al. (9) have noted that cen-
tral arterial perfusion was a reliable diagnostic parameter to
exclude testicular torsion. H owever, arterial blood flow ceases
only after venous obstruction and edema develop, which can
lead to a false-negative result early in the torsion. Intermittent
torsion may also go undiagnosed. As with many radiographic
technologies, interpretation is highly dependent on the experi-
ence of the technician or radiologist.
M anagement of the newborn with testicular torsion is an area
of controversy. To understand treatment in this age group, it is
important to define the condition as prenatal or postnatal.
FIGURE 67.2 Torsion of appendix testis showing the “ blue dot sign” Torsion that presents acutely after birth requires emergent sur-
(arrow ). gical exploration. The nonviable testicle should undergo or-
chiectomy while evidence of viability should prompt detorsion
majority of twisted appendages involve the appendix testis. In with orchidopexy. We recommend fixation of the contralat-
the pediatric age group, appendiceal torsion is nearly as com- eral testis, regardless of the condition of the affected testicle.
mon as testicular torsion and accounts for 20% to 40% of In the case of bilateral torsion (both prenatal and postnatal),
acute scrotum cases (8). Torsion of a testicular appendage is the threshold for performing bilateral orchidopexy should be
often characterized by a gradual onset and few systemic symp- lower in an effort to preserve testicular function. The most
toms. Early in the course of torsion of the appendix testis, common scenario in the perinatal period is the case of prena-
physical examination may reveal a tender mass located at the tal torsion, in which the baby is found to have chronic changes
upper pole of the testicle, sometimes adherent to the overlying and a nonviable testicle. These neonates should undergo elec-
skin. In our experience, it has been quite rare to see a small tive orchiectomy with contralateral testis fixation once anes-
area of ecchymotic skin at the upper pole (“ blue dot sign” ), thesia risk assessment has been stabilized (within 1 to 2 days
which is pathognomonic for torsion of the appendix testis of diagnosis). O perative risk is a concern, but in a series of
(Fig. 67.2). In almost all cases the testicle has a normal orien- 27 patients with perinatal torsion who underwent exploration
tation and the cremasteric reflex is intact (4). With time, tor- 2 hours to 2 months after birth, there were no surgery- or
sion of the testicle and torsion of an appendage can become anesthesia-related complications (10). Regular follow-up is
clinically indistinguishable. Imaging with Doppler ultrasound needed to assess testicular size and pubertal development, and
frequently shows a hyperechoic mass at the upper pole of a the services of an endocrinologist should be considered when
normal-appearing testicle. If the clinician is completely confi- hormonal dysfunction is expected (e.g., bilateral torsion). The
dent in the diagnosis of appendage torsion, the condition can option for testicular prosthesis placement in childhood should
be treated symptomatically. Therapy consists of bedrest, scro- be discussed with the parents of orchiectomy patients.
tal elevation, and nonsteroidal anti-inflammatory agents as The principles of management for patients beyond infancy
needed. Symptoms should begin to resolve within 1 to 2 weeks are similar to those for newborns, though the more acute pre-
as the infarcted appendage is gradually resorbed. If testicular sentation in the older group provides greater opportunity for
torsion cannot be ruled out with certainty, urgent surgical testicular salvage. To reiterate, a history and physical exam
exploration is needed. consistent with testicular torsion demand immediate surgical
Testicular torsion is a clinical diagnosis and is proven at the exploration. O rchiectomy is needed for the nonviable testicle,
time of surgery. Radiologic studies may support the diagnosis, while a viable testis should be untwisted and fixed to the scro-
but negative imaging should not preclude exploration when tum. O rchidopexy should be performed to protect the con-
clinical suspicion is high. N onetheless, diagnostic examina- tralateral testicle. Testicular prostheses are available for adults
tions should be performed when testicular torsion is consid- and can be placed during the initial operation or at a later
ered unlikely and the clinician has concluded that the patient date. Evidence of testicular atrophy should be noted during
has a nonsurgical condition. follow-up visits. Furthermore, it is important to discuss with
Color Doppler ultrasound is widely utilized in the evalua- patients the increased risk of subfertility.
tion of scrotal abnormalities and has been studied in patients
with testicular torsion. The capacity to view both blood flow
and anatomic detail is particularly useful in assessing the scrotal ALTERNATIVE THERAPY
contents and can provide valuable information about other
pathologic conditions. Because of the prompt availability, low Some clinicians recommend that manual detorsion should be
costs, short duration, and convenience of this examining method attempted. Studies evaluating the success rate for manual
when compared with alternative diagnostic tools such as mag- detorsion have produced conflicting evidence. Clinicians who
netic resonance imaging (M RI) or scintigraphy, sonography adopt this strategy must do so on the premise that it does not
has become the primary diagnostic modality in evaluating the substitute for or delay surgery. Because the majority of testes
acute scrotum (9). Color Doppler ultrasound has been re- twist inward (right testicle clockwise and left counterclock-
ported to have a sensitivity of 89% to 100% and a specificity wise as viewed from the foot of the bed), manual detorsion
Chap t e r 67: Torsion of the Te sticle 451
should occur in the opposite direction. N erve block of the

spermatic cord can facilitate this maneuver, but it may also
conceal the relief of detorsion or the pain of manipulation in
the wrong direction. Successful manual detorsion should be
followed by immediate surgical exploration.
While currently limited to animal models, medical adjuncts
may one day be implemented, along with surgical manage-
ment, to minimize the sequelae associated with testicular tor-
sion. Pentoxifylline, a methyl xanthine derivative that
decreases blood viscosity and platelet aggregation, appears to
improve blood flow to both testes and unilateral torsion (11).
N itric oxide has been shown to have a protective effect against
histopathologic change in the contralateral testicle, presum-
ably through the regulation of blood flow (12).
SURGICAL TECHNIQ UE
FIGURE 67.4 Intravaginal testicular torsion in an adolescent.
Aside from the choice of incision, the surgical treatment for
perinatal and childhood/adult (intravaginal) testicular tor-
sions is essentially the same. For perinatal torsion, we use an appears dark blue or black (Fig. 67.4). Following manual
inguinal approach on the affected side. The reason for doing detorsion, the testis is inspected for viability. If the viability of
so is that with extravaginal torsion (Fig. 67.3), there is a rare the testis is in question, the detorsed testis is wrapped in a
chance that another problem may exist, such as a hernia or tu- warm moist sponge to recover while the contralateral testis is
mor, that is best treated superior to the scrotum. being pexed. If there still remains concern about the viability,
For intravaginal torsion, a vertical midline incision is our a small nick can be made in the tunica albuginea to expose the
preferred approach to explore both testes. Two separate seminiferous tubules, which should appear dusky to pink.
hemiscrotal incisions may also be used with excellent cosmetic A nonviable testis should be removed to avoid possible
results. Following incision to the level of the dartos muscles, continued symptoms and possible infection and to reduce the
the affected testis is moved under the midline incision. The possibility of contralateral testicular damage from antisperm
layers of tunicae can be gently separated using a hemostat to antibodies. We routinely do not place a testicular prosthesis at
minimize bleeding. The final few layers of tunicae are opened the time of orchiectomy. For the individuals who request a tes-
in a vertical fashion to expose the testis. A torsed testis usually ticular prosthesis, we have performed delayed placement of
solid silicone prostheses through a low inguinal incision.
The techniques for fixation of the viable detorsed testis and
the contralateral testis still remain debated. Some of the con-
troversy includes fixation with or without eversion of the tu-
nica vaginalis, the use of absorbable or nonabsorbable suture,
and fixation at two or three sites on the testis (13–15). We be-
lieve that the most important step in the fixation is the ever-
sion of the tunica vaginalis (Fig. 67.5). This step produces two
effects: (a) the testis is in an extravaginal position, and thus
would not be at risk for intravaginal torsion; (b) everting the
tunica vaginalis allows for contact between the tunica albu-
ginea and the dartos. As an additional step, we perform two-
point fixation of superior and inferior peritesticular tissue
using absorbable (Vicryl) or nonabsorbable (Prolene) sutures.
O UTCO MES
Co mp licat io ns
The most significant complication of testicular torsion is in-
farction of the gonad. This event depends on the duration and
degree of torsion and is managed by orchiectomy. A testicle
that is viable at the time of surgery may later become atrophic
despite orchidopexy, and it must be monitored closely by
physical exam. Abnormal semen analysis and contralateral
testicular apoptosis are also recognized sequelae following tes-
ticular torsion (16,17). Therefore, the risk of subfertility
FIGURE 67.3 Exposure of the right spermatic cord and testicle should be discussed with the patient. Although rare, torsion of
through an inguinal incision reveals a case of extravaginal torsion. a previously pexed testicle may occur.
between prenatal and postnatal torsion. Very few cases of tes-

ticular salvage have been reported with an antenatal event. An
aggressive approach to postnatal torsion is likely to improve
the rate of testicular salvage for this subset of patients, which
was 20% in a recent study (10). Long-term assessment of fertil-
ity in patients with perinatal torsion is lacking.
Determining the duration of symptoms is easier in patients
outside of the newborn age group, for obvious reasons.
Workman and Kogan (18) found that patients who underwent
surgery within 6 hours of onset had testicular salvage rates of
83% to 97% . This figure dropped to 55% to 85% between 6
and 12 hours of onset, and after 24 hours the salvage rate fell
to 10% . These statistics are consistent throughout the litera-
ture. N otably, testicular salvage does not necessarily imply
normal testicular function. A number of studies have demon-
strated that men with testicular torsion are prone to subfertil-
ity and abnormalities of the contralateral testicle.
In summary, testicular torsion is a urologic emergency that
is diagnosed clinically and treated by immediate surgical ex-
ploration. The decision to perform orchiectomy versus orchi-
dopexy of the affected testicle is based on the viability of the
testis at the time of exploration. In either case, contralateral
orchidopexy should be performed. The anatomic abnormali-
ties that predispose the patient to testicular torsion are well es-
FIGURE 67.5 Scrotal incision with open tunica vaginalis reveals an tablished; however, the mechanisms responsible for long-term
intravaginal torsion.
testicular dysfunction and contralateral testicular damage are
under investigation. Rates of testicular salvage have improved
dramatically since the first recorded case of testicular torsion
Re sult s in 1840. With heightened awareness of the signs and symp-
toms on the part of patients and physicians, along with a bet-
The primary determinants of testicular viability are the degree ter understanding of the pathophysiologic mechanisms,
to which the spermatic cord twists and the duration of torsion. immediate and long-term outcomes of testicular torsion will
The literature reports dismal salvage rates in newborns (as low continue to improve.
as 5% ); however, these accounts do not always distinguish
References
1. Anderson J, Williamson R. Testicular torsion in Bristol: a 25 year review. 11. Savas C, Dindar H , Aras T, et al. Pentoxifylline improves blood flow to
Br J Surg 1988;75:988–992. both testes in testicular torsion. Int Urol N ephrol 2002;33:81–85.
2. M elekos M , Asbach H W, M arkou SA. Etiology of the acute scrotum with 12. Dokucu AI, O ztürk H , O zdemir E, et al. The protective effects of nitric ox-
regard to age distribution. J Urol 1988;139:1023–1025. ide on the contralateral testis in prepubertal rats with unilateral testicular
3. Williamson RCN . Torsion of the testis and allied conditions. Br J Surg torsion. BJU Int 2000; 85:767–771.
1976;63:465–476. 13. Bellinger M F, et al. Testicular torsion: late results with special regard to fer-
4. Van Glabeke E, Khairouni A, Larroquet M , et al. Acute scrotal pain in tility and endocrine function. J Urol 1980;124:375–378.
children: results of 543 surgical explorations. Pediatr Surg Int 1999;15: 14. Lent V, Stephani A. Eversion of the tunica vaginalis for prophylaxis of tes-
353–357. ticular torsion recurrences. J Urol 1993;150:1419–1421.
5. Das S, Singer A. Controversies of perinatal torsion of the spermatic cord: a 15. Rodriguez LE, Kaplan GW. An experimental study of methods to produce
review, survey and recommendations. J Urol 1990;143:231–233. intrascrotal testicular fixation. J Urol 1988;139:565–567.
6. Cuckow PM , Frank JD. Torsion of the testis. BJU Int 2000;86:349–353. 16. Bartsch G, Frank S, M arberger H , et al. Testicular torsion: late results with
7. Kadish H A, Bolte RG. A retrospective review of pediatric patients with epi- special regard to fertility and endocrine function. J Urol 1980;124:
didymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 375–378.
1998;102:73–76. 17. H adziselimovic F, Geneto R, Emmons LR. Increased apoptosis in the con-
8. Turgut AT, et al. Acute painful scrotum. Ultrasound Clin 2008;3:93–107. tralateral testes of patients with testicular torsion as a factor for infertility.
9. Gunther P, Schenk JP, Wunsch R, et al. Acute testicular torsion in children: J Urol 1998;160: 1158–1160.
the role of sonography in the diagnostic workup. Eur R adiol 2006;16: 18. Workman SJ, Kogan BA. O ld and new aspects of testicular torsion. Sem in
2527–2532. Urol 1988;6:146–157.
10. Pinto KJ, et al. M anagement of neonatal testicular torsion. J Urol 1997;
158:1196–1197.
CHAPTER 68 ■ SCRO TAL TRAUMA
AND RECO NSTRUCTIO N
TIMO THY O . DAVIES AND GERALD H. JO RDAN
The anatomy of the male genitalia is quite complex. In the deforming force to the scrotum. These forces can cause severe
scrotum, there are multiple fascial layers (Fig. 68.1 and 68.2). damage to the internal structures without disrupting the skin.
From the standpoint of trauma, however, most of the fascial With any nonpenetrating trauma to the scrotum or perineum,
layers are relatively unimportant. The Buck’s fascia is related one must suspect and rule out injury to the corpus spongio-
to the deep penile structures and is important in the contain- sum and urethra.
ment of periurethral processes or the occasional hematoma as-
sociated with injury to the corpora cavernosa and/or corpus
spongiosum. In the scrotum, the analogous fascia to the Buck’s DIAGNO SIS
fascia—the external spermatic fascia—is usually uninvolved
with scrotal trauma (Fig. 68.2). Penetrating injuries to the genitalia frequently involve the ure-
Culp (3) has classified injuries to the external male geni- thra. M ost of these injuries require exploration, irrigation,
talia into five categories: nonpenetrating, penetrating, avul- and removal of foreign-body material, if any, with anatomic
sions, burns, and radiation injuries (both direct and indirect). repair and drainage (Level of Evidence, LO E 4) (4). If there is
N onpenetrating injuries result from either a crushing or sudden any suspicion of urethral injury, a retrograde urethrogram
FIGURE 68.1 A: Cross section of the penis illustrating the fascial and structural components of the shaft
of the penis. B: Sagittal section of the pelvis demonstrating the fascial layers and structural component.
453
A B
FIGURE 68.2 A: Perineal view of a trauma patient illustrating a hematoma contained by Colles fascia
(classic butterfly hematoma). B: Same trauma patient illustrating the containment of the hematoma by
the extended Colles layer, that is, the fascia lata of the thigh and extending onto the abdomen beneath the
Scarpa fascia.
should be performed, and cystoscopy should be performed if usually not the genitalia. H owever, it is not uncommon to
further clarification of the injury is required. Saline should be have thermal burns in concert with electrical burns, as fre-
used for irrigation in these cases. Because of the position of the quently the clothing is ignited by the electrical spark. Thus,
urethra beneath the scrotum and perineum, significant pene- with electrical burns, fortunately, if the genitalia are involved
trating injuries to the scrotum can also often miss the urethra. it is usually a more superficial process.
Avulsion injuries of the genital skin most frequently involve Radiation injuries to the genitalia can occur either from di-
the scrotal skin and occur when the patient’s clothing becomes rect exposure to the genitalia or from the effects of radiation
entangled in machinery. The loose scrotal tissues ensnare, and on the venous and lymphatic drainage. N ow, by and large, we
as the clothing is ripped off, so is the loose genital skin. These do not see complications of direct radiation to the genitalia, as
avulsion injuries vary from minimal injuries, which are essen- radiation for penile lesions is rarely undertaken. The sec-
tially nothing more than lacerations, to emasculating injuries, ondary effects of radiation, as seen in the scrotum, are usually
which take not only the skin but also the deep structures. manifested by chronic lymphedema, lymphangiectasia, and, in
Usually, the deep penile structures are not avulsed, as the some cases, chronic recurring cellulitis.
injury, fortunately, takes only the skin and the dartos fascia/ To this list of traumas must be added the patient who has
tunica dartos, leaving the underlying Buck’s fascia of the penis required significant debridement because of rapidly progres-
and the fascial layers surrounding the testicle intact. sive, multiorganism fasciitis (Fournier’s gangrene). Fournier’s
O ccasionally, the testicle ensnares in the skin and is avulsed. In gangrene is often seen with processes of the anus or rectum, such
most cases of avulsion, bleeding is not a problem, as the skin as missed perianal abscess. Likewise, processes involving the
and fascia are avulsed in a plane between the fascial structures urethra, such as periurethral abscess, can accompany Fournier’s
related to the deep structures and the superficial fascia. gangrene. M any times Fournier’s gangrene is associated with
Burns to the genitalia are usually not isolated injuries but other comorbidities, such as diabetes mellitus. M any of these
reflective of a wider area of body burn. Chemical burns are in patients present late, and aggressive surgical debridement (LOE 2),
general only superficial and involve the skin. Thermal injuries while lifesaving, usually leaves a significant defect (4). If the
can be deep, but often, even with extensive deep burns proxi- fasciitis is associated with pathophysiology of the urethra
mate to the genitalia, the multiple clothing layers (i.e., under- and/or anus, then these situations must be managed and resolved
wear and other clothing) can protect the genitalia. Electrical before reconstruction (5). Recently there have been descriptions
burns disseminate via the deep vascular and neurological of the use of unprocessed honey to augment or provide an alter-
structures, and what may appear to be a minimal burn to the native treatment to wide surgical excision. H oney apparently
skin and scrotum may have significant deep injury associated contains antimicrobial agents and enzymes to digest necrotic
with it, and this can be devastating. H owever, usually the tissue as well as to promote epithelial growth (6).
deepest burns associated with electrical contact occur at the Also, in recent years we have seen several patients who
site of the current inflow and the ground site. These sites are have attempted to enhance the size and bulk of their genitalia
Chap t e r 68: Scrotal Trauma and Re construction 455
use of ultrasonography in the diagnosis of testicular trauma

can be helpful in situations when the physical examination is
difficult to perform or interpret. Ultrasonography is the most
sensitive and specific imaging technique, with heterogeneity of
the parenchyma of the testicle suggestive of testicular rupture
(LO E 2) (4). In the presence of penetrating trauma to the
genitalia, a retrograde urethrogram is always indicated be-
cause of the close proximity to the urethra. In all cases of gen-
ital avulsion, other than a simple scrotal avulsion, a complete
evaluation of the urethra must be done, along with a rectal
examination and possibly flexible sigmoidoscopy.
Exploration of the scrotum is indicated if the patient has sus-
tained either blunt or penetrating injury to the testicle (LO E 3)
(4). Scrotal reconstruction is required following complex
FIGURE 68.3 B-scan ultrasound demonstrating the classic distribu- lacerations and avulsion injuries. If a patient has required ex-
tion of a scrotal contusion (scrotal wall hematoma). N ote the testis cision for chronic cellulitis, lymphangiectasia, and lymphedema,
displaced anteriorly, with the hematoma contained in the multiple fas-
split-thickness skin graft reconstruction of the scrotum is very
cial layers of the scrotum.
effective and provides cosmetically very acceptable results. If
the lymphedematous process is due to a local process, then
with the injection of lipid-containing substances such as paraf-
often the lateral scrotum and the posterior scrotum are free of
fin or petroleum jelly or inert substances such as silicone. In
the process because the lymphatic drainage is lateral and often
these cases, one is often confronted with a fulminant cellulitis
uninvolved. In these cases lateral scrotal flap reconstruction is
that must be treated with broad-spectrum antibiotics. Later,
often very effectively employed.
one sees a sclerosing granulomatous process that can be trou-
If, however, the process causing the scrotal lymphedema
bling to the patients. In some cases, the skin must be excised
is “ systemic” (i.e., Charles’s disease, secondary to pelvic irra-
along with the deeper involved structures, but it is not unusual
diation, etc.), then Split-thickness Skin Graft (STSG) recon-
to be able to excise the deep process and leave the skin that
struction is always the best approach. The lymphatics of the
survives either on its random dermal blood supply or, in some
skin are carried in the reticular dermis (the deep layer of the
cases, on the tunica dartos fasciocutaneous blood supply.
dermis). If a thick STSG is used to reconstruct the genitalia, in
A contusion of the scrotum, that is, scrotal hematoma, can
cases of lymphedema, thelymphedema can significantly recur
be confused with a fracture of the testicle. The latter injury im-
in the graft. O ne must be careful of the patient with scrotal
plies disruption of the tunica albuginea and visceral tunica
lymphedema without “ involvement of the penile skin” ; follow-
vaginalis of the testicle. With a scrotal contusion the hematoma
ing scrotal reconstruction, often the penile skin becomes ede-
usually is noted to be posterior and lateral to the testicle
matous. Following burn injury to the genitalia, almost always
(Fig. 68.3), whereas with fracture of the testicle the parenchyma
graft reconstruction can be undertaken, and it offers ex-
of the testis is not normal and is often associated with a hema-
tremely good functional and cosmetic results.
tocele (Fig. 68.4). Physical examination remains the corner-
stone in the diagnosis of blunt testicular trauma. H owever, the
ALTERNATIVE THERAPY
Contusions of the scrotum are usually treated with bedrest,
analgesia, and scrotal elevation. Scrotal elevation can be ac-
complished very efficiently with a Bellevue-style (a taped sus-
pensory dressing to elevate the scrotum) bridge or with scrotal
support.
SURGICAL TECHNIQ UE
Scro t al He mat o mas and
Blunt Te st icular Injury
There is little to be accomplished in exploring the scrotal
hematoma secondary to external blunt trauma, as the
FIGURE 68.4 B-scan ultrasound of a patient with a fracture of the
testicle. N ote the disrupted parenchymal pattern of the testicle, the hematoma is usually disseminated throughout the highly elas-
hematocele, and the demonstration of extruded seminiferous tubules tic layers of the scrotum and does not form a drainable
within the hematocele. hematoma per se (3). O n the other hand, if there is a testicular
A B
FIGURE 68.5 A: Patient with fractured testicle; the skin has

been opened, as has the vaginal space. N ote the draining hema-
tocele fluid with clots affixed to the seminiferous tubules. B: The
testicle has been delivered. N ote the clot attached to the ex-
truded tubules. C: Appearance of the testicle following repair.
C
injury, exploration and repair of the testicle are indicated urethral involvement, amputation, or near-total amputation;
(Fig. 68.5). Exploration consists of exposure of the testicle. and with regard to the scrotum they imply amputation of or
The space of the tunica vaginalis is opened, the hematocele is injury to the testicle, with or without amputation of the over-
drained, seminiferous tubules are debrided, and the tunica al- lying scrotal skin (Fig. 68.6). Simple lacerations are managed
buginea is closed. The remaining viable testicular tissue should with primary closure and drainage, if indicated. In the case
be salvaged for endocrine function and psychological impact of amputation of the testicles, testicular microreplantation
(LO E 2) (4). In the past, polyglycolic (PGA) suture was used; has been performed, including vasovasostomy, along with
however, now we use polydioxanone suture, although reapproximation of the vasculature of the spermatic cord
M onocryl is also an option. The parietal tunica vaginalis is left (Fig. 68.7). The testicle is placed, as quickly as possible, in a
open and is reflected as would have been done for a hydrocele. sterile bag in saline-soaked gauze, and that bag is placed in a
The scrotum is drained and closed with 3-0 PGA suture, second bag filled with saline slush for cold preservation.
chromic suture, or M onocryl. Alternatively, in cases of testicu- Unlike amputation of the penis, where successful replantation
lar fracture secondary to either blunt or penetrating injury, has been done as long as 18 to 24 hours from the injury, the
rather than using aggressive debridement and primary closure testicle must be replanted by 6 to 8 hours due to the very high
of the tunica albuginea, one can close the testis with a tunica metabolic rate of the testicular tissue.
vaginalis graft or island. There can be some difficulty in identifying the vessels in the
spermatic cord, although they are somewhat compartmental-
ized. Identifying the artery proximally is not difficult, and
Pe ne t rat ing Injurie s t o t he Ge nit alia identification of the distal artery in the severed organ can be
aided by examining the relationship of the compartments to
Penetrating injuries have been subclassified as either simple the vas deferens. Coaptation of the artery and a number of
or complicated. By and large, complicated injuries imply veins is optimal using 9-0 or 10-0 Prolene, depending on the
FIGURE 68.6 A: Young patient with complex penetrating trauma to the

thigh and genitalia. Retrograde urethrogram, rectal examination, and flex-
ible sigmoidoscopy were normal. The patient’s scrotum was explored.
B: The patient’s right testicle is delivered; note the intact seminiferous
tubule pattern with virtual complete disruption of the tunica albuginea.
C: Appearance of the same testicle (B) following reconstruction of the
tunica albuginea with primary closure. D: Appearance of the genitalia
with the gunshot wounds debrided and the right hemiscrotum drained.
Dr. M ichael Coburn, Baylor University, Department of Urology, Personal
Communication, (January 16, 2009, N orfolk, Virginia) has assembled a
series of patients with similar injuries to that illustrated. In those cases, the
testicle was closed with a parietal tunica vaginalis patch. H e reports good
results with this technique.
A B
C D
size of the respective vessels. Vasovasostomy can be done us- wound should be irrigated and, if contaminated, packed to be
ing 9-0 or 10-0 Prolene or nylon sutures, either with a classic closed by secondary intention. If the wound is clean, then
microscopic two-layer technique or a single-layer “ tricorner” primary closure or primary grafting can be performed.
technique, depending on the surgeon’s preference.
If possible, the testicle should not be covered with a graft but
either placed in a thigh pouch and later liberated or, if there is Avulsio n Injurie s
some remaining redundancy of the scrotum, covered primarily
with reapproximation of the remaining scrotal tissues. Small scrotal avulsions are managed as simple lacerations with
O bviously, if the patient arrives without his amputated tes- either primary or delayed closure and drainage, as would be
ticle, then hemostasis must be ensured. Usually the vessels are indicated for any laceration (LO E 3; Fig. 68.8) (4). For larger
in spasm, but they clearly can come out of spasm later. The injuries, the emergency management consists of allowing the
FIGURE 68.7 A: Appearance of a patient following bilateral testicular amputation and scrotal amputa-
tion. The patient presented with only his right testicle. The left testicle could not be found at the trauma
scene. B: The right testicle is reanastomosed to the left (longer) spermatic cord. C: N ote the appearance
of the debrided spermatic cord and the debrided distal spermatic cord going to the testicle.
Vasovasostomy was performed with a two-layer microscopic technique. M icroscopic coaptation of the
spermatic artery and multiple spermatic veins was performed. D: Appearance of the replanted testicle
before closure of the scrotum.
injury to completely demarcate (Fig. 68.9). The area of the O ne option is to place the testicles in thigh pouches to be later
avulsed scrotum should be managed with cold saline packs liberated and later replaced to the area of the scrotum. The
and observed over 12 to 24 hours. Clear demarcation will preferable option is to perform a primary reconstruction of
occur and allow the surgeon to debride only the tissue that the scrotum using a mesh split-thickness skin graft. The graft
is nonviable. Debridement with closure is then performed should be harvested 0.016 to 0.018 in. thick and then meshed
(LO E 3) (4). on a 1.5- to 1.0- meshing template. The testicles must be fixed
If a primary closure cannot be accomplished with the rein position using permanent suture or absorbable suture that
maining scrotal tissue, then the surgeon has several options. is slowly absorbed so that they do not migrate beneath the
A B
FIGURE 68.8 A: Appearance of a left scrotal avulsion injury. The patient was injured in a motorcycle
accident in which his trousers were ripped off as he departed the motorcycle. B: Appearance after
closure. Primary closure is performed with drainage.
graft. The meshing of the graft allows for escape of serum and surrounding skin. It is the opinion of some authors that graft-
blood products from beneath the graft, but it also allows the ing directly on the visceral tunica vaginalis or tunica albuginea
graft to configure to the complex contours of the underlying can lead to a situation where there is chronic testicular pain.
testicles. The vaginal space is left open, and the parietal tunica This has not been the author’s (GH J) experience. Unless the
vaginalis is reflected to fix the testicle in place. The graft is wound is markedly contaminated, cases so managed have
then applied immediately to the testicles, suturing it to the yielded very successful results.
A B
FIGURE 68.9 A: Large avulsion injury of the genitalia. The patient was injured when his clothing
was ensnared in the power takeoff mechanism of a tractor. N ote the exposed shaft of the penis and the
exposed testicles bilaterally. B: The appearance after reconstruction with a split-thickness skin graft.
The patient was observed for 24 hours, allowing the wounds to demarcate. In this case, both the shaft
of the penis and the scrotum were reconstructed with a sheet split-thickness skin graft.
The grafts should be bolstered using Xeroform gauze or

one of the other commercially available fine meshed gauzes Ge nit al Burns
applied directly to the graft, with Dacron batting soaked in
The emergency therapy of genital burns is similar to that
saline and mineral oil placed over the finely meshed gauze.
for any burn. The scrotum can be dressed, open, with topical
Lately we have favored the use of the high-density polyethyl-
antibiotic ointments such as Silvadene, or a closed antibiotic
ene sheeting (N -Terface, Richardson, TX 75083–2297,
dressing regimen can be used. The integrity of the urethra
Winfield Laboratories, Inc.) to prevent adherence and subse-
must be determined when the patient presents. A Foley
quent graft displacement with bolster removal. The bolster is
catheter can be placed in the patient who has burns to his gen-
held in place with 4-0 chromic sutures. Unless there is an asso-
italia. If there is evidence of urethral burn, then most would
ciated urethral injury, the patient can be “ diverted” with a soft
suggest diversion with suprapubic cystostomy. If the burns to
Foley catheter. In patients in whom the avulsion injury extends
the genital and perineal area are extensive, then an occasional
near to the anus, colostomy may be required. It must be em-
patient will require colostomy. If the subscrotal urethra is in-
phasized that local skin flaps are not recommended for primary
volved in the burn, no attempt at initial reconstruction should
closure in these cases.
be made. In the case of the infant or young male, the move to
Should the testicles be avulsed, replantation is not an op-
a suprapubic tube should be made quickly if the need for a
tion. During the avulsion injury, the vasculature is stretched
urethral catheter is at all prolonged.
before giving way to the force, and the endothelial damage
The genital tissues are remarkably vascular. Debridement
can be significant and unpredictable.
of the genitalia, in general, should be accomplished care-
In patients in whom the avulsion injury is tantamount to
fully. Aggressive debridement should be avoided, as many of
emasculation, these injuries are often associated with signifi-
the tissues will recover and are nonreproducible. Whirlpools
cant injuries to the adjacent tissue. Reconstruction assumes a
and tank soaks are useful for gentle debridement and
very secondary position, as these patients require lifesaving
cleansing, and they may be done early on, two to three
steps. The vast majority of these patients will require
times per day.
colostomy, suprapubic cystostomy, and multiple dressing
Chemical burns rarely involve the structures deep to the
changes over the posttrauma course, and they often present
skin and are managed with copious irrigation and then as with
with significant bleeding.
a thermal burn (LO E 4). If a patient has evidence of an electri-
In general, the scrotal skin is highly distensible, and even
cal burn to the area of the genitalia, the patient must be ob-
a small fragment can be expanded to cover a large defect with
served for 12 to 24 hours and then explored. In electrical
a good functional result. There has been concern regarding
burns, the initial management is aimed at debridement, and
the effect of implantation of the testes in thigh pockets on
reconstruction can be offered later as the situation dictates
spermatogenesis, although there are few clinical data to sup-
(Fig. 68.10).
port this concern.
A B
FIGURE 68.10 A: The appearance of the genitalia in a patient who was burned in a steam-line accident.
N ote the burns to the glans, the dorsum of the shaft of the penis, and the right hemiscrotum. B: In this
particular case, reconstruction of the glans was accomplished with a small split-thickness skin graft.
Reconstruction of the shaft of the penis was accomplished with a penile skin island flap; the patient was
uncircumcised, and the ventral skin was mobilized to the dorsum. The scrotal burn was completely ex-
cised, and primary reconstruction of the right hemiscrotum was accomplished. This particular patient
demonstrates all of the possibilities for reconstruction following burn debridement.
A B
C D, E
FIGURE 68.11 Appearance of a young man with chronic genital lymphedema following irradiation ther-
apy for H odgkin lymphoma. A: Appearance of the massively lymphedematous scrotum. B: B-scan ultra-
sound demonstrating the large hydrocele. N ote the normal testis posteriorly. C: Appearance of the
genitalia after debridement of the lymphedematous tissue. N ote that orchidopexy has been performed.
D: Immediate appearance following reconstruction of the shaft of the penis with a split-thickness skin
graft and reconstruction of the scrotum with a meshed split-thickness skin graft. E: Appearance of that
same patient 6 months postoperatively. N ote the small amount of residual lymphedema of the preputial
cuff. Further note the redundant appearance of the scrotal graft.
skin grafts should not be used. The cosmetic results achieved

Rad iat io n Injurie s in these patients, so reconstructed, are excellent. The use of
lateral scrotal flaps as mentioned previously is worthy of con-
In the case of scrotal lymphedema and recurrent cellulitis, all
sideration in properly selected patients (Fig. 68.12). Radiated
layers of the scrotum should be excised, to the level of the ex-
patients in general are not candidates, as the problem is with
ternal spermatic fascia (Fig. 68.11). It is not uncommon for
the “ systemic” lymphatic drainage and not just the lymphatics
the patient also to have large hydroceles (2).
of the skin per se.
The vaginal space should be opened and the parietal tunica
vaginalis then reflected and incorporated in the orchidopexy.
Reconstruction can be accomplished, using split-thickness Fo urnie r’s Gang re ne
skin grafts, as already discussed, and on the scrotum these
grafts can be meshed as discussed earlier. In addition, the If the primary process has resulted in extensive debridement of
meshing seems to improve the cosmetic result by giving the the scrotum, the testicles can be placed in thigh pouches with
appearance of the normal scrotal rugations (1). Full-thickness the intention of later replacing the testicles in their normal
A B
FIGURE 68.12 A: Preoperative appearance of a chronically lym-

phedematous scrotum. B: Intraoperative appearance following the re-
section of the lymphadematous scrotum, exposed testicles, and lateral
scrotal flaps. C: Immediate postoperative appearance of the closure of
C the scrotum in the midline using lateral scrotal flaps.
anatomic area and for scrotal reconstruction. The author’s not only remain supple, but in many cases (as has been
(GH J) preferred approach was described by M cDougal and is shown), will actually become redundant.
illustrated in Fig. 68.13. The lateral defects on the thigh can
often be closed per prim am or can be grafted.
For most patients, however, the scrotal excisions do not ne-
cessitate placing the testicles in thigh pouches, but instead they
O UTCO MES
can be dressed in the wound (7). These patients often require
multiple dressing changes and wet-to-dry debridements. These Co mp licat io ns
techniques can be used in combination with negative pressure
dressings or vacuum-assisted closure (VAC) devices to reduce Complications of scrotal trauma and reconstruction are pri-
the defect size more quickly. When reconstruction is under- marily related to inadequate appreciation of the degree of
taken, the testicles must be fixed in their normal anatomic injury with subsequent necrosis of additional skin. It is
position. It is my custom to open the parietal tunica vaginalis important for the surgeon to adequately debride the devital-
and reflect it, and, as already described, graft techniques can ized skin, which may require more than one trip to the operat-
be utilized to restore the scrotum. Although local flaps can be ing room. The failure of a skin graft to take is usually a result
used, the cosmetic results achieved with local flaps are usually of technical errors such as accumulation of fluid under the
less than optimal in most of these circumstances when com- graft, inadequately prepared graft bed, or continual slippage
pared to reconstruction techniques utilizing split-thickness of the graft over the bed, which does not allow capillary
skin grafts. Interestingly, these mesh split-thickness skin grafts ingrowth.
FIGURE 68.13 Technique after M cDougal for liberation of testicles that have been placed in thigh
pouches. N ote that the testicles are mobilized with random thigh skin flaps and transposed to the midline
to reconstruct the scrotum. The lateral defects can be closed per prim am or can be grafted.
injuries require aggressive debridement of devitalized tissue to

Re sult s minimize infection and to prepare a healthy graft bed.
Reconstruction of the scrotal skin, most often performed with
As with most surgical conditions, prompt diagnosis and
meshed STSG, offers excellent graft take and survival with ac-
management of acute testicular injuries is paramount to
ceptable cosmetic results in closing the resultant defect.
maintaining testicular function. Burns, avulsion, and radiation
References
1. Arneri V. Reconstruction of the male genitalia. In: Converse J, ed. 6. Jordan GH , Gilbert DA. M anagement of amputation injuries of the male
R econstructive plastic surgery, 2nd ed. Philadelphia: WB Saunders, 1977: genitalia. Urol Clin N orth A m 1989;16:359–367.
3902–3921. 7. Tahmaz L, Erdemir F, Kibar Y, et al. Fournier’s gangrene: Report of thirty-
2. Charles RH . The surgical technique and operative treatment of elephantia- three cases and a review of the literature. Int J Urol 2006;13:960–967.
sis of the generative organs based on a series of 140 consecutive successful 8. Jordan GH , Schlossberg SM , Devine CJ. Surgery of the penis and urethra.
cases. Ind M ed G az 1901;36:84. In: Walsh PC, et al., eds. Cam pbell’s urology, 7th ed., Vol. 3. Philadelphia:
3. Culp D, Genital Injuries: Etiology and Initial M anagement. Urol Clinics WB Saunders, 1997:3316–3394.
N A 1977; 4 (1): 143–156. 9. M cDougal WS, Persley L. Traumatic Injuries of the Genitourinary System.
4. Jordan GH , Gilbert DA. M ale genital trauma. Clin Plast Surg 1988; International Perspective in Urology, Vol. 1. Baltimore/London, 1981:43.
15:431.
5. M orey AF, M etro M J, Carney KJ, et al. Consensus on genitourinary
trauma: external genitalia. BJU Int 2004;94(4):507–515.
SECTIO N VI ■ PENIS AND SCRO TUM
GERALD H. JO RDAN
CHAPTER 69 ■ ANATO MY O F THE PENIS

AND SCRO TUM
SAM D. GRAHAM, JR.
The penis is composed of three columnar bodies, a pair of Proximally the corpora cavernosa taper to form the crus and
which are larger, dorsally located, and extend the length of the are attached to the pubic arch. Each corpus is closely applied
penis (Fig. 69.1). These two columnar bodies contain caver- to the other, separated only by a septum, for most of the distal
nosal vascular tissue and are called the corpora cavernosa. penis. The corpora cavernosus is supported at its base by the
ischiocavernosus muscles, which arise from the inner surface
of the ischial tuberosity and are innervated by the perineal
nerves.
The third columnar body, the corpus spongiosum, contains
the urethra, and the distal end is bulbous, forming the glans
Glans
penis. The corpus spongiosum is attached proximally to the
perineal membrane and at the most proximal portion is larger,
forming the bulb.
Each of the corporal bodies is encased in its own tunica al-
Corpora
cavernosa buginea, and the three corporal bodies are surrounded by the
penis Corpus Buck fascia, which is a continuation of the Colles fascia (Fig.
cavernosum 69.2). The Buck fascia is attached posteriorly to the urogenital
urethra diaphragm and anteriorly forms the suspensory ligament.
There is little vascular communication between the corpora
cavernosa and the corpus spongiosum. There is, however, vas-
cular communication between the two corpora cavernosa via
pectiniform septa in the distal corpora.
VASCULAR ANATO MY
The superficial penile artery lies between the superficial and
Buck fascia and originates from the external pudendal artery,
which in turn is a branch of the femoral artery. This artery,
along with a corresponding vein, supplies the penile skin and
is located between the superficial penile fascia and the Buck
fascia. The deep arterial supply arises from the internal iliac
artery, which initially branches into the internal pudendal
Bulb artery and then into the penile artery. As the penile artery exits
the urogenital diaphragm, it branches into the bulbourethral,
Urogenital diaphragm cavernosus, and urethral arteries. The cavernosus artery is the
FIGURE 69.1 Anatomy of the three corporal bodies comprising the direct supply of the corpora cavernosa. The penile artery con-
penis. tinues along the corpora cavernosa as the dorsal artery.
465
466 Se ct io n VI: Pe nis and Scrotum
Superficial vein,
artery, and nerve
Skin
Deep dorsal vein, Buck fascia
artery, and nerve
Circumflex
vein
Emissary vein
Cavernous
artery
Corpus cavernosum
Tunica albuginea
Bulbourethral vein
Urethra
FIGURE 69.2 Cross section of the penis demonstrating

Corpus spongiosum
fascial layers as well as vascular and neural anatomy.
The corpus spongiosum is supplied by the bulbourethral

artery proximally, circumflex arteries from the dorsal artery LYMPHATIC ANATO MY
along its shaft. The glans is supplied by the dorsal artery. The
dorsal artery, the deep dorsal vein, and the dorsal nerve are The lymphatics of the penile skin drain into the superficial in-
enclosed within the Buck fascia. guinal and subinguinal lymph nodes. The lymphatics of the
The superficial penile vein drains into the external puden- glans penis empty into the subinguinal and external iliac
dal vein. The circumflex and deep dorsal veins drain into the nodes. The deep lymphatics drain into the hypogastric and
plexus of Santorini, as do the crural and cavernosal veins common iliac nodes.
(Fig. 69.3).
FIGURE 69.3 Venous drainage of the penis.

CHAPTER 70 ■ PARTIAL AND TO TAL
PENECTO MY IN THE MANAGEMENT O F
INVASIVE SQ UAMO US CELL CARCINO MA
O F THE PENIS
ANTO NIO PURAS BAEZ AND ALEX M. ACO STA MIRANDA
Squamous cell carcinoma of the penis is an epidermoid tumor inguinal area and pelvis is of extreme importance for staging
arising in the glans or mucosal lining of the prepuce. Its inci- and assessment of lymph node status. The lesion should be
dence follows a distinct geographic, racial, and socioeconomic cultured and the patient started on appropriate antibiotic ther-
distribution. The tumor is age-related, showing an age-specific apy. Any suspicious growth or ulceration should be biopsied,
rate of increase with each decade and having its peak inci- and meticulous pathologic analysis should be done for the
dence at the fifth and sixth decades (9). An earlier age of onset depth and type of invasion, the presence of microvascular per-
and a high proportion of younger patients have been reported meation, and the histologic grade of the tumor prior to initia-
in areas of high incidence, such as Africa, India, and South tion of any therapeutic modality.
America (8). In Puerto Rico the age-adjusted incidence is The definite diagnosis is made by biopsy of the lesion
around 5 per 100,000 men (7), whereas in the United States (Fig. 70.1) following appropriate antibiotic therapy. Adequate
and Europe it accounts for only 0.4% to 0.6% of all malig- anesthesia is obtained with 1% local lidocaine, and a 1.5-cm
nancies in men (8). elliptical wedge of tumor tissue is removed (Fig. 70.2). The
Although the precise etiology of penile carcinoma remains biopsy should include tumor growth and adjacent neighboring
undetermined, numerous factors have been associated with normal tissue to be examined for tumor infiltration. The inci-
the risk of developing squamous cell carcinoma of the penis, sion is closed with interrupted 3-0 chromic catgut. We prefer
such as chronic irritation, poor genital hygiene, the presence to perform a wedge biopsy as a separate procedure and dis-
of an intact foreskin, phimosis, smegma, and viruses. cuss with the pathologist the tumor grading, type of growth,
There is increasing evidence for a sexually transmitted viral and presence of microvascular permeation prior to initiation
etiology in penile cancer. H uman papilloma viruses (H PV), of any definite therapeutic modalities. Patients with tight
especially types 16, 18, 31, and 33, are the most frequently phimosis who have purulent discharge and a palpable mass
detected types in penile cancer. O ther investigators have or induration concealed underneath the foreskin should be
shown an association between the use of tobacco products
and penile tumors. It appears that an enclosed preputial envi-
ronment associated with poor genital hygiene of the foreskin,
chronic irritation, and exposure to certain etiologic agents,
such as viruses, smegma, and hydrocarbons, may also play a
causative role in the development of this tumor.
DIAGNO SIS
Patients with penile carcinoma may present with lesions that
are a subtle induration or erythema of the glans or foreskin, a
papule, a warty growth, or a large exophytic lesion with puru-
lent discharge and cellulitis. These lesions are usually non-
painful, and there is a delay in patient presentation due to
self-denial, ignorance, fear, and personal neglect (12).
Penile lesions such as erythroplasia of Q ueyrat, leuko-
plakia, cutaneous horn, balanitis xerotica obliterans, condy-
loma acuminatum, advanced melanoma, and giant condyloma
may resemble squamous cell carcinoma of the penis and must
be considered in the differential diagnosis.
Penile lesions should be examined thoroughly and assessed FIGURE 70.1 Wedge biopsy of the penile lesion. Biopsy should
in regard to location, tumor growth, size, and infiltration of include tumor growth and adjacent neighboring normal tissue to be
the corporal bodies and urethra. Careful examination of the examined for tumor infiltration.
467
ALTERNATIVE THERAPY
Various nonsurgical therapeutic modalities, including radia-
tion therapy, chemotherapy, and a combination of these, have
been used in the treatment of the primary lesion. Penile-
sparing procedures such as micrographic excision (M ohs
micrographic surgery) and laser procedures have been utilized
in other cutaneous malignancies and have been investigated
in penile cancer.
A
M ohs micrographic surgery is a technique of excision of
the lesion in thin horizontal layers using microscopic examina-
tion of the entire undersurface of each layer and systematic
use of frozen sections. Two techniques by which microscopic
control of the tumor is achieved have been described. The first
technique is a fixed tissue technique in which the tissues are
subjected to in situ chemical fixation with zinc chloride paste
before excision of successive layers. In the fresh tissue tech-
nique, a local anesthetic is injected and the tissues excised in a
fresh, unfixed state and examined by frozen section. The fresh
tissue technique is recommended for small tumors, whereas
for larger infiltrative lesions the fixed technique will provide
control of bleeding from the relatively noncontractile vessels
B of the erectile tissues of the glans and corpora cavernosa. Cure
rates for low-stage lesions that are 1 cm in diameter are
close to 100% , while cure rates for lesions 3 cm drop to
around 50% . It appears that microscopically controlled tumor
excision provides an effective treatment alternative for manag-
ing some types of penile cancer with good cosmetic results.
Complications related to most micrographic surgical tech-
niques are meatal stenosis and disfigurement of the glans.
Laser therapy has been used in the treatment of penile car-
cinoma with highly satisfactory cosmetic results as well as
good local tumor control. The major advantage of laser ther-
apy for carcinoma of the penis is the destruction of the tumor
C with penile preservation and function; it also gives the advan-
FIGURE 70.2 Wedge biopsy with wide excision at coronal sulcus. tages of destroying tissue, sealing small vessels and nerve end-
A: Tumor growth and adjacent normal tissue margins are marked. ings, and reducing the incidence of postoperative bleeding and
B: Wedge biopsy. C: Repaired defect with advancement of penile shaft pain. The main disadvantage of laser surgery is the difficulty
skin. of obtaining histologic documentation and determining the
depth of penetration by the tumor; it appears that the site and
depth of penetration of the primary lesion correlate with its
managed with a dorsal slit incision, long enough to retract the
curability. Bandieramonte et al. (1) were able to resect T1 tu-
prepuce and adequately examine and biopsy any suspicious
mors at the glans penis by using a very short pulse and high
lesion or growth.
peak power at the base of the lesion and at the meatus, pro-
Further assessment of local invasion to the corpora and
viding precise excision of the specimen for histologic examina-
spongiosum can be done with M RI. This radiologic cross-
tion; however, a 15% recurrence rate was reported.
sectional modality has been shown to be highly accurate in the
In a select group of patients with morphologically and
local staging of penile cancer and in surgical planning for the
anatomically suitable penile cancer with low-grade, low-stage
possible institution of conservative surgical treatments over
disease, conservative surgical techniques are safe and can pro-
more extensive procedures (5).
vide similar tumor control when compared to conventional,
more radical resections. The tumor size, location, and patho-
logic characteristics should dictate the treatment of the pri-
INDICATIO NS FO R SURGERY mary penile lesion (2).
Survival of patients with carcinoma of the penis depends pri-
marily on the tumor grade, the depth of invasion, and the sta-
tus of the regional nodes. The primary therapeutic goal in the SURGICAL TECHNIQ UE
management of penile carcinoma should be complete tumor
excision, regional lymphatic control, and a functional, cos- Circumcisio n and Glans-Sp aring Surg e ry
metic penis. Surgery plays a prominent role in the manage-
ment and control of the primary lesion. If adequately Patients presenting with small lesions involving the prepuce
performed, it will assess the histologic grade, depth, and type may be adequately managed by wide excision with a 1.5-cm
of tumor invasion and in many cases can be curative. margin. M icroscopic examination by frozen section should be
Chap t e r 70: Partial and Total Pe ne ctomy in the Manag e me nt of Invasive Sq uamous Ce ll Carcinoma of the Pe nis 469
C
FIGURE 70.3 Excision of recurrent penile carcinoma at the frenular
aspect of glans. A: Tumor growth with margins. B: Wedge excision
with care to avoid damage to urethra. C: Repaired defect.
C
performed to obtain a tumor-free margin due to the high risk
FIGURE 70.4 Glansectomy. A: Patient with recurrent carcinoma of
of recurrence. the glans penis following radiation therapy. B: Glans is excised with
The histopathologic slides should be reviewed with the preservation of a 1-cm urethral stump. C: Skin is closed longitudinally.
pathologist with special attention to the patterns of tumor
growth, grading, depth of invasion, and microvessel infiltra-
tion. Suspicious lesions at the glans or coronal sulcus should long-term follow-up, but each case must be individualized
be biopsied and proved to be free of tumor. Selected patients accordingly.
with superficial tumors of the shaft can be managed with a The incidence of local recurrence may be increased with
wide excision by excising around 2 cm of normal skin. The penile-preserving strategies. This carries a poor prognosis and
skin defect can be covered by a full-thickness skin graft, which may represent regional lymphatic spread. With careful patient
results in a functional and cosmetically appealing phallus selection and meticulous follow-up, some patients with invasive
without jeopardizing the cancer control surgical aspects. Small penile carcinoma can benefit from penile-preserving surgery.
lesions at the glans may be treated with local excision and pri-
mary closure of the surgical defect (Fig. 70.3). Glansectomy
can result in a very satisfactory cosmetic penile appearance af- Part ial Pe ne ct o my
ter reconstruction, preserving penile length and function while
offering an oncologically safe and effective procedure for pa- Partial penectomy for squamous cell carcinoma of the penis
tients with glans-confined low-grade squamous cell tumors provides excellent local control with a low recurrence rate and
(Fig. 70.4). In some rare cases large exophytic, low-grade, acceptable maintenance of urinary and sexual function.
well-differentiated noninvasive lesions can be managed with Invasive tumors involving the glans and coronal sulcus can be
organ-sparing surgery with complete disease-free status on adequately managed by a partial penile amputation excising
FIGURE 70.5 Partial penile amputation. A: A condom catheter is placed over the tumor and a circum-
ferential incision is marked on the skin 2 cm proximal to the lesion. B: A 14Fr catheter or 0.25-in.
Penrose drain is placed as a tourniquet at the base of the penis. The skin and Buck fascia are incised onto
the tunica albuginea. Corpora cavernosa are sharply divided down to the urethra. The urethra is dis-
sected free from the corpus spongiosum, and a 1-cm stump projects distally to the corpora cavernosa.
C: The urethra is spatulated on its dorsal surface, and the corporal ends are closed with horizontal mat-
tress sutures incorporating the Buck fascia, tunica albuginea, and intracavernosal septum. D: The tourni-
quet is released and adequate hemostasis is obtained. E: The dorsal skin is closed longitudinally.
F: Ventral approximation of the penile skin to the urethra is begun and continued dorsally. The remain-
ing dorsal skin is closed longitudinally.
around 1.5 to 2.0 cm of normal tissue proximal to the margin procedure. The penis is prepared with a povidone-iodine solu-
of tumor infiltration (Fig. 70.5). In most instances, this should tion and the tumor isolated using a sterile condom or glove
leave a functional penis of 4 cm in length, which allows that is sutured in place using 3-0 silk sutures. A 0.25-in. Penrose
standing micturition and enough rigidity and length for vagi- drain or 14Fr Red Robinson catheter is applied as a tourni-
nal penetration. Frozen sections of the proximal margins are quet at the base of the penis. A circumferential incision is
necessary to confirm tumor-free resection and a recurrence marked on the skin 1.5 to 2.0 cm proximal to the lesion. The
rate of 10% or less. Partial penectomy has consistently been skin is incised circumferentially, and the superficial and deep
shown to give better oncological results than conservative dorsal veins are divided and ligated using 3-0 silk sutures. The
treatment in the local management of the T1-stage tumor. Buck fascia is incised onto the tunica albuginea of the corpora.
The procedure can be performed under local, regional, or The corpora cavernosa are sharply divided down to the ure-
general anesthesia. The patient is placed in the supine position. thra and the central cavernosal arteries ligated on each side.
The lesion and urine should be cultured preoperatively and The urethra is dissected free from the corpus spongiosum
appropriate parenteral antibiotics started prior to the surgical in such a manner that an approximately 1-cm stump projects
Chap t e r 70: Partial and Total Pe ne ctomy in the Manag e me nt of Invasive Sq uamous Ce ll Carcinoma of the Pe nis 471
distally to the transected corpora cavernosa. The urethral dressing, and scrotal support are applied for 24 hours. The
stump and transected corpora are then washed with gen- Penrose drains are usually removed in 48 hours, and the Foley
tamycin solution. The corporal ends are closed with horizon- catheter should be removed when the urethrostomy is well
tal mattress sutures of 2-0 Vicryl incorporating the Buck healed.
fascia, tunica albuginea, and intercavernosal septum. The pe- Lesions involving the perineum and anterior abdominal
nile base tourniquet is then released, and all minor vessels are wall may need adjuvant preoperative chemotherapy in an
fulgurated or ligated until adequate hemostasis is obtained. attempt to downsize the tumor. If no adequate response is ob-
Skin closure can be performed either in the classic longitudinal served, the patient will need complete removal of the neoplasm,
fashion or using a buttonhole technique in which a flap of which may result in total emasculation and may require a
dorsal penile skin is left, a crescentic buttonhole incision in the musculocutaneous flap closure. In some rare instances cysto-
skin flap is made, and this flap is then rotated ventrally to- prostatectomy with urinary diversion will be necessary.
ward the urethra. In both techniques the urethra is spatulated
dorsally and sutured to the skin using 4-0 Vicryl. The remain-
ing skin is closed using 3-0 Vicryl sutures. A 16Fr Foley O UTCO MES
catheter is left indwelling to closed straight drainage for 48 hours,
and the wound is dressed with triple antibiotic and Vaseline Co mp licat io ns
gauze.
The most common complication of partial and total penec-
tomy is meatal stenosis. The V-inlay technique has been used
To t al Pe ne ct o my to decrease the stenosis at the urethral opening. Some institu-
tions also advocate the use of a “ loop” cutaneous urethros-
Patients with large, extensive, and infiltrating lesions involv- tomy, instead of the classic end cutaneous urethrostomy,
ing the glans and midshaft of the penis, in which the location during total penectomy, which may better preserve the distal
precludes adequate excision with a functional residual penile urethral blood supply and thus minimize the tendency for the
remnant, are managed by total penectomy (Fig. 70.6). The pa- urethral meatus to develop stenosis. Patients should be aware
tient is placed on lithotomy position and the lesion is prepared of this complication and instructed to start self-dilation as
with povidone-iodine solution. Appropriate antibiotic therapy soon as they notice a decrease in the urine stream.
should be started before the procedure according to penile and Patients with partial and total penectomy suffer serious
urine culture results. A condom catheter or sterile glove is psychological and physical trauma with major changes in their
secured to the base of the penis with interrupted 3-0 silk sutures. quality of life. They should undergo psychiatric evaluation
An elliptical incision is made around the base of the penis and and counseling and receive emotional support in which the
extended through the subcutaneous tissues until the surface of family and a team of social workers, psychologists, and physi-
the pubis is reached. All vessels and lymphatics are either ful- cians should take an active role. Some authors have proposed
gurated or ligated. The suspensory ligaments of the penis are that the classic 2-cm excision margin is not necessary and a
isolated with a right-angle clamp and divided. The dorsal vein more conservative approach might still offer adequate cancer
and penile arteries are identified, clamped, ligated, and di- control while providing a more cosmetic and functional penile
vided. The penis is then reflected cephalad, the Buck fascia is remnant.
opened ventrally, and the urethra is dissected free from the Various techniques for penile reconstruction have been
corpora cavernosa with sharp and blunt dissection. At the dis- described and include the radial forearm flap and the use of
tal bulbar region, the urethra is divided, leaving enough length innervated forearm osteocutaneous flaps combined with big
to reach the perineum. The corpora cavernosa are dissected up toe pulp for reconstruction of the glans. These complex recon-
to the ischiopubic rami, sutured, and ligated with 2-0 Dexon structive procedures require a multidisciplinary approach and
sutures and then transected. The specimen should be removed are usually performed at specialized referral centers.
with a 2-cm tumor-free margin.
The urethra is dissected to the area of the urogenital
diaphragm to obtain an unangulated straight course to the per- Re sult s
ineal urethrostomy site. The urethra is tagged with 3-0 catgut
sutures. A 1-cm ellipse of skin and subcutaneous tissues is re- Surgery plays a prominent role in the treatment and control of
moved from the midperineum just midway between the anus the primary lesion in squamous cell carcinoma of the penis.
and scrotum. A tunnel is developed in the perineal subcuta- The presence and extent of metastasis to the inguinal nodes
neous tissue using a curved clamp, and the urethra is drawn are the most important prognostic factors for survival in pa-
into the perineal incision, with care taken to avoid angulations tients with penile cancer (6). Patients who are at risk or have
in the urethra. The urethra is then spatulated dorsally, and a persistent adenopathy following treatment to the primary
V-inlay of skin can be created and anastomosed to the urethra lesion should undergo early regional inguinal lymphadenec-
using 3-0 or 4-0 Vicryl. A watertight technique should be used tomy. It has been shown that early resection of lymph node
to prevent urinary leakage under the flap. An 18Fr Foley metastases in patients with penile carcinoma improves sur-
catheter is inserted, and 0.25–in. Penrose drains are left to vival. H istologic grade, stage, and lymphovascular involve-
drain each side of the scrotum. The scrotal incision is closed ment are important parameters for selecting patients for
transversally to allow elevation of the scrotum away from the “ early” lymphadenectomy. Patients with microscopic disease
perineal urethrostomy using a two-layered closure with Vicryl to the inguinal nodes and well-differentiated tumor are at low
3-0. Triple antibiotic is placed over the wound incision and risk for developing pelvic lymph node involvement and thus
around the perineal urethrostomy. A Vaseline gauze, pressure have a good 5-year cancer-specific survival. Survival drops
FIGURE 70.6 Total penectomy. A: A condom

catheter is placed over the tumor. B: A diamond-
shaped incision is made around the base of the
penis. C: The dissection is extended superiorly
through the subcutaneous tissues until the surface
of the pubis is reached. The suspensory ligaments
are isolated (clamped and divided). D: The penis is
reflected cephalad, the Buck fascia is opened ven-
trally, and the urethra is dissected free from the
corpora cavernosa. At the distal bulbar region the
urethra is divided, leaving enough length to reach
the perineum. E: The corpora cavernosa are dis-
sected to the ischiopubic rami, the crura are
clamped and divided, and the specimen is removed
with a 2-cm tumor-free margin. The urethra is mo-
bilized to the urogenital diaphragm to maintain an
unangulated straight course to the perineal ure-
throstomy site. F: The urethra is tagged with a 3-0
chromic suture, a 1-cm ellipse of skin and subcuta-
neous tissues at the midperineum is removed, a
tunnel is developed in the perineal subcutaneous
tissue using a curved clamp, and the urethra is
brought into the perineal incision. G: The urethra
is spatulated dorsally and divided, and a V-inlay of
skin is created and anastomosed to the urethra.
The diamond-shaped defect is closed.
Chap t e r 71: Ing uinal Lymp had e ne ctomy for Pe nile Carcinoma 473
significantly in the presence of multiple nodal involvement, frozen section, which remain the “ gold standard” for defining
pelvic metastasis, and extranodal extension of cancer. the presence of microscopic lymph node metastases (4).
Several investigators have noted a correlation between tumor Sánchez-O rtiz and Pettaway (10) reviewed the M . D.
grade, regional metastasis, and survival. Well-differentiated Anderson Cancer Center series and proposed that follow-up
tumors seldom demonstrate nodal involvement and have a regimens should be tailored according to high-risk recurrence
high disease-specific survival. Tumors that exhibit a compact, stratification factors that include men treated with phallus-
vertical growth are usually high-grade neoplasms, associated sparing strategies such as laser ablation, topical therapies, or
with regional nodal metastasis (3). Slaton et al. (11) evaluated radiotherapy; patients with clinically negative inguinal lymph
48 patients with invasive squamous carcinoma of the penis nodes who are managed without lymphadenectomy despite
and examined the prognostic factors for lymph node metastasis high-risk primary tumors (pT2–3, grade 3, vascular invasion);
using univariate and multivariate analysis. These authors con- and those with lymph node metastases after lymphadenec-
cluded that the pathologic stage of the penile tumor, vascular tomy. Less rigorous surveillance protocols should be instituted
invasion, and 50% poorly differentiated cancer were inde- in patients with low-risk primary tumors (pTis, pTa, pT1,
pendent prognostic factors for inguinal lymph node metasta- grades 1–2) and those with negative inguinal nodes after lym-
sis. These data clearly establish the significance of histologic phadenectomy whose primary tumors were managed with
grade, patterns of tumor growth, depth of invasion, and vascu- partial or total penectomy (10).
lar permeation in predicting regional spread and survival. Squamous cell carcinoma of the penis, although a rare en-
Several new techniques are being applied to achieve local tity, represents a formidable challenge for the practicing urol-
and regional lymph node control in patients with penile cancer. ogist. Every therapeutic modality should be individualized to
Dynamic sentinel lymph node biopsy is a promising technique achieve the ultimate goals of complete tumor excision of the
in evolution that may become an alternative to superficial or primary lesion, provision of a cosmetic functional penis, and
modified inguinal dissection techniques with intraoperative early regional lymph node control.
References
1. Bandieramonte G, Santoro O , Boracchi P, et al. Total resection of glans pe- 8. M uir C, Waterhouse J, M ack T, et al., eds. Cancer incidence in five conti-
nis surface by CO 2 : laser microsurgery. A cta O ncol 1988;27:575. nents. Lyon, France: International Agency for Research on Cancer, 1987;
2. Bissada N K, Yakout H H , Fahmy WE, et al. M ulti-institutional long-term Publication 88.
experience with conservative surgery for invasive penile carcinoma. J Urol 9. Puras A, Rivera J. Invasive carcinoma of the penis: management and prog-
2003;169(2):500–502. nosis. In: O esterling JE, Richie JP, eds. Urologic oncology, 1st ed.
3. Cubilla AL, Barreto J, Vaballero C, et al. Pathologic features of epidermoid Philadelphia: WB Saunders, 1997:604–617.
carcinoma of the penis: a prospective study of 66 cases. A m J Surg Pathol 10. Sánchez-O rtiz RF, Pettaway CA. N atural history, management, and sur-
1993;17:753–763. veillance of recurrent squamous cell penile carcinoma: a risk-based
4. Izawa J, Kedar D, Wong F, et al. Sentinel lymph node biopsy in penile can- approach. Urol Clin N orth A m 2003;30(4):853–867.
cer: evolution and insights. Can J Urol 2005;12[Suppl 1]:24–29. 11. Slaton JW, M orgenstern N , Levy DA, et al. Tumor stage, vascular invasion
5. Kayes O , M inhas S, Allen C, et al. The role of M RI in the local staging of and percentage of poorly differentiated cancer: dependent prognosticators
penile cancer. Eur Urol 2007;51(5):1313–1318. for inguinal lymph node metastasis in penile squamous cancer. J Urol
6. Korets R, Kopie TM , Snyder M E, et al. Partial penectomy for patients with 2001;165:1138–1142.
squamous cell carcinoma of the penis: The M emorial Sloan Kettering expe- 12. Sufrin G, H uben R. Benign and malignant lesions of the penis. In:
rience. A nn Surg O ncol 2007;14(12):3614–3619. Gillenwater JY, Grayhack JT, H owards SS, et al., eds. A dult and pediatric
7. M arcial V, Puras A, M arcial VA. N eoplasms of the penis. In: H olland JF, urology, 2nd ed. St. Louis, M O : M osby–Year Book, 1991:1643–1678.
Frei E, Bast R Jr, et al., eds. Cancer m edicine, 4th ed. Baltimore: Williams
& Wilkins, 1996:2165–2175.
CHAPTER 71 ■ INGUINAL LYMPHADENECTOMY

FOR PENILE CARCINOMA
SHAHIN TABATABAEI AND W. SCO TT McDO UGAL
Squamous cell carcinoma of the penis tends to spread locally penile lymphatic drainage. The disease first spreads to the su-
to regional lymph nodes long before distant metastases occur. perficial and deep inguinal nodes, followed by the pelvic
Approximately 50% of patients have lymph node involvement nodes (i.e., external iliac and obturator lymph nodes).
at presentation. M etastatic spread to the locoregional lymph Although tumor metastasis to the contralateral inguinal nodes
nodes occurs in a stepwise fashion along the normal route of is common, pelvic cross-drainage has not been reported.
FIGURE 71.1 M anagement of inguinal lymph nodes

following primary surgery for carcinoma of the penis.
L N D , lymph node dissection.
The most important prognostic factors for survival in men patients with grade 1 squamous cell carcinoma (SCC) of the
with invasive squamous cell carcinoma of the penis are the penis, 24% to 37% may have inguinal lymph node involve-
presence and extent of inguinal lymph node metastasis (1). ment, while almost 82% of patients with grade 3 tumors have
Although penile carcinoma metastatic to the lymph nodes positive inguinal lymph nodes (3,4). Patients with carcinoma
portends a poorer prognosis, aggressive surgical excision of in situ and verrucous carcinoma of the penis are considered
the involved nodes is associated with increased long-term sur- low risk as there is no evidence that these lesions metastasize.
vival with a possible cure in 30% to 60% of patients with Patients with tumor stage T2 or greater (invasion into the cor-
inguinal lymph node metastasis (1,2). This is not true if the pora) have a 30% to 66% incidence of positive nodes. When
tumor has spread to the pelvic lymph nodes, however, in stage and grade are combined, those with grade 3 and/or those
which case there is a 10% survival rate. There is currently with stage T2 or greater have an 80% incidence of positive
no effective chemotherapy for patients with disease beyond nodes (3).
the inguinal nodes. Without treatment, patients with metasta- We advocate early lymphadenectomy in high-risk patients
tic disease die within 2 years. with nonpalpable groin adenopathy (5). Figure 71.1 summa-
Until recently, inguinal lymphadenectomy had been associ- rizes our current approach to managing inguinal lymph nodes
ated with significant morbidity (30% to 90% ) and up to 3% in these patients. As shown in the algorithm, all patients with
mortality. Further, previous studies reported up to a 50% penile cancer undergo 4 to 6 weeks of antibiotic therapy
false-positive rate in patients with clinically enlarged lymph before the inguinal lymphadenectomy. It has been shown that
nodes. These reports have generated considerable controversy most patients with ulcerative, penile SCC have infectious lym-
regarding the indications for a lymphadenectomy in patients phangitis. Inguinal lymphadenectomy in the absence of appro-
with penile carcinoma. priate antibiotic treatment may significantly increase the risk
of complications after the surgery.
Controversies regarding unilateral versus bilateral groin
DIAGNO SIS dissection have been resolved by recent data and studies indi-
cating that lymphatic cross-drainage to the contralateral side
The diagnosis is secured at the time of biopsy and definitive does occur. Therefore, we strongly recommend bilateral
treatment of the primary lesion (Chapter 66). A computerized inguinal lymphadenectomy.
tomography (CT) scan of the abdomen and pelvis is important The role of pelvic lymphadenectomy and whether the lym-
for staging the pelvic nodes. phadenectomy should start in the groin or pelvis are also con-
troversial issues. M any studies indicate that involvement of
pelvic lymph nodes is an ominous sign, and almost all of these
INDICATIO NS FO R SURGERY patients succumb to the disease in 2 years. Indeed, the knowl-
edge of pelvic lymph node status has prognostic significance
In the last two decades, improvements in surgical and periop- and may change the surgical approach. If the pelvic lymph
erative techniques have considerably decreased the complica- nodes are positive, the surgical intention will be focused on pal-
tion rates of inguinal lymphadenectomy. In addition, accurate liation. In these situations, we still perform inguinal lym-
prognostic factors to predict lymph node involvement have phadenectomy, but only on clinically palpable inguinal nodes,
been better defined. Therefore, a more proactive approach to to prevent lesions from penetrating through the skin and/or
treating penile cancer may be taken. Tumor grade and depth invading into the femoral vessels, which may result in fatal
of invasion help predict the lymph node involvement (1–3). In femoral artery bleeding. In these cases, we do not proceed to
contralateral inguinal lymphadenectomy for nonpalpable con- fixed regional nodes ( 4 cm in size and/or extracapsular
tralateral nodes. Pelvic lymphadenectomy could also serve as a extension). In the absence of surgical contraindications
tool for accurate staging in patients who are candidates for (medical comorbidities, patient’s refusal, bulky, infected lym-
adjuvant or neoadjuvant chemotherapy protocols. phadenopathy with distant metastasis), we are not in favor of
In patients with negative palpable inguinal lymph nodes inguinal area radiation, as flap viability may be compromised
who are at high risk for inguinal node involvement, several and there is no proven survival benefit in penile cancer. At the
approaches have been proposed to minimize morbidity. These present time inguinal radiotherapy is reserved only for inoper-
include (a) modified inguinal lymphadenectomy, (b) sentinel able nodes and palliative purposes.
lymph node biopsy (SLN B), and (c) intraoperative lymph node Experience with chemotherapy in penile carcinoma is ham-
mapping (IO LM ). Some investigators suggest a modified pered by a limited number of cases and lack of prospective tri-
inguinal lymphadenectomy for the side with nonpalpable als. Cisplatin, iphosphamide, taxol, bleomycin, vincristine,
inguinal lymph nodes and then radical lymphadenectomy only 5-fluorouracil, and methotrexate, as single agents or as combi-
if the superficial lymph nodes are positive for cancer on the nations, have all been shown to provide a partial response in
frozen section. This approach differs from radical dissection in selected cases. The use of chemotherapy as adjuvant or neoad-
four respects: (a) The skin incision is smaller, (b) the lymph juvant therapy may be beneficial, although the optimum
nodes lateral to the femoral artery or dorsal to the fossa ovalis chemotherapy regimen remains to be determined.
are spared, (c) the saphenous vein is preserved, and (d) the sar-
torius muscle is not transposed. Proponents of this approach
point to evidence that there is decreased morbidity without
any increase in mortality (6). The main argument against this SURGICAL TECHNIQ UE
approach is that it relies heavily on intraoperative frozen sec-
All patients undergo a thorough metastatic workup including
tion diagnosis of lymph node involvement, which may be
abdominal and pelvic CT scan, chest X-ray, and liver function
inaccurate (7).
tests. All patients complete 4 to 6 weeks of appropriate antibi-
Another approach is sentinel node biopsy. Lymphangiograms
otic therapy following excision of the primary lesion and
performed via the dorsal penile lymphatics demonstrate
wound closure, to treat any associated infection and decrease
drainage into a specific lymph node center, which is most
the risk of postoperative wound infection. Intravenous antibi-
often located between the superficial epigastric and superficial
otics with appropriate skin flora coverage are administered
external pudendal veins. Studies have suggested that the sen-
1 hour prior to the skin incision. Adequate hydration should
tinel lymph node is the first site of metastasis and is often the
be ensured before surgery. Antiembolism stockings and pneu-
only lymph node involved. Although the concept is intriguing,
matic compression boots are applied to the lower extremities
the location of the sentinel node varies, and therefore clini-
prior to induction of anesthesia.
cians have not found it particularly useful (8).
Based on the experience with breast and melanoma can-
cers, IO LM of the inguinal nodes has been proposed to
address the shortcomings of SLN B. The technique involves SURGICAL ANATO MY
injecting a vital blue dye and/or technetium-labeled colloid
adjacent to the primary lesion and following its drainage to a The lymphatics of the skin of the penis, scrotum, and per-
specific node in the inguinal region. This node is designated ineum drain into the superficial and deep inguinal nodes. The
the sentinel node. The goal is to eliminate the anatomic vari- superficial fascia of the thigh (fascia lata) separates the super-
ability of the sentinel node location. Although preliminary ficial inguinal nodes from the deep nodes. Extensive work by
results with IO LM are promising, lack of long-term follow-up, Daseler et al. (10) on inguinal lymph node dissection suggests
as well as the associated learning curve and technical difficul- that five node groups exist in the superficial inguinal area
ties of the procedure, limits its current use (9). We do not rec- (Fig. 71.2A) (10):
ommend IO LM as a standard approach at this time.
1. Central nodes at saphenofemoral junction
At the present time it seems that because of the unreliabiliy
2. Superolateral nodes around the superficial circumflex vein
of SLN B and the technical aspects of IO LM and its associated
3. Inferolateral nodes around the lateral (femoral) cutaneous
learning curve, superficial lymphadenopathy and modified
and superficial circumflex veins
inguinal lymphadenopathy are considered more informative
4. Superomedial nodes around the superficial external
and accurate for staging and carry minimal morbidity.
pudendal and superficial epigastric veins
5. Inferomedial nodes around the greater saphenous vein
ALTERNATIVE THERAPY O verall, 4 to 25 lymph nodes are present in the superficial
groups. All of these nodes are situated below the globular fat
The value of radiation therapy and chemotherapy is still of the superficial fascia called the Camper fascia.
uncertain. These treatments are currently considered palliative. The deep inguinal nodes are located medial to the femoral
In patients with positive inguinal lymph nodes, the survival vein in the femoral canal (Fig. 71.2B). The most cephalad deep
rate is significantly less when treated with radiation therapy inguinal node, known as the node of Cloquet, is located be-
than when treated with surgery. Based on the encouraging tween the femoral vein and the lacunar ligament. Deep in-
results of adjuvant radiation therapy in squamous cell carci- guinal nodes drain to obturator, hypogastric, and external
noma of the head and neck, some investigators advocate the iliac lymph nodes, which in turn drain to the common iliac
use of preoperative radiation therapy in patients with large, and para-aortic nodes.
SEV
SEPV
SCIV
Lymph Node of Cloquet
LCV
MCV
A B
FIGURE 71.2 A: Superficial lymph nodes and the five tributaries of the saphenous vein: medial (M CV )
and lateral (L CV ) cutaneous, superficial external pudendal (EPV ), superficial circumflex iliac (SCIV ),
and superficial epigastric (SEV ). These veins should be ligated and the surrounding package removed
with preservation of the saphenous vein. B: Deep inguinal lymph nodes, which in general number two to
four. The most cephalad lymph node is the node of Cloquet.
Blood supply to the inguinal skin derives from superficial

branches of the femoral artery (i.e., superficial external puden-
dal, superficial circumflex iliac, and superficial epigastric
arteries). Corresponding veins parallel the arteries that join
into the greater saphenous vein as it joins the femoral vein at
the fossa ovalis. These arteries are ligated in the inguinal lym-
phadenectomy. Skin flap viability depends on anastomosing
vessels within the superficial globular fat of the Camper fascia
that track from lateral to medial along the skin lines, parallel
to the inguinal ligament. In theory, the transverse skin incision
is least likely to compromise blood supply.
Rad ical Ing uinal Lymp had e ne ct o my

The patient is placed in the supine position with the ipsilateral
hip abducted and the ipsilateral knee flexed (Fig. 71.3). The
dissection margins for the classic radical inguinal lym-
phadenectomy cover the area outlined superiorly by a line
drawn from the superior margin of the external inguinal ring
to the anterosuperior iliac spine (ASIS), medially by a line
drawn from the pubic tubercle 15 cm down the medial thigh,
and laterally by a line drawn from the ASIS extending 20 cm
inferiorly (Figs. 71.3 and 71.4). A line drawn between the inferior
end of the lateral and medial margins marks the inferior limit
of the dissection. An incision is made 3 to 4 cm inferior and
parallel to the inguinal crease over the medial thigh from the
lateral to medial limits of the dissection. The femoral vessels
should be palpable in the medial aspect of the incision. We have
FIGURE 71.3 The patient is positioned with the hip abducted and
modified this approach to include more tissue above the inguinal knee flexed. The skin incision is demarcated by the line drawn two
ligament—see section entitled “ Suprainguinal Dissection in fingerbreadths below the inguinal crease (classic dissection) or two
Inguinal Lymphadenectomy” following. fingerbreadths above the groin crease.
Inguinal ligament
Fossa ovalis
Saphenous vein
FIGURE 71.4 Comparison of limits of dissection of modi-

fied inguinal lymphadenectomy (solid line) with classic
groin dissection (dotted line). N ote that with the modified
groin dissection the dissection is medial to the midpoint of
the femoral artery. Black , superficial inguinal nodes; w hite,
deep inguinal nodes; gray, external iliac nodes.
Skin flaps are developed superiorly and inferiorly as the far caudally (i.e., confluence of the two muscles will be displaced
first step of the dissection. Elevation of the skin edges with skin caudally).
hooks allows dissection within the superficial fatty fascia of the The saphenous vein is identified medially and preserved if
thigh. At the junction of the superficial globular fat and the possible. Although this vessel is by tradition sacrificed during
deeper membranous fat, the tissues are separated. The skin and radical lymphadenectomy, this achieves no therapeutic benefit
globular fat are elevated off of the deep membranous fascia and and may increase morbidity. If massive lymphadenopathy
the Scarpa fascia cephalad to a point 4 cm above the inguinal exists, however, the saphenous vein should be removed. The
ligament. The skin flaps are protected by gentle elevation with femoral sheath is incised over the femoral artery and vein.
Deaver retractors placed over moist sponges. Inferior traction M edial dissection isolates the lymph node of Cloquet between
on the lymphatic package with a small sponge under the left the Cooper and Poupart ligaments, lateral to the lacunar liga-
hand provides countertraction to facilitate dissection in the ment. The femoral sheath is stripped inferiorly to the apex of
proper plane. the femoral triangle, as the fascia overlying the sartorius and
Dissection is carried down through the Scarpa fascia onto adductor longus is stripped distally. The deep lymph nodes are
the external oblique aponeurosis. The external inguinal ring removed from their location between the femoral artery and
and emerging spermatic cord are identified medially and vein. The superficial cutaneous perforating arteries and veins
retracted as dissection extends to the pubic tubercle. The fat are ligated as they are encountered on the surface of the
and lymphatics are separated from the spermatic cord and base femoral artery and saphenous vein, leaving the intact saphe-
of the penis medially. Vascular and lymphatic channels are nous to join the femoral vein, in the area of the now absent
meticulously ligated to prevent postoperative fluid accumula- fossa ovalis. It is important to limit the lateral aspect of dissec-
tion under the skin flaps. The fatty lymph packet is elevated tion along the femoral sheath to the anterior surface of the
off of the external oblique fascia to the inferior border of the femoral artery. Dissection laterally on the femoral sheath can
inguinal ligament (Poupart ligament), where the femoral vessels injure the femoral nerve beneath the iliaca fascia (deep to the
are identified within the femoral sheath (Fig. 71.5A). fascia lata), and posterolateral dissection can injure the pro-
The medial (adductor longus muscle) and lateral (sartorius funda femoris artery.
muscle) borders of the dissection are identified next, and When this dissection is complete, the superficial and deep
the fascia lata is incised over the muscles. The muscles are lymphatics are removed together en bloc. The wound is irri-
traced to their confluence at the apex of the femoral triangle, gated liberally. The exposed femoral vessels are covered by
representing the inferior limit of dissection. The resulting mobilizing the sartorius from its insertion on the anterior
triangular packet of lymphatics and fat needs only to be superior iliac spine, transposing it over the vessels, and secur-
elevated off its deep margin to complete the dissection. Care ing its cephalad margin to the inguinal ligament with 2-0 silk
must be taken not to retract the adductor longus medially or suture (Fig. 71.5B). Blood supply to the sartorius arises from its
the sartorius muscle laterally as the dissection will extend too medial and inferior aspects, and care must be taken to protect
Iliopsoas muscle
Sartorius muscle
Inguinal ligament
FIGURE 71.5 A: Raised groin flaps and the completed

Pectineal muscle groin dissection. B: The sartorius muscle is detached
at the anterior superior iliac spine and moved medially,
thus providing for coverage of the vessels. B: The trans-
ferred sartorius muscle is sutured to the inguinal
ligament.
these vessels during mobilization. The medial edge of the mus- pressure dressing is applied for the first 12 hours. Care is
cle can be tacked to the adductor longus to ensure coverage of taken not to apply excessive pressure, which might further
the femoral vein. If pelvic lymphadenectomy has been per- compromise blood supply in the skin flaps.
formed simultaneously, this dissection should join with the Parenteral antibiotics are continued for 48 hours and then
distal limit of the pelvic dissection and allow free communica- converted to oral agents. The patient is maintained on bedrest
tion with the pelvis. To prevent herniation, the Cooper liga- for 1 day and ambulated on the second postoperative day.
ment should be secured to the shelving edge of the Poupart Deep vein thrombosis (DVT) prophylaxis, that is, throm-
ligament with permanent suture (2-0 Proline) without com- boembolic stockings or pneumatic compression boots, is cru-
promising the lumen of the femoral vein. cial. The drain is removed when the patient is ambulatory and
At this point the wound edges will be inspected for nonvi- drainage is 30 cc per day. Patients are instructed to use
able tissue. Any suspicious area with doubtful vascularization thromboembolic stockings for at least 6 months after the
should be excised. Some have suggested giving an ampule of surgery. H ospital stockings are converted to fitted compres-
fluorescein intravenously and inspecting the skin edges with a sion stockings 1 month postoperatively.
Wood lamp for viability. We have not found this technique to
be particularly useful.
A Jackson-Pratt drain is placed beneath the subcutaneous Mo d ifie d Ing uinal Lymp had e ne ct o my
tissue and brought out inferiorly. The skin flaps are tacked to
the surface of the exposed muscles with 3-0 chromic sutures The skin is incised transversely 2 cm below the groin crease
and the wound closed with nylon sutures or staples. A light- for a distance of 10 cm. Skin flaps are raised in the same
manner as described previously for a distance of approximately in the groin, when extensive dissections are required. The goal
8 cm cephalad and 6 cm caudally. Cephalad dissection onto is to provide muscle bulk to protect the femoral vessels and
the external oblique is performed as in radical lymphadenec- full-thickness skin for wound coverage. This will allow for the
tomy, and the medial extent of dissection is identical. The lat- least morbidity postoperatively and the least likelihood of
eral dissection is more limited, however. After opening the femoral vessel rupture should adjuvant radiotherapy be required.
femoral sheath, dissection lateral to the femoral artery is not Flaps described to accomplish this purpose have included a
performed. The sartorius is not exposed, and dissection inferi- tensor fascia lata myocutaneous flap, a gracilis myocutaneous
orly on the fascia lata and femoral sheath extends only to the flap, an abdominal rotation flap, a rectus abdominis myocuta-
caudal edge of the fossa ovalis (Fig. 71.4). The saphenous vein neous flap, a deep inferior epigastric artery myocutaneous
is preserved in the superficial nodal package, and the deep flap, a thigh rotational skin flap, and a scrotal advancement
lymphatics below the fascia lata between the femoral vessels flap. M ost of these reconstructive procedures are performed in
and medial to the femoral vein along the adductor longus fas- collaboration with a plastic or reconstructive surgeon.
cia up to the Cooper ligament are removed. Postoperative Recently, we proposed the use of an abdominal cutaneous
management is similar to that for radical lymphadenectomy. advancement flap as an alternative for primary skin closure of
large groin defects (11). The procedure involves sartorius
muscle transfer for vascular coverage followed by elevation of
the ipsilateral abdominal wall, immediately anterior to the un-
Sup raing uinal Disse ct io n in Ing uinal derlying rectus and external oblique fascia, cephalad to the
Lymp had e ne ct o my level of the umbilicus. This provides enough mobility for
closing a gap of up to 12 cm (Fig. 71.6A and B). For patients
As mentioned previously, the primary lymphatic drainage of with larger (up to 20 cm) gaps, a midline incision is made to
carcinoma of the penis is to the superficial inguinal region, the xiphoid process and the entire overlying skin and subcuta-
which is mostly inferior to the inguinal ligament. This is the neous tissue immediately superficial to the rectus abdominus
basis for the surgical approach, and hence for placing the inci- and external oblique muscle are raised on the ipsilateral side
sion inferior to the inguinal ligament. of the defect. The flap is then moved caudad to cover the de-
In a number of cases we have noted that the metastasis fect (Fig. 71.6C). Jackson-Pratt drains are employed beneath
from penile carcinoma occurs in lymph nodes above the the flap. Postoperative management is similar to that for the
inguinal ligament. Indeed, in some cases the only involved nodes standard inguinal lymphadenectomy described previously. The
have been superior to the inguinal ligament. For this reason, simplicity, lower morbidity, and excellent cosmetic results
we have begun to place the incision above the groin crease (2 cm are the main advantages of this procedure. The technique may
above the inguinal ligament) with the dissection extending at be utilized for bilateral groin defects as well. Abdominal scars
least to the level of the symphysis pubica, skeletonizing the (paramedian, appendectomy, Gibson, or flank incision) may
cord structures and the external oblique medially and extending compromise the blood supply to the flap and are considered
the incision laterally to the anterior superior iliac spine. The relative contraindications to this approach.
standard groin lymph node dissection is performed caudally.
It is important to encompass the soft tissue above the
inguinal ligament as lymphatic drainage from the penis may
extend directly to nodes above the inguinal ligament and O UTCO MES
superficial to the external oblique fascia. There is little addi-
tional morbidity in extending the groin dissection to this level, Co mp licat io ns
and we have found that skin flap viability is better preserved
when compared to incisions placed several centimeters below Skin necrosis, wound infection, vascular injuries, lower-
the groin crase. Although this is slightly more difficult for the extremity lymphedema, DVT, and death are some of the
most caudal portion of the groin dissection, the decreased potential complications. Skin necrosis and wound infection
need to retract flaps for the dissection of the groin around the are probably the most feared complications. O lder series
femoral vessels at the level of the inguinal ligament likely report up to 30% flap necrosis. Improved understanding of
reduces trauma to the skin. We have found that this extended the cutaneous blood supply, avoidance of the vertical skin
incision encompasses an area of nodal drainage that may be incision, improved surgical technique, and appropriate use of
missed with the standard groin dissection; indeed, in some perioperative antibiotics have resulted in significant reduction
patients positive nodes would have been missed with a standard in mortality, skin necrosis, and wound infection—to negligible
groin dissection. Furthermore, we believe that the incision for levels—in several recent reports (12).
this extended dissection improves skin flap survival.
Re sult s
Ing uinal Re co nst ruct io n aft e r Ing uinal
Lymp had e ne ct o my Currently, surgical intervention is the most effective approach
to treat SCC of the penis. Early inguinal lymphadenectomy can
Large groin defects may be created after inguinal lym- improve survival in the high-risk patient. Expectant follow-up
phadenectomy for bulky metastatic penile cancer. M any types of may be offered to low-risk patients with clinically negative groin
flaps have been described and advocated to cover large defects nodes who comply with comprehensive, close observation.
FIGURE 71.6 A: O n occasion overlying skin must be

removed with the lymph nodes, thus creating a large
groin defect that does not allow primary skin closure. An
advancement flap is a convenient method of covering
the defect. The lines of incision for raising the flap are
indicated. B: The flap is raised superficial to the abdominal
wall fascia. C: The flap is advanced and sutured over the
defect, thus providing full-thickness skin coverage to the
extensive groin defect.
References
1. M cDougal WS, Kirchner FK Jr, Edwards RH , et al. Treatment of carcinoma 7. Lopes A, Rossi BM , Fonseca FP, et al. Unreliability of modified inguinal
of the penis: the case for primary lymphadenectomy. J Urol 1986;136(1): lymphadenectomy for clinical staging of penile carcinoma. Cancer 1996;
38–41. 77(10):2099–2102.
2. H orenblas S, van Tinteren H . Squamous cell carcinoma of the penis. IV. 8. Pettaway CA, Pisters LL, Dinney CP, et al. Sentinel lymph node dissection
Prognostic factors of survival: analysis of tumor, nodes and metastasis for penile carcinoma: the M . D. Anderson Cancer Center experience.
classification system. J Urol 1994;151(5):1239–1243. J Urol 1995;154(6):1999–2003.
3. M cDougal WS. Carcinoma of the penis: improved survival by early 9. Izawa J, Kedar D, Wong F, et al. Sentinel lymph node biopsy in penile
regional lymphadenectomy based on the histological grade and depth of cancer: evolution and insights. Can J Urol 2005;12[Suppl 1]:24–29.
invasion of the primary lesion. J Urol 1995;154(4):1364–1366. 10. Daseler E, H anson BJ, Reimann AF. Radical excision of the inguinal and
4. H orenblas S, van Tinteren H , Delemarre JF, et al. Squamous cell carcinoma iliac lymph glands. Surg G ynecol O bstet 1948;87:679–694.
of the penis. III. Treatment of regional lymph nodes. J Urol 1993;149(3): 11. Tabatabaei S, M cDougal WS. Primary skin closure of large groin defects
492–497. after inguinal lymphadenectomy for penile cancer using an abdominal
5. M cDougal WS. Preemptive lymphadenectomy markedly improves survival cutaneous advancement flap. J Urol 2003;169:118–120.
in patients with cancer of the penis who harbor occult metastases. J Urol 12. M ilathianakis C, Bogdanos J, Karamanolakis D. M orbidity of prophylactic
2005;173(3):681. inguinal lymphadenectomy with saphenous vein preservation for squa-
6. Catalona WJ. M odified inguinal lymphadenectomy for carcinoma of the mous cell penile carcinoma. Int J Urol 2005;12(8):776–778.
penis with preservation of saphenous veins: technique and preliminary
results. J Urol 1988;140(2):306–310.
CHAPTER 72 ■ SURGICAL TREATMENT
O F PEYRO NIE DISEASE
URI GUR AND GERALD H. JO RDAN
Peyronie’s disease is characterized by the formation of a fi- present). An attempt to elicit known disease associations such
brous lesion within the tunica albuginea of the corpora caver- as Dupuytren’s contracture or other elastic tissue fibromatosis
nosa (Fig. 72.1). This lesion or “ plaque” is believed to be should be made. O bjective evaluation of penile curvature with
caused by repetitive microvascular trauma (3). It is proposed home-taken photographs of the erect penis, we find, is
that trauma, either acute or chronic, is sustained during inter- extremely helpful. Plain radiographs are effective in demon-
course, with subsequent scar formation in susceptible individ- strating plaque calcification, believed to be a sign of plaque
uals. The plaque’s inelasticity results in a functional maturity. Plaque calcification is also easily demonstrated with
shortening of the corporal body on the most affected side, re- ultrasonography (1). The plaque can be imaged by both CT
sulting in deformity during erection. The incidence of and M RI, both being unnecessary except for the possibility of
Peyronie’s disease has recently been estimated at up to 3% or using M RI to “ stage” the phase of disease for research or
as high as 7% to 9% of the general male population (9,10). study protocol purposes (5), or in a rare patient where the
Patients most commonly present with dorsal curvature. diagnosis is not certain and a concern for a possible malig-
Fortunately, only a small proportion of patients with Peyronie’s nancy arises.
disease have deformity requiring surgical intervention. It is important to evaluate and define the surgical candi-
Surgical intervention should be regarded as palliation of the date’s preoperative erectile function. Prospective surgical
deformity only and not as cure. patients, at our center, are evaluated with color duplex ultra-
sound (CDU) in the presence of pharmacologically induced
erection. Abnormalities in the resistive index and end-diastolic
velocity, at our institution, prompt further testing with
DIAGNO SIS dynamic infusion cavernosometry/cavernosography (DICC).
In addition, one must determine if acceptable intercourse can
The diagnosis of Peyronie’s disease can usually be made with a be accomplished by enhancement of erectile rigidity alone. In
focused history and physical examination. O n history, it is im- this scenario, patients may be best served with a pharmaco-
perative to elicit the duration of symptoms, the progression of logic erection program as an alternative to surgery.
the penile deformity, and the degree of sexual dysfunction. A frank discussion of treatment goals with the couple is im-
Erectile dysfunction, to some degree, is felt by many surgeons perative. The patient should be assured that the process is not
to be almost uniformly present. This may represent the psy- malignant or life-threatening. The goal of surgery is to
chological impact incurred from living with a genital defor- straighten the penis and maintain erectile function so that
mity but may also be due to several organic causes. satisfactory intercourse can be achieved.
The physical examination should be focused on delineat- Couples must be aware that pre-existing penile shortening
ing plaque location, size, and opposing plaque formation (if and erectile dysfunction will not be improved by straightening
procedures. Rigidity may be improved by straightening the
penis, but truly improved erectile function does not occur.
Evaluation with a sex therapist can help patients and partners
adjust to these new sexual expectations.
Although medical treatments targeting the evolution of scar
tissue have largely been unsuccessful, an attempt at treating
Peyronie’s disease medically may be beneficial for patients
prior to surgical intervention, provided the patient is in the
immature or active phase of the disease. A surgical candidate
must meet certain criteria. First, the disease process must be
stable and the “ plaque” mature and quiescent. In review, the
FIGURE 72.1 Cross-sectional penile anatomy with dorsal Peyronie’s signs of disease quiescence include unchanged penile defor-
plaque. mity for a minimum of 6 months, with the resolution of pain
481
associated with erection. M oreover, before surgical interven-

tion most investigators recommend a minimum 12-month
waiting period from disease onset. The experienced examiner
may recognize the clinical findings of a mature or calcified
plaque and could elect to intervene earlier than this arbitrary
time period. O nce disease stability exists, indications for surgi-
cal intervention are penile deformity and/or erectile dysfunc-
tion that precludes intercourse.
Three general techniques exist for the surgical management
of Peyronie’s disease: (a) corporoplasty or plication proce-
dures, (b) plaque incision or excision with grafting, and (c) pe-
nile prosthesis insertion with plaque modeling or incision with
or without grafting. M any protocols have been published
describing the treatment of Peyronie’s disease, but the best out-
come depends on an individualized approach. Straightening
techniques are appropriate for patients with adequate erectile
function in whom penile straightening alone will achieve satis-
factory intercourse.
Plication procedures involve shortening the tunica albug-
inea on the side opposite the plaque; this may eventually
shorten the penis, but it carries the advantages of being less
FIGURE 72.2 Dorsal penile curvature with incision marked at the
technically demanding, of involving a more rapid convales- circumcision scar.
cence, and in most series of having a smaller risk of postoper-
ative erectile dysfunction.
Plication or corporoplasty procedures may be the preferred
option for ventral curvatures, as historically this subset of pa-
tients has demonstrated poor outcomes with grafting proce- SURGICAL TECHNIQ UE
dures. Incision or excision of the Peyronie’s plaque with
grafting of the corporotomy defect is a more technically com- Skin Incisio n
plex procedure and may incur a higher risk of postoperative
erectile dysfunction. Patients with severe curvature, hourglass The initial skin incision is dependent on plaque location and
deformity, or inadequate penile length are more amenable to the procedure to be performed. As previously mentioned, cor-
incision or excision with grafting over corporoplasty or plica- poroplasty or plication procedures address the aspect of the
tion techniques that can further shorten or deform the erect corpora cavernosa opposite the plaque (most involved aspect),
penis. At our institution we prefer the technique of plaque in- whereas plaque incision or excision techniques approach the
cision with grafting and use this even for severely calcified plaque directly. The dorsum of the corpora cavernosa is best
plaques. H owever, there are cases where large, extensively cal- exposed by a circumferential degloving incision. If the patient
cified plaques may require plaque excision with grafting. has been previously circumcised, then the incision should
Last, insertion of penile prostheses for Peyronie’s disease be performed through the circumcision scar (Fig. 72.2).
was once considered a panacea but for most patients is now Approaching the penis through the previous circumcision scar
reserved for those with severe erectile dysfunction. In patients has not been problematic, even when the scar is displaced
with severe curvature, prosthetic implantation can be done in proximally. The penile shaft is degloved to its base by sharply
conjunction with an incision and grafting procedure. dissecting the dartos fascia from the underlying Buck’s fascia.
M odeling the plaque intraoperatively after prosthesis place- This maneuver gives good exposure for midshaft and distal
ment is remarkably successful and often avoids the need for lesions. For very proximal plaques or patients with a redun-
incision. The technique of penile prosthesis insertion is cov- dant prepuce, a second peripenile or periscrotal incision may
ered in Chapter 74. be helpful. After degloving the shaft of the penis, the surgeon
delivers it into the counterincision, laying the shaft skin aside
and covering it with a warm soaked gauze dressing. This pro-
tects the penile skin from trauma until the end of the proce-
ALTERNATIVE THERAPY dure, when it is returned to the shaft. Ventral exposure can
also be achieved through a midline incision on the ventral
M edical management includes oral agents, topical agents, aspect of the penis, which we prefer, as this results in less post-
with or without delivery modalities, and intralesional injec- operative penile edema.
tion protocols. Several surgeons are also examining the effi-
cacy of plaque expansion using devices that put traction on
the penis. As mentioned, the surgical management of Peyronie
disease should be viewed as a palliation of the mechanical ef- Co rp o ro p last y o r Co rp o ro p licat io n
fects of the disease rather than a cure. In a patient with erectile Pro ce d ure s
dysfunction, with or without curvature, penile prosthesis
insertion should be contemplated. M any patients will refuse Several techniques have been described to “plicate” the curva-
prosthetic implantation based on personal bias. ture associated with Peyronie’s disease. At our institution,
Chap t e r 72: Surg ical Tre atme nt of Pe yronie Dise ase 483
procedures are performed with the patient in the supine posi-

tion, via a degloving incision for dorsal “ plication,” and a
midline ventral incision for ventral “ plication.”
An artificial erection is created to accurately define the
point of maximal curvature using a pressure infuser with
0.9% saline. The use of a tourniquet for control of bleeding or
induction of an artificial erection is not favored as proximal
curvatures can be concealed. The Buck’s fascia opposite the site
of maximal curvature is sharply incised and elevated from the
underlying tunica albuginea. Correction of dorsal curvature
requires identification of the corpus spongiosum ventrally. For
ventral curvature, care must be taken to avoid injury to the
dorsal neurovascular structures. O nce the tunica albuginea is
exposed, “ plication” of the corpora can be performed in sev-
eral ways. Creation of an ellipse corporotomy defect with FIGURE 72.4 Deep dorsal vein dissection and ligation.
reapproximation of the corporal edges using 4-0 polydiox-
anone sutures effectively counteracts the opposing lesion (11).
The tunica albuginea may be excised or tucked underneath the
corporotomy closure. Correction of curvature can also be
achieved by plicating the tunica albuginea by a number of
techniques that use nonabsorbable sutures without incising
the tunica albuginea (4). O ne technique of corporoplasty uses
the H eineke-M ikulicz technique, which horizontally closes a
vertical incision of the tunica (12). O nce acceptable straight-
ening is achieved, the penis is closed anatomically in layers,
and we place a small-caliber, closed-suction drain superficial
to the Buck fascia.
FIGURE 72.5 Elevation of the Buck’s fascia concurrently with the
dorsal neurovascular structures.
Plaq ue Incisio n and Graft ing
After incision and degloving, exposure for the incision of a with the inner lamina of the Buck’s fascia. The Buck’s fascia is
dorsal plaque requires elevation of the dorsal neurovascular widely mobilized from the base of the penis to the coronal
bundle concurrently with the Buck’s fascia. This can be margin and to the lateral aspect of the penis (Fig. 72.5). If nec-
approached by several techniques. O ne technique involves essary, the glans can be partially detached from the tips of the
making bilateral incisions lateral to the corpus spongiosum corporal bodies in order to expose distal dorsal plaques.
and then dissecting the Buck’s fascia and the dorsal neurovas- Austoni E and Perovic S, Personal Communication, Peyronie’s
cular bundle off the lateral and dorsal aspects of the corpora M eeting, Washington, DC attended by Dr. Charles J. Devine,
cavernosa. Alternately, a dorsal plaque can be approached Jr., have both advocated penile disassembly for certain pa-
through the bed of the deep dorsal vein with a modified vein tients with Peyronie’s disease; however, the complication rate
dissection and excision. can be significantly higher. Approaching the dorsal plaque
This is done by sharply opening the Buck’s fascia over the through the bed of the dorsal vein is our favored approach.
path of the deep dorsal vein to the level of the penopubic liga- O nce appropriately exposed, the extent of the plaque can
ments (Fig. 72.3). The dorsal vein is elevated and ligated as be determined by palpating the surface of the tunica albug-
proximally as possible without detaching the penopubic inea. After creation of an artificial erection, an H -shaped inci-
attachments and then distally to the “ trifurcation” of the vein sion is marked at the point of maximal curvature (Fig. 72.6).
(Fig. 72.4). The circumferential veins are ligated at their junc-
tion with the deep dorsal vein. The dorsolateral neurovascular
structures are reflected off the tunica albuginea in concert
FIGURE 72.3 Incision of the Buck’s fascia overlying the dorsal vein FIGURE 72.6 An H -shaped incision marked at the point of maximal
after penile degloving. deformity.
tensile strength and is best applied to small defects. Prosthetic

(e.g., Gore-Tex, silastic) grafts, historically, have tended to
fibrose and contract. The authors feel that caution should be
used when applying these “ grafts” in the absence of concur-
rent prosthetic implantation.
The dermal graft is obtained from the nonhirsute area of
abdominal skin located superior and lateral to the iliac crest
(Fig. 72.9). The Surgisis Biodesign graft requires soaking
when removed from the package. There is a “ fuzzy side” and
a smooth side. For no good reason, we have always placed the
“ fuzzy side” inward. By hyperflexing the penis, the graft is
placed approximately 30% larger than the corporotomy defect
in all dimensions.
O nce tailored, the dermal graft or the Surgisis Biodesign
FIGURE 72.7 Incision of the tunica albuginea. graft is sewn into the corporotomy defect using interrupted
4-0 polydioxanone sutures followed by a running locked 4-0
polydioxanone suture (Fig. 72.10). An artificial erection is
performed after graft placement to ensure a watertight suture
line and an acceptably straight penis. Any leaks, if present, are
oversewn. An obvious disadvantage, as opposed to “ off-the-
shelf grafts,” is the time necessary for graft harvest as well as
donor site morbidity.
We have found that curvature can be corrected with a sin-
gle incision and grafting in the majority of instances. Some
patients will require an additional “ touch-up” plication or in
the rare case a second incision of the plaque. Incision as
opposed to excision limits the size of the applied graft
and may be more reliable in preserving erectile function
(Dr. Friedhelm Schreiter, International Reconstructive Live-
Surgery Congress, Genitourinary Reconstructive Surgeons
M eeting, H amburg, Germany, February 28-M arch 2, 1999).
The penis is closed as described previously for surgical plica-
tion. We have also noted that in patients where erect penile
length is not equivalent to stretched length, the Surgisis
FIGURE 72.8 Creation of a square defect in the tunica albuginea. Biodesign graft may be more likely to inadequately correct the
Darting incisions are performed if indentation persists. curvature as opposed to autografts.
Recently, we have modified our technique of “ H incision”
in an effort to more efficiently correct the curvature without
O nce the incision is created, the “ flaps” of the H are elevated the need for touch-up plications. The site of maximal curva-
and allowed to “ slide” (Fig. 72.7). During this maneuver the ture is identified and marked. H owever, a strip of tunica
thickened septal fibers are divided from their attachment to albuginea, a thick cross member of the H , is marked
the tunica albuginea. Complete release of all of the thickened (Fig. 72.11). The H is incised with the flaps elevated and de-
fibers appears integral to achieving good straightening. It is not tached from the septal fibers as already described (Fig. 72.12).
necessary to remove thickened septal fibers, and it is unneces- The strip of the H is excised and the flap sutured as already
sary and potentially harmful to remove any spongy erectile tissue. described (Fig. 72.13). The resulting corporotomy defect is
A square defect is then created by suturing the flap corners grafted (Fig. 72.14).
into place with interrupted 4-0 polydioxanone sutures. If an
indentation exists after corporotomy, darting incisions are
made to allow for expansion of the defect (Fig. 72.8). Plaq ue Excisio n and Graft ing
After the incision is completed, we measure the corporo-
tomy defect with the penis flexed to ensure accurate graft cov- Plaque excision (vs. incision) may be required in the patient
erage. The ideal graft material is not known. We have with a severely calcified plaque. In this scenario the plaque is
preferentially in the past used dermis at our institution (2). exposed as previously discussed. Prolene stay sutures are used
Alternatively, corporotomy defects can be patched with the to mark the plaque at the proximal and distal aspects. An inci-
saphenous vein (8) or the deep dorsal vein with good long- sion outlining the plaque is made and the plaque is excised
term results. Temporalis fascia, fascia lata, tunica vaginalis, (Fig. 72.15). The corporotomy defect left by plaque excision is
and nonautologous pericardial grafts have also been described, converted from ovoid to stellate by creating lateral incisions
as have small intestinal submucosa (Surgisis Biodesign, Cook into the tunica albuginea (Fig. 72.16). Grafting and closure
M edical Inc., Bloomington, IN ) grafts. Recently we have used are then accomplished in the same manner as in the technique
the Surgisis Biodesign graft at our institution with good out- of plaque incision and grafting. In most cases the calcified
comes. A recent comparative report (7) was shown to be at plaque can be removed without excising the entire thickness
least equivalent to the dermal graft. Tunica vaginalis lacks of the tunica, and that is our favored approach.
Chap t e r 72: Surg ical Tre atme nt of Pe yronie Dise ase 485
FIGURE 72.9 Dermal harvest from the nonhir-

sute skin above the iliac crest.
PO STO PERATIVE CARE

A loosely applied Bioclusive (Johnson& Johnson M edical
Limited, Gargave, Skipton, UK) dressing is used to dress the
penis. M ildly compressing Conform gauze dressing (Tyco
H ealthcare Group LP, M ansfield, M A) is wrapped around the
Bioclusive to reduce edema and keep the surgical spaces col-
lapsed around the suction drains. The compressing dressing is
FIGURE 72.11 M odification of the sliding H technique, in which a

small strip is excised at the point of maximal curvature. The stitch
marks that point. (From Jordan GH . Peyronie’s disease. In: Wein AJ,
Kavoussi LR, N ovick AC, et al., eds. Cam pbell-Walsh urology, 9th
ed. Philadelphia: Saunders Elsevier, 2007:818–838, with permission.)
removed in 4 hours and the glans is checked every 30 minutes

during this interval. A 14Fr Foley catheter is placed intraoper-
atively and left for 24 hours. The drains are, in general,
removed on postoperative day 1 and the patient is discharged
FIGURE 72.10 Watertight closure of the corporotomy after dermal the same day. Erections are suppressed with diazepam and
graft. amyl nitrite for a short period postoperatively.
FIGURE 72.12 The incisions are made; the H flaps are incised and
elevated from the underlying erectile tissue. The septal fibers are
divided. The septal fibers are detached back to the point of normal
tunica albuginea both proximally and distally. This maneuver is FIGURE 72.14 Alternatively, the corporotomy defect can be replaced
extremely important in achieving straightening with this technique. with a vein graft. N otice that the vein graft is oriented so that the cir-
N ote the expansion of the corporotomy defect. (From Jordan GH . cumferential distensibility allows long axial lengthening. (From
Peyronie’s disease. In: Wein AJ, Kavoussi LR, N ovick AC, et al., eds. Jordan GH . Peyronie’s disease. In: Wein AJ, Kavoussi LR, N ovick AC,
Cam pbell-W alsh urology, 9th ed. Philadelphia: Saunders Elsevier, et al., eds. Cam pbell-W alsh urology, 9th ed. Philadelphia: Saunders
2007:818–838, with permission.) Elsevier, 2007:818–838, with permission.)
FIGURE 72.15 Excision of Peyronie plaque.
FIGURE 72.13 The transverse strip is excised; the H flaps are then
sutured. The flap can be darted if lateral expansion is needed. (From
Jordan GH . Peyronie’s disease. In: Wein AJ, Kavoussi LR, N ovick AC,
et al., eds. Cam pbell-W alsh urology, 9th ed. Philadelphia: Saunders
Elsevier, 2007:818–838, with permission.)
After that, erections are felt to be beneficial and integral to

FIGURE 72.16 Creation of stellate defect after plaque excision.
good graft healing. Levine (13) and M oncado, Personal
Communication at Experts in Urology Conference, London,
England, June 12–16, 2007, are using a mechanical stretching
device to distend the penis and graft postoperatively and are O UTCO MES
encouraged that the results seem better.
After 2 weeks, patients are encouraged to have erections A successful reconstructive procedure for Peyronie disease re-
but refrain from intercourse. At about 10 to 12 weeks postop- sults in a satisfactory straightening of the penis such that any
eratively, patients may resume sexual intercourse. residual deformity does not interfere with sexual intercourse.
Chap t e r 73: Priap ism 487
A second component of success is preservation of adequate Patients should be informed of the risk of experiencing a
erectile function. In our experience surgical success correlates change in glanular sensation. This applies predominantly to
linearly with preoperative erectile function (6). Patients with those patients requiring dissection of the Buck’s fascia dor-
good erectile function have a surgical success rate in the range sally. The vast majority of patients recover adequate glanular
of 85% . Poor preoperative erectile function correlates sensation, and it is unusual for persistent bothersome neu-
strongly with a poor surgical outcome, and these patients may ropathies of the glans to occur.
be best managed with prosthesis placement. The demonstra- Late and chronic complications may include the risk of a
tion of corporal veno-occlusive dysfunction preoperatively bothersome granuloma (“ lump” ) formation after the use of
seems to correlate strongly with diminished success (i.e., poor permanent sutures during a plication procedure. Recurrent
preservation of erectile function), particularly with grafting disabling curvature is uncommon but may occur. Patients re-
operations. quiring grafting with dermis should be counseled that during
The ultimate goal of surgery is to resume satisfactory sex- the late phase of maturation the graft tends to contract and
ual intercourse by correcting penile curvature without further may be inelastic enough to recreate some of the curvature.
diminishing erectile function. With proper patient selection, Patients can be reassured that this is transient and that
surgical correction for Peyronie disease yields reliable results. straightening will occur when the graft softens.
The most frequently encountered “ complication” is that of
diminished penile rigidity postoperatively. With plication pro-
CO MPLICATIO NS cedures this occurs in approximately 5% to 6% of patients
and with grafting procedures in approximately 12% to 15%
Early postoperative complications include hematoma forma- of cases. Erectile dysfunction can occur as a consequence of
tion, wound infection, and persistent penile edema. M eticulous surgery but may also represent the natural history of the pa-
hemostasis with bipolar cautery, the use of small closed-suction tient. M any of these patients benefit from the addition of
drains, and careful tissue handling can minimize the risk of pharmacologic therapy to enhance their erectile function.
these complications.
References
1. Altaffer LF III, Jordan GH . Sonographic demonstration of Peyronie 8. Lue TF, El-Sakka AI. Venous patch graft for Peyronie’s disease. Part I:
plaques. Urology 1981;17(3):292–295. Technique. J Urol 1998;160:2047.
2. Devine CJ Jr, H orton CE. Surgical treatment of Peyronie’s disease with a 9. M ulhall JP, Creech SD, Boorjian SA, et al. Subjective and objective analysis
dermal graft. J Urol 1974;111:44. of the prevalence of Peyronie’s disease in a population of men presenting
3. Devine CJ Jr, Somers KD, Jordan GH , et al. Proposal: trauma as the cause for prostate cancer screening. J Urol 2004; 171(6, Pt 1):2350–2353.
of the Peyronie’s lesion. J Urol 1997;157:285. 10. M ulhall JP, Schiff J, Guhring P. An analysis of the natural history of
4. Gholami SS, Lue TF. Correction of penile curvature using the 16-dot plica- Peyronie’s disease. J Urol 2006;175(6):2115–2118; discussion 2118.
tion technique: a review of 132 patients. J Urol 2002;167:2066. 11. Pryor JP, Fitzpatrick JM . A new approach to the correction of the penile
5. H auck EW, H ackstein N , Vosshenrich R, et al. Diagnostic value of mag- deformity in Peyronie’s disease. J Urol 1979;122:622.
netic resonance imaging in Peyronie’s disease—a comparison both with 12. Yachia D. M odified corporoplasty for the treatment of penile curvature.
palpation and ultrasound in the evaluation of plaque formation. Eur Urol J Urol 1990;143(1):80–82.
2003;43:293–300. 13. Levine LA, N ewell M , Taylor FL. “ Penile traction therapy for treatment of
6. Jordan GH , Angermeier KW. Preoperative evaluation of erectile function Peyronie’s disease” a single-center pilot study. J Sex M ed 2008 June; 5(6):
with dynamic infusion cavernosometry/cavernosography in patients under- 1468–73.
going surgery for Peyronie’s disease: correlation with postoperative results.
J Urol 1993;150:1138.
7. Kovac JR, Brock GB. Surgical outcomes and patient satisfaction after der-
mal, pericardial, and small intestinal submucosal grafting for Peyronie’s
disease. J Sex M ed 2007;4(5):1500–1508.
CHAPTER 73 ■ PRIAPISM
TRINITY J. BIVALACQ UA AND ARTHUR L. BURNETT
Priapism is defined as an erectile disorder in which erection erection. The pain associated with priapism is perceived to be
persists uncontrollably without sexual purpose. This disorder a consequence of tissue ischemia and increased pressure gen-
is likely a result of disturbances in the mechanisms governing erated within the corporal bodies. This condition frequently
erection physiology as it relates to regulatory control of pe- results in erectile dysfunction (ED), and therefore prompt
nile detumescence and initiation and maintenance of penile management is indicated. The natural sequelae of untreated
flaccidity. Priapism represents one of the greatest challenges ischemic priapism or recurrent stuttering priapism is global
in therapeutic management among erectile disorders. During penile fibrosis with significant impairments in erectile mecha-
a single episode of ischemic priapism, blood fails to drain nisms, resulting in an overall rate of ED as high as 59%
from the corporal sinusoids, resulting in prolonged painful (1–3).
A B
FIGURE 73.1 Pie graphs demonstrating the percentage of (A) pediatric ( 18 years) and (B) adult ( 18
years) patients suffering from priapism.
Ischemic (venous, low-flow) priapism is more prevalent mechanisms involved in the progression of ischemia-induced
than nonischemic (arterial, high-flow) priapism. Ischemic pri- fibrosis are the upregulation of hypoxia-induced growth fac-
apism due to pharmacologic, hematologic, or neurogenic tors such as transforming growth factor- (8). Recently, we
causes is a condition whereby there is a persistent, painful have shown that recurrent priapism is a manifestation of de-
erection characterized clinically by absent cavernous blood fective phosphodiesterase type 5 (PDE5) regulatory function
flow. Failure to recognize this as an emergency and instigate in the penis, resulting from altered endothelial nitric oxide and
immediate treatment may lead to corporal tissue ischemia or cyclic guanosine monophosphate (cGM P) signaling in the organ
anoxia, fibrosis, and long-term ED. After 24 hours there is ev- and recurrent priapism (9,10).
idence of irreversible smooth muscle cell necrosis, destruction
of the vascular endothelium, and exposure of the basement
membrane with adherence of thrombocytes (4). N onischemic
priapism commonly follows an episode of trauma to the per- DIAGNO SIS
ineum or genitalia resulting in increased flow through cavernosal
arteries, which leads to the formation of arteriocavernous The diagnosis and classification of priapism are based on clin-
shunts with increased well-oxygenated arterial flow into the ical evaluation, including laboratory tests and corporal blood
cavernous tissue and may not need urgent surgical attention. gas evaluation via aspirated blood directly from the corpora
Priapism is associated with a number of diverse disease cavernosa. O n initial evaluation, patients should have a de-
states, and a number of clinical contexts have risk associations tailed history and physical examination, with emphasis on
for developing the disorder (1,5,6). Etiologic categories include possible causative factors (Fig. 73.2). H istorical features
trauma, neurological conditions (multiple sclerosis, spinal should include the duration and previous episodes of pri-
cord tumor with compression), hematologic dyscrasias (sickle apism, a detailed medical and social history to evaluate for
cell anemia, thrombophilia, and thalassemia), malignancies, hematologic or neurologic conditions, and illicit drug use (co-
intracavernous injection therapy (prostaglandin E1 , papaverine, caine). Physical examination should assess the penis and per-
and combination therapy), pharmacologic and drug exposure ineum, inspecting for any neurologic defects and pelvic or
(psychotropic and antidepressant medications, and illicit drugs), penile masses, and checking the perineum for evidence of re-
and idiopathic circumstances (Fig. 73.1) (1). Urogenital carci- cent trauma. Laboratory tests should include a complete
nomas can cause priapism either by local invasion and growth blood count, reticulocyte count, and sickle cell anemia screen
into the adjacent tissue or by the hematogenous, lymphatic, or when appropriate, as well as urinalysis and urine toxicology.
retrograde venous routes. Priapism associated with malig- Patients with significant sustained penile pain with a rigid
nancy may be ischemic secondary to veno-occlusion or non- penis and soft glans are more likely to have ischemic priapism,
ischemic secondary to high arterial blood flow. whereas patients with nonischemic priapism will have a semi-
In principle, ischemic priapism consists of an imbalance of erect penis without pain. Corporal blood gas analysis will help
vasoconstrictive and vasorelaxatory mechanisms, thus predis- delineate the type of priapism. Acidotic (pH 7.25, pO 2 30
posing the penis to hypoxia and acidosis. In vitro studies have mm H g, pCO 2 60 mm H g) penile blood gas indicates isch-
demonstrated that when corporal smooth muscle strips are emic priapism, whereas a blood gas consistent with arterial
exposed to hypoxic conditions, significant apoptosis results, blood gas (pH 7.4, pO 2 90 mm H g, pCO 2 40 mm H g) is
and alpha-adrenergic stimulation fails to induce corporal suggestive of nonischemic priapism. To further determine the
smooth muscle contraction (7). Additional pathophysiologic type of priapism, color duplex Doppler ultrasound may be
phenylephrine is preferred for this application since it minimizes

the risk of cardiovascular side-effects. Phenylephrine in a dose
of 100 to 200 g is injected via the same needle into the cor-
pora cavernosa and observed for 5 minutes.
If the penis is still rigid, then aspiration of blood and injec-
tion of phenylephrine (100 to 200 g) is performed until
detumescence occurs. If the penis remains tumescent after a
reasonable duration and dose escalation of phenylephrine
(1 mg of diluted phenylephrine 1 hour), then another
Doppler ultrasound can be performed to evaluate the status of
cavernosal arterial flow in the penis. Re-evaluation may be
warranted at this time because the penis may simply be ede-
matous with restored corporal arterial flow and not in a per-
sistent ischemic state. It is recognized that ischemic priapism
of extended durations, that is, 48 hours, is unlikely to re-
solve with intracavernous injection or irrigation therapy;
therefore, surgical shunting should be performed in a timely
manner.
FIGURE 73.2 Algorithm for the management of priapism. (Adapted

from M ontague DK, Jarow J, Broderick GA, et al. M embers of the
Erectile Dysfunction Guideline Update Panel; American Urological
Association. American Urological Association guideline on the man-
ALTERNATIVE THERAPY
agement of priapism. J Urol 2003;170:1318–1324.)
Aspiration or irrigation in combination with intracavernous
injection therapy represents first-line therapy in patients with
underlying etiologic disorders such as sickle cell anemia and
performed to evaluate cavernosal arterial inflow (1,11). N o other hematologic disorders, metastatic neoplasia, or other
cavernosal artery flow is pathognomonic for ischemic pri- causes having standard treatments. For priapism related to
apism, whereas a ruptured cavernosal artery with unregulated sickle cell disease, medical therapies such as intravenous hy-
arterial flow and blood pooling may be seen in the non- dration, oxygenation, alkalinization, and exchange transfu-
ischemic form of priapism. After the correct form of priapism sion may be performed. H owever, these interventions should
is determined, then rapid medical and/or surgical intervention not lead to delays in intracavernous therapies directed at the
is a necessity. In ischemic priapism, definitive first-line treatment end organ. The use of antiandrogens or gonadotropin-releasing
consists of evacuation of blood and irrigation of the corpora hormone agonists is successful for the treatment of recurrent
cavernosa along with intracavernous injection of an alpha- stuttering priapism. The use of sympathomimetic intracav-
adrenergic sympathomimetic agent before initiating any surgi- ernous injection therapy with phenylephrine is also successful
cal treatment (Fig. 73.2). If the diagnosis of nonischemic in patients with stuttering priapism. The use of other agents
priapism is confirmed by ultrasound imaging, then emboliza- such as baclofen and digoxin is less efficacious.
tion of the ruptured cavernous artery angiographically may
be indicated after initial observation and supportive therapy
(Fig. 73.2).
SURGICAL TECHNIQ UE
Surgical management of ischemic priapism represents a surgi-
INDICATIO NS FO R SURGERY cally created fistula that allows blood to drain from the cor-
pora cavernosa until the penile compartment syndrome has
The goal of therapy is to relieve pain and decompress the cor- subsided. Ideally, the surgically created fistula will sponta-
poral bodies, thus reducing anoxia and the risk of tissue neously close after the priapic event has resolved. Before pro-
necrosis or injury. Ischemic priapism of 4 hours warrants ceeding to distal corporoglanular surgical shunt procedures,
decompression of the corpora cavernosa. O ne can proceed the placement of needles into the corpora cavernosa distally
earlier if a patient is in severe pain, but action m ust be taken if and proximally at the penile crura with the patient in litho-
4 hours have elapsed (Fig. 73.2). Typically, if treatment is tomy position offers an approach for maximally irrigating the
delayed, tissue injury and risk for development of ED may oc- corporal bodies. Distal corporoglandular shunts represent the
cur. A dorsal nerve block or local penile shaft block with lido- first-line surgical therapy because they are easy to perform
caine is usually performed. Then, a scalp vein needle (19- or and have fewer complications (Fig. 73.2) (1,11,12).
21-gauge) is inserted directly in the penile shaft for therapeutic
aspiration of old blood and injection of alpha-adrenergic
agonists (sympathomimetics) (5,6). H emodynamic monitoring Co rp o ro g lanular (Wint e r) Shunt
is recommended to monitor potential side-effects, such as
hypertension, headache, reflex bradycardia, tachycardia, and Under local or general anesthesia, a penile-glans block is per-
cardiac arrhythmia, which may result from medication entry formed to ensure adequate local anesthesia. The tips of the
into the systemic circulation. The alpha-1 selective agonist rigid corpora cavernosa are palpated, and a large biopsy needle
FIGURE 73.4 Corporoglanular (Al-Ghorab) shunt. An incision is

made dorsally into the glans penis, and portions of the distal corpus
FIGURE 73.3 Corporoglanular (Winter) shunt. A needle is placed cavernosum are excised as a vent for blood drainage. (Adapted from
through the glans penis into the corpora cavernosa in order to make Burnett AL. Priapism. In: Wein AJ, Kavoussi LR, N ovick AC, et al.,
multiple core biopsy windows or fistulas between the glans and each eds. Cam pbell-Walsh urology, 9th ed. Philadelphia: Saunders Elsevier,
corporal body. (Adapted from Burnett AL. Priapism. In: Wein AJ, 2007:839–849.)
Kavoussi LR, N ovick AC, et al., eds. Cam pbell-Walsh urology, 9th
ed. Philadelphia: Saunders Elsevier, 2007:839–849.)
Co rp o ro g lanular (Al-Gho rab ) Shunt

is inserted through the glans into the corpus cavernosum sev-
eral times (1,11,12). This results in multiple core biopsy win- If the previous percutaneous distal shunts are unsuccessful,
dows or fistulas between the glans and each corporal body then an Al-Ghorab shunt is performed (1). Typically, distal
(Fig. 73.3). Several biopsy core fistulas are necessary to create shunts fail because a large enough window between the pri-
enough communicating channels to cause detumescence. The apic corpora cavernosa and corpus spongiosum does not exist
puncture site is closed with a figure-of-eight 3-0 chromic (Fig. 73.4). This shunt is usually done under general anesthe-
suture. The patient is instructed to squeeze the penis every few sia in combination with a penile-glans block. A tourniquet is
minutes for the next 12 hours to lessen blood pooling in the placed around the penis. A 2-cm transverse incision is made
penis. If partial ( 50% ) erection persists, the procedure is re- on the dorsum of the glans 1 cm distal to the coronal sulcus. A
peated or an alternative shunt is used. An adequate result is transverse incision is not recommended in the distal penile
evidenced by swelling of the glans and detumescence. shaft proximal to the corona because this incision may cut
sensory nerves to the dorsal aspect of the glans and possibly
cause distal atrophy. The tips of the corpora cavernosa should
be separated from the glans and transfixed with 2-0 sutures or
Co rp o ro g lanular (Eb b e ho j and T-) Shunt
grasped with a Kocher clamp so that they will not withdraw
The Ebbehoj shunt procedure involves the use of a no. 11 during detumescence, and a circular cone segment of tunica
blade scalpel passed percutaneously several times through the albuginea approximately 5 by 5 mm should be sharply excised
glans into the corpus cavernosum (1,11,12). This results in from each corporal body. Dark blood will drain from the cor-
several larger fistulas between the glans and each tip of the poral bodies, and once detumescence occurs, then reapproxi-
corpus cavernosum. The scalpel blade is inserted into the cor- mation of the skin with 3-0 chromic sutures is performed.
pora away from the urethral meatus and pulled back to create Care is taken not to obliterate the spongy vascular space of the
an opening in the tunica albuginea between the glans and cor- glans penis.
poral bodies. A modification of the Ebbehoj shunt is the T-
shunt procedure (1,11,12). A no. 10 blade scalpel is placed
vertically through the glans penis into the corpus cavernosum. Co rp o ro sp o ng io sal Shunt s
The scalpel is then turned 90 degrees away from the urethra
and pulled out. This maneuver creates a T-shaped opening in A proximal corporospongiosal shunt is performed in rare cir-
the tunica albugenia. Both of these shunts can be performed cumstances (1,11,12). When distal shunts are unsuccessful or
unilaterally or bilaterally if necessary. In theory, this T-shunt technically unachievable, then a proximal shunt may be per-
should provide a large enough fistula between the corpora formed to re-establish blood drainage and thus produce penile
cavernosa and spongiosal tissue of the glans for detumescence. detumescence. H owever, these surgical maneuvers are often
Closure of the defects in the glans is performed using 3-0 ineffective, lead to significant ED, and have a number of po-
chromic sutures, especially for the T-shunt. tential complications. For the Q uackel or Sacher shunt, the
spatulated and anastomosed to the tunica albuginea using a

continuous 5-0 polydioxanone suture. A dry dressing is ap-
plied, and a standard protocol of intermittent squeezing is rec-
ommended.
Co rp o ro –De e p Do rsal Ve in Shunt

As with the previous two shunts, the Barry shunt is a last re-
sort for a patient with severe priapism refractory to distal
shunt maneuvers (1,11,12). With this shunt, a 4-cm skin inci-
sion is made at the base of the penis. The superficial or deep
dorsal vein is identified, taking care not to injure the dorsal
artery or sensory nerves. The vein is ligated distally and di-
vided. The proximal limb is spatulated on its ventral surface
and anastomosed to the corpora cavernosa end-to-side in a
tension-free manner. The penile skin is replaced and sutured at
the base.
No nische mic Priap ism

The initial management of nonischemic priapism is observa-
tion. The diagnosis is confirmed by detecting high flow or the
site of rupture with color duplex Doppler imaging in combi-
FIGURE 73.5 Q uackel or Sacher shunt, a proximal cavernospon- nation with normal arterial blood gas analysis. Spontaneous
giosal (corporospongiosal) shunt procedure. O penings are placed in a resolution of untreated nonischemic priapism occurs in 50%
staggered fashion connecting a cavernosum and spongiosum bilater- of patients. Therefore, the patient is advised about chances for
ally for blood drainage. spontaneous resolution, complication risks after treatment
(ED, abscess, neurological sequelae), and lack of significant
adverse consequences resulting from delayed therapy for
patient is placed in lithotomy position and the bulbocaver- many months. Early presentation of nonischemic priapism can
nosus muscle is dissected off the corpus spongiosum. A longi- be managed with ice or pressure packing to cause vasospasm
tudinal incision or excision of 1-cm-long ellipses of tissue is and thrombosis of the ruptured artery to efficiently close the
made in the spongiosal and corporal bodies (Fig. 73.5). Care fistula. If the fistula does not close, selective angiographic ar-
is taken to avoid incising the urethra, which would result in a terial embolization may be needed. This should be performed
fistula. The incisions or excisions are made in close proximity in concert with interventional radiology. Use of nonpermanent
to each other in order to suture the defects together. The walls materials is associated with less ED rates postprocedure (5%
of the two openings in the spongiosum and corpora are sewn vs. 39% with permanent substances); therefore, these biomate-
together in a running fashion using 5-0 polydioxanone suture. rials are preferred. If angiographic embolization fails, then pe-
It may be necessary to perform bilateral shunting procedures nile exploration and direct surgical ligation of sinusoidal
if detumescence is not satisfactory. This technique involves fistulas or pseudoaneurysms may be performed with the assis-
staggering positions of the proximal shunts on the spongiosal tance of intraoperative color duplex ultrasonography.
and corporal bodies to avoid urethral fistulas.
O UTCO MES
Co rp o ro –Sap he no us Ve in Shunt
Po st o p e rat ive Manag e me nt
The Grayhack shunt is rarely performed due to the technical
difficulties of the surgical approach and lack of efficacy and After shunt procedures the patient should receive periopera-
complication rate (1,11,12). For this shunt, an incision is tive and postoperative antibiotics. It is important to avoid cir-
made at the penile base and the tunica albuginea of the corpus cular pressure dressings that may compromise the shunt and
cavernosum is exposed. N ext, the femoral artery is palpated decrease venous drainage. Intermittent manual squeezing and
and an incision is made at the saphenofemoral junction, which milking of the penis will help keep the shunt open and prevent
is approximately 3 to 4 cm below the inguinal ligament. The recurrence of priapism. The penis often still appears partially
saphenous vein is identified and mobilized for a distance of erect after shunting procedures due to postischemic hyper-
approximately 10 cm distal to the fossa ovalis. The surgeon emia. Color duplex Doppler imaging may be performed to
ligates the vein distally and burrows beneath the skin with the document penile vascular arterial blood flow status if desired
index finger to join the two incisions. An ellipse of tunica al- after corporoglanular and proximal shunts. Additionally, in-
buginea 1.5 by 0.5 cm is excised, and the vein is drawn with- tracavernosal pressure monitoring may help evaluate the
out tension or torsion into the penile wound; then the vein is effectiveness of the shunt procedures.
procedures proposed to alleviate severe priapic events and in

Pe rsp e ct ive practice have not been as successful as expected. Therefore,
corporoglanular and corporospongiosal shunt procedures are
The most common complication of priapism is complete ED,
preferred.
which has been reported as high as 59% (2,3). The most criti-
cal factor in maintaining potency is immediate treatment of
men presenting with priapism. Patients treated within 12 to
24 hours will more likely have a favorable response than those CO MPLICATIO NS
with delayed treatment. Patients with prolonged priapism
( 36 hours) and recurrent episodes are more likely to suffer Complications associated with shunt procedures are urethral
ED as a result of impaired smooth muscle function and fibro- damage and fistulas, bleeding, purulent cavernositis, skin
sis. This group of patients will ultimately proceed to a penile necrosis, abscess, and pulmonary embolus after the Grayhack
prosthesis because pharmacologic erectogenic therapy will procedure. Since most shunts appear to close in time, it is be-
fail. N onischemic priapism has the best prognosis in the lieved that shunting does not cause permanent ED. H owever,
preservation of erectile function. failure of venous shunts to close spontaneously will lead to
The Grayhack and Barry shunts are less efficacious in re- venogenic ED. Penile vascular dysfunction after shunt procedures
ducing priapism, perhaps due to the small-caliber size of the may be a direct result of the repeated and prolonged priapism
veins, especially regarding the Barry shunt. These are historical itself with significant fibrosis of the erectile compartments.
References
1. Burnett AL. Priapism. In: Wein AJ, Kavoussi LR, N ovick AC, et al., eds. for Urologic Disease (AFUD) Thought Leader Panel on evaluation and treat-
Cam pbell-W alsh urology, 9th ed. Philadelphia: Saunders Elsevier, 2007: ment of priapism. Int J Im pot R es 2001;13[Suppl 5]: S39–S43.
839–849. 7. Broderick GA, Gordon D, H ypolite J, et al. Anoxia and corporal smooth
2. Earle CM , Stuckey BGA, Ching H L, et al. The incidence and management muscle dysfunction: mechanism for ischemic priapism. J Urol 1994;151:
of priapism in western Australia: a 16 year audit. Int J Im pot R es 2003;15: 259–262.
272–276. 8. Ul-H asan M , El-Sakka AI, Lee C, et al. Expression of TGF-beta-1 mRN A
3. Adeyoju AB, Olujohungbe ABK, Morris J, et al. Priapism in sickle cell disease; and ultrastructural alterations in pharmacologically induced prolonged
incidence, risk factors and complications—an international multicentre penile erection in a canine model. J Urol 1998;160:2263–2266.
study. BJU Int 2002;90:898–902. 9. Bivalacqua TJ, Burnett AL. Priapism: new concepts in the pathophysiology
4. Spycher M A, H auri D. The ultrastructure of the erectile tissue in priapism. and new treatment strategies. Curr Urol R ep 2006;7:497–502.
J Urol 1986;135:142–147. 10. Burnett AL, Bivalacqua TJ, Champion H C, et al. Long-term oral phospho-
5. M ontague DK, Jarow J, Broderick GA, et al. M embers of the Erectile diesterase 5 inhibitor therapy alleviates recurrent priapism. Urology 2006;
Dysfunction Guideline Update Panel; American Urological Association. 67:1043–1048.
American Urological Association guideline on the management of pri- 11. Lue TF, Pescatori ES. Distal cavernosum-glans shunts for ischemic priapism.
apism. J Urol 2003;170:1318–1324. J Sex M ed 2006;3:749–752.
6. Berger R, Billups K, Brock G, et al. AFUD Thought Leader Panel on 12. Bochinski DJ, Deng DY, Lue TF. The treatment of priapism—when and
Evaluation and Treatment of Priapism. Report of the American Foundation how? Int J Im pot R es 2003;15[Suppl 5]:S86–S90.
CHAPTER 74 ■ PENILE PRO STHESIS

IMPLANTATIO N
CULLEY C. CARSO N
While erectile dysfunction has been described since ancient between the early prosthetic devices and the currently implanted
times, adequate treatment has only been available for the last inflatable penile prostheses. M echanical malfunction rates in
four decades. The era of implantable devices began with the these early devices, however, were reported in excess of 60%
development of silicone-based prosthetic materials in the late of cases. Current inflatable prosthetic devices have a far more
1960s as a result of the U.S. space program (4). M odern penile improved mechanical reliability. These current devices can be
prosthetic devices were first developed in the early 1970s divided into semirigid, mechanical, and multiple-component
when Small et al. (6) along with Scott et al. (5) reported the inflatable penile prostheses, of which there are two- and three-
implantation of penile prosthetic devices into the corpora cav- piece models available.
ernosa to fill the corpora cavernosa and provide a physiologi- The semirigid rod and mechanical prostheses available
cally functional erection with good cosmetic results. These today are the successors of the devices designed in the 1970s
devices have undergone multiple revisions and redesigns (Table 74.1). These devices, while easier to implant, have few
Chap t e r 74: Pe nile Prosthe sis Imp lantation 493
TA B LE 7 4 . 1
AVAILABLE PEN ILE PROSTHESES
Semirigid rods Inflatable
AM S 600 (AM S) 700 CX (AM S)

M alleable (Coloplast) 700 LGX(AM S)
Dura II (AM S) Alpha 1 (Coloplast)
Ambicor (AM S)
advantages over the newer inflatable devices because infection

and mechanical malfunction rates are similar. The semirigid
devices consist of a central metal core and a silicone elastomer
rod, whereas the mechanical Duraphase implant is a series of FIGURE 74.2 American Medical Systems’ Ambicor two-piece inflatable
disks held in position by a central cable. The latter design penile prosthesis.
facilitates positioning of the implant between uses.
The three-piece inflatable penile prostheses vary in con-
struction from three-layer silicon, Dacron, Lycra, or silicone
to a single layer of silicon or Bioflex (Fig. 74.1). O ptions with satisfactory rigidity and excellent flaccidity for optimal
include girth expansion and/or length elongation. Aneurismal concealment. They also have advantages for many patients
dilatation is rare with both of these cylinder designs, but it has with complex penile implantations because the flaccid posi-
been reported. Similarly, other design changes—including tion removes pressure from the corporal cavernosa and
replacement of stainless steel connectors with plastic connec- decreases the possibility of erosion in these highly difficult
tors, addition of nonkinked tubing, single design construction, implantations.
Teflon cylinder input sleeves, and multiple-layer cylinders— To improve the ease of surgical implantation by removing a
have improved the longevity of these devices. These modifica- portion of the prosthesis placed within the abdominal region,
tions have decreased mechanical malfunction rates from two-piece prostheses were designed (Fig. 74.2). Because these
30% to 5% . The most significant recent advance is the two-piece inflatable prostheses remove the separate reservoir,
coating of three-piece implants to reduce infection risk. additional fluid is available either by a larger scrotal pump or
The three-piece inflatable penile prostheses continue to be a combination of a proximal cylinder and pump reservoir.
the most satisfactory prostheses once they are implanted and Although these devices provide adequate erection in many pa-
while they remain functional. These prosthetic devices pro- tients, the limited reservoir capacity decreases flaccidity and
duce the most natural-appearing erection in girth and length, may, in some patients, diminish rigidity. These prostheses are
especially difficult to deflate in patients with small penises and
frequently provide inadequate rigidity in patients with longer
penises. While less optimal than three-piece devices, these
two-piece implants may be ideal for patients in whom reser-
voir placement is difficult or contraindicated. Such patients as
renal transplant recipients and patients who have undergone
significant radical pelvic exenteration procedures may benefit
from two-piece devices.
DIAGNO SIS
The diagnosis of erectile dysfunction can be obtained by
history. The clinician should determine whether the erectile
dysfunction is situational or constant, whether the degree of
dysfunction is partial or total, and also include the details of
the relationship with the partner. Any coexisting conditions
such as diabetes, vascular disease, smoking, medications
(especially steroids, hormones, antihypertensives, or antide-
pressants), and use of alcohol or drugs should be identified.
Physical examination should include the genitalia, including the
testes, hair distribution, femoral and distal lower-extremity
pulses, and the penis for Peyronie plaques or other abnormal-
ities. N octurnal tumescence studies, cavernosometry, caver-
FIGURE 74.1 American M edical Systems’ AM S 740CX three-piece nosography, and penile Doppler are useful in some patients in
inflatable penile prosthesis. securing the diagnosis.
INDICATIO NS FO R SURGERY SURGICAL TECHNIQ UE

Although there are a variety of penile prosthesis designs cur- Surgical implantation of penile prostheses can be carried out
rently available for implantation, not all patients with erectile using a variety of surgical approaches and incisions. Semirigid
dysfunction are candidates for penile prosthesis implantation. and malleable prostheses can be implanted through a distal
Penile prostheses are generally the procedure of last resort for penile approach. M ultiple-piece prostheses, however, can be
those men failing more conservative measures such as oral implanted by the infrapubic or penoscrotal approach. While
PDE5 inhibitors, vacuum erection device, urethral alprostadil, individual surgeons have a variety of rationales for each of
and cavernosal injection therapy. For those men in whom penile these approaches, there does not appear to be any clear
prostheses are suggested, careful counseling before penile advantage in patient satisfaction or outcome between the two
implant procedures will limit many of the problems with post- approaches. Patient anatomy may dictate appropriate choice.
operative dissatisfaction. O nce the discussion and demonstra- Patients with previous abdominal surgical procedures where
tion of penile implant varieties have been carried out, patients reservoir placement is difficult may be better served with an
can be counseled about the most appropriate penile prosthesis infrapubic approach, whereas patients with massive obesity
for their individual use. Patients may choose a specific pros- may be better approached through a penoscrotal incision.
thetic type based on their needs and preferences (1). Younger Two-piece devices, because there is no separate reservoir, are
patients with normal manual dexterity and patients who wear best implanted through a penoscrotal incision.
stylish, form-fitting, athletic clothing or who shower in public
at a health club or other athletic facility often choose a three-
piece inflatable penile prosthesis because appearance in the Dist al Pe nile Ap p ro ach
flaccid position is better than with other designs. For these
patients, implantation of a semirigid rod penile prosthesis A distal penile approach is usually the best approach for inser-
requires a significant lifestyle change, and they are better tion of a semirigid or mechanical penile prosthesis. This incision
served with an inflatable-type prosthesis. Similarly, patients heals well, allows complete corporeal dilation, and facilitates
with Peyronie disease, secondary implantation, or significant rod placement. After placement of a Foley urethral catheter, a
peripheral neuropathy such as occurs in severe diabetes are best circumcoronal incision is carried out 180 degrees of the sub-
served with an inflatable penile prosthesis because interior coronal region of the penis. Dissection is carried down to the
tissue pressures are diminished between uses and the possibil- layer of the Buck fascia, taking care to avoid the dorsal penile
ity of extrusion is diminished. nerves, which course within the Buck fascia. After the Buck
For patients in whom the convenience of inflation and fascia is identified, stay sutures are applied to the two corpora
deflation is not important, the risks and mechanical malfunc- through the tunica albuginea lateral to the penile nerves.
tions may outweigh the disadvantage of a malleable penile These longitudinal incisions can be extended as much as is
prosthesis (Fig. 74.3). Such patients as paraplegics who necessary for dilation and cylinder insertion. The corporal di-
require an external urinary collection device, those with inad- lation is begun with M etzenbaum scissors to establish a track
equate manual dexterity, or those with significant obesity may in the corporal tissue. Dilation then follows with H egar,
be better served with a malleable penile prosthesis. Brooks, or Dilamezinsert dilators to 9 to 11 cm, depending
upon the required cylinder girth (Fig. 74.4). O nce the corpora
are sized using a Furlow or other dilator, the cylinders can be
ALTERNATIVE THERAPY placed (Figs. 74.5 and 74.6). A small vein retractor can be
used to facilitate placement of the distal end of the cylinder.
Alternative therapy includes sexual counseling, vacuum erection The corporotomy is closed with 2-0 absorbable, synthetic
devices, intracavernosal injection therapy, intraurethral medica- sutures. With noninflatable cylinders, a penile block can be
tion, or oral PDE5 inhibitor medications. Less commonly used performed and a noncompression dressing is applied.
therapies include penile vascular (arterial or venous) surgery.
FIGURE 74.3 American M edical Systems’ AM S 600 malleable penile

prosthesis. FIGURE 74.4 Corporal dilation using Brooks dilators.
FIGURE 74.5 Prosthesis cylinder loaded onto Furlow inserter and placed into the corporal tunnel.
cavernosum dilation. After incision of the subcutaneous tis-

Infrap ub ic Ap p ro ach sue, the dissection is continued to the rectus fascia. The rectus
fascia is incised horizontally and dissected cephalad for
The infrapubic approach allows better visualization of the
approximately 2 to 3 cm. A midline separation of the rectus
reservoir placement than the penoscrotal approach. H owever,
muscles is carried out using sharp and blunt dissection. A
because of the proximity of the dorsal neurovascular bundle
pouch is created bluntly beneath the rectus muscles to com-
in the infrapubic approach, injury is possible, resulting in de-
fortably insert the inflatable reservoir without compression
creased distal penile sensation in some patients. The infrapu-
(Fig. 74.8).
bic approach is usually carried out with a horizontal incision
approximately one fingerbreadth below the symphysis pubica,
allowing implantation with an easily concealed incision once
the pubic hair regrows (Fig. 74.7). In patients with significant
obesity or a previous midline incision, however, a midline inci-
sion carried out just to the base of the penis facilitates expo-
sure of the corpus cavernosum and improves ability for corpus
FIGURE 74.7 Infrapubic incision for prosthesis implantation.
FIGURE 74.8 Blunt dissection establishes a location for the pump

FIGURE 74.6 Placement of proximal cylinder base. device.
FIGURE 74.10 Device in place with connections complete.
cavernosum to ensure that there is no kinking and that com-

plete proximal and distal seating has taken place (Fig. 74.10).
FIGURE 74.9 Corporotomy incision between two stay sutures, avoid- The corporal incision should be placed proximal enough to
ing the dorsal neurovascular bundles. allow easy exit of the input tube and minimize contact between
the cylinder and input tube. Closure of the corpora caver-
nosum is carried out with traction on the cylinder placement
Dissection is then carried out over the corpora cavernosa. suture to maintain it in a flat, nonkinking position and ensure
Sharp and blunt dissection is begun on either side of the fun- adequate seating. Following placement of cylinders and clo-
diform ligament identifying the dorsal neurovascular bundle. sure of the corporotomy incision, cylinder inflation can be
N ote that the dorsal nerves of the penis lie approximately 2 to tested by placing fluid in each of the cylinders through the
3 mm lateral to the deep dorsal vein. O nce the Buck fascia has input tubes, gently inflating the prosthesis to identify any
been dissected free from the tunica albuginea, the shiny white abnormalities in position, curvature, or other problems.
tunica albuginea is fixed with traction sutures. A corporotomy A finger is then placed in the most dependent portion of the
incision is then carried out between the traction sutures and scrotum lateral to the testicle on the right or left side. The fin-
the corpora cavernosa entered (Fig. 74.9). The corporotomy ger is then pushed to the area of the external inguinal ring, and
incision can be carried out with scalpel or electrocautery. any adipose tissue in this area is dissected free to expose the
M etzenbaum scissors are then used to carefully initiate the dartos fascia. The dartos fascia is thoroughly cleaned to allow
tunneling of the corpora cavernosa, gently spreading the cav- pump placement. Following development of this subcuta-
ernosal tissue both proximally, until the ischial tuberosities neous pouch for the pump, the pump is positioned in the most
and crura of the corpora are encountered, and distally, palpat- dependent portion of the scrotum and temporarily fixed into
ing the glans penis to identify the distalmost aspect of dilation. position using a Babcock clamp. The inflatable reservoir is
H egar dilators from size 9 to 12 or Brooks, Pratt, or then placed in the previously constructed subrectus pocket
Dilamezinsert dilators can be used. If corporeal fibrosis is en- and filled with an appropriate volume of normal saline or
countered, Rosillio cavernatomes can be used to dilate to size water/radiographic contrast media. Before connection, it is
12. O nce dilation has been adequately carried out bilaterally, important to release pressure on the filling syringe and deter-
the Furlow introducer or Dilamezinsert is used to measure the mine if any backfilling is seen. This backfilling or backpres-
corpora cavernosal length using a traction suture as a central sure may predict autoinflation in the postoperative period.
point of reference. The proximal and distal measurements are Tubing connection is then carried out using quick connectors
added to identify total corporal length and obtain appropri- or suture tie plastic connectors. The snap-on connectors are
ately sized inflatable cylinders. A length slightly less than used for M entor prostheses. In a redo prosthesis in which a
measurement is usually obtained to permit comfortable posi- residual tubing segment is connected to a new device piece,
tioning of the cylinders. Rear tip extenders of size 0.5, 1.0, suture tie plastic connectors must be used. The tubing is
2.0, or 3.0 cm or combinations thereof are placed on the prox- tailored prior to connection to allow for adequate pump posi-
imal cylinder end to adjust length. O nce measurement has tioning is carried out prior to connection. Shodded clamps are
been obtained, interrupted sutures can be placed for later cor- used to compress the tubing, and the ends of the tubing, once
porotomy closure. The advantage to this technique is the elim- tailored, are flushed with inflation fluid to eliminate small
ination of suture needles close to the area of the inflatable particles and blood clots. After the tubing is connected, the
cylinder, diminishing the possibility of cylinder damage during adequacy of the connection is tested by gently pulling on the
corporotomy closure. O ther methods of corporotomy closure connectors. All shodded clamps are removed and the device is
include running sutures with or without a locking technique. inflated and deflated on multiple occasions to ensure adequate
O nce the corporotomy sutures are placed, cylinders are posi- location, placement, and erection.
tioned in the dilated corpora cavernosa using the inserting Following testing, thorough irrigation with antibiotic solu-
tool with distal needle to pull the cylinders into position. O nce tion is carried out and the rectus fascia closed with interrupted
positioned, it is essential to visualize the cylinder in the corpus sutures. The wound is then closed in the standard fashion with
two layers of subcutaneous tissue and a subcuticular skin

suture. A dry sterile dressing is applied, a Foley catheter
placed if necessary, and an ice pack applied. Suction drains
could be used at the surgeon’s discretion.
Postoperatively patients are instructed to maintain their
penis in a Sutherland position for 4 to 6 weeks. Tight under-
wear and athletic supporters are not used in an effort to main-
tain the pump in its most dependent position.
Pe no scro t al Ap p ro ach
Three-piece inflatable penile prostheses, as well as semirigid
and two-piece prostheses, can be implanted by a transverse or
vertical penoscrotal incision. This approach has distinct ad-
vantages in obese patients and is the most common approach
for routine penile prosthesis implantation. Because the peno-
scrotal approach requires differentiation of the corpora caver-
nosa from the corpus spongiosum during resection, initial
placement of a Foley catheter is necessary for this approach.
The incision is placed in the upper portion of the scrotum and
is usually horizontal, one fingerbreadth below the penoscrotal
junction.. The Scott/Lone Star retractor (Lone Star M edical
Products, Stafford, TX) facilitates exposure with this incision.
O nce the skin incision has been carried out, dissection is con-
tinued lateral to the corpus spongiosum and urethra to expose FIGURE 74.12 Reservoir placement with penoscrotal approach.
the corpora cavernosa. Incision, dilation, and closure of the
corpora cavernosa are similar to those described previously Dissection for reservoir placements can be carried out with
for the infrapubic incision, but synthetic absorbable sutures a second separate infrapubic incision but is more commonly
must be used with this approach because the suture line may performed through the penoscrotal incision (Fig. 74.12). The
be palpable postoperatively (Fig. 74.11). Cylinder sizing and scrotal skin incision is retracted to the area of the external
placement are as described above. Pump placement is likewise inguinal ring, and dissection is carried out medial to the sper-
in the most dependent portion of the scrotum just above the matic cord. The transversalis fascia is identified and incised
dartos fascia, with positioning using a Babcock clamp. sharply using M etzenbaum scissors placed firmly against the
pubic tubercle. Dissection is carried out using a combination
of sharp and blunt dissection. Dilation is carried out with the
index finger after incision of the transversalis fascia and with
gentle blunt dissection using a large Kelly clamp. The reservoir
balloon is then positioned over the index finger and placed in
the perivesical space. Inflation of the reservoir is carried out
with care that no backpressure is observed. If refilling of the
syringe occurs, the reservoir is removed and reservoir pocket
enlargement must be carried out. O nce the reservoir is placed
and inflated and the tubing is connected as previously de-
scribed, the device is tested in inflation and deflation
(Fig. 74.13). Closure is carried out with a subcuticular suture
in the standard fashion. In men with a penoscrotal skin web,
the horizontal skin incision can be closed in a midline fashion
to enhance functional penile length.
Perioperative antibiotic treatment is critical in diminishing
the incidence of perioperative infection and prosthetic removal.
The Inhibizone (American M edical Systems, M innetonka, M N )
coating consisting of rifampin and minocycline or the lubricious
coating of the Titan implant (Coloplast Inc, M inneapolis, M N ),
which allows antibiotics to adhere to the Bioflex, has reduced
infection risk by threefold. An initial perioperative dosage of
an antibiotic agent effective against the most common infectious
pathogens should be administered 1 to 2 hours prior to surgery
and continued for 24 hours postoperatively. The choice of an
aminoglycoside with a first-generation cephalosporin, ampicillin/
sulbactam, a cephalosporin alone, vancomycin, or a fluoro-
FIGURE 74.11 Penoscrotal incision with exposure of corpora cavernosa. quinolone is appropriate for prophylaxis of the most common
prostheses will benefit from sexual counseling or continued

counseling assistance from the implanting surgeon to be sure
that they are able to operate the device satisfactorily and
understand its use.
Most patients’ dissatisfaction results from difficulty with oper-
ation of the device and unrealistic expectations. Preoperative
discussions with patients should include the concept that penile
prostheses do not create normal erections but only support the
penis for sexual activity. Penile prosthesis surgery brings about
the ability to resume sexual functioning and vaginal penetra-
tion, but decreased penile sensation, length, and engorgement
may result. Patients should also be advised that a penile pros-
thesis will not improve libido or ejaculation. Patients frequently
report delayed or difficult ejaculation initially following penile
prosthesis surgery. This delay is primarily a result of inade-
quate preparation, stimulation, and psychological adjustment
to the prosthesis. M ost patients require 3 to 6 months of pros-
thesis use with careful attention to presexual stimulation
before ejaculation routinely returns to preoperative levels.
Because the prosthesis neither improves nor detracts from pre-
operative ejaculatory ability, patients must be counseled re-
garding their preoperative ejaculatory ability before prosthesis
placement.
The most worrisome postoperative complication is infec-
tion, which occurs in fewer than 10% of all patients.
Perioperative prosthetic infections can, however, occur at any
time in the postoperative period in patients with penile or
other prosthetic devices. Patients continue to be at risk for
hematogenously seeded infections from gastrointestinal, den-
FIGURE 74.13 Pump placed for penoscrotal approach.
tal, or urologic manipulations as well as remote infections.
Patients must be counseled to request antibiotic coverage if re-
infections from Staphylococcus epiderm idis. Patients may be mote infections occur. M ost periprosthetic infections are
discharged for 7 days of continued antibiotic therapy. The use caused by gram-positive organisms such as S. epiderm idis, but
of antibiotic-coated penile implants, while reducing the inci- fungi or gram-negative organisms such as Escherichia coli and
dence of postoperative infection, does not preclude the need Pseudom onas are also common culprits. Severe gangrenous
for systemic, perioperative antibiotics. The penile prosthesis infections with a combination of gram-negative and anaerobic
remains deflated for 4 weeks while healing occurs. Prior to organisms have also been identified and frequently result in
activation, the patient is advised to retract the pump into his significant disability and tissue loss. Patients at increased risk
scrotum on a daily basis, and tight underwear and athletic for perioperative infections include diabetics, patients under-
supports are avoided to maintain pump position. A return going penile straightening procedures or circumcision with
office visit for activation of the device is carried out once prosthetic implantation, patients with urinary tract bacterial
discomfort has resolved. Patients are advised to inflate and colonization, and immunocompromised patients, such as
deflate the device on a daily basis for 4 weeks to allow tissue posttransplant patients. Spinal cord injury patients have also
expansion around the prosthesis. M ost patients can then been reported to have a specially increased risk of infections,
begin use of their device 4 to 6 weeks after implantation. with rates reported as high as 15% .
Appropriate treatment of periprosthetic infections requires
early and immediate identification with institution of par-
enteral antibiotic therapy and early prosthesis removal (2).
O UTCO MES Conservative treatment would dictate a healing period of 3 to
6 months followed by repeat prosthesis implantation.
Co mp licat io ns Satisfactory results with prosthesis removal, a 5- to 7-day
course of antibiotic irrigation, followed by additional replace-
Despite careful counseling, many patients enter penile pros- ment has been reported for selected patients. Better long-term
thesis procedures with expectations that cannot be met by pe- results with no additional morbidity can be achieved with
nile prosthesis surgery. Decreased penile length compared the prosthesis salvage technique reported by M ulcahy (4).
with the preimplant state, decreased penile sensation, “ cool- This technique—which requires removal of the infected im-
ness” of the penis and glans penis, and chronic pain, as well as plant and vigorous irrigation using solutions of antibiotics,
partner dissatisfaction, are among the complaints patients povidone-iodine, hydrogen peroxide, and a repeat of these
may voice despite adequate surgical implantation and satisfac- solutions—is successful in 75% of infected prostheses (2).
tory mechanical functioning. Fortunately, these complaints are The most common complication of penile prosthesis func-
unusual, and 90% of patients report satisfaction with their tion is mechanical malfunction. M echanical malfunction has
prostheses. M any patients who are dissatisfied with their penile declined from rates as high as 61% to levels below 5% since
Chap t e r 75: Pe nile Ve nous Surg e ry 499
the 1970s (3,7). Aneurismal dilation of inflatable cylinders, is most common in diabetics and spinal cord injury patients,
both American M edical Systems and M entor, kinks in tubing, especially those requiring urinary management with catheter
reservoir leakage, and pump malfunction have been limited by placement or with condom catheter collection devices.
device modifications. Fluid leak, however, continues to be a Extrusion can also occur beneath the penile skin distally
problem for many inflatable penile prostheses. These mechan- from vigorous dilation or remotely from trauma or repeated
ical malfunctions require replacement of the leaking portion use. These extrusions are characterized by distal penile pain
of the inflatable portion of the prosthesis. If a nonfunctioning with use. Correction can be carried out with the use of a patch
prosthesis has been in place 4 years, however, it is usual graft, but a better approach is rerouting with no grafting ma-
practice to replace the entire device to reduce further mechan- terial. Rerouting is associated with less infection and pain and
ical malfunction (1). a reduced recurrence rate.
Semirigid rod penile prostheses are associated with fewer
mechanical problems; the most common complication associ-
ated with these prostheses is cylinder erosion through skin or Re sult s
urethra. Prosthesis fracture or breakage has been reported,
and patients may return 6 to 8 years postimplantation with Long-term function and use have been confirmed in studies of
complaints of decreased rigidity of their semirigid rod, indicat- patients who have had implants as long as 10 years (3). While
ing fracture of the central prosthetic cylinder wires. These partner satisfaction notes are few, patients have a 90% satis-
wire fractures usually cannot be appreciated radiographically faction, and those with functioning devices for 5 years use
unless the prosthesis is put on stretch once it has been ex- them 27 times monthly (3). O ther studies have confirmed that
planted. Replacement of these devices is indicated when pa- patient satisfaction is greater than with any other erectile dys-
tients note decreased rigidity. Prosthesis extrusion or erosion function treatment modality (1).
References
1. Carson CC. Penile prosthesis implantation: surgical implants in the era of 4. M ulcahy JJ. Long-term experience with salvage of infected penile implants.
oral medication. Urol Clin N orth A m 2005;32(4):503–509. J Urol 2000;163:481–482.
2. Carson CC. Diagnosis, treatment and prevention of penile prosthesis infec- 5. Scott FB, Bradley WE, Timm GW. M anagement of erectile impotence. Use
tion. Int J Im pot R es 2003;15[Suppl 5]:S139–S146. of implantable inflatable prosthesis. Urology 1973;2:80–82.
3. Carson CC, M ulcahy JJ, Govier FE. Efficacy, safety and patient satisfaction 6. Small M P, Carrion H M , Gordon JA. Small-Carrion penile prosthesis. N ew
outcomes of the AM S 700CX inflatable penile prosthesis: results of a long- implant for management of impotence. Urology 1975;5:479–486.
term multicenter study. AM S 700CX Study Group. J Urol 2000;164: 7. M ulcahy JJ, Austoni E, Barada JH , et al. The penile implant for erectile
376–380. dysfunction. J Sex M ed 2004;1(1):98–109.
CHAPTER 75 ■ PENILE VENO US SURGERY

AUDREY C. RHEE, MARK R. LICHT, AND RO NALD W. LEWIS
Although the exact incidence of vasculogenic erectile dysfunc- abnormal venous channels may be a less frequent source of
tion (ED) is not known, arterial insufficiency and/or venous veno-occlusive disorders. In this chapter, we discuss the diag-
leakage of varying etiology probably account for the majority nosis of venogenic ED and detail the surgical correction of this
of cases of ED. Sustaining a rigid erection depends on both form of ED by penile venous dissection and ligation.
adequate perfusion pressure of the erectile bodies via arterial
inflow and maintenance of intracavernosal pressure by increased
venous outflow resistance. The trapping of blood within the
expanding corporal bodies during erection by direct compres- DIAGNO SIS
sion of subtunical venules as they exit through the tunica al-
buginea is known as the corporal veno-occlusion mechanism. A history and physical examination help identify patients who
Venous leak ED refers to the inability of an individual to may have venous leak ED. Patients present with complete loss
maintain a rigid erection because of abnormal venous outflow of erection, decreased penile rigidity, or rapid loss of erection
from the corpora cavernosa secondary to failure of the corpo- during intercourse. M edication side-effects, significant cardio-
ral veno-occlusive mechanism. Failure of full expansion of vascular disease, psychologic disorders, and tobacco use
the sinus spaces due to sinus smooth muscle malfunction or should be excluded as contributing causes of ED. Penile
replacement with fibrous tissue probably accounts for the trauma, surgery for priapism or Peyronie disease, and previ-
majority of veno-occlusive dysfunction. Focal defects in the ous endoscopic incision of urethral strictures can all lead to
integrity of the tunica albuginea or congenital or arteriogenic focal defects in the corporal veno-occlusive mechanism (7).
FIGURE 75.1 Penile venous anatomy.
The first diagnostic test that we employ in the diagnosis of sites of venous leakage seen in patients with veno-occlusive
venogenic ED is color penile duplex Doppler ultrasonography. dysfunction are the deep dorsal vein, the cavernosal veins, and
This test allows for the evaluation of both penile arterial in- the circumflex veins at the base of the penis. A large amount
flow (peak systolic velocity) and veno-occlusion (end-diastolic of drainage into all of these systems is a contraindication to
velocity), as well as for observing the erectile response to the surgery, since these patients do not do well.
intracavernosal injection of a vasodilating agent. O ur pre-
ferred injection agent is 0.25 mL of a Tri-M ix agent (contain-
ing 6 mg of papaverine, 0.2 mg of phentolamine, and 2 µg of
prostaglandin E1 ). Patients with measured end-diastolic veloc-
ities 3 cm per second for up to 20 minutes (measured at 5- Patients must meet strict criteria to be selected for venous
minute intervals) after the administration of the vasodilating surgery. Candidates must first have a history that is consistent
agent despite normal arterial inflow, a peak systolic velocity with venous leak ED, corroborated by color duplex Doppler
30 cm per second, are likely to have venogenic ED (4). ultrasonography or intracavernosal test injection findings.
Patients who obtain a full rigid erection within 10 minutes of O ther causes of ED should be ruled out. N ormal penile arter-
injection that lasts for 30 minutes probably have no clinically ial inflow must also be documented in response to an intra-
significant vascular disease. O ur practice is to reinject and to cavernosal injection agent because patients with concomitant
measure values every 5 minutes for 20 minutes if after the first arterial disease often have a poor outcome after venous
injection the response is not a full erection or not equal to the surgery. Pharmacocavernosometry and pharmacocavernosog-
best attained erection at home. Patients who achieve only raphy must confirm veno-occlusive dysfunction and outline
tumescence or who rapidly obtain a rigid erection that dissi- the sites of leakage. Patients should have no medical con-
pates within 15 to 20 minutes are suspected of having a ve- traindications to surgery. There is no strict age limit, but we
nous leak. prefer to perform venous surgery on patients 65 years old.
Infusion pharmacocavernosometry and pharmacocaver- Sasso et al. (12) advise veno-occlusive dysfunction for patients
nosography are the definitive tests for diagnosing venous leak 50 years of age.
ED and visualizing the sites of leakage. Knowledge of the Patients need to eliminate all tobacco use at least 6 months
anatomy of the venous drainage of the penis is critical in inter- before surgery. Finally, patients must select venous surgery
preting this study (Fig. 75.1). Two 19-gauge needles are placed only after presentation of alternative forms of therapy and
into each of the corpora cavernosa. O ne is connected to a discussion of the 50% long-term expected success rates
pressure transducer, and the other is connected to an infusion ( 2 years). We also perform venous surgery in conjunction
pump with metered delivery rates of heparinized saline. After with penile arterial revascularization in select patients with
injection of a vasodilating agent, the need for a flow rate of both focal arterial disease and veno-occlusive dysfunction (8).
20 mL per minute of saline to maintain a rigid erection at an
intracorporeal pressure of at least 90 mm H g is indicative of
corporal veno-occlusive dysfunction. A maintenance flow rate
between 10 and 20 mL per minute is considered borderline for ALTERNATIVE THERAPY
venous leakage. O thers have used lower flows to maintain as
diagnostic cutoff. Excessively high maintenance flows ( 50 Patients with venous leak ED have other effective surgical and
mL per minute) usually indicate massive venous runoff, and nonsurgical options to consider instead of penile venous dis-
these patients do not do well with veno-occlusive surgery (12). section and ligation. Some patients with mild to moderate
Isosmotic contrast material is infused into the corpora at the veno-occlusive disorders will respond to oral phosphodi-
previously defined maintenance flow rate from cavernosome- esterase inhibition therapy for ED. Vacuum erection devices
try, and then Anterior Posterior (AP) and oblique radiographs create an adequate erection by drawing blood into the penis
of the penis are taken (cavernosography). The most common with negative pressure in the vacuum cylinder tube. An occlusion
band placed at the base of the penis prevents outflow of blood

and substitutes for a faulty veno-occlusive mechanism. Self-in-
jection of intracavernosal vasodilating agents at higher doses
can often produce a functional erection in patients with mild
to moderate venous leak. Patients with severe leakage, how-
ever, will most often not respond to injection therapy.
Combining self-injection with an occlusion band is also help-
ful in maintaining an erection in some patients. Implantation
of a penile prosthesis effectively replaces the natural veno-
occlusive mechanism with a mechanical device capable of pro-
ducing a sufficiently rigid erection. A short-time high success
rate (68.7% ) with an embolization of the deep dorsal vein
technique was reported in 2000 by Peskircioglu et al. (10). A
goal-directed approach is used to help the patient select an ap-
propriate form of therapy.
SURGICAL TECHNIQ UE
Patients receive a dose of intravenous cephalosporin or a fluo-
roquinolone within an hour before surgery. Surgery is per- FIGURE 75.3 Inversion of the penile shaft into the wound.
formed under either general intubated or spinal anesthesia.
The patient is positioned supine with legs abducted to allow
inferior extent is the median raphe of the scrotum below the
easy access to the perineum. If crural ligation and banding are
penile shaft. Superficial tissue is dissected free of the corporal
planned as part of the operative procedure, then a dorsal
bodies with sharp and blunt dissection. Communicating veins
lithotomy position is preferred. A lighted suction device can
joining the deep and superficial drainage systems are isolated,
facilitate illumination of the deep infrapubic dissection. An in-
ligated with 3-0 plain gut sutures, and divided. The penile skin
traoperative Doppler probe can be helpful in localizing small
is then inverted into the wound to gain exposure to the super-
arteries in this region. O ptical magnification can be used for
ficial and deep venous systems (Fig. 75.3). Any other venous
the dissection, although we do not routinely use it. The opera-
trunks of the superficial system that receive tributaries from
tive field is prepared and draped in a sterile fashion from the
the corpora are ligated with absorbable suture material and
umbilicus to the perineum, and an 18Fr Foley catheter is
divided at this time (Fig. 75.4).
placed for the purpose of bladder drainage and facilitating
A 19- or 21-gauge butterfly needle is placed into the base
urethral identification during the dissection.
of the corpus cavernosum and fixed in place to the tunica al-
An infrapubic curvilinear anterior peripenile scrotal inci-
buginea with a 3-0 chromic pursestring suture (Fig. 75.5). The
sion is made with a no. 15 blade (Fig. 75.2). The superior ex-
cavernosal tissue receives an injection of 30 mg of papaverine
tent of the incision is the inferior border of the pubis, and the
(or similar vasodilating agent[s]), followed 10 minutes later by
indigo-carmine colored saline (12 mL in 250 mL of saline) to
help visualize abnormally effluxing veins. The butterfly needle
tubing is clamped for the duration of the procedure and is
FIGURE 75.4 Ligation of superficial veins with connections to the

FIGURE 75.2 Peripenile scrotal incision for penile venous surgery. corpora.
FIGURE 75.5 Placement of a butterfly needle for intraoperative cav-

ernosometry.
used again after the dissection to perform intraoperative cav-

ernosometry. A 3/8–in. Penrose drain is looped around the pe-
nile shaft between the corpora. This allows retraction of the
penile skin, allows elongation and stabilization of the penile
shaft, and affords exposure for the proximal vein dissection.
The superficial fundiform ligament is identified at the base
of the penis and is divided to expose the underlying suspensory FIGURE 75.7 Division of the deep dorsal vein in the infrapubic region.
ligament. The suspensory ligament is then sharply divided close
to the underside of the pubic symphysis (Fig. 75.6). The sus-
pensory ligament must be completely taken down to expose the If the deep dorsal vein is a significant source of abnormal
deep infrapubic region. Care is taken to identify and divide penile drainage, then it is dissected from the infrapubic region
small veins emanating from the underside of the pubis and join- along the penile dorsal midline under the Buck fascia distally
ing the superficial drainage system as well as veins perforating toward the glans. It is important to stay in the midline during
the Buck fascia to connect the deep and superficial systems at the dissection to avoid the laterally located dorsal arteries and
this level. Failure to ligate these vessels can lead to significant nerves. Circumflex and emissary veins encountered on either
bleeding, which can be difficult to control and obscure expo- side of the deep dorsal vein are ligated with 3-0 plain gut su-
sure for the proximal portion of the venous dissection. tures and divided (Fig. 75.8). Bipolar electrocoagulation on
Deep in the infrapubic region, the Buck fascia is opened in low setting can be used to cauterize some small vessels along
the midline over the deep dorsal vein. The vein usually has a the shaft.
single large main trunk at this level. The deep dorsal vein is Sometimes the deep dorsal vein is composed of two trunks
dissected free of the tunica albuginea, ligated with 0 silk ties, along the penile shaft, and each must be dissected separately.
and divided (Fig. 75.7). Inferior to the deep dorsal vein, the Dissection continues until several fanning tributaries consti-
cavernosal veins can be identified in the penile hilum at this tute the deep dorsal vein approximately 1 cm from the glans.
time. They may be divided if they are a major source of leak- Rarely, a large vein arises from the tunica albuginea and pene-
age. Great care is taken to preserve the cavernosal arteries and trates the Buck fascia to join the deep dorsal vein. Ligation of
nerve trunks that lie lateral to these veins. this vein may create a sinusoidal defect in the tunica, which
must be closed with a 3-0 chromic figure-of-eight suture liga-
ture. The junction between the corpora cavernosa and the
spongiosum is carefully inspected as well, and circumflex
veins connecting the two structures are ligated and divided.
After vein dissection and ligation are completed, 30 mg of
papaverine or equivalent is injected into the corpora via the
butterfly needle, and cavernosometry is performed 10 minutes
later. If the abnormal draining veins have been eliminated,
then a rigid erection is easily maintained at a flow of saline
considerably 5 mL per minute (Fig. 75.9). Following this,
the suspensory ligament is reapproximated with a 0 silk suture
ligature between the infrapubic periosteum and the penile
shaft. A no. 10 Jackson-Pratt fenestrated bulb suction drain is
then placed in the wound with the tubing exiting via a sepa-
rate stab incision lateral to the surgical incision. The Scarpa
fascia is closed with a running 3-0 chromic suture, with care
taken to approximate equal tissue planes to minimize the
chance of scar formation resulting in fixation of the base of
the penis. The skin edges are then reapproximated with a run-
FIGURE 75.6 The suspensory ligament is divided to expose the base ning subcuticular 3-0 M onocryl suture. The wound is covered
of the penis. with a standard sterile dressing, and the penis is snugly
FIGURE 75.8 Division of circumflex and emissary

veins on both sides of the deep dorsal vein.
wrapped with a self-adherent Coban wrap. Care is taken to

avoid glanular edema from a dressing that is too tight. The
Foley catheter and the dressing are removed the day after
surgery. The drain is removed as soon as drainage is negligible,
usually in 24 to 48 hours. Patients are discharged from the
hospital on postoperative day 2 or 3. They are advised against
engaging in intercourse for 6 weeks.
Crural Band ing and O t he r Pro ce d ure s

If the crural veins are found to be the only source of major ve-
nous leakage by cavernosography, we perform a crural band-
ing procedure. The crura are exposed near the bulb of the
urethra via a perineal incision, and a 1/4-in. M ersilene ribbon
(Ethicon, Inc.) is used to band the crura (Fig. 75.10). Veins
FIGURE 75.10 Crural banding to correct venous leakage from crural

veins.
draining from the edge of the crura are ligated as well. Crural
banding is not routinely performed at the time of deep dorsal
vein ligation and is usually a secondary procedure. Lue’s group
described (11) recently published their case series on crural
ligation in 11 patients. Cavernosometry and cavernosography
were utilized to diagnose these patients with crural leakage. At
mean follow-up of 34 months, 9 of 11 patients noted marked
improvement in their erectile function.
FIGURE 75.9 Cavernosometry after completion of the dissection Another secondary procedure that is rarely employed is spon-
confirms correction of the venous leak. giolysis. Via a penile scrotal incision, the corpus spongiosum is
exposed and stripped away from the ventral surface of the

corpora cavernosa. All communications between the two Re sult s
structures are ligated or coagulated.
Although individual reports of successful vein ligation proce-
M ore direct approaches to site-specific areas may be used
dures date back to the early 1900s, the modern era of penile
to treat focal venous outflow abnormalities. These can be due
venous surgery did not begin until the development of accu-
to trauma, previous patent shunts for priapism, Peyronie dis-
rate and appropriate diagnostic and surgical techniques. A
ease primary or secondary venous outflow sites, or venous
number of surgeons have since reported on the initial and
leaks secondary to previous stricture repair.
long-term success rates for this procedure. A detailed tabula-
tion of the published results of veno-occlusive surgery for sex-
O UTCO MES ual dysfunction has been prepared by the senior author of this
chaper (9). Some of these outcomes are discussed in the fol-
lowing paragraphs with also more recent data.
Co mp licat io ns Donatucci and Lue (2) reported on 100 patients operated
on between 1986 and 1988. Forty-four patients (44% ) had an
Table 75.1 lists the complications that have been encountered excellent result, defined as a complete return of spontaneous
after penile venous surgery. Complications can be divided into erections rigid enough for penetration, and 24 patients (24% )
immediate and long-term. M ost patients experience some su- noted some improvement in rigidity. All patients were fol-
perficial bruising of the shaft and scrotum. Penile edema is lowed for longer than 1 year after surgery. Knoll et al. (5) re-
usually moderate and resolves within 2 to 3 weeks. The inci- ported a 46% excellent response to surgery in 41 patients
dence of penile edema has decreased since our use of a com- followed for an average of 28 months. Claes and Baert
pression dressing and a closed wound drainage system. (1) similarly reported a return of normal erectile function in
Painful nocturnal erections often occur for the first 24 to 30 of 72 patients (42% ) and a partial response in 23 others
48 hours after surgery. Infrequently, this may last for longer (32% ). Patients were all followed for 1 year.
than 1 week. Wound infection and true hematoma rarely Lewis (8) reported on 60 patients, of whom 16 (27% ) ini-
occur. Care taken during the infrapubic portion of the dissec- tially had return of normal erections. Seventeen other patients
tion can eliminate the risk of postoperative hematoma. (28% ) experienced improved rigidity and were able to have
Despite careful reapproximation of the suspensory liga- intercourse with the aid of intracavernosal pharmacologic in-
ment after the vein dissection is complete, approximately 20% jections for a combined success rate of 55% . All patients were
of patients complain of penile shortening. The amount of per- followed for at least 2 years. O ver time, 13 of the 33 patients
ceived loss of length, however, is rarely clinically or functionally (39% ) who initially experienced a successful result later re-
significant. H ypoesthesia or numbness of the glans or shaft of ported failure of the procedure. Kropman et al. (6) also re-
the penis is a common occurrence after surgery. Patients who ported a 40% late failure rate at a mean follow-up of
report a loss of sensation often experience a diminished ability 28 months in 10 of 20 patients who initially experienced a
to achieve orgasm as well. In most cases, though, penile sensa- successful result from surgery.
tion returns completely within 7 to 9 months. Infrequently, The best long-term results were reported by Sasso et al.
wound scar contractures occur that lead to true penile tether- (12) in 1999. Seventeen of 23 patients (74% ) had normal erec-
ing. In these cases, revision surgery is necessary, consisting of tions within 1 year of venous ligation surgery, and 12 of 17
release of scar tissue and skin Z -plasty. maintained normal spontaneous erectile function long-term.
The authors describe strict operative selection criteria, includ-
ing the need to determine a crucial percentage of smooth muscle
TA B LE 7 5 . 1 ( 30% ) in the corporeal tissue found on preoperative biopsy.
M ost recently H su et al. (3) have reported a repeat venous
COMPLICATION S OF PEN ILE VEN OUS dissection and ligation series in 45 men who failed their first
SURGERY meticulous surgery. Long-term successful erections were
achieved in 35 of the 45 men (78% ), with 4 more obtaining
Immediate
success with the use of prostaglandin E5 inhibitors and 3 more
Common
with intracavernous injection, for a total improved of 91% .
Penile and scrotal bruising
They attribute their success in the first and second operation
Penile edema series to meticulous microsurgery ligation of 76 to 125 sites
Painful nocturnal erections and avoidance of Bovie coagulation and suction.
Rare Several different factors can account for the approximately
Wound infection 40% to 50% immediate failure rate and 75% long-term failure
H ematoma rate of penile venous surgery. Inability to accurately diagnose
Long-term concomitant arterial disease and less extensive venous dissec-
Common tion probably accounts for many of the early patient failures
Penile shortening in the series reported above. With the use of stricter diagnostic
Decreased penile sensation
inclusion criteria and a more aggressive surgical approach,
many of these early failures could have been avoided (3).
Decreased ability for orgasm
Collateralization has limited the long-term success rates of
Rare
other types of venous surgery as well. H su et al. (3) describe
Wound scar contractures and penile tethering most failures as due to residual veins, not recurrent veins. A
Chap t e r 76: Microvascular Arte rial Byp ass Surg e ry for Ere ctile Dysfunction 505
final reason for failure is that the ligation of penile veins may cause of veno-occlusive dysfunction (13). To date, though, no
not address the true underlying pathologic disorder in many practical test is available to accurately diagnose this entity.
patients. Sinus smooth muscle disease that prohibits the ex- Penile venous surgery remains a reasonable surgical option for
pansion of the tunica albuginea and the subsequent compres- highly selected patients with venous leak impotence, particu-
sion of subtunical venules has been postulated as a major larly those with focal or iatrogenic etiology.
References
1. Claes H , Baert L. Cavernosometry and penile vein resection in corporeal 7. Lewis RW. Venogenic impotence. Diagnosis, management, and results.
incompetence: an evaluation of short-term and long-term results. Int J Probl Urol 1991;5:567.
Im pot R es 1991;3:129. 8. Lewis RW. Venous surgery in the patient with erectile dysfunction. A tlas
2. Donatucci CF, Lue TF. Venous surgery: are we kidding ourselves? In: Lue Urol Clin N orth A m 1993;1:21.
TF, ed. W orld book of im potence. London: Smith-Gorthdon and Co, 1992: 9. Lewis RW. M unarriz R. Vascular surgery for erectile dysfunction. In: Wein
221–227. AJ, et al., eds. Cam pbell-W alsh urology, 9th ed. Philadelphia: Saunders
3. H su GL, Chen H S, H sieh CH , et al. Insufficient response to venous strip- Elsevier, 2007:802–817.
ping surgery: is the penile vein recurrent or residual? J A ndrol 2006; 10. Peskircioglu L, Tekin I, Boyvat F, et al. Embolization of the deep dorsal
27:700. vein for the treatment of erectile impotence due to veno-occlusive dysfunc-
4. King BF, Lewis RW, M cKusick M A. Radiologic evaluation of impotence. tion. J Urol 2000;163:472.
In: Bennett AH , ed. Im potence. D iagnosis and m anagem ent of erectile dys- 11. Rahman N , Dean R, Carrion R, et al. Crural ligation for primary erectile
function. Philadelphia: WB Saunders, 1994:52–91. dysfunction: a case series. J Urol 2005;173:2064.
5. Knoll LD, Furlow WL, Benson RC. Penile venous ligation surgery for the 12. Sasso F, Gulino G, Weir J, et al. Patient selection criteria in the surgical
management of cavernosal venous leakage. Urol Int 1992;49:33. treatment of veno-occlusive dysfunction. J Urol 1999;161:1145.
6. Kropman RF, N ijeholt AABL, Giespers AGM , et al. Results of deep penile 13. Wespes E, M oreira De Goes P, Sattar AA, et al. O bjective criteria in the
vein resection in impotence caused by venous leakage. Int J Im pot R es long-term evaluation of penile venous surgery. J Urol 1994;152:888.
1990;2:29.
CHAPTER 76 ■ MICRO VASCULAR ARTERIAL

BYPASS SURGERY FO R ERECTILE
DYSFUNCTIO N
IRWIN GO LDSTEIN AND MARTIN BASTUBA
When a middle-aged or elderly man (age 50 or more years) existence of vasculogenic erectile dysfunction in younger men?
presents to a physician with complaints of consistent or persis- Unfortunately, many physicians who evaluate younger men do
tent inability to obtain and/or maintain a penile erection for not seek a history of blunt perineal trauma. Endothelial dys-
satisfactory sexual activity, the “ new” thinking is that the function resulting in focal arterial occlusive disease can be as-
diagnosis is likely organically based erectile dysfunction. This sociated with a history of blunt trauma (3). Evidence for
is especially true if the patient also has a history of diabetes, trauma-associated focal arterial obstructive pathology is well
hypertension, high cholesterol, cigarette smoking, or myocar- established in the medical literature for several other arterial
dial infarction (1). This contemporary knowledge represents a beds (4). Such arterial beds include the radial artery (construc-
shift in understanding; 40 years ago, at the time of M asters tion workers), the axillary artery (crutch-related injuries), and
and Johnson, most of erectile dysfunction was thought to be the popliteal artery (football players). The distal internal pu-
psychogenic in origin and sex therapy and cognitive behavior dendal, common penile, and proximal cavernosal arteries are
therapy were the primary treatment options. There are wide- susceptible to blunt trauma by virtue of the anatomic relation-
spread data to support an organic vascular pathophysiologic ship to the ischiopubic rami within the Alcock canal. They can
basis of erectile dysfunction in strong association with be injured during bicycle riding (5) and other sources of strad-
endothelial dysfunction in older men with vascular risk dle injuries such as blows to the perineum during martial arts.
factors (2). The aim of this chapter is to expand the knowledge con-
H owever, when a young man (age teens to 40 years) pre- cerning microvascular arterial bypass surgery as a therapeutic
sents to a physician with complaints of erectile dysfunction, option for young patients with erectile dysfunction secondary
the “ old” thinking still prevails and the diagnosis most likely to focal arterial obstructive pathology. Data supporting the
to be considered is psychogenically based erectile dysfunction. existence of traumatic-associated vasculogenic erectile dysfunc-
Why do practitioners have such great difficulty accepting the tion and the associated diagnostic and therapeutic paradigm
in young men will be reviewed. The overall goal is to stimulate and progressive occlusive arterial pathology over time, leading
basic science and clinical research in the management of to diminished systolic arterial perfusion pressures and dimin-
young men with erectile dysfunction. ished erectile hardness during sexual stimulation.
Bicycle Rid ing and Ere ct ile Dysfunct io n

ERECTILE FUNCTIO N PHYSIO LO GY
Data in the peer review medical literature of an appropriate
Penile erectile function results following autonomic caver- level of scientific evidence show an association of erectile dys-
nosal nerve stimulation (6). N itric oxide synthase (N O S), an function with those who ride bicycles.
enzyme in lacunar space vascular endothelial cells and auto- M arceau et al. (9) studied a community-based popula-
nomic cavernosal nerve endings, facilitates the synthesis of ni- tion exceeding 1,700 men 40 to 70 years of age. The odds
tric oxide (N O ) from molecular oxygen and L-arginine. ratio for men developing moderate to severe erectile dysfunc-
During sexual stimulation, nitric oxide (N O ) activates gua- tion who acknowledged riding 3 hours per week was 1:72.
nylyl cyclase, an enzyme that facilitates the synthesis of the This analysis was performed where covariates were factored,
second messenger, cyclic guanosine monophosphate (cGM P) such as age, energy expenditure, body mass index, cigarette
from guanosine triphosphate (GTP). The elevated concentra- smoking, depression, cancer, high blood pressure, and
tions of cGM P result in lowered intracellular calcium, thus diabetes.
promoting penile smooth muscle relaxation. Biologic conse- Schrader et al. (10) published a unique N ational Institute
quences of N O -cGM P relaxation include increased arterial for O ccupational Safety and H ealth study of bicyclists involv-
blood inflow, engorgement of the lacunar spaces, lengthening ing the determination of nocturnal penile tumescence activity
and enlargement of the corporal erectile tissue within the con- as recorded by RigiScan and perineal or nose pressure
strained tunica albuginea, and eventual subtunical venule oc- recorded by specialized pressure-sensitive sheets placed over
clusion with increased penile venous outflow resistance and the rider’s saddle. They reported a significant inverse correla-
corporal veno-occlusive function (7). tion between the magnitude of nose pressure values and the
percentage of sleep time in erection. Control subjects exhib-
ited 30% sleep time in erection, whereas those who rode
with nose pressures exceeding 1,000 and 2,000 U revealed
ERECTILE DYSFUNCTIO N 20% sleep time in erection.
PATHO PHYSIO LO GY Dettori et al. (11) reported on the erectile dysfunction char-
acteristics of several hundred men who performed long-
The N O S-N O -cGM P pathway is, in part, interfered with by distance bicycle rides. In those men who exceeded 328
multiple organic pathophysiologies, including hypogonadism, kilometers, who complained of current perineal numbness,
hypothyroidism, and metabolic conditions such as diabetes and who used a saddle with a cutout (which acted to lower
and reduced insulin sensitivity, metabolic syndrome, low surface area contact and increase perineal compressure pres-
testosterone, elevated body mass index, elevated waist circum- sures), a surprising 18% were found at risk for developing
ference, abnormal lipids, elevated blood pressure, sedentary erectile dysfunction.
lifestyle, cigarette smoking, and increased age. Endothelial Cohen and Gross (12) studied 30 male cyclists and exam-
dysfunction ultimately leads to reduced arterial blood inflow ined transcutaneous penile oxygen pressures. Compared to
and arterial systolic perfusion pressures during erection (8). values obtained during standing, cyclists who straddled on
commercially available saddles with nose extensions such as
the Vetta Lite, Terry, and Specialized exhibited significant re-
Fo cal End o t he lial Dysfunct io n ductions in transcutaneous penile oxygen pressures.
Se co nd ary t o Trauma-Asso ciat e d Leibovitch and M or (13) performed a literature search of
Ere ct ile Dysfunct io n 62 articles in the peer review medical literature on bicycling
and genitourinary disorders. They reported that 13% to 24%
There is a puzzling resistance to acknowledge that focal en- of bicyclists in the literature claimed erectile dysfunction. They
dothelial dysfunction may also occur following blunt trauma concluded that although bicycling is associated with estab-
to the distal internal pudendal, common penile, and proximal lished cardiovascular benefits, it was a not infrequent cause of
arteries. These critical arteries to erectile function lie in close injury to the genitourinary system.
proximity to the hard bony surface, the lateral aspect of the Bacon et al. (14) reported that the risk of developing erec-
Alcock canal, the ischiopubic rami. Endothelial injuries in- tile dysfunction among the 20,000 men in the H ealth
duced by blunt trauma may be classified as either nondenuded Professional Follow-up Study who were healthy and had good
or denuded. While some nondenuded endothelial injuries may or very good erectile function before the study decreased as
spontaneously heal, some progress to frank endothelial dys- the subjects reported increasing metabolic energy transfer
function, increased permeability, and thrombogenicity to units (M ETS) during various exercise forms, including bicy-
eventually, over a variable time period, focal atherosclerosis, cling. The authors also performed a unique multivariate and
focal arterial lumen stenosis, and reduced systolic arterial per- total physical activity subanalysis of the data by the various
fusion pressures. Denuded endothelial injuries that result fol- exercise forms. The risk of developing erectile dysfunction
lowing blunt trauma to the arterial wall often result in medial among healthy participants who had good or very good erec-
smooth muscle cell proliferation, smooth muscle cell migra- tile function before the study (and no prostate cancer) was re-
tion, myointimal thickening, extracellular matrix production, duced at the highest tertile of physical activity such as jogging,
running, swimming, tennis, rowing, and squash or raquetball. risk factors, who have erectile dysfunction of a pure arterio-
Curiously, there was no risk lowering for bicycle riding. genic nature represent the ideal patient population for this
Goldstein et al. (19) reported in the Journal of Sex ual procedure.
M edicine a prospective study recording cavernosal artery peak The diagnostic algorithm is aimed at ensuring that this op-
systolic velocity values using duplex Doppler ultrasound in eration is performed on the ideal candidate, that is, one in
men who lay supine, sat on the examination table, straddled a whom there is erectile dysfunction purely on the basis of arte-
saddle, sat on a two-cheek noseless seat, and then lay supine. rial insufficiency. All young patients with a history suggestive
In all subjects who straddled a saddle, peak systolic velocity of trauma-associated impotence (pelvic fractures and perineal
values approached zero. All remaining interventions were as- trauma) should undergo a comprehensive history, physical ex-
sociated with mean peak systolic velocity values that were not amination, and psychologic interview. They should have a
significantly different from each other and that ranged from routine endocrinologic evaluation to ensure adequate circulat-
20 to 26 cm per second. It was estimated that the compression ing levels of unbound, free testosterone. Duplex Doppler ul-
pressure on the perineum while bearing body weight on a bi- trasonography should be performed to provide diagnostic
cycle saddle exceeded 300 mm H g (15). hemodynamic data (cavernosal peak systolic and end-diastolic
Another study published in the Journal of Sex ual M edicine velocities) and preoperative information such as the presence
was performed, for the first time with women bicyclists. This of communicating branches from the dorsal to the cavernosal
study is being reported because it is likely that blunt perineal artery. Finally, vascular assessment by dynamic infusion caver-
trauma causes similar injuries to perineal contents in women. nosometry should be considered to document the degree of ar-
O ther than the pudendal artery, critical structures in the terial pressure gradients between the brachial artery and the
Alcock canal in both genders include the pudendal nerve. In cavernosal arteries and to further evaluate the veno-occlusive
this study, female bicyclists were compared to female runners function. Following hemodynamic diagnosis, if the patient has
for the value of vibration quantitative sensory testing by bio- pure arterial insufficiency, a selective internal pudendal arteri-
thesiometry. Female bicyclists had significantly lowered sensa- ogram should be performed to confirm the location of the ob-
tion in the clitoris, labia, and vaginal introitus compared to structive lesion, most often in the common penile or
runners (16). cavernosal artery(ies), and to select the best inferior epigastric
An additional study in the Journal of Sex ual M edicine ex- artery (18).
amined whether noseless bicycle saddles would be an effective
intervention for alleviating deleterious health effects, erectile
dysfunction, and groin numbness caused by bicycling on the
traditional saddle with a protruding nose extension. N inety SURGICAL CRITERIA
bicycling police officers from five metropolitan regions in the
United States (N orthwest, Southern, Desert West, M idwest, The success of this operation is based on the selection of
and Southeast) using traditional saddles were evaluated prior the correct operative candidate and the microsurgical capabil-
to changing saddles and then again after 6 months of using the ities of the surgeon. To this end, the following represents a
noseless bicycle saddle. The findings showed that use of the list of criteria to ensure optimum results. The criteria are as
noseless saddle resulted in a reduction in saddle contact pres- follows:
sure in the perineal region. There was a significant improve- 1. The patient’s history is characterized by (a) intact libido,
ment in penile tactile sensation, and the number of men who (b) a consistent reduction in erectile rigidity during sexual
used no-nose saddles and who indicated they had not experi- activity, (c) variable sustaining capability with the best
enced genital numbness while cycling for the preceding 6 maintenance of the rigidity during early morning erec-
months rose from 27% to 82% . Use of the noseless saddle tions, and (d) poor spontaneity of erections, taking much
also resulted in significant increases in erectile function as as- effort and excessive time to achieve the poorly rigid erec-
sessed by the initial evaluation. With few exceptions, bicycle tile response.
police officers were able to effectively use no-nose saddles in 2. N ormal hormonal and neurologic evaluation.
their police work, and 97% of officers completing the study 3. Suspicion of arterial insufficiency as evidenced by reduced
continued to use the no-nose saddle afterward. In summary, peak systolic velocity values during duplex Doppler ultra-
for the first time, a prospective study of healthy policemen rid- sonography and increased arterial gradients during caver-
ing bikes using wider no-nose bike saddles for 6 months re- nosal artery occlusion pressure determination using
vealed improved perineal sensation and improved erectile dynamic infusion cavernosometry.
function. Changing saddles changed physiology (17). 4. N ormal veno-occlusive parameters during both duplex
Doppler ultrasonography and dynamic infusion caver-
nosometry.
5. The presence of a distal occlusive lesion in one or both hy-
DIAGNO STIC TESTING pogastric-cavernous arterial beds, usually within the com-
mon penile artery or cavernosal artery, that is amenable to
The overall goal of microvascular arterial bypass surgery is to distal bypass (Fig. 76.1).
create an alternative arterial inflow route around obstructive 6. The presence of an inferior epigastric artery of sufficient
arterial lesions in the hypogastric-cavernous arterial bed. The length to allow anastomosis to the dorsal artery (Fig. 76.2).
specific objective of the surgery is to increase the cavernosal 7. The presence of a communication branch(es) between the
arterial perfusion pressure and arterial blood inflow in pa- dorsal artery and the cavernosal artery distal to the occlu-
tients with vasculogenic erectile dysfunction secondary to sion that will allow the inflow of new blood and the devel-
pure arterial insufficiency. Young men, without other vascular opment of increased intracorporal pressure.
A B
C D
FIGURE 76.1 The presence of a distal occlusive lesion on selective internal pudenal arteriography in one
or both hypogastric-cavernous arterial beds, usually within the common penile artery or cavernosal
artery that is amenable to distal bypass, is an inclusion criterion for microvascular arterial bypass surgery.
A B
FIGURE 76.2 A: An inferior epigastric artery of sufficient length to allow anastomosis to the dorsal
artery. B: The inferior epigastric artery bifurcates too early to provide sufficient donor artery length. This
will place the anastomosis under risk for excessive tension.
rectus muscle) relaxation and facilitates harvesting the donor

ALTERNATIVE THERAPY inferior epigastric artery vessel. The patient’s abdomen and
genitalia are carefully shaved, prepared, and draped, follow-
N onsurgical treatment options for young men with erectile ing which a 16Fr Foley catheter is placed using sterile tech-
dysfunction include psychotherapeutic, hormonal, pharmaco- nique. The patient is given one dose of preoperative
logic, and external device interventions. Surgical treatment antibiotics (cefazolin or vancomycin if penicillin allergic).
options consist primarily of penile prosthesis insertion. From a technical standpoint, the operation can be divided into
three stages: dorsal artery dissection, inferior epigastric artery
harvesting, and microsurgical anastomosis (19).
SURGICAL TECHNIQ UE
The patient is placed supine on the operating table and his Do rsal Art e ry Disse ct io n
arms secured next to his body to minimize upper-extremity
nerve injuries. As this operation may last in excess of 5 hours, A curvilinear incision is made, in general on the side opposite
great care must be taken in the positioning and padding of the the planned abdominal incision for the donor inferior epigas-
limbs, in particular the neurovascular points on the upper tric artery harvesting (Fig. 76.3A). The advantages of this inci-
limbs. Sequential compressive devices are placed aouund each sion are that it offers (a) excellent proximal and distal
calf. General endotracheal anesthesia with complete muscle exposure of the penile neurovascular bundle, (b) the ability to
relaxation provides complete skeletal muscle (especially the preserve the fundiform ligament preventing penile shortening,
A B
FIGURE 76.3 A: A curvilinear incision is made, in general on

the side opposite to the planned abdominal incision for the
donor inferior epigastric artery harvesting. The advantages of
this incision are that it offers (a) excellent proximal and distal
exposure of the penile neurovascular bundle, (b) the ability to
preserve the fundiform ligament, preventing penile shortening,
and (c) the absence of unsightly postoperative scars on the
penile shaft or at the base of the penis. Use of a Scott ring re-
tractor with its elastic hooks maximizes operative exposure of
the penis with a minimum of assistance. B: The penis is inverted
through the skin incision, with care taken to push the glans in
fully. C: The preselected right or left dorsal penile artery is iden-
tified. The course of the appropriate dorsal artery is followed
proximally underneath the fundiform ligament, with care being
taken to leave the fundiform ligament intact. Blunt dissection is
performed under the proximal aspect of the fundiform ligament
C above the pubic bone toward the external ring.
and (c) the absence of unsightly postoperative scars on the pe-

nile shaft or at the base of the penis. Use of a Scott ring retrac-
tor with its elastic hooks maximizes operative exposure of the
penis with a minimum of assistance.
The incision is made 2 fingerbreadths from the base of the
penis, from a point opposite the ventral root of the penis, to
the scrotal median raphe. This incision is carried down through
the dartos layer using blunt dissection. The ipsilateral tunica
albuginea is subsequently identified at the midpenile shaft.
With the penis stretched, blunt finger dissection along the tu-
nica albuginea is performed in a distal direction deep and infe-
rior to the spermatic cord structures along the lateral aspect of
the penile shaft, avoiding injury to the fundiform ligament.
The penis is then inverted through the skin incision, with
care taken to push the glans in fully (Fig. 76.3B). The penis
must not be tumesced during this maneuver. If a partial erec-
tion is present, an intracavernosal alpha-adrenergic agonist
(100 g phenylephrine) should be administered. Blunt finger
dissection around the distal penile shaft enables a plane to be FIGURE 76.4 A transverse semilunar abdominal incision following
established between the Buck fascia and the Colles fascia, and Langer lines is the preferred incision. The transverse incision provides
a Penrose drain is secured in this plane. excellent operative exposure of the inferior epigastric artery and heals
with a more cosmetic scar compared to those observed with parame-
Exposure of the neurovascular bundle and, in particular,
dian skin incisions. The starting point of the transverse incision is ap-
the right and left dorsal penile arteries is now performed. The proximately three-fourths of the total distance from the pubic bone to
arteries are usually obvious, located on either side of the deep the umbilicus in the midline. It extends laterally along Langer lines for
dorsal vein and surrounded by the dorsal nerves. Isolation of approximately 5 cm.
the dorsal penile arteries for such arterial bypass surgery re-
quires limited dissection at this time in the procedure; thus,
ischemic, mechanical, and thermal trauma to the dorsal penile junction between the rectus muscle and underlying preperi-
arteries may be minimized. To avoid injurious vasospasm, toneal fat is identified and the preperitoneal space is entered.
topical papaverine hydrochloride irrigation is applied fre- The rectus muscle is reflected medially.
quently. In this way, preservation of endothelial and smooth The inferior epigastric artery and its two accompanying
muscle cell morphology during dorsal artery preparation is en- veins are located beneath the rectus muscle in the preperi-
sured. This is very critical as the room temperature of the op- toneal plane. The ring retractor is again utilized to optimize
erating room, the use of room temperature irrigating solution, operative exposure. It is critical to harvest an inferior epigas-
and even the skin incision can induce vasoconstriction, spasm, tric artery of sufficient length to prevent tension on the mi-
and possible endothelial cell damage. crovascular anastomosis. Application of topical papaverine is
The preselected right or left dorsal penile artery is identi- utilized on the inferior epigastric artery throughout the dissec-
fied. The course of the appropriate dorsal artery is followed tion. Thermal injury is avoided using low-current microbipo-
proximally underneath the fundiform ligament, with care be- lar cautery set at the minimum level necessary for adequate
ing taken to leave the fundiform ligament intact (Fig. 76.3C). coagulation, and the vasa vasorum are preserved by dissecting
Blunt dissection is performed under the proximal aspect of the the artery en bloc with its surrounding veins and fat.
fundiform ligament above the pubic bone toward the external Dissection of the inferior epigastric is required from its origin
ring. This dissection enables the inferior epigastric artery to at the level of the external iliac artery to a point at the level of
pass from its abdominal location to the appropriate location the umbilicus.
in the penis while simultaneously preserving the fundiform The transfer route of the neoarterial inflow source is pre-
ligament. The penis is placed back in its normal anatomic po- pared from the abdominal perspective prior to transecting the
sition and the inguinoscrotal incision is temporarily closed vessel distally (the penile transfer route has previously been
with staples. dissected). The temporary scrotal staples are removed and the
penis is reinverted. The internal ring on the side of the har-
vested artery is identified lateral to the origin of the inferior
Harve st ing o f t he Infe rio r Ep ig ast ric epigastric artery. Using blunt finger dissection through the in-
Art e ry guinal canal, a long fine vascular clamp is passed through the
fenestration in the fundiform ligament and the external and
A transverse semilunar abdominal incision following Langer internal inguinal rings, and a Penrose drain is placed to pro-
lines is the preferred incision. The transverse incision provides tect this transfer route.
excellent operative exposure of the inferior epigastric artery The donor inferior epigastric artery vascular bundle is tran-
and heals with a more cosmetic scar compared to those ob- sected at the level of the umbilicus between two LigaClips and
served with paramedian skin incisions. The starting point of carefully inspected for any proximal bleeding points. This
the transverse incision is approximately three-fourths of the donor artery should pulsate briskly (Fig. 76.5A). All attach-
total distance from the pubic bone to the umbilicus in the ments to the retroperitoneal fat are carefully removed prior to
midline (Fig. 76.4). It extends laterally along Langer lines for artery transfer as any attachments will diminish donor artery
approximately 5 cm. The rectus fascia is incised vertically. The length and place the subsequent anastomosis with the dorsal
A B
FIGURE 76.5 A: The donor inferior epigastric artery vascular bundle is transected at the level of the umbilicus
between two LigaClips and carefully inspected for any proximal bleeding points. This donor artery should pul-
sate briskly. All attachments to the retroperitoneal fat are carefully removed prior to artery transfer as any
attachments will diminish donor artery length and place the subsequent anastomosis with the dorsal artery at
risk due to excessive tension. B: Using blunt finger dissection through the inguinal canal, a long fine vascular
clamp is passed through the fenestration in the fundiform ligament and the external and internal inguinal rings,
and a Penrose drain is placed to protect this transfer route. The inferior epigastric vascular bundle is transferred
to the base of the penis. It should be briskly pulsating and of adequate length.
artery at risk for being made under undue tension. The long The rectus fascia is closed utilizing a running 0 polyglycolic
fine vascular clamp is brought through the internal inguinal acid suture, one suture started at either end of the incision.
ring again, this time to grasp the end of the transected inferior O n-Q SilverSoaker catheters, which will stay in place postop-
epigastric artery. The inferior epigastric vascular bundle is eratively for 48 to 72 hours, are placed below and above the
transferred to the base of the penis (Fig. 76.5B). It should be rectus fascia, and 0.5% M arcaine is delivered at 2 mL per
briskly pulsating and of adequate length. The origin of the in- hour through each catheter (Fig. 76.6A). The skin edges are
ferior epigastric artery should be inspected for kinking or opposed using 4-0 M onocryl, and Dermabond is applied over
twisting. Following the achievement of complete hemostasis, the skin incision. O n-Q SilverSoaker catheters are secured to
closure of the abdominal wound is performed in two layers. the skin temporarily using Steri-Strips (Fig. 76.6B).
A B
FIGURE 76.6 A: O n-Q SilverSoaker catheters, which will stay in place postoperatively for 48 to 72 hours, are
placed one each below and above the rectus fascia, and 0.5% M arcaine (plain) is delivered at 2 mL per hour
through each catheter. B: The skin edges are opposed using 4-0 M onocryl, and Dermabond is applied over the
skin incision. The O n-Q SilverSoaker catheters are secured to the skin temporarily using Steri-Strips.
A B
FIGURE 76.7 A: Prior to the anastomosis, it is appropriate to assess the integrity of the donor inferior
epigastric perfusion pressure. Grossly this is assessed by temporarily removing pressure on the gold-
plated (low-pressure) aneurysm vascular clamps under minimal tension. The donor artery should exhibit
brisk arterial inflow. B: Following release of the temporary occluding vascular clamps on the dorsal pe-
nile artery, the anastomosed segment should reveal arterial pulsations along its length and retrograde into
the inferior epigastric artery. Such an observation implies a patent anastomosis. At this time, the inferior
epigastric artery gold-plated aneurysm clamp may be removed. The intensity of the arterial pulsations in
the anastomosis usually increases.
Micro vascular Anast o mo sis the vessel wall. The preservation of the adventitia is also im-
portant in terms of vessel innervation.
A ring retractor and the associated elastic hooks are utilized Prior to the anastomosis, it is appropriate to assess the in-
once again on the inguinoscrotal incision and the fenestration tegrity of the donor inferior epigastric perfusion pressure. This
of the fundiform ligament to gain exposure of the proximal is assessed grossly by temporarily removing pressure on the
dorsal neurovascular bundle. The pulsating inferior epigastric gold-plated (low-pressure) aneurysm vascular clamps under
artery is placed against the recipient dorsal penile arteries, and minimal tension (Fig. 76.7A). The donor artery should exhibit
a convenient location is selected for the vascular anastomosis. brisk arterial inflow. A plastic colored background material
The anastomosis is created based on the arteriographic and is used to aid in vessel visualization under the microscope.
duplex Doppler ultrasound findings. An end-to-end anasto- An end-to-end anastomosis is performed between the inferior
mosis is best under conditions whereby dorsal penile artery epigastric artery and the dorsal artery using interrupted 10-0
communications exist to the cavernous artery. In addition, an N ylon sutures (single-armed, 100-mm, 149-degree curved
end-to-end anastomosis transfers perfusion pressure more ef- needle) under 10 magnification. Sutures are usually passed
fectively than an end-to-side anastomosis with less turbulence. from the outside of the inferior epigastric artery (1 mm from
For intraluminal arterial irrigation, we utilize a dilute pa- the cut edge) to the inside lumen and then from the inside of
paverine, heparin, and electrolytic solution believed to be ca- the dorsal artery lumen to the outside wall of the dorsal artery
pable of inhibiting the early development of myointimal (1 mm from the cut edge) and then tied. Usually 15 or more
proliferative lesions during surgical preparation. interrupted sutures are used. All sutures used to complete the
The appropriate dorsal penile artery segment is freed from anastomosis are inserted equidistant from each other to avoid
its attachments to the tunica albuginea, with care being taken an uneven anastomosis.
to avoid injury to any communicating branches to the caver- Following release of the temporary occluding vascular
nosal artery. Vascular hemostasis of this segment of the dorsal clamps on the dorsal penile artery, the anastomosed segment
penile artery may be achieved with or gold-plated (low- should reveal arterial pulsations along its length and retro-
pressure) aneurysm vascular clamps under minimal tension grade into the inferior epigastric artery. Such an observation
for the minimal of operating time. The only location where implies a patent anastomosis. At this time, the inferior epigas-
the adventitia must be carefully removed is at the site of the tric artery gold-plated aneurysm clamp may be removed. The
vascular anastomosis, that is, the distal end of the inferior epi- intensity of the arterial pulsations in the anastomosis usually
gastric artery and the free end of the dorsal artery, to avoid increases (Fig. 76.7B). O n occasion, the application of a small
causing subsequent thrombosis. If segments of adventitia enter amount of hemostatic material may be needed to aid in pro-
the anastomosis, the patency of the anastomosis is in jeopardy moting hemostasis from suture needle holes in the vessel walls.
as adventitia activates clotting factors from the extrinsic clot- After complete hemostasis has been achieved and correct
ting system. The remaining adventitia should be preserved in instrument and sponge counts are ensured, closure of the in-
the vessels as the vasa vasorum provide a nutritional role to guinoscrotal incision may begin. The dartos layer is reapprox-
success rate (clinically relevant improvement in erectile func-

tion) is approximately 65% to 70% . Since relocating to San
Diego, a review has been made of the latest 30 microvascular
arterial bypass procedures using postoperative validated out-
come scales, ultrasonography, and arteriography. The scores
of the International Index of Erectile Function have improved
significantly in the total score, the erectile function domain,
the desire domain, the orgasm domain, the intercourse satis-
faction domain, and the overall satisfaction domain. There
has been marked and significant lowering of the sexual dis-
tress scale. Postoperative duplex Doppler ultrasonography has
confirmed marked increases in cavernosal artery peak systolic
velocity. Postoperative selective inferior epigastric arteri-
ograms have been performed that have documented intact ar-
terial anastomoses between the inferior epigastric artery and
the dorsal penile artery with subsequent visualization of con-
trast in the cavernosal artery (Fig. 76.9). Finally, use of O n-Q
pump delivery of M arcaine for 48 to 72 hours has resulted in
significant lowering of postoperative morphine and Percocet
FIGURE 76.8 After complete hemostasis has been achieved and cor- while the patients have simultaneously experienced excellent
rect instrument and sponge counts are ensured, closure of the inguino- pain relief.
scrotal incision may begin. The dartos layer is reapproximated using
3-0 polyglycolic acid sutures in a running fashion. The skin edges are
opposed using 4-0 M onocryl, and Dermabond is applied over the skin
incision. The O n-Q SilverSoaker catheters are coiled and secured to
the skin with Tegaderm. A compressive scrotal dressing is placed using
fluffs and Elastoplast. The Foley catheter is left to closed-system grav-
ity drainage overnight.
imated using 3-0 polyglycolic acid sutures in a running fash-

ion. The skin edges are opposed using 4-0 M onocryl, and
Dermabond is applied over the skin incision. The O n-Q
SilverSoaker catheters are resecured to the skin with
Tegaderm. A compressive scrotal dressing is placed using
fluffs and Elastoplast. The Foley catheter is left to closed-
system gravity drainage overnight (Fig. 76.8).
CO MPLICATIO NS A
M echanical disruption of the microvascular anastomosis and
subsequent uncontrolled arterial hemorrhage may occur from
blunt trauma in the first few postoperative weeks following
coitus or masturbation, or from accidents. Abstention from
sexual activities involving the erect penis is recommended un-
til 6 weeks postoperatively. O ther complications include pe-
nile pain and diminished penile sensation from injury to the
nearby dorsal nerve. Loss of compliance of the suspensory and
fundiform ligaments postoperatively may lead to diminished
penile length. Preserving the two ligaments has markedly min-
imized those complications in our series. Glans hyperemia,
once a complication seen when anatomoses between the infe-
rior epigastric artery and the deep dorsal vein (dorsal vein ar-
terialization) were performed, is no longer seen because we no
longer perform this kind of anastomosis.
RESULTS B
FIGURE 76.9 Postoperative selective inferior epigastric arteriograms
M icrovascular arteral bypass surgery has been performed in document intact arterial anastomoses between the inferior epigastric
this above fashion since 1981. An estimated 1,500 procedures artery and the dorsal penile artery with subsequent visualization of
have been performed over 25 years. It is estimated that the contrast in the cavernosal artery.
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cases. Folia M orphol (W arsz) 2006;65(2):116–120. dynamic study of the perineum-saddle interface in men with erectile dys-
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from erectile dysfunction to priapism. J Sex M ed 2006;3(4):578–582. penis. J Sex M ed 2008;5(8):1932–1940.
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dysfunction. J Sex M ed 2005;2(1):26–39. erectile dysfunction: data and solutions. Curr Urol R ep 2007;8(6):
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CHAPTER 77 ■ PENILE TRAUMA

DANIEL I. RO SENSTEIN, ALLEN F. MO REY, AND JACK W. MCANINCH
Trauma to the penis is an uncommon event. Because of the rel- out of bed with an erect penis, masturbation, or manipulation
atively protected position of the penis between the thighs and of the erect penis. The patient often reports a cracking or pop-
pubic bone, it is usually able to avoid direct injury from exter- ping noise at the time of injury, leading to immediate detumes-
nal forces. N onetheless, penile trauma may arise from both cence and rapid onset of discoloration and swelling over the
blunt and penetrating injuries. Such injuries present unique site of injury. There is frequently a delay in presentation to the
and difficult management problems to the urologic surgeon, hospital—presumably secondary to patient embarrassment.
in particular regarding long-term cosmesis, voiding function,
and future potency. M ajor blunt penile injuries include penile
rupture and skin loss from strangulation or degloving injuries. Diag no sis
Penetrating penile trauma is usually secondary to stab or gun-
shot wounds and thus seldom occurs in the absence of associ- The diagnosis of penile rupture is easily made by physical ex-
ated genital, urethral, or major organ injury, except in the amination along with the appropriate history. Swelling and
event of bites and self-inflicted wounds. Due to the wide dis- discoloration may or may not be limited to the penis, depend-
parity in the causes, diagnosis, and treatment, this chapter is ing on the integrity of the Buck fascia. If the Buck fascia is in-
divided into three parts: penile rupture, penile skin loss, and tact, the hematoma will be contained and will not usually
penetrating penile trauma. spread below the base of the penis, resulting in the typical
“ eggplant” deformity (Fig. 77.1). H owever, if the laceration in
the tunica albuginea involves the Buck fascia, extravasation
PENILE RUPTURE will be contained by the Colles fascia and ecchymosis will ex-
tend in a “ butterfly” distribution over the perineum, scrotum,
The most common blunt injury involving the penis is rupture and lower abdomen. Examination may reveal angulation of
of the corpora cavernosa, or penile fracture. This almost the penis away from the side of rupture because of the mass
invariably occurs when the erect penis is forced to bend in an effect of the hematoma. In addition, focal tenderness and a
irregular fashion, such as when it accidentally impinges on the palpable defect in the tunica albuginea may help localize the
pubis or perineum after slipping out of the vagina during sex- fracture site. There is often a clot lying over or near the frac-
ual intercourse (11). The remainder of cases are caused by falls ture site that corresponds to the site of cavernosal rupture.
Chap t e r 77: Pe nile Trauma 515

Conservative treatment consists of cool compression dress-
ings, anti-inflammatory agents, and sedatives to reduce erec-
tions. This results in eventual resorption of the hematoma and
scar formation at the site of the tunical rupture.

The patient is placed in a supine position and a Foley catheter
is placed to facilitate identification of the urethra and urinary
drainage. Exposure is usually obtained through a subcoronal
circumferential incision, and the penile skin is degloved down
to the base. The distal circumferential incision is favored
because it allows both exposure of the ruptured corpus and
adequate assessment of the contralateral corpus and corpus
spongiosum. Alternatively, an incision may be made on the
shaft directly over the fracture site. This approach is only use-
ful if the fracture is palpable preoperatively as the corporal
bodies may not be easily explored through this incision.
Further, the corpus spongiosum cannot be directly inspected
via this approach.
FIGURE 77.1 Fractured penis displaying the pathognomonic “ egg- Following the circumcising incision, the corpus spongio-
plant deformity” with swelling and discoloration extending to the sum is carefully inspected to evaluate for potential urethral in-
base of the shaft. The penis usually bends away from the side of injury jury. Inspection of the fracture site usually reveals a transverse
because of the hematoma. laceration, between 0.5 and 2.0 cm long, in the tunica albu-
ginea of the proximal penile shaft (4). After evacuation of the
hematoma and irrigation, minimal debridement of nonviable
wound edges may be necessary before closure with interrupted
Penile rupture can occur anywhere along the shaft, includ- 4-0 M axon sutures (Fig. 77.2). The surgeon should not probe
ing the base of the penis, where the corpora are fixed by the the exposed cavernous tissue unnecessarily as this may elicit
penile suspensory ligament. The fracture is typically located at troublesome bleeding. A tourniquet may be used intraopera-
the base of the penis, just proximal to the penoscrotal junc- tively to control hemorrhage. Lacerations may run directly un-
tion. In general only one corporal body is injured, although der the dorsal neurovascular bundle located on the dorsal
both corpora and the corpus spongiosum can be affected de-
pending on the severity of the injury. M ost patients are able to
urinate normally, but the urologist must maintain a high index
of suspicion for urethral injury. Failure to void spontaneously
may signify compression of the urethra by hematoma but
should lead to evaluation of urethral injury by retrograde ure-
thrography (RUG). Urethral injury occurs in up to one third
of cases and usually consists of partial disruption, although
complete transection can result (10). RUG is mandatory in all
patients with blood at the urethral meatus, hematuria of any
extent, or inability to void (11). H owever, because RUG is
easy to perform and provides reliable results, we perform it
routinely in all cases of suspected penile rupture. Adjunctive
imaging studies in penile fracture (including ultrasound, mag-
netic resonance imaging, and cavernosography) are usually
unnecessary as the clinical picture is frequently adequate to
initiate therapy.

Although penile fractures can be managed nonoperatively, the FIGURE 77.2 Identification and repair of penile fracture. A distal cir-
literature shows a clear advantage to early operative repair cumferential subcoronal incision is made and skin and soft tissue are
(10,11). This approach results in faster recovery, shorter hos- mobilized off the underlying corporal bodies down to the base of the
penis. This maneuver exposes the transverse laceration in the tunica
pital stay, less morbidity, and less long-term penile curvature. albuginea. The laceration is repaired using interrupted 4-0 M axon
The goals of acute exploration are evacuation of the hema- with the knots buried. Exposed corporal erectile tissue should not be
toma and primary repair of the laceration. probed or explored as this may cause troublesome bleeding.
experienced impotence, penile curvature on erection, or

painful intercourse (4,11).
PENILE SKIN LO SS
Diag no sis
Penile skin loss can occur from necrotizing infection, burns,
constrictive bands, or degloving injuries from blunt or pene-
trating trauma. Dog and human bites may also result in con-
siderable penile skin loss. When the skin loss is secondary to
infection (e.g., Fournier gangrene), repeated debridement with
FIGURE 77.3 Penile fracture extending beneath dorsal neurovascular antibiotics and moist dressing changes must be instituted to
bundles. Elevation of the ipsilateral dorsal neurovascular bundle facil- prepare the underlying tissue for delayed reconstruction. If the
itates repair of lacerations and protects these structures from inadver-
wounds are grossly contaminated, the testes may be placed in
tent injury. Division of the deep dorsal vein in the midline provides
access to the correct surgical plane beneath the ipsilateral neurovascu- subcutaneous thigh pouches with a view toward delayed scro-
lar bundle. tal reconstruction. Avulsions are most often caused by power
tool injuries or motor vehicle accidents, although this injury
may rarely be self-inflicted secondary to insertion of the penis
surface of the corpora at approximately the 10 and 2 o’clock into vacuum cleaners and other suction devices (1). Because of
positions (Fig. 77.3). This necessitates careful dissection of the laxity of penile skin, the avulsion usually extends just to the
these structures off the corpora to allow a safe, watertight clo- subcutaneous dartos layer, leaving the corporal bodies unin-
sure. Division of the deep dorsal vein facilitates unilateral dis- volved. Immediate repair is frequently possible in cases of trau-
section of the neurovascular bundle off the underlying corpus matic skin loss. If immediate closure is to be attempted, the
cavernosum. The penile skin is then replaced and the subcoro- wound edges must be clean and viable and hemostasis must be
nal incision is closed with interrupted 4-0 chromic sutures. If excellent to avoid delayed skin necrosis and sloughing.
the patient is uncircumcised, the prepuce must be closely mon-
itored for development of subcoronal edema. Postoperatively,
a loose compression dressing (Coban) is gently placed, and the Ind icat io ns fo r Surg e ry
urethral catheter may be removed on postoperative day 1.
Partial penile skin loss, especially in the distal shaft, is best man-
Systemic antibiotics, anti-inflammatory agents, and fibrinolyt-
aged by rotational mobilization of a local skin flap. Primary
ics are unnecessary. M ost patients can be discharged home
closure may be appropriate if the defect is short and there is
within 1 to 2 days of surgery. Sexual activity can be resumed
abundant remaining shaft skin. Extensive skin loss, whether
at about 4 to 6 weeks. Painful erections may be present in the
from the injury itself or surgical debridement, usually requires
early postoperative period. Suppression of erections with ben-
tissue transfer for repair. In impotent patients, the penis can be
zodiazepines or amyl nitrate may provide symptomatic relief.
buried under a scrotal flap with the glans left exposed to allow
When urethral transection occurs in the context of penile
micturition (Fig. 77.4) (5). The penis may be liberated at a later
rupture, we advocate primary repair with interrupted 5-0 or
date using the scrotal skin as a graft to cover the previously
6-0 M axon sutures over a 16Fr silicone catheter. In cases of
denuded area. In sexually active patients, a thick (0.016- to
complete urethral transection, additional urinary diversion
0.018-in.), nonmeshed split-thickness skin graft is used. Thick
through a percutaneous suprapubic cystostomy tube may be
split-thickness grafts are preferred because they are non–hair-
prudent (11). A voiding cystourethrogram (VCUG) should be
bearing, have minimal contraction, and offer excellent cosmesis
carried out at approximately 14 days postrepair to document
and viability. If sexual function is not a concern, a thinner skin
adequate healing before catheter removal.
graft may be harvested and meshed. The avulsed skin that is
still attached on a viable pedicle can be gently washed and reap-
O ut co me s plied with the knowledge that it may need to be debrided at a
later time. Completely avulsed penile skin will usually not sur-
Co mp licat io ns vive as a free graft if reapplied to the denuded penile shaft.
M any patients treated conservatively or with delayed repair

have some form of sexual dysfunction, such as painful erec- Alt e rnat ive The rap y
tion, disabling curvature, or erectile dysfunction secondary to
cavernous-venous occlusive disease (1,14). Patients with a There are no alternatives to surgery.
missed urethral injury associated with penile fracture are also
at risk of periurethral abscess, stricture, and fistula formation.
Re sult s
Patients who have operative repair within 48 hours of the The patient is placed supine and both the genitals and a care-
injury have excellent functional results. In two relatively large fully chosen donor site are prepared into the field. The antero-
studies, none of the patients with early operative repair lateral thigh provides thickness, texture, and color resembling
Chap t e r 77: Pe nile Trauma 517
FIGURE 77.5 Penile split-thickness skin graft. A thick (0.016- to

0.018-in.) split-thickness skin graft is applied to the denuded penile
shaft. The distal skin is discarded to just beneath the corona when a
circumferential graft is indicated. The graft is placed with the seam in
the midline ventrally and secured with 5-0 chromic sutures to itself
and along the shaft, while 4-0 silk sutures placed proximally and dis-
tally are left long to secure a bolster dressing.
FIGURE 77.4 Scrotal tunnel maneuver for penile skin coverage. The
penis shaft may be buried beneath a flap of scrotal skin to provide
skin coverage, leaving the glans exposed. This is a viable option in is placed directly on the graft. A bolster dressing is then fash-
older patients who either were impotent before their injury or who ioned using mineral oil–soaked cotton and fluffs. The whole
have sustained severe associated injuries. dressing is secured in place using the bolster sutures, leaving
the glans visible for inspection. To keep the penis in a vertical
penile skin and is therefore the preferred donor site. Alter- position, a padded plastic splint is placed around the bolster
natively, the medial or posterior thigh or buttock may be used dressing. This housing may be fashioned out of a 500-cc ster-
as a skin donor site. A Foley catheter is placed to prevent post- ile water container.
operative urinary contamination. The shaved donor site is Postoperatively, the patient is kept at strict bedrest until
coated with sterile mineral oil, and a Brown or Padgett der- the dressing is removed, usually after 5 days, when the Foley
matome (10-cm-wide strip) is used to harvest the graft in an ap- catheter is also removed. Immobilization of the penis in the
proximately 0.018-in. thickness. The graft is then tailored to fit extended position maintained by the bolster is critical for graft
the defect on the shaft. The donor site may be dressed with fine survival. Broad-spectrum antibiotics and administration of
mesh gauze under slight pressure to ensure adequate hemo- subcutaneous heparin for deep venous thrombosis prophy-
stasis. Placement of a semipermeable plastic or silicone mem- laxis are useful adjuncts. We do not routinely administer med-
brane (e.g., Biobrane) directly against the donor site helps reduce ications to reduce frequency of erections unless they are
contamination. After about 24 hours, the Biobrane is adherent painful for the patient. Erections may provide natural tissue
to the donor site and the redundant edges may be trimmed. This expansion, and the grafts usually slide easily along the loose
dressing usually falls off spontaneously after 2 weeks. areolar tissue superficial to the Buck fascia. O nce the penile
To prepare the penile shaft for grafting, it must be sharply dressing is removed, twice-daily sitz baths can be started to
debrided of all devitalized tissue and any chronic granulation enhance epithelialization and reduce bacterial contamination.
tissue. It is imperative to prepare the recipient site so that
the graft will have adequate blood supply. Debridement of the
glans should be avoided, but all nonviable skin, including the O ut co me s
distal prepuce, should be excised up to the coronal sulcus.
N ative penile skin distal to the graft will become edematous Co mp licat io ns
because of disruption of native lymphatic and venous drainage The common causes of early failure of penile skin grafting are
along the shaft. H emostasis in the graft bed is essential to pre- infection, shearing forces causing graft separation, and under-
vent hematoma formation under the graft. lying hematoma. It is imperative that the graft bed be free of
O nce prepared, the penis is stretched and the graft applied infected granulation tissue and any necrotic tissue. Shearing
circumferentially around the shaft. The graft seam is placed at forces disrupt the blood supply to the new graft and are pre-
the ventral aspect to simulate the appearance of the median vented by the penile splint and bolster dressing, provided the
raphe (Fig. 77.5). The graft is sutured in place using inter- patient is cooperative with strict bedrest for 5 days. It is criti-
rupted 5-0 chromic sutures. Chordee formation has in general cal that the penis be maintained in the extended position
not been a problem because the graft will have minimal longi- within the bolster dressing as this will prevent folding or tele-
tudinal contraction. The graft is secured to itself and along the scoping of the fresh graft on the penile surface. H ematoma
shaft with interrupted 5-0 chromic sutures. Several 4-0 Vicryl causes failure by creating poor contact between the graft and
sutures are placed at the proximal and distal graft edges and the recipient bed. It is prevented by ensuring meticulous he-
left long to use as bolster tieover sutures. A Xeroform dressing mostasis of the graft bed prior to laying the graft in place.
M eshed grafts allow better dissipation of hematoma fluid but before the skin grafting. Immediate primary closure or recon-
are discouraged in potent patients because of their increased struction should take place only with a clean wound that is in
degree of contraction. general 8 hours old.
Re sult s
Long-term results of reconstruction have been excellent, with Alt e rnat ive The rap y
successful graft take exceeding 90% . Sensation remains absent
in the grafted skin but is retained in the glans and in deeper Single pellet wounds with small entrance sites and superficial
structures. Potency is unaffected by this type of reconstruc- stab wounds in which there is no active bleeding or hematoma
tion. M ost patients have satisfactory intercourse after recon- may not require surgical exploration (3).
struction. Cosmetic and functional results of nonmeshed,
thick split-thickness penile grafts are superior to either meshed
grafts or scrotal flaps. Surg ical Te chniq ue
The operation consists of judicious debridement of devital-
PENETRATING PENILE TRAUMA ized tissue and hemostasis. The wound must be copiously
irrigated to remove all foreign bodies, including powder from
Penetrating trauma to the penis is most often caused by
shotgun pellets and pieces of clothing. Bleeding almost al-
firearms but can also result from stab wounds, industrial
ways occurs from a lacerated corporal body but may also be
accidents, self-mutilation attempts, and bites. In all cases,
from disrupted superficial veins. The primary objective of
general principles of management include judicious debride-
surgical exploration is control of corporal bleeding and repair
ment and hemostasis within the wound as well as careful
of corporal defects. The corpora are well vascularized, and
exploration and repair of corporal and urethral injuries.
extensive debridement is usually unnecessary and will hinder
M ost civilian penile gunshot wounds are caused by low-
future potency. We thus do not recommend extensive explo-
velocity missiles, which cause damage only in the path of the
ration of erectile or glanular tissue. H emostasis is obtained by
bullet. Penetrating penile injuries are a more common genito-
gentle compression and watertight closure of the tunica
urinary injury during wartime, possibly because of inadequate
albuginea alone, usually with interrupted 4-0 M axon sutures.
genital coverage by protective body armor (12). Associated
Urethral injuries are repaired with 5-0 Vicryl sutures over a
wounds of the thigh and pelvis are common and may require
silicone catheter. A devitalized urethra must be carefully
urgent exploration and repair. Successful treatment of pene-
debrided, and primary repair with a tension-free anastomosis
trating penile injuries must address and preserve normal void-
can usually be accomplished. Associated scrotal and sper-
ing, potency, and penile cosmesis.
matic cord injuries are treated with debridement and, if nec-
essary, orchiectomy or ligation of the vas deferens. The skin
Diag no sis can be closed primarily unless viable skin edges cannot be ap-
proximated. In contaminated wounds or those encountered
Genital injury is determined by careful physical examination, after 8 hours, immediate skin closure or grafting is not rec-
with special attention paid to the trajectory of the bullet and ommended and the wound is packed instead. O nce the
initial hemostasis. The finding of a palpable corporeal defect in wound is clean, delayed primary closure, staged reconstruc-
combination with an expanding penile hematoma or signifi- tion, or healing by secondary intention may be selected. An
cant bleeding from the entry/exit wound is highly predictive of important contraindication to debridement and primary clo-
corporeal injury and should prompt expedient exploration (7). sure is the case of massive tissue destruction often associated
The exam should include a vascular (glanular capillary refill) with close-range shotgun blasts. These should be debrided
and penile sensory assessment (9). Urethral injury, which oc- and allowed to declare themselves in terms of the extent of
curs in 25% to 40% of penetrating injuries to the penis, should injury. They may then be repaired in a staged fashion. It ap-
be excluded with RUG in all cases (6). The triad of no blood at pears that longer-range injuries due to shotgun blasts may
the meatus, absence of hematuria, and normal voiding suggests create multiple low-velocity wounds with less significant
that there is no urethral injury; however, penetrating trauma blast effect. Carefully selected longer-range shotgun injuries
can cause urethral injury without clinical signs of damage. have been successfully managed with immediate debridement
Cystography, intravenous pyelography, and scrotal ultrasonog- and primary repair (13).
raphy may be necessary to evaluate associated urologic in- Penile bites deserve special mention as they can rapidly
juries. Cavernosography is rarely indicated in this setting (9). progress to severe infection. Wounds should be copiously irri-
gated and all devitalized tissue debrided. All wounds should
be left open and prophylactic antibiotics administered.
Ind icat io ns fo r Surg e ry Antibiotic treatment should cover gram-positive and gram-
negative organisms as well as anaerobic gram-negative rods.
Penetrating injury to the penis most often requires surgical The most common colonizing organisms in the mouth of a
exploration. In addition, patients with unstable major organ dog include Pasteurella, Streptococcus, and Staphylococcus
injury will be unable to undergo immediate exploration. In species (2). H ospitalization with frequent wound inspection
these cases, initial treatment consists of hemostasis and pack- and intravenous antibiotics is necessary in those with delayed
ing of major wounds. Penetrating injury causing major skin presentation or with increased risk factors such as steroid use,
loss will require tissue transfer for satisfactory coverage, but diabetes, or immunodeficiency syndromes. Close follow-up is
associated corporal and urethral injuries must be repaired mandatory in all outpatients.
Chap t e r 78: Pe nile Re p lantation 519
Re sult s
O ut co me s
Excellent functional results can be expected except in those
Co mp licat io ns cases of high-velocity injuries where massive tissue destruction
has occurred. M ost patients report retained potency without
Early complications of penetrating penile trauma include re-
penile curvature and with satisfactory cosmetic results (5,8).
bleeding and infection. Because the corpora are heavily vascu-
Patients who develop late penile curvature in the absence of
larized, breakdown of repair in the tunica albuginea is rare. A
palpable corporeal defects or plaques may have scarring and
small minority will report superficial sensory loss, pain with
contraction of the underlying cavernosal tissues and the inter-
erection, and rapid detumescence. Complications attributable
cavernous septum (7).
to the urethral injury include urethral stricture, periurethral
abscess, and urethrocutaneous fistula.
References
1. Armenakas N A, M cAninch JW. Use of skin grafts in external genital recon- 9. M iller KS, M cAninch JW. Penile fracture and soft tissue injury. In:
struction. In: M cAninch JW, ed. N ew techniques in reconstructive urology. M cAninch JW, ed. Traum atic and reconstructive urology. Philadelphia:
N ew York: Igaku-Shoin, 1996:127–141. WB Saunders, 1996:693–698.
2. Cummings JM , Boullier JA. Scrotal dog bites. J Urology 2000;164:57. 10. N icolaisen GS, M elamud A, Williams RD, et al. Rupture of the corpus cav-
3. Goldman H B, Dmochowski RR, Cox CE. Penetrating trauma to the penis: ernosum: surgical management. J Urol 1983;130:917.
functional results. J Urol 1996;155:551. 11. O rvis BR, M cAninch JW. Penile rupture. Urol Clin N orth A m 1989;16:369.
4. Gomez RG. Genital injuries: presentation and management. In: McAninch 12. Salvatierra O , Rigdon WO , N orris DM , et al. Vietnam experience with 252
JW, ed. Problems in urology. Philadelphia: JB Lippincott Co, 1994:279–289. urological war injuries. J Urol 1969;101:615.
5. Gomez RG. Genital skin loss: reconstructive techniques. In: M cAninch JW, 13. Tigert R, H arb JJ, H urley PM , et al. M anagement of shotgun injuries to the
ed. Problem s in urology. Philadelphia: JB Lippincott Co, 1994:290–301. pelvis and lower genitourinary system. Urology 2000;55:193.
6. Gomez RG, Castanheira AC, M cAninch JW. Gunshot wounds to the male 14. Volz LR, Broderick GA. Conservative management of penile fracture may
external genitalia. J Urol 1993;150:1147. cause cavernous–venous occlusive disease and permanent erectile dysfunc-
7. H all SJ, Wagner JR, Edelstein RA, et al. M anagement of gunshot injuries to tion. J Urol 1994;151:358A.
the penis and anterior urethra. J Traum a 1995;38:439. The opinions expressed herein are those of the authors and are not to
8. M cAninch JW. M anagement of genital skin loss. Urol Clin N orth A m be construed as reflecting the views of the US Armed Forces or the
1989;16:387. Department of Defense.
CHAPTER 78 ■ PENILE REPLANTATIO N

URI GUR AND GERALD H. JO RDAN
Penile amputation is a rare injury in the Western world, aris- subgroup includes schizophrenic patients in a decompensated
ing largely from attempts at self-emasculation or as the result (actively psychotic) state. O ne study found that 87% of self-
of violent assault. It may also arise secondary to industrial emasculating patients were psychotic at the time of injury (3).
work accidents or as a war injury. Injuries amounting to penile These patients are usually victims of command hallucinations
amputation have also been reported as a rare complication of that coerce the patient to mutilate his genitals.
circumcision (5). The largest single series of penile amputation Because these patients respond well to psychiatric rehabili-
injuries comes from Thailand, where in the 1970s an epidemic tation, they are unlikely to repeat an attempt at self-mutilation,
of approximately 100 cases was reported (1). In these cases, provided they remain under chronic pharmacotherapy and
adulterous husbands had their penises amputated by their surveillance (3,9). Penises should therefore be replanted in a
humiliated wives while they slept. Unfortunately, only 18 of timely manner following amputation, with psychiatric sup-
100 cases in this series were successfully replanted using mi- port throughout the patient’s admission and probably lifetime.
crosurgical techniques, as the amputated penis was often N onpsychotic patients who self-emasculate are often diag-
rapidly disposed of by the wife. Thus, experience with penile nosed with severe personality disorders. These patients are
replantation is largely based upon case reports and smaller more difficult to rehabilitate.
series. Despite the rarity of this injury, good functional and While early attempts at penile replantation were frequently
cosmetic results are routinely attainable using the microsurgi- fraught with complications including skin and glans slough,
cal approach to penile replantation. the majority of these attempts were successful at salvaging the
Psychotic patients who carry out self-emasculation may penis with corporal reapproximation alone. This field was
be broadly divided into two categories. The more common revolutionized in 1976, when two independent groups
described the first successful penile replantations using mi-

crovascular techniques (2,11). Since that time, microneurovas-
cular repair has been considered the standard of care in penile
replantation and has provided superior results with regard to
postoperative sensation, erectile function, and overall graft
viability, with durable results in the long term (1).
The remarkable ability of an amputated penile tip to sur-
vive even in the absence of penile arterial and venous reanas-
tomosis attests to the unique vascular supply of the penis. It
seems that the sinusoidal blood within the corporal bodies
sufficiently approximates arterialized parameters, thus ade-
quately nourishing the distal bodies and skin early on without
having to depend upon collateral vessel development. M icro-
vascular reanastomosis has further decreased skin and glans
slough because the skin may be perfused directly rather than
via corporal perforators.
DIAGNO SIS FIGURE 78.1 The typical appearance of a penile amputation injury.
(From Jordan GH , Gilbert DA. M anagement of amputation injuries
The physical diagnosis is obvious with complete loss of the of the male genitalia. Urol Clin N orth A m 1989;16:359–367, with
distal penis. As already mentioned, most patients who have permission.)
self-inflicted wounds will have responded to a command psy-
chosis. O thers have severe personality disorders. Thus, the
surgery staff must work closely with a psychiatrist for these
patients, as the emasculation is only a symptom of the under-
lying disease. Traumatic amputations either from an assault or
industrial equipment will also likely have a postsurgical need
for psychiatric evaluation.
All of these patients should be aware of the potential for
loss of the penis if replantation is not successful, as well as the
potential for erectile dysfunction.
Because penile tissue has a remarkable resistance to prolonged
ischemia (10), all attempts to replant the penile remnant
should be carried out unless the penis has been extremely
mutilated. Replantation has been successful despite cold
ischemic times of 24 hours or longer. M ost patients have
sharply lacerated their penises, with clear anatomic structures
and vessels often visible both in the stump and the distal por-
tion (Fig. 78.1). The penis should be preserved with the “ bag-
within-a-bag” technique (Fig. 78.2). This serves to increase
ischemic tolerance. The amputated penis is wrapped in saline-
soaked gauze in a sterile plastic bag. This bag is then im-
mersed in ice slush. The patient should be kept warm and
peripherally vasodilated throughout the procedure as well as
in the postoperative period.
ALTERNATIVE THERAPY
Alternatives are limited, as the alternative is to not reconstruct
the penis and thus close the penis and perform a urethrostomy.
O ne alternative, if microsurgery is not available but the pe- FIGURE 78.2 Illustration of the bag-within-a-bag technique of organ
nis is otherwise “ replantable,” would be macroscopic approx- emergent cold storage. The amputated part of the penis is placed on a
imation of the urethra and corpora. This approach harbors saline-soaked gauze sponge, within a sterile (if possible) plastic bag.
The plastic bag is then immersed in a second container of iced slush.
substantial risk for edema, skin necrosis, and sloughing of the (From Jordan GH . Initial management and reconstruction of male
glans skin. O ften the deeper tissues of the glans survive and genital amputation injuries. Traum a R econstr Urol 1996;57:673–681,
will re-epithelialize or can be grafted. with permission.)
Chap t e r 78: Pe nile Re p lantation 521
cavernosal arteries is difficult and does not seem to offer any

SURGICAL TECHNIQ UE advantage (6). The tunica albuginea of the corpora cavernosa
should then be meticulously closed with interrupted 4-0 or
M icrosurgical replantation is carried out using microsurgical 5-0 PDS sutures, as this will further provide stability for the
techniques (2), with systematic exploration and debridement microsurgical anastomoses.
of the corporal bodies and dorsal neurovascular structures as The dorsal neurovascular structures are repaired next.
necessary (Fig. 78.3). Both dorsal penile arteries should be anastomosed using 11-0
The urethra should be spatulated and reanastomosed first, nylon or polypropylene (Prolene), and the deep dorsal vein is
as this provides stability to the remainder of the repair. A two- then repaired with 9-0 or 10-0 nylon or Prolene. Follow-
layer repair using 6-0 polydioxanone suture (PDS) or 6-0 ing completion of the vascular anastomoses, the dorsal nerve
polyglactin (Vicryl) for the epithelium followed by 5-0 PDS bundles should be reapproximated with 10-0 nylon. The
for the spongy erectile tissue is appropriate. Coaptation of the epineurium of each side should be placed in apposition so that
fascicular regrowth is facilitated (Fig. 78.4). For distal injuries,
fascicular coaptation may be required. These nerves are
branches of the pudendal nerve and are responsible for sensa-
tion within the glans. The autonomic cavernous nerves branch
proximally within the corporal bodies and are not repaired.
Following completion of the microsurgical anastomoses,
the dartos fascia should be reapproximated using 5-0 Vicryl
sutures and the skin loosely reapproximated using 5-0 or 6-0
Vicryl sutures. Shaft skin should be preserved if at all possible,
as initially questionable skin may appear more viable in the
postoperative period (Fig. 78.5). A diverting suprapubic
cystotomy catheter should be placed and the urethra stented
with a small soft silicone catheter. The penis should be immo-
bilized and elevated to facilitate venous and lymphatic
drainage. A subcutaneous suprapubic tunnel technique has
been described for protection of the replanted penis in the
early postoperative period, in cases where there is not ade-
quate skin for coverage (4).
If the microvascular approach to replantation is technically
or otherwise not feasible, the penis should be replanted via cor-
poral and urethral reapproximation. The denuded replanted
penis may be buried in the scrotum or a subcutaneous supra-
pubic tunnel as above, followed by delayed liberation with
scrotal skin cover, as described by M cRoberts et al. (8), or with
FIGURE 78.3 The urethra, corpora cavernosa, and dorsal neurovas-
cular structures are exposed and minimally debrided. (From Jordan
grafting. Although penile salvage is usually successful via this
GH , Gilbert DA. M anagement of amputation injuries of the male technique, it obviously requires a second procedure. Covering
genitalia. Urol Clin N orth A m 1989;16:359–367, with permission.) the penis with scrotal skin is cosmetically less than optimal,
FIGURE 78.4 A two-layer spatulated urethral anastomo-

sis is completed. M icrovascular coaptation of the dorsal
vein, deep dorsal artery, and dorsal nerves is accom-
plished. (From Jordan GH , Gilbert DA. M anagement of
amputation injuries of the male genitalia. Urol Clin N orth
A m 1989;16:359–367, with permission.)
with Doppler and observed for signs of skin slough or de-

creased glans viability. The stenting catheter may be removed
at the 3-week postoperative period, with a voiding urethro-
gram carried out to document the healing of the urethra. The
use of daily aspirin in the postoperative period is recom-
mended. M ore aggressive anticoagulation is usually not war-
ranted but should be addressed on a case-by-case basis.
O UTCO MES
Given the uniformly good results of microvascular penile re-
FIGURE 78.5 Postoperative result. (From Jordan GH , Gilbert DA. plantation from both cosmetic and functional aspects, this ap-
M anagement of amputation injuries of the male genitalia. Urol Clin proach should be used if at all possible. If microsurgery is not
N orth A m 1989;16:359–367, with permission.) feasible, macroscopic replantation should still be offered.
while grafting the penis provides much more acceptable re- CO MPLICATIO NS
sults. In either case, the shaft sensation will be compromised.
If the amputated penis is absent or too mutilated for replan- The frequency of skin necrosis, glans slough, and urethral
tation, hemostasis should be achieved, followed by spatulation complications has been reduced with the microvascular ap-
of the neomeatus. The proximal shaft may be buried in the sur- proach to replantation. Edema and congestion are common
rounding skin, or the residual corporal stumps may be covered but are usually of a self-limited nature.
by a split-thickness skin graft. In the unusual circumstance that Adjuvant treatment with hyperbaric oxygen in the early
contamination in the area of the genitalia precludes immediate postoperative period was reported as possibly advantageous
replantation, temporary ectopic microsurgical implantation (to to treat the edematous and/or ischemic replanted penis (12).
the forearm) followed by delayed anatomic replantation has As with other “ free flaps,” the successful use of medicinal
been employed successfully (7). leeches to treat postoperative venous congestion has been
reported (9).
Several reports document the return of partial or complete
PO STO PERATIVE MANAGEMENT erectile function in the months following the replantation.
Patients who fail to achieve adequate return of erections may
The patient is kept on bedrest for approximately 1 week, with
still respond to pharmacologic erection therapy.
urinary diversion continuing for approximately 3 weeks. During
this period, the replanted penis should be closely monitored
References
1. Bhanaganada K, Chayavatana T, Pongnumkul C, et al. Surgical manage- 7. M atloub H S, Yousif N J, Sanger JR. Temporary ectopic implantation of an
ment of an epidemic of penile amputations in Siam. A m J Surg 1983; amputated penis. Plast R econstr Surg 1994;93:408–412.
146:376. 8. M cRoberts JW, Chapman WH , Ansell JS. Primary anastomosis of the trau-
2. Cohen BE, M ay JW, Daly JS, et al. Successful clinical replantation of an matically amputated penis: case report and summary of the literature.
amputated penis by microneurovascular repair. Plast R econstr Surg 1977; J Urol 1968;100:751.
59:276. 9. M ineo M , Jolley T, Rodriguez G. Leech therapy in penile replantation: a
3. Greilheimer H , Groves JE. M ale genital self-mutilation. A rch G en Psychiatry case of recurrent penile self-amputation [Review]. Urology 2004;63(5):
1979;36:441. 981–983.
4. H arris DD, Beaghler M A, Stewart SC, et al. Use of a subcutaneous tunnel 10. M osahebi A, Butterworth M , Knight R, et al. Delayed penile replantation
following replantation of an amputated penis. Urology 1996;48:628–630. after prolonged warm ischemia. M icrosurgery 2001;21:52–54.
5. Jong KP, Jun KM , H yung JK. Reimplantation of an amputated penis in 11. Tamai S, N akamura Y, M otomiya Y. M icrosurgical replantation of a com-
prepubertal boys. J Urol 2001;165:586–587. pletely amputated penis and scrotum. Plast R econstr Surg 1977;60:287.
6. Jordan GH , Gilbert DA. M anagement of amputation injuries of the male 12. Z hong Z , Dong Z , Lu Q , et al. Successful penile replantation with adjuvant
genitalia. Urol Clin N orth A m 1989;16:359–367. hyperbaric oxygen treatment. Urology 2007;69(5):983.e3–5.
CHAPTER 79 ■ VARICO CELE: GENERAL
CO NSIDERATIO NS
CARIN V. HO PPS AND MARC GO LDSTEIN
A varicocele is an abnormal dilation of the veins draining the essential for proper examination of scrotal contents. Grade I
testis, the internal spermatic veins, that can be palpated varicocele is palpable with Valsalva maneuver only, grade II
through the scrotal skin. While varicoceles are present in 15% is palpable in the standing position, and grade III is visually
of the male population overall, they are present in 35% of apparent through the scrotal skin as a “ bag of worms.”
men with primary infertility and in 81% of men with sec- Transscrotal ultrasound is not necessary to diagnose varicocele
ondary infertility (3). Varicocele is the most common etiology but may be utilized if physical examination cannot be ade-
of male factor infertility, and varicocelectomy (ligation of the quately accomplished or findings on physical examination are
internal spermatic veins) is the most commonly performed equivocal. Internal spermatic vein diameter 3 mm and
surgical procedure for men with infertility. Varicocele is asso- demonstration of retrograde flow through the vein with
ciated with decreased testicular volume, impaired sperm qual- Valsalva maneuver on ultrasound are consistent with the diag-
ity, and a decline in Leydig cell function (13). Surgical repair nosis of clinical varicocele. Varicoceles that do not meet these
of clinical varicocele has been shown to avert further damage criteria are defined as subclinical.
to testicular function, improve spermatogenesis, and improve
Leydig cell function. Large varicoceles are associated with
greater testicular dysfunction than are small varicoceles, and INDICATIO NS FO R SURGERY
repair of large varicoceles results in greater improvement in
semen parameters when compared with repair of small varico- Most varicoceles are not associated with infertility, decreased
celes (10). testicular volume, or pain and therefore do not require surgical
Varicoceles most commonly occur on the left. Whereas the correction. A clinical varicocele in a patient with abnormal se-
right internal spermatic vein drains into the vena cava, the left men parameters should be surgically corrected to reverse the
internal spermatic vein drains into the left renal vein and process of progressive and duration-dependent decline in testicu-
therefore is significantly longer than the right vein, resulting in lar function. Repair of subclinical varicocele has not been shown
greater transmission of pressure to the pampiniform plexus. to confer a benefit to the patient with male factor infertility and
Contributing to increased venous pressure is the position of is not recommended (4). Varicocele associated with ipsilateral
the left renal vein, which crosses anterior to the aorta and pos- testicular atrophy or with ipsilateral testicular pain that worsens
terior to the superior mesentery artery, potentially causing progressively throughout the day, but subsides in the recumbent
compression of the renal vein, known as the “ nutcracker position, should be repaired as well. Varicocele ligation in ado-
effect.” Retrograde flow of blood into the pampiniform lescents with ipsilateral testicular atrophy has been shown to re-
plexus due to incompetent valves within the internal spermatic sult in a significant increase in testis volume (5), and therefore
vein may also contribute to dilation of this venous system. surgical correction is recommended in this group. Adolescents
The pathophysiology by which varicocele impairs testicu- with small- to moderate-grade varicoceles in the absence of atro-
lar function is poorly understood. O f several proposed mecha- phy are followed with yearly examination to assess testicular
nisms of injury, thermal testicular injury is the hypothesis growth; the occurrence of diminished growth on the side of the
most supported by animal and human studies. Animal models varicocele warrants varicocelectomy. A sound argument could
have demonstrated a clear adverse effect of heat on testicular be made for repair of all grade III varicoceles in adolescents to
function. Varicocele is thought to affect thermoregulation of conserve testicular function. Approximately 3% of adolescent
the testis by interfering with the countercurrent heat exchange males have grade III varicoceles.
mechanism within the pampiniform plexus. Although the
scrotal location of the testes appears to underscore the impor-
tance of temperature regulation, the mechanism by which ALTERNATIVE THERAPY
varicocele causes injury to the testis is likely multifactorial.
For men with infertility, abnormal semen parameters, and clin-
ical varicocele, few alternatives to varicocelectomy are available.
DIAGNO SIS Currently utilized nonsurgical techniques include percutaneous
radiographic occlusion and sclerotherapy. The retrograde per-
Varicocele is diagnosed by thorough examination of the scrotal cutaneous approach employs cannulation of the femoral vein
contents with the patient in both the supine and standing posi- and placement of a balloon or coil within the internal sper-
tions. Relaxation of the dartos muscle, facilitated by a warm matic vein. Although this technique is associated with preser-
scrotum (we favor a simple heating pad on the scrotum), is vation of the testicular artery and lymphatics, it has a high
523
unperformable rate due to difficulty in accessing the internal rate from the internal spermatic veins. A disadvantage to this
spermatic vein, and these men ultimately require surgical inter- approach is difficulty in preserving lymphatics due to the
vention. Radiographic occlusion is also associated with com- poorly accessible retroperitoneal location of the vessels, lead-
plications such as migration of embolization material into the ing to a higher incidence of postoperative hydrocele. In addi-
renal vein resulting in kidney loss or pulmonary embolization, tion, a high recurrence rate is observed when the testicular
thrombophlebitis, arterial injury, and allergic reaction to con- artery is preserved due to preservation of the periarterial
trast materials. This technique may have a role in the manage- plexus of fine veins (venae comitantes), which may dilate
ment of varicoceles that persist or recur following open surgical with time and present as the source of recurrence. Parallel in-
repair to avoid reoperation through scar tissue. Antegrade guinal or retroperitoneal collaterals originating at the testis
varicocele occlusion performed by percutaneous cannulation and joining the internal spermatic vein cephalad to the level
of a scrotal pampiniform vein and injection of a sclerosing of ligation, in addition to cremasteric veins that are not lig-
agent has been described. This technique is associated with ated, may contribute to recurrence. Intentional ligation of the
higher performability rates but similar recurrence rates when testicular artery has been suggested in children to minimize
compared with the retrograde approach, in addition to pre- recurrence, but in adults who present with infertility, ligation
senting risk of injury to the testicular artery. of the testicular artery cannot be recommended as this is un-
likely to enhance testicular function.
The patient is placed in the dorsal supine position on an
SURGICAL TECHNIQ UE operating table. A horizontal iliac incision equidistant from
the umbilicus and anterior superior iliac spine is made (7 to
Ligation of the internal spermatic veins can be approached in 10 cm, depending on the patient’s body habitus). The exter-
several ways. The earliest described technique involved plac- nal oblique aponeurosis is incised obliquely. The internal
ing an external clamp on the veins through the scrotal skin. oblique is split 1 cm off the lateral edge of the rectus abdo-
Surgical varicocele ligation techniques include retroperitoneal, minis, and the transversus abdominis is incised. The peri-
inguinal or subinguinal ligation, laparoscopic, and microsur- toneum is dissected free from the abdominal wall and
gical varicocelectomy. retracted. The spermatic vessels appear adherent to the peri-
toneum, making it important to remain close to the peri-
toneum. Continued dissection along the abdominal wall
Re t ro p e rit io ne al (Po lo mo ) Ap p ro ach would lead posteriorly to the psoas muscle. Retraction of the
peritoneum allows easy identification of the spermatic veins,
The retroperitoneal (Polomo) approach (Fig. 79.1) has the and in 10% of cases the spermatic artery is clearly visible,
advantage of isolating the internal spermatic veins proxi- isolated from the rest of the spermatic structures, identified,
mally, near the point of drainage into the left renal vein. At and preserved.
this level, only one or two large veins are present. In addition, The remainder of the operation depends on the intraopera-
the testicular artery has not yet branched and is often sepa- tive findings. In the case of a single vein and no collateral, the
FIGURE 79.1 M odified Palomo retroperitoneal approach for

varicocelectomy. The internal spermatic vein is found on the
posterior aspect of the peritoneum. It is isolated and divided
between ligatures.
Chap t e r 79: Varicoce le : Ge ne ral Consid e rations 525
artery is identified and will only be preserved when it is not

accompanied by a plexus of small veins indissociable from the
artery. In the case of multiple veins, the collaterals are identi-
fied and all vessels from the ureter to the abdominal wall are
ligated. Spermatic vessels are in general inspected over a dis-
tance of 7 or 8 cm and ligated by braided, permanent suture
material.
After verification of hemostasis, the internal oblique, trans-
versus abdominis, and external oblique aponeurosis are reap-
proximated with absorbable suture. The Scarpa fascia is
closed by a resorbable running suture. The skin is closed in
subcuticular manner with absorbable suture.
Ing uinal (Ivanisse vich) Ap p ro ach

The incision is made 2 cm above the symphysis pubica
(Fig. 79.2). The external oblique aponeurosis is carefully FIGURE 79.3 Subinguinal approach. An index finger is hooked into
the external inguinal ring retracting cephalad, while a small
divided to avoid injuring the underlying ilioinguinal nerve. Richardson retractor retracts the soft tissues caudad toward the scro-
The cord is mobilized and a Penrose drain is inserted beneath tum. The assistant grasps the spermatic cord with a Babcock clamp
the cord and retracted to gain exposure of the cord. The sper- for elevation of the cord into the wound.
matic fascia is then incised and the vessels are identified. Each
vein is isolated, doubly ligated with nonabsorbable suture,
and transsected. Intraoperative Doppler may be utilized to veins present at this level and the venae comitantes adherent
identify the testicular artery. After all collaterals are identi- to the testicular artery. Laparoscopic technique introduces a
fied, the external oblique aponeurosis is closed with running unique set of complications, including injury to bowel, intra-
absorbable suture and the skin is closed in a subcuticular abdominal vessels, and viscera in addition to air embolism
manner. and peritonitis, all of which are much more serious than those
associated with open varicocelectomy.
Lap aro sco p ic Varico ce le Re p air

Micro surg ical Varico ce le ct o my
Laparoscopic varicocele repair is a modification of the
retroperitoneal technique with similar advantages and disad- M icrosurgical subinguinal or inguinal varicocelectomy is our
vantages. The optical magnification afforded through the la- preferred approach to varicocele ligation. The spermatic cord is
paroscope provides the ability to preserve the lymphatics and elevated into the incision (Fig. 79.3), providing excellent expo-
the testicular artery while ligating the few internal spermatic sure, and with use of the microscope providing 6 to 25
A B
FIGURE 79.2 A: Position of inguinal and subinguinal incisions. The external inguinal ring can be
located by invaginating the scrotal skin with an index finger in a cephalad direction over the pubic tuber-
cle. The location of the ring is marked on the skin. B: A subinguinal incision measuring only 2.5 cm in
length.
C
FIGURE 79.4 A: Following delivery of the testis, the cord and guber-
C
naculum are inspected for extraspermatic collateral veins. B: All
external spermatic and gubernacular veins are doubly clipped and FIGURE 79.5 A: Diagram of a cross-section of the spermatic cord,
transected. C: The testis and cord following division of these veins. All illustrating the anatomic relationship between the external and internal
remaining venous drainage is contained within the cord itself. spermatic fasciae. A (B) diagram and (C) intraoperative photo of the
spermatic cord with opened external and internal spermatic fasciae.
magnification the small periarterial and cremasteric veins can

be readily ligated, as can extraspermatic and gubernacular veins readily identified under the microscope, and preservation of the
when the testis is delivered into the wound (Fig. 79.4). The artery is more likely with enhanced visualization (Fig. 79.6).
external and internal spermatic fasciae are carefully opened to Lymphatics are also identified and preserved (Fig. 79.7), result-
expose the vessels (Fig. 79.5). The testicular artery can be ing in a lower incidence of hydrocele postoperatively.
Chap t e r 79: Varicoce le : Ge ne ral Consid e rations 527
33% with an average of 7% . Examination of the hydrocele fluid

has shown that the fluid characteristics are consistent with ob-
struction of lymphatics (12). The effect of a hydrocele on sperm
function and fertility is uncertain. Nearly half of postoperative
hydroceles require surgical correction due to size. Use of magni-
fication to identify lymphatics and preserve them has nearly
eliminated the incidence of hydrocele formation (2,8).
Testicular artery injury is a complication of varicocelectomy.
Although the testis also receives blood supply from the cremas-
teric and deferential arteries, ligation of the testicular artery may
result in atrophy and/or impaired spermatogenesis. Microscopic
technique facilitates identification and preservation of the testic-
ular artery, minimizing the risk of testicular injury (2).
Varicocele recurrence occurs in periarterial, parallel in-
guinal, midretroperitoneal, or transscrotal collaterals (6).
Parallel inguinal collaterals are missed with retroperitoneal re-
FIGURE 79.6 A vessel loop is placed around the testicular artery for
pair. Routine inguinal techniques without optical magnification
identification throughout the procedure. The artery has been dissected
free of all adjacent veins and lymphatics. miss scrotal collaterals and small veins adherent to the testicular
artery. The microsurgical approach with delivery of the testis is
associated with a varicocele recurrence rate 1% when com-
pared with 9% for nonmagnified inguinal techniques (2,8).
Re sult s
Varicocelectomy has been found to improve sperm concentra-
tion, motility, and morphology with a corresponding increase in
pregnancy rate. A randomized controlled trial of surgery com-
pared with no surgery (control group) showed that 60% of men
who underwent varicocelectomy initiated a pregnancy within 1
year, whereas pregnancy was achieved in only 10% of those
couples in which the varicocele went unrepaired (7). The con-
trol group then underwent varicocelectomy, and during the sec-
ond year of the study 44% initiated a pregnancy. A series of
1,500 men who underwent microsurgical varicocelectomy re-
sulted in 43% pregnancy at 1 year and 69% at 2 years when fe-
FIGURE 79.7 A lymphatic measuring 1 mm in diameter is visualized male factors were excluded (2). Varicocelectomy improves
under the microscope and preserved.
semen parameters sufficiently such that for most couples as-
sisted reproductive techniques (ARTs) are either rendered un-
necessary or the type of ART necessary to bypass the male
O UTCO MES factor is downstaged (1). In addition, up to 50% of men with
nonobstructive azoospermia will respond to varicocelectomy
Co mp licat io ns with return of sperm to the ejaculate (9). In adolescents, a mod-
erate to large varicocele can be responsible for testicular growth
The most common complication following varicocelectomy is retardation, and early ligation of the varicocele may reverse this
hydrocele formation. The incidence of postoperative hydrocele process (5). Finally, varicocelectomy can increase serum testos-
following the nonmicrosurgical technique ranges from 3% to terone levels for infertile men with varicoceles (11).
References
1. Çayan S, Erdemir F, Ö zbey I, et al. Can varicocelectomy significantly 8. M armar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical
change the way couples use assisted reproductive technologies? J Urol critique and statistical analysis of semen and pregnancy data. J Urol
2002;167:1749–1752. 1994;152:1127–1132.
2. Goldstein M , Gilbert BR, Dicker AP, et al. M icrosurgical inguinal varico- 9. M atthews GJ, M atthews ED, Goldstein M . Induction of spermatogenesis
celectomy with delivery of the testis: an artery and lymphatic sparing tech- and achievement of pregnancy after microsurgical varicocelectomy in
nique. J Urol 1992;148:1808–1811. men with azoospermia and severe oligoasthenospermia. Fertil Steril 1998;
3. Gorelick JI, Goldstein M . Loss of fertility in men with varicocele. Fertil 70:71.
Steril 1993;59:613. 10. Steckel J, Dicker AP, Goldstein M . Influence of varicocele size on response
4. Jarow JP, O gle SR, Eskew LA. Seminal improvement following repair of to microsurgical ligation of the spermatic veins. J Urol 1993;149:769–771.
ultrasound detected subclinical varicoceles. J Urol 1996;155:1287–1290. 11. Su LM , Goldstein M , Schlegel PN . The effect of varicocelectomy on serum
5. Kass EJ, Belman AB. Reversal of testicular growth failure by varicocele testosterone levels in infertile men with varicoceles. J Urol 1995;154:
ligation. J Urol 1987;137:475–476. 1752–1755.
6. Kaufman SL, Kadir S, Barth KH , et al. M echanisms of recurrent varicocele 12. Szabo R, Kessler R. H ydrocele following internal spermatic vein ligation: a
after balloon occlusion or surgical ligation of the internal spermatic vein. retrospective study and review of the literature. J Urol 1984;132:924–925.
R adiology 1983;147:435–440. 13. World H ealth O rganization. The influence of varicocele on parameters of
7. M adgar I, Weissenberg R, Lunenfeld B, et al. Controlled trial of high sper- fertility in a large group of men presenting to infertility clinics. Fertil Steril
matic vein ligation for varicocele in infertile men. Fertil Steril 1995;63:120. 1992;57:1289.
CHAPTER 80 ■ HYDRO CELE AND
SPERMATO CELE
JO HN A. NESBITT
H ydrocele and spermatocele refer to common but abnormal Epididymitis or orchitis may cause an acute hydrocele that
collections of fluid within the scrotum and must be included in usually resolves with the resolution of the inflammation.
the differential diagnosis of scrotal masses. The etiology of Tropical infections, such as filariasis, may produce hydroceles
each of these masses is different, and both may require surgi- where the tunica thickens due to lymphatic obstruction by the
cal intervention for cure. They occur in males of all ages, be- parasites. In these cases, the fluid is usually turbid due to chy-
ginning at birth. lous drainage secondary to the lymphatic obstruction. It is
generally thought that tense hydroceles are caused by lack of
reabsorption of the fluid, and the more flaccid type from ex-
HYDRO CELE cess fluid production.
H ydrocele (from the Greek hydros for water and k ele for
mass), literally a watery rupture or water in the scrotum, is an Diag no sis
abnormal collection of fluid in the tunica vaginalis that may
surround the testicle. The fluid is usually amber and is consid- In the pediatric population, hydroceles may present at birth or
ered to be an exudate. A small amount of fluid, several cubic within the first year of life and are found in about 6% of full-
centimeters, is normally present around the testicle. This fluid term males. In general, a painless swelling is noticed in the
is present between layers of the tunica vaginalis and the tunica scrotum. The scrotal enlargement may increase or decrease in
albuginea covering the testis. About 0.5 cc of fluid is continu- size if the processus is patent, allowing peritoneal fluid or
ously secreted and reabsorbed by this mesothelial layer daily. bowel to enter the scrotum. If the processus is small, only fluid
Several types of hydroceles exist that may be associated with will enter. This persistence of the patent processus allowing the
other pathologic findings, including cancer. The majority of connection from the peritoneal cavity to the scrotum is known
hydroceles occur congenitally, and most of these resolve spon- as a communicating hydrocele. The change in size may not be
taneously during the first year of life. Acquired hydroceles are apparent to the clinician but will be noticed by the parents.
found later in life. If due to local inflammation, these hydroce- In acquired hydroceles, the swelling may be accompanied by
les may resolve as the inflammation resolves. Intervention is pain, especially if caused by an inflammatory process. The
usually only required for size or discomfort. patient may report an enlargement within the scrotum, a tense
During month 3 of gestation, the gubernaculum traverses sac, or some discomfort within the scrotum that may radiate
the inguinal canal from the internal ring, through the external inguinally or into the ipsilateral flank. The swelling is smooth,
inguinal ring, and out into the scrotum, pulling with it the confined to the scrotum, and will usually transilluminate if the
parietal peritoneal lining of the abdominal cavity (processus wall is not too thickened. With somewhat large and tense hy-
vaginalis). Late in the third trimester, the testis leaves its intra- droceles, the testis is not palpable. Because testicular neoplasms
abdominal location, descends along the same route as the gu- may also cause hydroceles, transscrotal ultrasonography is a
bernaculum through the inguinal canal, and exits the external useful preoperative diagnostic tool for imaging an otherwise
ring posterolateral to the processus vaginalis. N ormally, the inevaluable testicle.
segment of the processus vaginalis lying in the inguinal canal
obliterates by the time of birth. A portion of the processus is
left within the scrotum closely applied to the testicle. This Ind icat io ns fo r Surg e ry
structure is then termed the tunica vaginalis. Persistence of the
inguinal portion of the processus may lead to a patent proces- Surgical intervention is indicated when the hydrocele is symp-
sus vaginalis, a hernia, or a localized portion of fluid lying tomatic either due to discomfort or size impairing daily activ-
within the inguinal canal known as a hydrocele of the cord. ity. H ydrocelectomy is inappropriate in the face of a testicular
M ost acquired hydroceles are idiopathic. H owever, the neoplasm.
clinician must be careful to consider other causes, such as
trauma, infection, or testicular tumor, when evaluating a pa-
tient. Lymphatic obstruction due to ipsilateral inguinal or Alt e rnat ive The rap y
pelvic surgery may result in a secondary hydrocele. A common
surgical cause for hydrocele is renal transplantation. In In congenital hydroceles, the treatment is usually observation,
this scenario, the spermatic vessels and vas deferens are di- unless the patient has an accompanying hernia. This is an
vided on the ipsilateral side, leading to hydrocele development. important distinction to make because the latter should be
528
Chap t e r 80: Hyd roce le and Sp e rmatoce le 529
repaired surgically. When the diagnosis is uncertain, some have

advocated repair. A period of observation would be appropri-
ate in the absence of other symptoms. M any of these hydroce-
les will resolve within the first year of life if left untreated.
In acquired hydroceles requiring treatment, the approach is
in general considered to be surgical. Various surgical tech-
niques have been described, all of which yield satisfactory re-
sults (7). The surgical approach is generally preferred due to
the high success and low recurrence rates. Alternative therapies
may be considered in symptomatic patients who are poor sur-
gical risks. H ydroceles may be aspirated with some expected
temporary pain relief. In addition, a sclerosing agent, such as
tetracycline, may be placed within the empty space in an effort
to keep the fluid from reaccumulating (2). This treatment has
met with mixed results and may be very painful. O ther scle-
rosants have been used, including ethanolamine oleate, polido-
FIGURE 80.1 The Andrews operation. A small incision is made high
canol, sodium tetradecyl sulfate, and phenol. Sclerosing in the sac prior to eversion of the sac about the cord.
therapy typically requires up to three treatment sessions, and
although high success rates have been reported (9), many
physicians still reserve this treatment for poor surgical candi-
dates. The recurrence and complication rates associated with
sclerotherapy are higher than with the surgical approach, and
some side-effects can include infection, impaired fertility, and
testicular loss (11). Due to these risks, some authors feel that
sclerotherapy is not appropriate for young healthy patients (6).

There are several successful surgical techniques utilized to
treat hydroceles. The scrotum is shaved, and, along with the
penis, the entire area is cleaned with antiseptic preparation.
The approach is usually midline scrotal or transverse between
transversely running blood vessels, unless the diagnosis is in
question. When neoplasm or hernia cannot be ruled out, the
approach should be inguinal. The scrotal incision should be
carried down to the tunica vaginalis, where the blue hue of FIGURE 80.2 The Jaboulay or Winkleman technique. The redundant
the hydrocele is seen. The hydrocele and testicle may be deliv- sac is excised, leaving enough room to be loosely closed about the
ered through the incision. Blunt dissection and use of a surgi- cord. A running suture may be used to close the sac and rapidly
control bleeding from the free edges.
cal sponge will free any surrounding tissue from the
hydrocele sac. O nce this parietal layer of tunica vaginalis is
exposed, one may select the type of procedure to perform. In the free edges around the cord structures (Fig. 80.2).
general, the Lord procedure is suitable for more thin-walled Reapproximation of the edges is done loosely around the cord
hydroceles, whereas the other described techniques are used so as not to compromise the blood supply to the testicle. In an-
with thicker sacs. other variation of this technique, the parietal tunica vaginalis
is resected nearly flush with the testis and epididymis.
And re w s Pro ce d ure Electrocautery may be used around the edge to aid in hemo-
This technique was described in 1907 by Andrews (1) and is stasis, or bleeders may be ligated (Fig. 80.3). The standard
referred to as the “ bottle operation.” A 2- to 3-cm incision is two-layer closure is used to close the scrotum.
made in the hydrocele sac near the superior portion (Fig. 80.1).
The procedure may be completed by tacking the cut edges Lo rd Pro ce d ure
around the cord structures or leaving the everted sac open. A In utilizing this plication technique for hydrocelectomy
two-layer wound closure is then accomplished with absorbable described by Lord in 1964 (8), a small incision is made just
suture, such as 2-0 or 3-0 chromic, approximating the skin large enough to deliver the testis into the field. The parietal
over the dartos layer. layer of the tunica vaginalis is opened without dissection from
the dartos layer. With little dissection of the scrotal sac, this
J ab o ulay o r Winkle man Pro ce d ure procedure is relatively bloodless. Placing the Allis forceps on
As described by Jaboulay in 1902 (13), this technique involves the cut edges of the open sac allows the testicle to be brought
delivering the testicle through an incision in the tunica. The into the wound. N ext, the edges are plicated circumferentially
majority of the sac is then resected, leaving a small cuff along with interrupted 2-0 or 3-0 chromic catgut sutures, placing
the border of the testicle. After everting the remnant, bleeding them about 1 cm apart. The bites should be approximately
may then be controlled rapidly by a running suture closing 1 cm as well (Fig. 80.4). As these sutures are tied, the sac will
In general, any of these procedures may be performed

without surgical drainage. When hemostasis is difficult to
obtain or the hydrocele particularly large, a small Penrose
drain, placed through a separate stab incision in the inferior
aspect of the scrotum and left overnight, is useful. This ma-
neuver will also help prevent serous fluid from accumulating
in the scrotum postoperatively. Because the scrotum is difficult
to dress, fluff dressings held in place by a standard athletic
supporter do well in this situation. An ice pack is kept in place
for at least 24 hours to help diminish postoperative pain and
swelling. O ral analgesics are utilized for several days.
Preoperative antibiotics are helpful but not usually continued
postoperatively.
FIGURE 80.3 Alternate technique. The sac is excised nearly flush

with the testicle, and the epididymis and bleeders are ligated or fulgu-
SPERMATO CELE
rated individually.
A spermatocele (from the Greek sperm atos for sperm and k ele
for cyst or mass) is a cystic structure arising out of the epi-
didymis, rete testis, or ductuli efferentes. These structures are
filled with spermatozoa containing fluid that may be milky.
These cysts are usually outside the tunica vaginalis and, as
with hydroceles, transilluminate easily. They are frequently
seen on scrotal ultrasound as an incidental finding and may be
present in as many as 30% of males.
The etiology of most spermatoceles is idiopathic, although
trauma, infection, or an inflammatory process within the epi-
didymis or scrotum may precede the development of a sper-
matocele. It is hypothesized that the epididymal ducts become
obstructed, causing proximal dilation. The cause of the ob-
struction is thought to be the seminiferous epithelium continu-
ally shedding immature germ cells that are deposited in the
efferent ducts (4).
Diag no sis
Because most spermatoceles are asymptomatic, they are usu-
FIGURE 80.4 The Lord operation. The testis is extruded through a ally discovered incidentally on self-examination or on physical
small incision placed in the middle of the sac, and interrupted placat- examination by a physician. The typical location within the
ing sutures are placed in a circumferential fashion. The sutures are scrotum is cephalad and sometimes posterior to the testicle.
tied, and the sac will “ accordion” into a collar superior to the testicle.
H owever, spermatoceles may arise from any location on the
epididymis. These cystic structures are not usually painful, are
round, and have distinct borders. The mass is easily separable
accordion, forming a collar around the testis and epididymis from the testis. Scrotal ultrasound may be helpful when the di-
(Fig. 80.4 inset). Wound closure is accomplished as discussed agnosis is uncertain.
for the other procedures.
Ing uinal Ap p ro ach Ind icat io ns fo r Surg e ry

When a neoplasm is a concern but not definitively diag-
nosed preoperatively, a Chevassu maneuver may be per- M ost spermatoceles do not require intervention. Painful or
formed or the Goldstein and Waterhouse modification large, socially embarrassing spermatoceles may require inter-
employed (3). Preservation of the testicle may be accom- vention. Surgery should be entertained when there is a ques-
plished without compromising the cancer operation. tion of diagnosis of a potential tumor. Spermatocelectomy
Biopsies of the suspicious area may be performed utilizing should be avoided in men desiring future fertility.
these techniques and the testicle spared if no cancer is
found. These approaches involve exposure through an in-
guinal incision, clamping the cord with noncrushing clamps, Alt e rnat ive The rap y
ligating the gubernaculum prior to transection, and cooling
the testis with ice slush. The benign testicle is then replaced In those requiring treatment, the options are aspiration with
into the scrotum or a radical orchiectomy performed in the the use of sclerosing agents or surgery. Results are similar to
case of malignancy. those of hydrocele.
Chap t e r 80: Hyd roce le and Sp e rmatoce le 531
FIGURE 80.5 Spermatocelectomy. The spermatocele is

separated from the globus major of the epididymis by
sharp dissection and excised.
M agnification may be of benefit when fertility is a concern.

Surg ical Te chniq ue H emostasis is accomplished with needle tip cautery or
chromic ligatures. The edges of the epididymis are reapproxi-
The spermatocele is approached through the same incision as
mated or a portion of adjacent fascia or tunica may be used to
for the hydrocele. The tunica vaginalis is incised, and the testi-
close the epididymal defect (Fig. 80.6 inset). In some cases it
cle, along with the spermatocele, is delivered into the incision.
may be necessary to resect a portion of the tunica vaginalis to
Utilizing sharp dissection, the cystic structure may be excised
perform a hydrocelectomy in conjunction with this procedure.
or “ shelled out” from the epididymis without excessive mobi-
Wound closure and postoperative management are similar to
lization of the epididymis or testis (Fig. 80.5). O n occasion, an
those for hydrocelectomy.
attachment to the epididymis can be identified and ligated
or cauterized carefully with minimal trauma (Fig. 80.6).
O UTCO MES
Co mp licat io ns
The usual surgical complications are seen with these proce-
dures. The most common complication is hematoma, usually
within the scrotum. In some cases, testicular atrophy or ob-
struction of the epididymis (12) or vas deferens may occur (5).
Bleeding, wound infection, scrotal abscess, and recurrent hy-
drocele or spermatocele complete the list of possible complica-
tions, but they are much less common. There is some evidence
that the Lord procedure for hydrocelectomy has fewer of these
complications (10).
Re sult s
FIGURE 80.6 Attachments to the epididymis are identified, ligated,
or cauterized with minimal mobility. The epididymal defect is closed M ost patients have a successful outcome with a minimal inci-
with chromic sutures. dence of recurrence.
References
1. Andrews EW. The “ bottle operation” method for the radical cure of 7. Landes RR, Leonhardt KO. The history of hydrocele. Urol Surv 1967;17: 135.
hydrocele. A m Surg 1907;46:915–918. 8. Lord PH . A bloodless operation for the radical cure of idiopathic hydro-
2. Beiko DT, Kim D, M orales A. Aspiration and sclerotherapy vs hydrocelec- cele. Br J Surg 1964;51:914–1916.
tomy for treatment of hydrocele. Urology 2003;4:7808–7712. 9. N ash JR. Sclerotherapy for hydrocele and epididymal cysts: a five year
3. Goldstein M , Waterhouse K. When to use the Chevassu maneuver during study. Br M ed J Clin R es 1984;288(6431):1652.
exploration of intrascrotal masses. J Urol 1983;130:1199–1200. 10. Rodriquez WC, Rodriquez DD, Fortunado RF. The operative treatment of
4. Itoh M , Li XQ , M iyamoto K, et al. Degeneration of the seminiferous ep- hydrocele: a comparison of four basic techniques. J Urol 1981;125:804.
ithelium with aging is a cause of spermatocele? Int J A ndrol 1999;22(2):91. 11. Thompson H , O dell M . Sclerosant treatment for hydroceles and epididy-
5. Kiddoo DA, Wollin TA, M ador TR. A population based assessment of mal cysts. Br M ed J 1979;2:704.
complications following outpatient hydrocelectomy and spermatocelec- 12. Z ahalsky M P, Berman AJ, N ayler H M . Evaluating the risk of epididymal
tomy. J Urol 2004;171:746–748. injury during hydrocelectomy and spermatocelectomy. J Urol 2004;171:
6. Ku JH , Kim M E, Lee N K, et al. The excisional, plication, and external 2291–2292.
drainage techniques: a comparison of the results for idiopathic hydrocele. 13. Jaboulay M . Chirurgie des centres nerveux , des viscères et des m em bres.
Br J Urol Int 2001;87:82. Vol 2. Lyon/Paris, 1902:192.
CHAPTER 81 ■ CO NGENITAL CURVATURE

TIMO THY O . DAVIES AND KURT A. MCCAMMO N
N ormal erectile function is not only dependent on normal vas- type III congenital curvature, the patient’s urethra, corpus
cular and neurologic function but also requires elasticity and spongiosum, and Buck fascia are all developed normally. The
compliance of all tissue layers of the penis. During tumescence abnormality in these patients is in the dartos fascia, which
the penis begins to fill with blood and the corporal bodies and has an elastic band that causes the penis to bend sharply. N ot
tunica albuginea reach their limits of compliance, causing infrequently these patients have a large and prominent mons
rigidity. Patients with straight erections have normal and sym- pubis.
metrical expansion of the tunica albuginea. Those with curva-
ture have an asymmetrical expansion of one aspect of their
penis. This could be due to decreased compliance of one
aspect of the tunica or foreshortening of one erectile body.
Patients usually present in their late teens to early 30s.
M ost men cannot remember their penis being straight and
have always assumed their curvature was normal. After pu-
berty and onset of sexual activity, they realize that the curva-
ture impedes normal sexual relations. Some patients also
notice that their curvature worsens with puberty. O n occa-
sion, a patient will present after the age of 30 either having
been sexually active but found sex difficult functionally or
psychologically or, less commonly, sexually inactive due to the
curvature and the embarrassment he feels.
Penile curvature is described as either congenital or ac-
quired. There is some confusion with the terms congenital cur-
vature and chordee w ithout hypospadias. Some use these
terms interchangeably; however, we do not think they are syn-
onymous. This curvature is associated with abnormalities of
the ventral tissue planes or the corpus spongiosum.
Devine and H orton (2) proposed a classification system for
congenital penile curvature identifying five separate types of
curvature. Types I to III can be collectively termed chordee
without hypospadias (Fig. 81.1). This refers to an abnormal
FIGURE 81.1 Cross section of the penis displaying the forms of con-
development of ventral penile tissue with the patient having a genital curvature of the penis. The normal penis is in the center. Class I:
normally placed meatus. For patients with type I, none of the Epithelial urethra beneath the skin. Dysgenic tissue beneath it repre-
surrounding layers are normal and there is malfusion of the sents undeveloped corpus spongiosum, Buck fascia, and dartos fascia.
corpus spongiosum. Patients with type II curvature have a Class II: N ormal urethra and spongiosum but abnormal Buck and
dartos fasciae. Class III: Abnormal dartos fascia only. Class IV :
dysgenic band of fibrous tissue lateral and dorsal to the ure- N ormal urethra and fascial layers with abnormal corporocavernosal
thra, which is believed to have formed from the mesenchyme development. Class V : Congenital short urethra (rare). (From Devine
that would have become the Buck and dartos fasciae. In CJ Jr, H orton CE. Bent penis. Sem in Urol 1987;5:252, with permission.)
Chap t e r 81: Cong e nital Curvature 533
Type IV curvature is commonly referred to as congenital

curvature of the penis by the authors. In type IV penile cur- SURGICAL TECHNIQ UE
vature, development of the urethra, fascial layers, and corpus
spongiosum is normal but there is also a relative shortness There are a wide variety of surgical procedures to repair con-
or inelastic area of the tunica albuginea. Experience with genital curvature, including incision and plication, incision
these patients has shown that they have a penis of normal with grafting, and penile disassembly. M ost congenital curva-
length when flaccid, but when erect the penis may be larger tures are straightened completely with incision and plication.
than expected, thought to be due to hypercompliance of the
tunica albuginea. M any of these patients will note curvature
prior to puberty, but this becomes more accentuated after Incisio n and Plicat io n
pubescence and the penile growth spurt that occurs during
adolescence. If the patient has been previously circumcised, an incision is
Type V curvature is the rarest of all types, and some even made through the circumcision scar. Due to the previous cir-
question whether it exists. This type is known as the congeni- cumcision, there are new patterns of lymph and venous
tally short urethra. The short urethra is not elastic enough or of drainage, and an incision proximal or distal to the old scar
adequate length, leading to ventral curvature during erections. could lead to marked penile edema. The incision is made
down to the superficial layer of the Buck fascia, and the penis
is degloved in this plane. O nce completely degloved, an artifi-
DIAGNO SIS cial erection is created using intravenous normal saline and a
high-pressure pump. Perineal pressure may be needed initially,
All patients should undergo a complete history, including an but prolonged pressure is not needed as these patients have
extensive sexual history and physical examination. Complete normal erectile function. A tourniquet placed at the base of
examination is done to rule out evidence of subclinical frac- the penis is not recommended as this can mask the proximal
ture or Peyronie disease, which is obviously rare in the extent of curvature.
younger patient population. Patients are required to supply The artificial erection demonstrates the degree and location
photographs of their erect penis for documentation of the cur- of maximal curvature. In patients with ventral curvature, a
vature. The photographs are beneficial in distinguishing be- layer of dysgenic tissue may be noted that includes the Buck
tween congenital curvature and chordee without hypospadias. and dartos fasciae. This tissue is completely mobilized and ex-
Psychological aspects of the disease also need to be addressed. cised. Care is taken not to injure the corpus spongiosum,
O n occasion, patients are evaluated preoperatively by a certi- which will need to be detached from the glans to the peno-
fied sex therapist and treated as needed. scrotal junction. If injured the urethra is closed primarily.
Patients with chordee without hypospadias usually present Patients who suffer from a differential elasticity between dor-
with a ventral or ventral-lateral curvature and are noted to sal and ventral aspects of the corporal bodies may receive
have a penis that is normal or shorter than normal in length. some benefit from the excision of the inelastic dysgenic tissue
As mentioned earlier, these patients also have noted penile but are rarely straight and often require further maneuvers to
curvature throughout their whole life and may note some pro- straighten the penis. An artificial erection is repeated after
gression of the curvature during puberty. M any of these pa- this, and if straight the skin is closed (Fig. 81.2).
tients have abnormalities of the ventral penile skin. This may The options to straighten the penis are to either lengthen
be a hooded preputial skin or a high insertion of the peno- the short side with incisions and grafts or to shorten the long
scrotal skin. The deep ventral tissues of the penis seem to be side with excisions and/or incisions and plication. In the set of
inelastic to examination and stretch. The inelastic tissue that is patients for whom penile length is not a major issue, we usu-
palpable is the dysgenic tissue that has replaced the Buck and ally choose to excise and perform plications. The patients re-
dartos fasciae. cover from plication procedures more quickly, and graft take
Some of these patients, because of their curvature and is not an issue. Although rare, there is a possibility to induce
smaller-than-average length, have poor self-images. When veno-occlusive dysfunction with dermal grafts (Fig. 81.3).
identified, these are the patients who benefit from psychologi- O nce it has been determined to proceed with excision of tu-
cal counseling preoperatively. nica and dorsal plication, the Buck fascia is elevated, incorpo-
rating the neurovascular structures via one of two techniques.
O ne approach is to start lateral to the corpus spongiosum and
INDICATIO NS FO R SURGERY carry the incision medially. The alternative approach is to ex-
cise the deep dorsal vein and approach the tunica from the dor-
Patients who have significant enough curvature to impair their sal midline. If done through this approach, after the dorsal vein
sexual function are candidates for surgery. Surgery for chordee is excised the inner layer of the Buck fascia is elevated off the tu-
without hypospadias is successful in this patient population, nica, including the dorsal neurovascular structures; this dissec-
with most curvatures repaired in a single procedure. Many times tion is carried laterally to the corpus spongiosum.
the curvature is corrected by excising the dysgenic tissue on the An artificial erection is again performed and the point of
ventrum of the penis and mobilizing the corpus spongiosum. maximal curvature identified. The areas of ellipses are identi-
fied and marked. Edges of the planned ellipses are apposed
with a 3-0 polypropylene (Prolene) suture, and a repeat artifi-
ALTERNATIVE THERAPY cial erection is performed. If this demonstrates adequate
straightening, the edges are marked, the suture is removed,
There are no alternatives to surgery. and the ellipse of tunica is excised using a sharp scalpel. The
FIGURE 81.2 Surgery for chordee without hypospadias.

A: Ventral curvature demonstrated with artificial erec-
tion. B: Dysgenic dartos fascia is elevated and will be ex-
cised. C: The dysgenic layer of the Buck fascia is
undermined by spreading the scissors. D: The inelastic
fascia is excised as the corpus spongiosum and urethra
are mobilized. E: Artificial erection demonstrates correc-
tion of the curvature.
FIGURE 81.3 Surgery for chordee without hy-

pospadias. A: A circumcision incision has been
made and the urethra has been mobilized by re-
secting the dartos and Buck fasciae. The needle is
in place for an artificial erection. The erection
shows continuing chordee. The elastic urethra is
not the cause of this curvature. The point of maxi-
mum concavity has been marked. B: An ellipse of
tissue is outlined opposite the point of maximum
concavity. As an alternative, two smaller ellipses
are shown. C: Excision of the ellipse of tunica.
N ote the tips of the septal strands in the midline.
D: Closure of the edges of the incision. E: Artificial
erection revealing a straight penis. When the bend
is more complex, ellipses must be excised in other
locations. (From Devine CJ Jr, H orton CE. Bent
penis. Sem in Urol 1987;5:4, with permission.)
Chap t e r 81: Cong e nital Curvature 535
FIGURE 81.4 Congenital lateral curva-

ture. A: An artificial erection reveals the
curvature. The incision to gain access to
the potential ellipse of tissue is marked.
B: The tunica albuginea has been exposed
by mobilizing the Buck fascia, and Prolene
sutures have been placed at the dorsal and
ventral tips of the potential ellipse. While
maintaining the artificial erection, tension
is established on the two sutures as the pe-
nile shaft is straightened. The fold pro-
duced in the tunica is marked. C: When the
penis is relaxed, this mark defines the el-
lipse of tunica to be removed. D: The tunica
is excised. E: The edges are approximated.
F: The penis is straight. The Buck fascia and
the skin are closed.
underlying erectile tissue is left undisturbed by staying in the

space of Smith. Watertight closure is performed with inter- Yachia Lo ng it ud inal Plicat io n
rupted 4-0 polydioxanone suture (PDS) and a running 5-0
There are other techniques described for the repair of congen-
PDS. An artificial erection is performed after each ellipse is ex-
ital curvature. Yachia (6,7) described a plication procedure us-
cised to determine results. If the penis is not straight, further
ing longitudinal incisions in the tunica albuginea that are
ellipses are excised to straighten it.
closed transversely. The long side is therefore plicated without
O nce straight, the Buck fascia is closed. Two small suction
excising tunica. The procedure is similar to that previously de-
drains are placed superficial to the Buck fascia. The skin is
scribed, with an incision through the previous circumcision
reapproximated with a 4-0 Vicryl suture, and a small Foley
scar and complete mobilization (Fig. 81.5).
catheter is placed overnight. A bio-occlusive dressing is
placed. The Foley catheter is removed on postoperative day 1.
O ne drain is removed in the morning as well, and if output is
low, the other is removed that afternoon and the patient is dis-
charged from the hospital.
Patients with lateral curvature may have associated ventral
curvature or rarely dorsal curvature. O n occasion, patients
with lateral curvature may only have lateral curvature. In pa-
tients with only lateral curvature, this can be approached
through a small incision at the maximal point of curvature.
After an artificial erection is obtained, the point of maximal
curvature is identified and a small incision is made on the con-
tralateral side at the site of maximal convexity. Again, there is
minimal dissection of the dorsal neurovascular structures.
After 3-0 Prolene sutures are placed, an artificial erection is
performed; if straight, ellipses are excised and closed as previ-
ously discussed (Fig. 81.4).
Although uncommon, congenital dorsal curvature is usu-
ally approached through a circumcising incision. The corpus FIGURE 81.5 Technique after Yachia for correction of curvature, in
spongiosum is partially mobilized so that small incisions in the this case a patient with congenital lateral curvature. A: The Buck fas-
corpora can be placed just lateral to the ventral midline. The cia is reflected, exposing the lateral tunica albuginea. B: Longitudinal
incisions are created at the area of maximal curvature as demon-
techniques used are those previously described, and the post- strated by artificial erection. C: The longitudinal closures are closed
operative course is similar to that of the patient with ventral transversely, with artificial erection demonstrating good straightening
curve. of the penis.
Mult ip le Paralle l Plicat io n

M ultiple parallel plication (M PP) is another technique used in
the repair of congenital curvature of the penis without excising
any tunica albuginea. In the original description, a pharmaco-
logic agent is used to induce an erection. A circumcising inci-
sion is performed, the penis is degloved, and the deep dorsal
artery and vein are identified. The dorsal neurovascular bundle
does not need to be dissected and freed. M ultiple deep plication
sutures are placed into the tunica albuginea at the point of max-
imal curvature between the deep dorsal artery and vein using
four to six nonabsorbable 3-0 braided sutures. Some of the su-
tures may not be fully tied down to prevent overcorrection. For
patients with lateral or ventral lateral curvature, the sutures are
placed more laterally using the same vertical orientation. When
the patient has dorsal curvature, a ventral incision is made and
the sutures are placed just lateral to the corpus spongiosum
(which does not need to be mobilized).
Pe nile Disasse mb ly
Perovic et al. (5) proposed a penile disassembly technique in
hopes of avoiding penile shortening with the plication proce-
dures. This technique requires complete disassembly of the pe-
nis into its component parts, these being the glans cap with its
neurovascular bundle dorsally, the urethra ventrally, and the
corporal bodies. Unfortunately, this technique only straight-
ened the penis satisfactorily in 68% of patients, and on occa-
sion a plication procedure was required.
FIGURE 81.6
Cho rd e e w it ho ut Hyp o sp ad ias
The corpus spongiosum is rarely the limiting factor in these
patients, even if they appear to have obvious abnormalities.
The curvature in these patients is due mainly to the inelasticity
of the ventral aspect of the corporal bodies. After the dysgenic O UTCO MES
tissue is excised, if there is residual chordee a small incision
can be made in the ventral midline of the corporal bodies after Co mp licat io ns
an artificial erection is obtained. The erectile tissue is not en-
tered with this incision, and this allows the ventral tunica to Surgical complications associated with congenital penile cur-
move laterally and noticeably straightens the penis. If this is vature surgery are relatively rare. This is in general a healthy
unsuccessful in correcting the curvature, the dorsal neurovas- population of patients. Complaints of penile shortening and
cular structures are mobilized and a small ellipse of tunica is penile irregularity from suture sites are heard. There are also
excised and closed as discussed earlier (Fig. 81.6). complaints of suture granuloma and sometimes pain at the
Some advocate the use of dermal grafts for patients with plication site. Temporary loss of glans sensation has been re-
chordee without hypospadias, especially in those patients with ported in the past, and there is one report of a patient with
severe chordee or those with a smaller-than-average penis. permanent loss of sensation. Postoperative erectile dysfunc-
This approach does not shorten the penis as a plication proce- tion is extremely rare, and there is one reported case of penile
dure would, but there are complications associated with it as necrosis secondary to a tourniquet; we would not recommend
well. The major concern with placing a dermal graft is the risk using these.
of veno-occlusive dysfunction. This is a known complication
when using dermis in adult patients with Peyronie disease.
Grafting the corpora cavernosa in any patient has the poten- Re sult s
tial for creating erectile dysfunction. The majority of patients
seek surgery as young adults, and the occurrence of erectile The reported success rates of the N esbitt, Yachia, and incision/
dysfunction can be devastating. It is thought that the pediatric plication surgical procedures vary from 85% to 100% . Eight
patient may not develop veno-occlusive dysfunction because percent of M PP patients were satisfied with their correction,
no tunica is excised and a much smaller graft is used than in although two of the eight had to undergo a second procedure
the adult. N o long-term studies have been published following to correct a residual 15% curvature. All patients did notice the
these patients into adult life to determine the risk. sutures, but only one considered them bothersome.
Chap t e r 82: Re construction of the Pe nis for Comp lications of Pe nile Enhance me nt Surg e ry 537
References
1. Baskin LS, Lue TF. The correction of congenital penile curvature in young 5. Perovic SV, Djordjevic M LJ, Djakovic N G. A new approach to the treat-
men. Br J Urol 1998;81:895–899. ment of penile curvature. J Urol 1998;160:1123–1127.
2. Devine CJ, H orton CE. Chordee without hypospadias. J Urol 1973; 110: 6. Yachia D. M odified corporoplasty for the treatment of penile curvature.
264–271. J Urol 1990;143:80–82.
3. Kaplan GW, Brock WA. The etiology of chordee. Urol Clin N orth A m 7. Yachia D, Beyar M , Aridagon A, et al. The incidence of congenital penile
1981;8:383–387. curvature. J Urol 1993;150:1478–1479.
4. Kramer SA, Aydin G, Kelalis PP. Chordee without hypospadias in children. 8. N yirady P, Kelemen Z , Banfi G, et al. M anagement of congenital penile
J Urol 1982;128:559. curvature. J Urol 2008;179:1495–1498.
CHAPTER 82 ■ RECO NSTRUCTIO N O F THE

PENIS FO R CO MPLICATIO NS O F PENILE
ENHANCEMENT SURGERY
GARY J. ALTER
Surgery to enlarge the length and girth of the penis has been The larger flap encompasses the entire dorsal base of the penis
developed over the past few decades. These procedures were and part of the scrotum, which causes interruption of a signif-
derived from a combination of plastic surgical techniques and icant portion of the proximal penile dartos fascia and skin.
urologic reconstructive pediatric and adult surgical operations The blood supply and lymphatic drainage of the penis are thus
(1–4). Penile length is increased by releasing the suspensory partially interrupted, which can cause healing complications
ligament of the penis followed by the use of penile weights or such as flap tip loss, poor wound healing with wound dehis-
stretching devices. The girth is increased by either injecting fat cence, and postoperative swelling. H ealing problems predis-
into the dartos fascia or by inserting dermal fat grafts or allo- pose to hypertrophic or wide scars, which create hairless
plastic cellular matrix grafts such as AlloDerm. Unfortunately, suprapubic scars and depressions (Figs. 82.2A and 82.3A) (6).
these procedures are often based on faulty concepts or are not The large V-Y flap also advances thick, hair-bearing tissue
performed meticulously, which has led to many complications. onto the penis, which frequently creates an unnatural hump at
The purpose of this chapter is to outline techniques to recon- the penile base and the appearance of a low-hanging penis.
struct these unfortunate outcomes. The penis can appear surrounded by the scrotum (scrotaliza-
tion) with an overhanging large pubic fat pad, which makes
the penis look shorter and hidden. A V-Y flap can also create
“ dog-ears” at the distal scrotal flap incision. Smaller V-Y ad-
DIAGNO SIS vancement flaps cause less frequent problems but have wound
and aesthetic complications.
A patient may present for reconstruction after only a penile
An occasional patient may complain of penile shortening
lengthening procedure or also with some girth enhancement.
after release of the suspensory ligament. Since there is a dead
An assortment of deformities can occur (6,7).
space between the pubic symphysis and the corpora, it is pos-
sible for the corpora to reattach in a shortened position. This
dead space can be filled by a proximally or distally based fat
Pe nile Le ng t he ning flap transposed from the spermatic cord (5). H owever, most
doctors tell the patients to stretch the penis after the release
Penile lengthening is achieved by releasing the suspensory lig- without filling the space.
ament of the penis and the postoperative use of penile weights Penile instability is very rare after suspensory ligament re-
or stretching devices (Fig. 82.1A) (6). A small lower transverse lease and usually results from an overly aggressive release of
pubic incision is usually used, but many surgeons advance in- the corporal bodies from the inferior rami of the ischium. If
frapubic skin onto the penis using a V-Y advancement flap the release is limited to one fingerbreadth on the midline of the
(Fig. 82.1B and C) (6,8,9). This theoretically increases penile pubic symphysis, this will not occur. Dorsal nerve or vessel in-
length and gives the penis the appearance of increased flaccid juries are prevented by staying directly on the pubic perios-
length. This penile length gain is disputed in most cases, and it teum of the midline of the symphysis with the penis on full
can cause the penis to appear either longer or shorter in the stretch and by not releasing the corpora laterally. A mild de-
flaccid state. The V-Y flap is based distally at the penopubic crease in the elevation of the erection can occur with release
junction, varying from a small (2- to 3-cm) to a large base. but is not problematic.
A
FIGURE 82.1 Method commonly used
for penile lengthening that often causes
penile deformities. A: The suspensory
ligament is released. B: A large V-Y
advancement flap is designed. C: The
flap is advanced, resulting in hair on
B the proximal penile shaft, bilateral
C dog-ears, and a lower-hanging penis.
A B
FIGURE 82.2 Patient who had release of the suspensory ligament, a large V-Y advancement flap, and
multiple fat injections (same case as in Fig. 82.4). A: The deformity shows a low-lying penis, hair on the
proximal shaft, bilateral dog-ears at the penoscrotal junction, a shorter-appearing penis, wide pubic
scars, and a large amount of fat in the shaft. B: Reconstruction after complete reversal of the V-Y ad-
vancement flap, correction of V-Y dog-ears, scar revision, selective removal of fat nodules, and contour-
ing of the left side of the penis.
circumcision removes this “ excess foreskin,” then there can be

Fat Inje ct io ns inadequate shaft skin to perform a later reversal of the V-Y ad-
vancement flap, thus limiting the reconstructive options.
Significant complications can occur from autologous fat injec-
Patients sometimes complain of inadequate rigidity if a
tions (Figs. 82.2 and 82.3) (6). The penis is a relatively cylin-
large amount of injected fat survives, since the fat bulk over-
drical structure, so asymmetrical fat absorption can cause
whelms the corporal erection. Intercourse difficulty can also
severe penile distortion with S-shaped curves, nodules, or liq-
occur if large fat injections are combined with a large V-Y
uefied cysts. The larger the amount of fat injected, the greater
flap, since a soft penile shaft is combined with loose penile
the chance of deformities. H owever, a small amount injected
skin.
may not result in any long-term girth gain. If fat is injected in
large amounts, it frequently migrates distally during the initial
postoperative period, which causes unsightly fat deposits at De rmal Fat Graft s
the corona. If the fat migrates distally causing penile skin to
stretch, and if the patient has a large V-Y flap, then the previ- Dermal fat grafts are used for girth enlargement by either in-
ously circumcised patient can look uncircumcised. If another serting dermal fat strips into the dartos along the length of the
A B
FIGURE 82.3 Patient who had release of the suspensory ligament, a large V-Y advancement flap, and fat
injections. A: The deformity shows a low-lying penis, hair on the proximal shaft, bilateral dog-ears at the
penoscrotal junction, a short-appearing penis, wide pubic scars, and fat in the shaft. B: Reconstruction
after partial reversal of the V-Y advancement fat, correction of the V-Y dog-ears, scar revisions, and se-
lective removal of fat. Complete reversal of the V-Y flap was not possible due to previous partial loss of
a portion of the V-Y flap (Fig. 82.5).
penis or by wrapping sheets of dermal fat around the shaft plan and probable result are realistically discussed with the
between the dartos and the Buck fasciae. The grafts are stabi- patient and often shown while he is standing in front of a
lized proximally and distally with sutures to prevent migra- mirror. Discussion of expectations and goals is crucial to pre-
tion. If the grafts do not survive completely and symmetrically, venting a hostile patient.
the patient can have fibrosis and firmness. As a result, the pa-
tient can complain of loss of penile length, asymmetry, curva-
ture, or firm areas.
SURGICAL TECHNIQ UE
Allo De rm M ost commonly, patients complain of complications of the
large V-Y advancement flap. Usually most of the extensive pu-
The use of AlloDerm for girth expansion was motivated by bic, penile, and scrotal scars is excised (Figs. 82.2B and 82.4)
the unpredictability of dermal fat graft “ take” with its cosmet- (6). The defect after the excision of the Y scar is much larger
ically unappealing donor site scars. Layers of AlloDerm are in- than usually anticipated, with the width of the vertical scar
serted in a plane above the Buck fascia and stabilized often exceeding 5 cm. Ideally, the V flap is re-elevated to near
proximally and distally. Theoretically, the AlloDerm is a ma- its original previous location, aligning the hair on the V flap
trix for the ingrowth of tissue and becomes integrated into the with the pubic hair. This will result in an inverted U closure.
area. H owever, this does not always occur, so the AlloDerm Determination needs to be made as to the adequacy of shaft
can be isolated within a capsule. The AlloDerm does not skin so that complete reversal of the flap does not shorten the
stretch, so the patient may complain of loss of length or cur- penis (either real or illusory) and restrict an erection. An arti-
vature. Patients may also complain of an unnatural feel of the ficial erection achieved by intracavernosal injection of
penis, migration of the AlloDerm, asymmetry, and visual and Prostaglandin E1 helps to determine skin adequacy. Penile skin
palpable deformities. M any cases of infected AlloDerm have may be inadequate from a previous circumcision or from flap
occurred, resulting in chronic infections and chronic skin si- tip loss from the first procedure. If the skin is inadequate, par-
nuses with or without skin loss. tial V-Y reversal results in a Y-shaped scar with a shorter ver-
tical limb (Figs. 82.3B and 82.5) (6). N o restriction of erection
should occur by pulling on the erect penis.
The scrotal dog-ears are excised at this time. Prolonged
INDICATIO NS AND lymphedema or potential skin loss can occur if the skin and
ALTERNATIVE THERAPY dartos fascia at the penile base are completely circumcised
while repairing these scars and dog-ears. The method of clo-
Secondary surgery should not be performed until at least sure and dog-ear excision is determined by judging the tight-
6 months after the enlargement operation to allow resolution ness of the penile skin, taking care not to restrict an erection.
of swelling, revascularization of tissue, and elimination of If the discrepancy of skin occurs from reversal of the V-Y flap,
induration. The patient must prioritize his reconstructive op- the dog-ear is usually followed along the lateral scrotum.
tions and be specific as to his desires. H e may want only lim- Alternatively, the dog-ear is excised from the midportion of
ited fat removal, partial or no V-Y flap reversal, or minimal the lateral side of the incision, which creates a lateral dart
scar revisions. Additionally, it may not be possible to correct instead of following the dog-ear around the penile base
all deformities at one or multiple operations. The operative (Fig. 82.5B) (6).
FIGURE 82.4 Complete reversal of V-Y flap

(same case as Fig. 82.2). A: A scar is marked for
excision with solid lines. Fat nodules to be excised
are marked by dotted lines on the penis. B:
Complete reversal of V-Y advancement flap, re-
sulting in a semicircular incision line. H air on the
V-Y flap is aligned with the pubic hair. The marked
A B fat nodules were removed.
FIGURE 82.5 Diagram of partial reversal of V-Y advance-

ment flap. A: The V-Y flap is reversed as much as possible
while preserving penile length. A Y-shaped incision line re-
sults. B: Dog-ears are removed by making lateral darts.
They can also be removed by extending the incision along
A B the lateral scrotum.
In order to reduce the risk of redeveloping a hypertrophic then the subcutaneous fat on the V flap is conservatively ex-
scar, closure should be meticulous and without tension. The cised to prevent devascularization. This will improve the ap-
skin, subcutaneous tissue, and Scarpa’s fascia are undermined pearance, but the difference in skin texture and hair growth
and then closed in layers. Intradermal buried 4-0 M onocryl continues.
sutures are placed, and the skin is closed with a subcuticular The resulting scars are better with the inverted U scar than
suture. A suction drain is used. If the upper limb of the vertical with the partial V-Y reversal. The reversal and scar revision
incision pulls, then one of two small Z -plasties can be used to improve the wide or hypertrophic scars and eliminate the
release tension and decrease the risk of a restrictive hyper- suprapubic concavity. They eradicate the unsightly dorsal
trophic scar contracture. Even with careful closure, the com- penile hump and proximal hair-bearing tissue by redraping the
mon junction of the V flap with the vertical closure often has penis with the normal shaft skin and elevating the penis to its
minor healing problems. Also, over time, the pulling of the normal position. They can also improve or eliminate com-
penis on the incision lines usually causes some stretching of plaints of penile instability.
the scars. Rereleasing the suspensory ligament is performed only if
If complete V-Y reversal is not possible due to restriction the patient complains of penile shortening. Transposing a
of erection and if a significant dorsal flap hump is present, fat flap from the lipomatous tissue of the spermatic cord
Infe ct e d Fat
The surgeon should remove fat nodules or contour the penile
fat through a limited or complete circumcising incision, a
medial raphe incision, or part of the previous V-Y or pubic
transverse incision. N ew incisions on the penile shaft are un-
sightly and unnecessary. Deforming or firm fat deposits are
very conservatively removed and then the residual fat is con-
toured while leaving as much dartos fascia as possible. It is
very important not to overresect fat, which will create an un-
sightly concavity, so resection is performed in very small incre-
ments. Large diffuse fat deposits are usually removed through
a circumcision incision (Fig. 82.7). O nly rarely will a patient
want all of the fat removed. Skin necrosis, chronic lym-
phedema, or skin attachment to the Buck fascia can occur
FIGURE 82.6 Bilateral fat flaps from the medial spermatic cords are
transposed to the midline to fill the dead space at the penile base. with overly aggressive removal of the dartos fascia. The goal
of fat removal is contouring, not complete fat elimination.
If the patient is undergoing V-Y flap reversal, then simulta-
eliminates the dead space between the corpora and pubic sym- neous removal of fat nodules or deforming deposits is limited.
physis (Fig. 82.6). The fat flap is dissected off of the cord, di- If large diffuse fat deposits are removed at the same time as V-
vided proximally to leave an intact distal random blood Y reversal, then further flap disruption and dartos fascia in-
supply, and sutured to the periosteum with 3-0 absorbable jury decrease the flap vascularity and possibly prolong edema.
sutures. Fat is removed through a several-centimeter tunnel on one or
A B
C D
FIGURE 82.7 A: Patient with large volume of injected penile fat that is causing obvious convexities.
B: Circumcision incision reveals diffuse fat deposits. C: Residual fat after contouring. Patient did not
want complete fat removal. D: Penis appearance after closure. It is very difficult to achieve ideal symmet-
rical contouring.
patients with penile shortening, penile curvature, or chronic

infection caused by graft necrosis and subsequent scar con-
tracture may require a difficult dissection. An extensively fi-
brotic AlloDerm or dermal graft may adhere to the Buck
fascia, so extreme care must be taken not to injure the dorsal
neurovascular bundles. Loupe magnification is usually neces-
sary. Removal of the scarred dermal graft may eliminate the
deformity, curvature, or penile length restriction, but total re-
turn of penile length may not occur due to permanent scarring
of the skin or of the dartos or Buck fascia. Under rare circum-
stances, severe fibrosis may require penile plication. The sur-
geon should preserve as much dartos fascia as possible during
graft removal to prevent skin adherence to the Buck fascia.
A dead space often occurs at the penopubic junction after
graft removal. The space must be filled with vascular fat flaps
FIGURE 82.8 The fat nodule is removed through a 1- to 2-cm tunnel transposed from the medial spermatic cord or other nonadher-
underneath the V flap, thereby preserving the vascularity of the flap. ent vascularized tissue, which will help prevent penile shorten-
ing (Fig. 82.6). A closed-suction drain is necessary.
Chronic infections with dermal fat grafts or AlloDerm are
both limbs of the distal V-Y incisions without undermining the often seen. The patient presents with infected sinuses and
flap, or through a limited circumcision incision (Fig. 82.8) (6). chronic drainage, erythema, and so forth. Removal of the en-
O ne side of the penis should be kept relatively inviolate to re- tire graft is usually recommended. These cases should initially
tain good blood and lymphatic drainage. Degloving of the pe- be treated in the short term with antibiotics, but aggressive re-
nis through a circumcision incision and V-Y flap reversal moval of the dermal grafts and AlloDerm should be done
should not be done at the same time. Residual deposits re- without delay if infection persists. Persistent delay in treatment
moved at least 6 months later are done through a circumci- may complicate the ability of the patient to regain his penile
sion, median raphe, or previous incision. length due to scar contracture of the dartos and Buck fasciae
and the skin. These cases can have tragic consequences.
O n occasion, dorsal penile skin loss has been seen from
De rmal Fat Graft s and Allo De rm both AlloDerm and dermal fat grafts, probably from venous
congestion due to stretched dartos fascia and skin combined
The presence of dermal fat grafts and/or AlloDerm creates a with a tight dressing. These situations have disastrous conse-
different set of problems. Patients complain of penile curvatures, quences. A thick skin graft is needed to maintain the length of
shortening, abnormal texture, chronic infections, and penile the penis or secondary contracture of the wound will cause a
distortion. Sometimes patients present after a combination of short, distorted penis. Unfortunately, the graft has a poor
procedures, such as a V-Y advancement flap and fat injections color match, is cosmetically deforming, and may not allow
followed by dermal fat grafts and/or AlloDerm. The graft complete length preservation.
causing the problems can usually be totally removed through The dressing used around the penis after any of these surg-
one or a combination of circumcision, median raphe, or pubic eries is crucial to recovery, since it will help prevent
incisions. Penile shaft incisions should be avoided. An in- hematomas and swelling that can lead to secondary deformi-
durated, scarred graft that is not attached to the Buck fascia ties. Any significant fat removal or degloving of the penis usu-
can be removed without much difficulty, thereby usually ally requires a small closed-suction drain placed through a
correcting or improving the deformity (Fig. 82.9). H owever, small pubic stab incision. A thin Duoderm dressing is loosely
wrapped around the penis followed by a loose Coban. This
dressing is not removed for a minimum of 2 days but fre-
quently longer. It is then replaced with a circumferential loose
Tegaderm wrap. Drains are left until they cease draining.
O UTCO MES
Co mp licat io ns
Frequently, the patient states that he would just like to return
to the appearance of his penis prior to any penile enlarge-
ment surgery, but this is usually impossible. Sometimes he
just wants to achieve some final girth increase, albeit minor,
in order to feel that the enlargement process was not a total
loss.
After reversal of the V-Y flap, the patient may have some
FIGURE 82.9 AlloDerm elevated off the Buck fascia without much eventual stretching of the scar so that it does not give the fine
difficulty. line that was present initially. H owever, there is certainly an
improvement in the scar and elimination of the other V-Y weights or stretching devices can also be helpful to prevent
deformities. scar retraction or regain some length.
Despite careful contouring of injected fat, it is extremely
difficult to have a smooth penile contour postoperatively.
Residual nodules, lumps, concavities, and convexities are Re sult s
common and certainly expected, but the goal is to minimize
them as much as possible. Complete removal of all injected fat Reconstruction of the complications of these procedures is
is to be avoided if at all possible, since restricting bands can challenging, requiring an understanding of blood flow, tissue
form at the penopubic junction and the skin can attach to the transfer techniques, and plastic surgical principles. These pa-
Buck fascia. The surgeon should always try to leave some dar- tients are often psychologically devastated when coming for
tos and fat in order to minimize this possibility. Secondary reconstruction, since they started with self-esteem issues that
surgery to repair these bands and attachments is not always led to their initial penile enlargement operation. Thus, the re-
successful. constructions must be done with extreme care in order to re-
Removal of restricting bands and tissue of the penopubic gain the patients’ penile form and function and psychological
junction from dermal fat grafts or AlloDerm can still result in health.
erectile restriction at the base of the penis from bands and scar The outcome for most patients with reconstruction is usu-
tissue. Postoperatively, tissue reaction at the penopubic junc- ally satisfactory. There is a low complication rate if meticulous
tion often requires time and multiple Kenalog injections to technique is used. H owever, more than one operation is often
soften the palpable bands attached to the corpora and penile necessary. The vast majority of these patients are able to re-
skin. These usually soften 6 months. O n occasion, a limited sume normal sex lives without being self-conscious after cor-
release of these recurrent bands needs to be performed. Penile rection of their deformities.
References
1. Johnston JH . Lengthening of the congenital or acquired short penis. Br J 6. Alter GJ. Reconstruction of deformities resulting from penile enlargement
Urol 1974;46:685. surgery. J Urol 1997;158:2153.
2. Kelley JH , Eraklis AJ. A procedure for lengthening the phallus in boys with 7. Wessells H , Lue TF, M cAninch JW. Complications of penile lengthening
exstrophy of the bladder. J Pedriatr Surg 1971;6:645. and augmentation seen at 1 referral center. J Urol 1996;155:1617.
3. Kabalin JN , Rosen J, Perkash I. Penile advancement and lengthening in 8. Long DC. Elongation of the penis [in Chinese]. Chung-H ua-Cheng-H sing-
spinal cord injury patients with retracted phallus who have failed penile Shoa-Shang-Wai-Ko-Tsa-Chih 1990;6(2):17–19, 7.
prosthesis placement alone. J Urol 1990;144:316. 9. Roos H , Lissoos I. Penis lengthening. Int J A esthetic R estorative Surg
4. Rigaud G, Berger RE. Corrective procedures for penile shortening due to 1994;2:89.
Peyronie’s Disease. J Urol 1995;153:368.
5. Alter GJ. Penile enhancement surgery. Techniques Urol 1998;4:70.
SECTIO N VII ■ URINARY DIVERSIO N
URS E. STUDER
CHAPTER 83 ■ ILEAL CO NDUIT URINARY

DIVERSIO N
MICHAEL C. LEE AND ERIC A. KLEIN
Despite the established role of continent catheterizable and or- Colonic conduits, which are thought to be more protective
thotopic voiding urinary diversion techniques, the ileal con- of kidney function by some surgeons due to the ability of
duit remains the most common form of urinary diversion colonic conduits to accommodate nonrefluxing anastomoses,
performed worldwide. The operation, first described by may be preferable in children and adults with a longer life ex-
Bricker in 1950, maintains this popularity in large part be- pectancy. A transverse colon conduit may be safest in patients
cause of its applicability to a wide variety of urologic disor- who have undergone pelvic irradiation due to its higher intra-
ders, its tolerability in patients with often significant abdominal position outside of the radiation field. Another use
comorbidities, and its adaptability to almost all patients’ of colon for conduits is the sigmoid conduit diversion in pa-
anatomic constraints. tients who are undergoing pelvic exenteration, with a trans-
verse colostomy that avoids the potential morbidities of a
bowel anastomosis.
DIAGNO SIS O ther potential urinary diversions include an ileovesicos-
tomy, which can be used in patients undergoing diversion for
The ileal conduit may be constructed as part of a reconstruc- reasons other than malignancy and avoids the complications
tion following extirpative pelvic surgery, such as radical or associated with ureteral mobilization and ureteroenteric anas-
simple cystectomy and pelvic exenteration, or as a diversion tomoses. In patients requiring urinary diversion with life
with the bladder left in situ, such as in cases of neuropathic expectancies less than several months, percutaneous nephros-
bladder refractory to conservative management. The clinical tomy tubes should be considered.
evaluation in these patients is therefore directed to their blad-
der pathology.
SURGICAL TECHNIQ UE
INDICATIO NS FO R SURGERY M ost patients can tolerate an at-home preoperative regimen of
a clear liquid diet 1 to 2 days before surgery, followed by 4 L
Before choosing an ileal conduit, patients should be counseled of polyethylene glycol or two bottles of magnesium citrate on
on all forms of diversion. Comorbidities such as renal insuffi- the afternoon before surgery. Broad-spectrum intravenous an-
ciency (serum creatinine 2.5 mg per dL), bowel disease (in- tibiotics are given at the time of the surgery. The stoma site
flammatory or malignant), extreme obesity, or neurologic should be selected after examining the patient in the supine,
illness that prevents the ability to perform self-catheterization seated, and standing positions. To best accommodate an
may make incontinent diversion a wise choice. While it was appliance, the site should not be too near the anterior superior
suggested in the past that patients with cardiovascular or iliac spine, costal margin, umbilicus, surgical scars, or skin
pulmonary diseases may do better with the shorter, simpler folds. The usual ideal location is just medial to the linea semi-
conduit diversions, newer evidence suggests that periopera- lunaris on a line between the umbilicus and the anterior supe-
tive morbidity is equivalent with conduit and continent diver- rior iliac spine.
sions (12). M arkedly obese patients may require a higher site to allow
them to perform stoma care under direct vision. In instances
where there is a question regarding the ideal stoma site, ambu-
ALTERNATIVE THERAPY latory trials of pouching candidate sites can help determine
the optimal location.
Continent catheterizable or orthotopic voiding diversions are Laparoscopic techniques have been reported for the cre-
the most common alternatives to conduit diversion. If the ation of ileal conduits and have been successfully performed
aforementioned concerns make conduit diversion preferable with no reported intra- or postoperative complications (10).
to continent diversion, there still exist options regarding the H owever, the open approach remains the standard given the
bowel segment to be used and the type of ureteroenteric anas- technical difficulty and the need to remove the specimen through
tomosis. Jejunal conduits are associated with a higher incidence a minilaparotomy when performing a concurrent cystectomy.
of metabolic complications, characterized by hypochloremia, A low midline incision extending from just above the um-
hyponatremia, hyperkalemia, and acidosis, but may be the only bilicus down to the symphysis pubica allows for exposure of
viable option in certain patients due to previous surgery, irradi- the bladder for cystectomy as well as bowel exposure for the
ation, or concomitant bowel diseases (6). conduit portion of the procedure. The patient is positioned
545
546 Se ct io n VII: Urinary Dive rsion
supine. A Bookwalter-type retractor may be used to retract the anastomosis. Sterile towels are placed beneath the isolated
bowel from the cystectomy field, and then the blades may be ileal conduit, which is irrigated free of enteric contents with an
repositioned on the abdominal wall for the conduit procedure. antibiotic solution.
The posterior peritoneum is incised at the pelvic inlet above At this point in the procedure, either stoma formation or
the iliac vessels, where the ureter can be found coursing over ureteroenteric anastomosis can be performed. This choice is
the vessels. The ureters are then dissected with care distally based on surgeon preference. If ureteral stents are to be used,
and transected as close to the bladder as possible. A lesser de- performing the ureteroileal anastomosis first allows for easier
gree of proximal mobilization is also usually necessary. antegrade passage of the stent out of the distal end of the con-
During mobilization of the ureter, care should be taken to duit. Creating the stoma first provides for more optimal local-
maintain its blood supply by leaving a generous amount of ization of the ureteroileal anastomotic sites and helps direct
periureteral soft tissue. The distal ends of the ureters may be the optimal level of the sigmoid mesentery through which the
clipped to allow dilatation while the ileal conduit is harvested left ureter should be passed.
and prepared. Construction of the stoma begins with the excision of a cir-
The terminal ileum is then identified and examined. If signs cular plug of skin around the preselected stoma site.
of inflammatory bowel disease, radiation changes, or insuffi- Dissection is carried down to the anterior rectus fascia, and a
cient mesenteric length are not present, then this segment is in cruciate incision is made in this layer. A Kelly clamp is passed
general preferred for conduit formation. The mesentery is ex- bluntly through the rectus muscle after palpating for and
amined by transillumination, and the watershed area between avoiding the pulsations of the inferior epigastric artery. The
the ileocolic artery and the right colic artery is selected for the Kelly is then spread to create a hiatus that allows the passage
distal mesenteric incision. This is typically located 15 to 20 cm of two fingers; this breadth is usually ideal for not compro-
from the ileocecal valve, and the preservation of this length of mising the mesenteric blood flow to the stoma while minimiz-
terminal ileum suffices to maintain bile salt and vitamin B12 ing the risk of parastomal hernia.
absorption. The bowel incision is continued proximally into In the standard end stoma (“ rosebud” ) technique, the effer-
the mesentery to allow the distal end to reach the stoma site ent end of the conduit is grasped and pulled through the
without tension. Figure 83.1 demonstrates the isolation of the abdominal wall defect until the end is 2 to 3 cm above the skin
ileal segment. surface. Each of the four tabs of the cruciate incision is then
The mesentery is again transilluminated, and a relatively sutured to the bowel serosa, taking care not to pass sutures
avascular site is selected for the proximal incision. The opti- through the bowel mesentery. Absorbable sutures are then
mal length of the conduit differs from patient to patient due to passed through the mucosal edge of the bowel, then the bowel
differences in body habitus and the degree of ureteral mobi- serosa and muscularis deep to the skin edge, and finally
lization. The longest length of conduit should not exceed the through the dermal tissue just deep to the skin edge. Care is
distance between the sacral promontory and the stoma site; taken not to suture the bowel mucosa to the epidermis, as this
usually, if there is adequate left ureteral mobilization, a can lead to mucosal rests that complicate pouching of the
shorter length than this is optimal. If there is any question re- stoma. Figure 83.2 shows the technique of suture placement
garding the length, one should err on the longer side, as re- for the end stoma. Four quadrant sutures placed in this man-
dundant conduit is much easier than insufficient conduit to ner usually suffice to evert the stoma; additional sutures may
treat intraoperatively. The conduit and its mesentery are posi- be placed for reinforcement.
tioned caudal to the rejoined bowel and its mesentery. In obese patients or patients with a short mesentery, a
Standard hand-sewn or staple techniques are then per- Turnbull loop stoma should be considered. The distal end of
formed to reestablish bowel continuity. The mesenteric win- the loop is closed with absorbable sutures (if the GIA stapler
dow is also closed with a shallow running suture to prevent was used to harvest bowel, no additional closure is needed).
internal bowel herniation. Care should be taken during clo- An umbilical tape is passed through the mesentery at its
sure of the mesenteric window to avoid ligation of the ileal border, with the ileum about 3 cm proximal to the end of the
blood supply, which might compromise the healing of the conduit. The tape is then grasped and pulled through the
FIGURE 83.1 A: The ideal segment of bowel for

the ileal conduit spares the terminal 10 to 20 cm
of ileum and should require minimal ligation of
mesenteric vessels to harvest. B: O nce isolated,
the conduit mesentery is positioned caudal to the
bowel mesentery, which is reapproximated with a
running silk suture.
Chap t e r 83: Ile al Cond uit Urinary Dive rsion 547
ureteral blood supply, the avoidance of tension on the anasto-

mosis, the documentation of malignancy-free status in the dis-
tal ureter (if the diversion is performed for cancer), and the
avoidance of ureteral kinking. While techniques for nonre-
fluxing ureteroileal anastomoses have been described (9), the
benefits of a nonrefluxing anastomosis have never been con-
clusively proven. M oreover, these techniques are likely to re-
sult in higher rates of anastomotic obstruction and prevent the
use of the simple loopogram study in the evaluation of upper-
tract pathology after ileal conduit formation. Therefore, the
freely refluxing end-to-side (Bricker) and conjoined end-to-
end (Wallace) techniques remain the most commonly per-
formed and recommended techniques.
In the Bricker technique, the proximal end of the conduit is
either left closed if staples were used in the bowel harvest or
closed in two layers with absorbable sutures. The left ureter is
FIGURE 83.2 The end stoma (“ rosebud” ) is everted by passing su- passed through a hole created in the sigmoid mesocolon. This
tures first through a full-thickness bite at the cut edge, then through hole is typically created at the level of the sacral promontory
the bowel serosa at the skin level, and finally through the dermis. but may be moved cephalad or caudally to avoid ureteral
kinking. A site on the conduit where the ureter lies naturally is
incised down to the submucosal layer. The submucosa is
abdominal wall defect. A stomal rod is in general passed grasped with forceps, and a small portion is excised along
through the umbilical tape defect to prevent stomal retraction; with its mucosa. The ureter is then spatulated, and a single-
this is then sutured in place and left in for 1 to 2 weeks. The layer full-thickness anastomosis is performed with 4-0 or 5-0
blind end of the loop is positioned cephalad, and the loop is interrupted absorbable sutures. Prior to closing the anastomo-
opened transversely nearer to the distal limb. The stoma is sis, silicone ureteral stents may be placed; these can be guided
then matured using eversion sutures in the same manner de- in through the stoma using a Kelly clamp or a copper suction
scribed for the rosebud stoma. The technique for end-loop tip. Anchoring sutures through the ureteral adventitia and the
stoma formation is detailed in Fig. 83.3. bowel serosa may be placed 1 to 2 cm proximal to the anasto-
A long-term follow-up study comparing the results of these mosis. Figure 83.4 demonstrates the ideal locations of the
two techniques revealed no major differences in outcome (2). ureteroenteric anastomoses using the Bricker technique.
Patients with an end stoma had slightly more ischemic compli- The Wallace technique involves leaving the proximal end
cations, while those with the loop stoma required more fre- of the conduit open. The ureters are spatulated for a distance
quent repair of parastomal hernias, presumably due to the slightly greater than the conduit diameter. The posterior edges
need for a wider aperture in the abdominal wall. may be joined side-by-side or end-to-end using two running
Principles to consider in the creation of the ureteroenteric 4-0 absorbable sutures. O ne suture is then used to join the
anastomoses include the maintenance of an adequate distal back walls of the conjoined ureters and the conduit, after
FIGURE 83.3 Creation of the end-loop stoma. The

defunctionalized limb is positioned cephalad.
of one ureter (recurrent malignancy, anastomotic stricture) is

more likely to cause bilateral obstruction.
After performing the ureteroileal anastomosis, the proxi-
mal end of the conduit is retroperitonealized by sewing the cut
edges of the peritoneum to the conduit. Closed-suction drains
(Jackson–Pratt type) are placed in the area of the ureteroileal
anastomoses and maintained for the first few postoperative
days.
The return of bowel function is the major determinant of
the length of the postoperative hospital stay; this is evidenced
by similar lengths of hospitalization for urinary diversion pro-
cedures with and without cystectomy. M ost patients can ex-
pect a hospital stay of 6 to 8 days in centers with well-defined
clinical pathways (1). N asogastric decompression is optional.
The conduit also experiences an ileus, and its return of peri-
stalsis parallels that of the small bowel; therefore, some sur-
geons advocate placement of a cut Foley or Rob-N el catheter
to promote conduit drainage in the first few postoperative
days. There is no consensus for the optimal length of ureteral
stenting (if it is performed at all); the timing of stent removal is
left to the discretion of the surgeon. Jackson–Pratt drains are
left in place until the drainage is negligible; if drainage persists
at high levels several days postoperatively, the drain fluid
FIGURE 83.4 Ideal placement of the vesicoenteric anastomoses using should be sent for creatinine analysis to rule out a urine leak.
the Bricker technique. The spatulated ureters should pass under the If a rod is left under the stoma, this may be removed prior to
conduit and lie without tension or kinking. discharge.
Counseling and teaching by the enterostomal therapist
should begin in the preoperative period and continue during
the hospitalization. The patient or his or her caregivers
should be competent in all aspects of stoma care prior to
discharge. Follow-up care is tailored to the individual pa-
tient; in most cases, a periodic serum renal profile is indi-
cated. In patients undergoing cystectomy for malignancy,
urine cytology should be followed. The upper tracts can be
assessed via a loopogram, avoiding the toxicity of intra-
venous contrast agents.
O UTCO MES
Co mp licat io ns
The mortality rates for cystectomy and diversion have steadily
decreased over the years since Bricker’s initial description; in a
recent series a mortality rate of 0.3% was reported (1).
The most common morbidity causing prolonged hospital
stay is ileus (1). This usually resolves quickly with nasogastric
decompression; failure to do so after a few days should
prompt a diagnostic workup for bowel obstruction. Urine
leak at the ureteroileal anastomosis or from the conduit clo-
sure and urosepsis are the most common urologic complica-
tions of the procedure. Urine leaks can usually be managed
FIGURE 83.5 The side-to-side Wallace technique creates a widely successfully with placement of an abdominal drain and percu-
patent vesicoenteric anastomosis at the “ butt” end of the conduit. taneous nephrostomy diversion.
Late complications of ileal conduits are common but usu-
ally not severe. Stomal stenosis has been reported in up to
which the anterior walls are closed. The side-to-side Wallace 29% of ileal conduits (11); proper stoma construction can de-
technique is detailed in Fig. 83.5. Stents may be passed prior crease this incidence. Definitive treatment includes removal or
to closure of the anterior wall. This technique allows for the partial resection of conduit. Parastomal hernias have been
rapid creation of a widely patent ureteroileal anastomosis; its reported in 14% of patients with obesity as an independent
theoretical disadvantage is that a process creating obstruction risk factor (8); stoma relocation may be superior to fascial
Chap t e r 84: Transve rse Colonic Cond uit 549
repair in these cases. H yperchloremic metabolic acidosis can can develop renal failure requiring dialysis (5). Renal function
occur but is rare in well-functioning conduit; the presence of should be monitored periodically, and declines in function
more than a mild acidosis should prompt an evaluation for should alert the clinician to examine for correctable causes of
obstruction or redundancy of the conduit. Alkalinizing agents renal dysfunction.
(sodium bicarbonate) or chloride transport blockers (chlor-
promazine, nicotinic acid) can effectively treat this acidosis.
Ureteroileal anastomotic strictures are also uncommon (about Re sult s
6% in older series); these can be successfully managed with
dilation with a cutting balloon (about a 50% success rate), The ileal conduit has provided reliable urinary diversion for
with open surgical repair (76% long-term success) (4), or patients with a variety of underlying illnesses for over 50 years.
chronic ureteral stents. The Wallace anastomosis has been Continent catheterizable diversions and orthotopic neoblad-
reported to have a lower stricture rate than the Bricker (7). ders continue to gain acceptance, and recent studies have
Acute pyelonephritis occurs commonly in patients with focused on quality-of-life outcomes after continent and incon-
ileal conduits (18% of patients) (5). Indeed, bacteriuria can be tinent diversions. Existing studies are unable to prove that
found in up to three-fourths of ileal conduit urine specimens continent reconstruction is superior to conduit diversion (4).
(5). M ost of these can be safely observed without treatment, Unfortunately, as younger, thinner, and healthier patients un-
as patients seem to tolerate this chronic colonization well, and dergo continent diversion while older and more frail patients
few progress to acute pyelonephritis. Infections with Proteus undergo ileal conduit, a real comparison of the quality of life
or Pseudom onas are associated with deterioration of the after these procedures will likely never be possible. Still, it is
upper tracts and should therefore be treated. clear that ileal conduit is a simple form of diversion that is
Deterioration in renal function occurs in a significant por- well tolerated by most patients and has fewer contraindica-
tion of patients undergoing conduit diversion; over the long tions than continent diversions. These factors make it likely
term, 50% of patients have radiographic evidence of functional that the ileal conduit will continue to play a major role in
deterioration at 15-year follow-up, and up to 7% of patients many urologists’ practices.
References
1. Chang SS, Baumgartner RG, Wells N , et al. Causes of increased hospital 8. Kouba E, Sands M , Lentz A, et al. Incidence and risk factors of stomal
stay after radical cystectomy in a clinical pathway setting. J Urol complications in patients undergoing cystectomy with ileal conduit urinary
2002;167:208–211. diversion for bladder cancer. J Urol 2007;178:950–954.
2. Chechile G, Klein EA, Bauer L, et al. Functional equivalence of end and 9. Leduc A, Camey M , Teillac P. An original antireflux ureteroileal implanta-
loop ileal conduit stomas. J Urol 1992;147:582–586. tion technique: long-term follow-up. J Urol 1987;137:1156–1158.
3. DiM arco DS, LeRoy AJ, Thieling S, et al. Long-term results of treatment 10. M atin SF, Gill IS. Laparoscopic radical cystectomy with urinary diversion:
for ureteroenteric strictures. Urology 2001;58:909–913. completely intracorporeal technique. J Endourol 2002;16:335–341.
4. Gerharz EW, M ansson A, H unt S, et al. Q uality of life after cystectomy and 11. Dahl DM , M cDougal WS. Use of intestinal segments and urinary diver-
urinary diversion: an evidence based analysis. J Urol 2005;174:1729–1736. sion. In: Wein AJ, Kavoussi LR, N ovick AC, et al., eds. Cam pbell-Walsh
5. H autmann RE, Abol-Enein H , H afez K, et al. Urinary diversion. Urology urology, 9th ed. Philadelphia: Saunders Elsevier, 2007.
2006;69(1A):17–49. 12. Parekh DJ, Gilbert WB, Koch M O , et al. Continent urinary reconstruction
6. Klein EA, M ontie JE, M ontague DK, et al. Jejunal conduit urinary diver- versus ileal conduit: a contemporary single-institution comparison of peri-
sion. J Urol 1986;135:244–246. operative morbidity and mortality. Urology 2000;55:852–855.
7. Kouba E, Sands M , Lentz A, et al. A comparison of the Bricker versus
Wallace ureteroileal anastomosis in patients undergoing urinary diversion
for bladder cancer. J Urol 2007;178:948–949.
CHAPTER 84 ■ TRANSVERSE CO LO NIC CO NDUIT

MARGIT FISCH, RUDO LF HO HENFELLNER, RAIMUND STEIN, AND JO ACHIM W. THÜRO FF
Since the first publication in 1969 (10), the transverse colonic and descending colon are located in a retroperitoneal position,
conduit has been increasingly implemented in patients with as is the sigmoid colon. There are no limitations with regards
urologic or gynecologic malignancies and additional radio- to short ureters. As part of the colon, the segments offer the
therapy (2,9,11,12). With its cranial position outside the irra- option of antirefluxing as well as refluxing ureteral implanta-
diation field, it fulfills the requirement of not being irradiated, tion (3,5,8,13) and for positioning of the stoma either to the
which is of utmost importance for a segment to be used for left or right upper abdomen. In addition, colon can be used
urinary diversion. N ot only the transverse segment but also the either in an isoperistaltic or anisoperistaltic way and is less
ascending and descending colon can be used, which offers an prone to stoma stenosis than ileum when used for creation of
adaptation to the individual patient’s situation. The ascending a conduit.
In patients with total damage of the ureters by irradiation

or retroperitoneal fibrosis and in patients with recurrent
urothelial tumors (7), a direct anastomosis of the conduit to
the renal pelvis represents an option (pyelotransverse pyelocu-
taneostomy) (4).
DIAGNO SIS
Preoperatively, an intravenous (IV) urography should be per-
formed to evaluate the upper urinary tract. An enema with
water-soluble contrast medium should be done to exclude
diverticuli or polyps. The bowel is irrigated with Ringer lactate
solution (8 to 10 L) via a gastric tube or oral intake of 5 to 7 L
of Fordtran solution. The day before surgery, positioning of
the stoma should be done. The best position is in the epigastric
region; the attached stoma plate has to be checked in sitting,
lying, and standing positions of the patient.
Indications for transverse colonic conduit include urinary
diversion in patients with urologic or gynecologic malignan-
cies and irradiation damage of bowel and distal ureters. O ther
FIGURE 84.1 A bowel segment of approximately 15 cm in length in
indications are urinary incontinence in patients with radiation patients with normal weight is selected, respecting the course of the
cystitis, complex vesicovaginal and rectovesicovaginal fistulas vessels.
after irradiation, recurrent retroperitoneal fibrosis, Crohn dis-
ease, and unsuccessful primary urinary diversion requiring
conversion. Complex cases of prostate cancer with a history and are dissected in the cranial direction. The dissection to-
of irradiation or brachytherapy, recurrent stenosis of the pos- ward the bladder goes down until the irradiated level is
terior urethra, and/or fistula formation in addition to a small reached. The ureters are cut above the irradiated field where
bladder capacity represent rare indications. In patients with they show good vascularization. There should be capillary
recurrent urothelial tumors, anastomosis of the conduit to the arterial bleeding out of the ureteral wall and spontaneous
renal pelvices allows direct endoscopic access to the calices. urine efflux. The ureteral stump is ligated, and the cranial end
Absolute contraindications for the transverse colonic conduit is marked by a stay suture. Depending on the remaining length
are irradiation of the upper abdomen, previous extensive colon of the ureters, it is decided which one can be brought to the
resection, and ulcerative colitis. opposite side by a retromesenteric pull-through. The retrome-
senteric entrance should be wide enough and the path of the
ureter slightly curved in order not to angle or compress it.
A bowel segment of approximately 15 cm in length in patients
ALTERNATIVE THERAPY with normal weight is selected respecting the course of the ves-
sels (Fig. 84.1). The length of the segment depends on the
In young and healthy patients capable of catheterization, a
thickness of abdominal wall. Stay sutures outline the segment.
continent transverse pouch (6) represents an alternative.
Bowel mobilization differs depending on the segment chosen:
If the ascending segment is selected, the right colonic flexure is
mobilized. The greater omentum is separated from the trans-
SURGICAL TECHNIQ UE verse colon over a distance of 10 to 15 cm starting at the right
side. When the descending colon is chosen, the left colonic
Instruments required include a basic kidney set with addi- flexure has to be mobilized, and the left part of the omentum
tional instruments for intra-abdominal surgery, a Siegel retrac- has to be separated from the transverse colon. The selection of
tor, suction, and a basin containing prepared iodine solution a transverse colonic segment makes it necessary to mobilize
for disinfection. Absorbable monofilament sutures like poly- both the right and left flexure and to completely separate the
glycolic acid 4-0 are used for closure of the conduit and in- greater omentum from the transverse colon.
testinal anastomosis to re-establish bowel continuity as well The mesentery of the selected segment is incised lateral to
as to create the stoma. The ureters are implanted using 5-0 the supplying artery, and the arcade is divided between mos-
and 6-0 sutures. Intraoperatively, a gastric tube (alternatively quito clamps and ligated. The fat is dissected from the sero-
gastrostomy), a rectal tube, and a central venous catheter are muscularis of the bowel in the area where the segment will be
placed. cut, and bleeding vessels are coagulated. The segment is iso-
Access is gained by a median laparotomy. Both ureters are lated without the use of clamps so that the bleeding out of the
identified at the points where they cross over the iliac vessels ends can be seen. The segment is cleaned using moist sponges.
placed at the 6 o’clock position and a ureteral stent inserted.

The first suture for anastomosis of the medial margins of the
ureters is placed at the 12 o’clock position and tied later. The
anastomosis is performed by a running suture of polyglycolic
acid 5-0. The ureteral stents are fixed to the ureteral mucosa
(polyglactin 4-0 with short reabsorption time) and subse-
quently brought out through the conduit. The ureteral plate is
then anastomosed to the oral end of the conduit by two run-
ning sutures of polyglycolic acid 5-0 (Fig. 84.3A). When the
conduit is positioned on the right side and the left ureter is rel-
atively short, it can be implanted antidromically to the right
ureter (like the “ crossed hands of a ballerina” ; Fig. 84.3B).
An alternative method of refluxing ureteral reimplantation
is a direct implantation using a “ buttonhole” technique. The
conduit is longitudinally opened in the area of the taenia lib-
era over a length of 3 to 4 cm starting at the oral end. Two
stay sutures are placed at the back wall of the conduit. The
mucosa in between is excised and the seromuscular layer in-
cised to create an entrance for the ureter. The ureter is pulled
through and implanted by two anchor sutures at the 5 and 7
o’clock positions (polyglycolic acid 4-0) and mucomucous su-
tures (polyglycolic acid 5-0). A stent is inserted, fixed, and led
out through the conduit (Fig. 84.4). The contralateral ureter is
implanted in the same manner and the conduit closed.
An antirefluxive ureteral implantation can be performed
FIGURE 84.2 Bowel continuity is reestablished by a one-layer sero- using the Goodwin–H ohenfellner technique (1). The conduit
muscular suture using polyglycolic acid 4-0, and the mesenteric slit is is longitudinally opened over a length of approximately 4 cm
closed by running suture.
starting from the end chosen for ureteral implantation (proxi-
mal end preferable). Four stay sutures are placed to facilitate
Bowel continuity is re-established by a one-layer seromuscular ureteral implantation. A submucosal tunnel is dissected start-
suture using polyglycolic acid 4-0, and the mesenteric slit is ing from the end of the conduit (tunnel length, 3 to 4 cm). The
closed by running suture (Fig. 84.2). bowel mucosa at the end of the tunnel is incised, and the
O ne option for ureteral reimplantation uses the refluxing ureter is pulled through the respective submucosal tunnel.
Wallace technique (13). Both ureters are resected to an adequate After spatulation and resection of the ureter to an adequate
length and spatulated over a distance of 3 cm. A stay suture is length, implantation is performed by one anchor suture at the
6 o’clock position, grasping the seromuscularis of the bowel
and all layers of the ureter (polyglycolic acid 5-0). The anasto-
mosis is completed by mucomucous single sutures (polygly-
colic acid 6-0).
To secure the ureteral implantation, a 6Fr ureteral stent is
inserted in each ureter and fixed to the bowel mucosa
A B
FIGURE 84.3 The ureteral plate is then anastomosed to the oral end of the conduit by two running sutures of
polyglycolic acid 5-0. A: Classical implantation; B: Implantation with left ureter in opposite direction to the right.
FIGURE 84.5 For implantation of the second ureter, a second tunnel

is prepared beside and parallel to the first; the implantation is done in
the same way.
completely dissected from the transverse colon, and the bursa

omentalis is opened. The bowel is exteriorized out of the ab-
FIGURE 84.4 The mucosa in between is excised and the seromuscu-
domen. The ureters are cut at the ureteropelvic junction, and
lar layer incised to create an entrance for the ureter. the renal pelvis is longitudinally spatulated. A transverse colon
segment with a length of 25 to 30 cm and an adequate blood
supply is isolated (Fig. 84.7B). After having placed a ureteral
stent in a calyx of the right kidney, and fixed it within the
(polyglactin 4-0 with short reabsorption time). For implanta- renal pelvis (using polyglactin 4-0 with short reabsorption
tion of the second ureter, a second tunnel is prepared beside time), an end-to-end anastomosis of the right renal pelvis and
and parallel to the first; the implantation is done in the same the distal end of the conduit is performed using two running
way (Fig. 84.5). Both ureteral stents are led out through the sutures of polyglycolic acid 5-0. The ureteral stent is led out
aboral end of the conduit. The proximal ends of the conduit through the conduit before the anastomosis is completed. The
and of the incision line in the area of the taenia libera are conduit is brought to the left renal pelvis without tension
closed (single seromuscular sutures, polyglyconic acid 4-0). (Fig. 84.7C). Also on this side, a stent is inserted into the kid-
A circular area of the skin (approximately 3 cm in diame- ney, fixed, and led out through the conduit later. For anasto-
ter) is excised. The abdominal fascia is crosslike incised, and mosis of the renal pelvis with the conduit, the wall of the
the conduit is pulled through the fascial and the skin opening, conduit is incised at the taenia libera over an adequate length,
together with the ureteral stents, by means of two Allis clamps and an end-to-side anastomosis of the renal pelvis and the
after having freed the distal end of the conduit of fat and epi- conduit is done by two running sutures of polyglycolic acid 5-0
ploic appendages. The seromuscularis of the conduit is fixed (Fig. 84.7D). The stoma formation is identical to the standard
to the abdominal fascia by circular single stitches of polygly- technique. In patients with a single kidney, the technique is
colic acid 3-0, and the oral end of the conduit is anastomosed more simple: a direct anastomosis of the spatulated renal
to the skin by circular single stitches of polyglycolic acid 5-0 pelvis and the oral end of the isolated bowel segment is per-
everting the stoma (Fig. 84.6). formed, and the aboral end is led out through an abdominal
stoma created as described previously.
Pye lo t ransve rse Pye lo cut ane o st o my

Surg ical Tip s
An extensive bowel mobilization is necessary, including cae-
cum, root of the mesentery, the Treitz ligament, and the right Transilluminating the mesentery with a fiberoptic light source
and left colonic flexures (Fig. 84.7A). The omentum majus is visualizes the vessels and facilitates the selection of the segment
FIGURE 84.6 The seromuscularis of the conduit is fixed to the abdominal fascia by circular single stitches of polygly-
colic acid 3-0, and the oral end of the conduit is anastomosed to the skin by circular single stitches of polyglycolic acid
5-0 everting the stoma.
as well as the preparation of the mesenteric slits. When the clamping. The rectal tube stays for 3 days. Today, fast-track
conduit is positioned on the right side and the left ureter is regimes with early removal of the gastric tube and early oral
relatively short, it can be implanted directly to the right nutrition are being increasingly implemented. Ureteral stents
ureter (like the crossed hands of a ballerina). This is applica- are loosened after day 9 and removed after day 10, begin-
ble for the Goodwin–H ohenfellner as well as the Wallace ning on one side with a check of the kidney by ultrasonog-
technique. The colonic conduit can be performed so that the raphy on day 11. Then the second stent is removed. An IV
urine flow is peristaltic and antiperistaltic and so that the urography demonstrates regular kidney function after stent
stoma can be alternatively positioned in the right or left removal.
upper-abdominal quadrant. For an antiperistaltic application, The acid-base balance should be checked before the patient
an extensive mobilization of the Treitz ligament and the is discharged. The patient should be taught about all aspects
descending part of the duodenum becomes necessary; other- of stoma care.
wise, compression of the duodenum by the conduit may re-
sult. If an isoperistaltic application is preferred, either the
right or left colonic flexure can be used for conduit creation.
Extraperitonealization of the conduit facilitates revisional O UTCO ME
surgery, and this can be done through a flank incision. As a
result, a transabdominal approach with the need for adhesi- Co mp licat io ns and Re sult s
olysis can be avoided.
At M ainz University, an incontinent diversion using the trans-
verse conduit was performed in 78 patients. Six of the 78 pa-
tients developed early complications requiring revision in 3.
PO STO PERATIVE CARE Forty-nine of the patients were followed for an average of 81
months. Twenty-two of the 49 patients developed a total of 27
Antibiotics are given for 5 days. As a standard for postoper- complications, and 11 patients required operative interven-
ative care, parenteral nutrition is continued until bowel con- tion. In the long-term follow-up, the status of the upper-tract
tractions appear and then gradually reduced. The gastric dilatation improved or remained stable in 85% of the renal
tube is removed starting from postoperative day 3 after units.
A B
C D
FIGURE 84.7 An extensive bowel mobilization is necessary, including caecum, root of the mesentery,
the Treitz ligament, and the right and left colonic flexures.
Chap t e r 85: Manag ing the Patie nt with O rthotop ic Blad d e r Sub stitution 555
References
1. Altwein JE, Jonas U, H ohenfellner R. Long-term follow-up of children 7. Lindell O , Lehtonen T. Rezidivierende urotheliale Tumoren in einzelnieren
with colon conduit urinary diversion and ureterosigmoidostomy. J Urol mit Anschluss eines kolonsegmentes an das nierenbecken. A k t Urol 1988;
1977;118:832–836. 19:130–133.
2. Altwein JE, H ohenfellner R. Use of the colon as a conduit for urinary di- 8. M ogg RA. Urinary diversion using the colonic conduit. Br J Urol 1967;
version. Surg G ynecol O bstet 1975;140:33–38. 39:687–692.
3. Camey M , Le Duc A. L’enterocystoplastie après cystoprostatectomie totale 9. M orales P, Golimbu M . Colonic urinary diversion: 10 years of experience.
pour cancer de la vessie. A nn Urol 1979;13:114. J Urol 1975;113:302–307.
4. Fisch M , Riedmiller H , H ohenfellner R. Pyelotransverse pyelocolostomy: 10. N elson JH . A tlas of radical pelvic surgery. London: Butterworth, 1969.
an alternative method for high urinary diversion in patients with extended 11. Schmidt JD, Buchsbaum H J, Jacobo EC. Transverse colon conduit for
bilateral ureter damage. Eur Urol 1991;19:142–149. supravesical urinary diversion. Urology 1976;8:542–546.
5. Leadbetter WF, Clarke BG. Five years experience with ureteroenterostomy 12. Schmidt JD, Buchsbaum H J, N achtsheim DA. Long-term follow-up.
by the “ combined technique.” J Urol 1954;73:67–82. Further experience with and modifications of the transverse colon conduit
6. Leissner J, Black P, Fisch M , et al. Colon pouch (M ainz pouch III) for in urinary tract diversion. Br J Urol 1985;57:284–288.
continent urinary diversion after pelvic irradiation. Urology 2000;56: 13. Wallace DM . Ureteric diversion using a conduit: a simplified technique.
798–802. Br J Urol 1966;38:522–527.
CHAPTER 85 ■ MANAGING THE PATIENT WITH

O RTHO TO PIC BLADDER SUBSTITUTIO N
URS E. STUDER AND N. BHATTA-DHAR
O rthotopic bladder substitution approximates the original

bladder in both location and function. The goal of lower- DIAGNO SIS
urinary-tract reconstruction is to create a reservoir that provides
a safe and continent means to store and eliminate urine. O ver A thorough preoperative assessment requires that the follow-
the last 100 years, bowel has been utilized in various ways for ing factors be evaluated when determining candidacy for blad-
bladder substitution, but only with a recent improved under- der substitution (Table 85.1).
standing of bowel physiology and Laplace’s law (pressure
tension/radius) has bowel been successfully applied.
In the 1980s, orthotopic reconstruction became the proce-
Pat ie nt Ag re e me nt and Me nt al St at us
dure of choice in selected male patients. The excellent clinical
Perhaps the single most important factor contributing to a
and functional results achieved subsequently motivated an in-
successful bladder substitute is the willingness of a patient to
terest in applying orthotopic reconstruction to women (8).
comply with indefinite follow-up. Adequate physical dexterity
This option is now possible because of an improved under-
and a thorough understanding of how one’s bladder substitute
standing of female pelvic anatomy as well as the substantiated
works are mandatory. In addition, ongoing educational rein-
low risk of urethral recurrence in women. Specific pathologi-
forcement is necessary for long-term management and success.
cal criteria have allowed clinicians to select appropriate female
A dedicated nurse can facilitate the preoperative assessment
candidates for orthotopic diversion.
Several different bladder substitutes have been developed,
some of which are presented in the following chapters. Each TA B LE 8 5 . 1
of these bladder substitutes has its own specific advantages
and disadvantages. Regardless of the type of substitution, an PREOPERATIVE CHECKLIST
optimal outcome requires a low-pressure, high-compliance
reservoir made of detubularized bowel segments with minimal • Patient agreement to indefinite follow-up
outlet resistance and a preserved sphincter function. • Adequate mental status, dexterity, and mobility
The critical components to good long-term results with any • Serum creatinine of 1.5 mg/dL
bladder substitute include not only surgical finesse but also a • Liver function within normal limits
thorough preoperative evaluation, meticulous postoperative • N o evidence of significant bowel disease
care, and patient compliance. Therefore, this chapter is di- • N o evidence of tumor in the distal urethra, paracollicular,
vided into the preoperative, intraoperative, and postoperative or bladder neck region
periods followed by a discussion of the necessary long-term • Continence status
management of these patients.
and education, as well as be a useful resource as patients be-

come comfortable with their bladder substitutes. Co nt ine nce
Incontinence, especially in female patients, may reflect a
Re nal Funct io n poorly functioning rhabdosphincter. These patients require
urodynamic evaluation, including a urethral pressure profile,
The most frequently observed postoperative issues are meta- since this may identify an etiology and thereby potential treat-
bolic acidosis followed by electrolyte abnormalities. The type ment options. Severe incontinence is a contraindication to
and severity of these disorders depend on the intestinal seg- bladder substitution.
ment used, the length of this segment, the time of urine con-
tact with bowel mucosa, and the compensatory renal reserve.
While a creatinine level of 1.5 mg per dL is considered the up- INDICATIO NS FO R SURGERY
per limit, some patients with significant creatinine elevations
due to primary bladder cancer may recover sufficient function O rthotopic bladder substitution is generally used in patients
to allow for continent diversion once the obstruction is re- who are undergoing radical cystectomy for cancer. Patients
lieved. Placement of a percutaneous nephrostomy tube in must meet the preoperative assessment noted in the Diagnosis
these patients before surgery may provide a better idea of the section.
true renal function (10).
He p at ic Funct io n ALTERNATIVE THERAPY

A bladder substitute candidate must have adequate preopera- Alternatives to orthotopic bladder substitution include ileal
tive liver function. The reservoir’s continuous contact with and colon conduits and other continent urinary diversions.
urine permits ammonium to shift through the bowel mucosa
and into circulation. A urinary tract infection caused by a
urease-splitting organism will further increase the ammonium SURGICAL TECHNIQ UE
load. With pre-existing liver disease, hyperammonemia results,
which can lead to neurologic decompensation and eventual Pre o p e rat ive Pe rio d
coma (7).
The preoperative evaluation is the same as that for a radical
cystectomy: exclusion of metastases and establishment of
Bo w e l Funct io n medical clearance for surgery. Any significant liver, renal, or
bowel pathology must also be fully evaluated to determine
Since bowel is needed for a bladder substitute, the impact of a
candidacy for bladder substitution.
prior bowel resection or a diseased or radiated bowel needs
The type of bowel preparation depends on the bowel seg-
to be considered as it relates to malabsorption or diarrhea.
ment needed for the bladder substitute. Colonic bladder sub-
The bowel segment used for the bladder substitute itself needs
stitutes often require a full mechanical bowel preparation with
to be free of any pathology. To minimize vitamin B12 defi-
agents such as Glycoprep. For ileal bladder substitutes, a lim-
ciency and diarrhea induced by bile acid, the terminal ileum
ited bowel preparation with two enemas late in the afternoon
needs to be preserved. Ileal segments of up to 60 cm can be
before the day of surgery suffices. For this type of substitute,
resected in healthy individuals without any significant conse-
antegrade rinses of the bowel and neomycin-erythromycin in-
quences provided the ileocecal valve is left intact. When
testinal preparations are avoided. In addition, such prepara-
60 cm of bowel is resected, the risk of malabsorption further
tions can increase the risk of fluid imbalances. In the elderly
increases, and it becomes inevitable if 100 cm is used. If the
patient, this can produce cardiovascular instability due to
right colon is preserved, an extended length of colon can be re-
intravascular volume depletion as well potentially place the
sected without significant malabsorptive side-effects because
patient in a catabolic state even prior to surgery.
fluid reabsorption occurs predominantly in the right colon,
Subcutaneous deep venous thrombosis prophylaxis is
whereas the left colon serves as a conduit.
started the evening before surgery and continued postopera-
tively. It is administered in the upper extremity so as to pre-
Paraco llicular and Blad d e r Ne ck Bio p sy vent a pelvic lymphocele. All patients receive perioperative
and postoperative prophylactic antibiotics. Also, to prevent a
Positive biopsies from the paracollicular region in the prosta- deep venous thrombosis of the lower extremities or broncho-
tic urethra or the bladder neck in women (site of bladder sub- pneumonia, patients wear stockings and are taught appropriate
stitution anastomosis) indicate a high likelihood of a urethral exercises by a physiotherapist.
recurrence. These patients should undergo a primary urethrec-
tomy and be considered for an alternative form of urinary di-
version. Prostatic infiltration (superficial or stromal) proximal INTRAO PERATIVE MANAGEMENT
from the paracollicular site, carcinoma in situ, and multifocal
transitional cell cancer confer a higher risk of urethral recur- There are certain critical surgical steps that, if adhered to dur-
rence (2). H owever, these findings are not absolute contraindi- ing the cystectomy, will allow for optimal functional results of
cations for a bladder substitution. the bladder substitute (Table 85.2).
TA B LE 8 5 . 2 directly along the prostatic capsule, and the membranous urethra

is delivered sharply out of the donut-shaped prostatic apex to
IN TRAOPERATIVE CHECKLIST avoid nerve damage on the dorsolateral side of the urethra.
• Antibiotics and compression stockings
For nerve sparing in women, the vaginal wall dissection at
the cervical level is in the anteroventral plane of the vagina,
• Anatomical pelvic exenteration with attempt of nerve
preservation on the non–tumor-bearing side
that is, at the 2 or 10 o’clock position. An empty sponge-holding
forceps in the vagina helps facilitate dissection along the
• Atraumatic dissection with maximum urethral length
preservation
whitish vaginal wall. It is important to remain in close contact
with the whitish wall of the vagina to ensure that the paravaginal
• Preservation of periureteric tissue
venous plexus is hemostatically controlled and resected with
• Epidural anesthesia stopped 1 hour prior to bowel length
the dorsomedial bladder pedicle. The endopelvic fascia is
measurement
disturbed as little as possible to minimize damage to the in-
• Preservation of the ileocecal valve and distal 25 cm of ileum
trapelvic branch of the pudendal nerve, which also contributes
• Small bowel resection limited to under 60 cm to urethral innervation.
• Ureterointestinal anastomosis should not be obstructive
• Low-pressure reservoir with transected/opened, cross-
folded bowel segments, spheroidal in shape At raumat ic Disse ct io n o f t he Ure t hra
• Ureteric stents and cystostomy tubes placed through the
fatty tissue of the bowel mesentery To obtain maximum urethral length, sharp, atraumatic dissec-
• Tension-free anastomosis of the reservoir to the urethra tion of the urethra with minimal use of electrocautery at the
• The anastomosis of the urethra to the bladder substitute is prostatic apex in men and the bladder neck in women is re-
not to the funnel-shaped end of the reservoir quired. Preservation of the puboprostatic and pubourethral
ligaments and incision of the endopelvic fascia, not at its deep-
est point, but along the bladder neck in female patients, will
allow for further urethral stability and improved continence.
Pre se rvat io n o f Pe lvic Ne rve s

Ure t e rs
In general, nerve sparing should be performed on the non–
tumor-bearing side and extensive surgery on the tumor-bearing The ureters need to be resected at a safe oncologic distance
side. It has been shown that nerve-sparing radical cystectomy from the bladder, allowing for removal of periureteral lym-
does have a positive impact on erectile function and urinary phatics that may harbor micrometastases. In addition, by re-
continence after bladder substitute (5). For nerve-sparing cys- moving most of the proximal ureter, ureteral ischemia is
tectomy in men, the nerve fibers in the dorsomedial pedicles precluded and thereby subsequent stricture formation.
lateral to the seminal vesicles as well as the paraprostatic When mobilizing the ureters, the periureteric tissue must be
neurovascular bundle have to be spared. The pelvic plexus can preserved, since this contains the ureters’ blood supply. This
be preserved by sectioning the dorsomedial pedicle along its will also help prevent anastomotic strictures. The left ureter
ventral aspect, anterolateral to the seminal vesicles, and ter- is brought without tension to the right side of the abdomen
minating the dissection at the base of the prostate. A nerve- retroperitoneally by crossing the aorta above the inferior
sparing prostatectomy must also be performed, which requires mesenteric artery. An antireflux ureteral anastomosis is not
a lateral approach with incision of the endopelvic and required in low-pressure ileal bladder substitutes (11).
periprostatic fascia and bunching of the Santorini plexus at Another important point is to pass the ureteral stents through
the level of the prostate and not distal to it. The dorsolateral the distal tubular wall where their exit sites are covered with
neurovascular bundle can be separated from the prostatic mesenteric fat so as to prevent urine leakage when they are
capsule. The prostatic apex needs to be approached laterally removed (Fig. 85.1).
FIGURE 85.1 Placement of cystostomy and ureteric catheters through the fat of the mesentery.
patches. The ureteral stents should be removed between postop-

Blad d e r Sub st it ut e erative days 5 and 7, around the time bowel function returns.
O n postoperative day 10 and provided a pouchography
If small bowel is used for the reservoir, the ileocecal valve and
documents no evidence of urinary extravasation, the suprapu-
the most distal 25 cm of ileum should be preserved to reduce
bic tube can be removed. The urethral Foley catheter remains
the associated risk of malabsorption and bile acid–induced
in place for an additional 2 days to provide enough time for
diarrhea. O ne hour prior to bladder substitute construction,
the suprapubic tube exit site to heal.
administration of anesthetics via the epidural is stopped. This
prevents increased muscle tone and activity which results in an
artificial shortening of bowel and thereby avoids removal of Manag e me nt o f Pat ie nt s aft e r
more bowel than is necessary for reservoir construction.
The reservoir should be spherical to achieve maximum ca- Cat he t e r Re mo val
pacity and the lowest possible pressure for the given surface of
M anagement after catheter removal is outlined in Table 85.4.
bowel used. As illustrated by Laplace’s law (pressure tension/
After all drains are removed, any bacteriuria should be man-
radius), intraluminal pressure is low for a given tension, since
aged with antibiotics until the urine is sterile. Infected urine
conversion of a tubular structure into a spherical reservoir
can cause reservoir instability with subsequent urinary incon-
increases the radius. Furthermore, the spherical shape obtains
tinence as well as increased mucus production, which can lead
maximal capacity while the surface-volume ratio limits the
to increased postvoid residuals and even urinary retention.
reabsorbing surface and therefore minimizes associated meta-
Patients must be carefully instructed on how to void.
bolic issues.
Initially, they are taught to empty the bladder substitute every
It is imperative that the anastomosis of the urethra to the
2 hours during the daytime in a sitting position by relaxing the
bladder substitute is not to the funnel-shaped end of the reser-
pelvic floor and if necessary by also increasing their intra-
voir. This error would increase the risk of kinking and ob-
abdominal pressure. At night, they should use an alarm clock
struction at the anastomotic site, especially when the reservoir
to void every 4 hours. The adequacy of emptying needs to be
is full. To obtain optimal voiding, the anastomosis should sit
monitored postvoid with a straight catheterization and/or ul-
broadly on the pelvic floor (Fig. 85.2). In addition, all suture
trasound of the reservoir.
material should be absorbable, thereby eliminating any poten-
Patients without metabolic acidosis (no negative base ex-
tial nidus for stone formation.
cess) or those managed with oral sodium bicarbonate are in-
structed to retain urine thereafter for 3 hours and later for
4 hours in order to obtain a bladder capacity of up to 500 mL.
PO STO PERATIVE MANAGEMENT During this exercise, increased bladder substitute pressures
may cause incontinence, but the elevated pressures are re-
During the postoperative period, fluid and electrolyte manage- quired to increase the reservoir’s capacity. Therefore, patients
ment predominates; however, it is also important to use this are advised not to void when they experience such inconti-
time to educate and encourage patients to become comfort- nence; otherwise the bladder substitute will never achieve the
able with their bladder substitute. desired capacity. It is essential to increase the capacity to ap-
proximately 500 cc in order to have low-end fill pressures
to ensure urinary continence. With increasing capacity, night-
Imme d iat e Po st o p e rat ive Pe rio d time continence will improve; on the other hand, a bladder
Table 85.3 lists the elements of immediate postoperative care.

The suprapubic and transurethral catheters must be flushed and TA B LE 8 5 . 4
aspirated with normal saline 0.9% every 6 hours. This is needed
to prevent mucus buildup, which can block catheters and result POST-CATHETER REMOVAL CHECKLIST
in rupture of the bladder substitute. This complication is great-
est when bowel activity has resumed but while the catheter is • Antibiotic prophylaxis with a quinolone following catheter
removal for 5 days
still in situ. Prevention of abdominal distention and return of
bowel activity can be accelerated with parasympathomimetic • All urinary tract infections must be treated
medications (neostigmine) and in smokers with nicotine • Proper voiding technique must be taught
• Ensure reservoir is emptying completely with ultrasound
and/or in-out catheterization
• Voids are gradually increased from every 2 hours to every
TA B LE 8 5 . 3 4 hours (at night with the help of an alarm clock)
IMMEDIATE POSTOPERATIVE CHECKLIST • Effective sphincter training must be taught and performed
regularly
• Deep venous thrombosis prophylaxis • M easure daily body weight and correct a negative base
• Catheters irrigated every 6 hours excess
• Ureteral stents removed day 5 to 7 • O ral fluid intake of 2 to 3 L/day for the first 3 months
• Cystogram day 10 with withdrawal of suprapubic tube if • Ileal bladder substitute patients should increase salt
no leakage consumption for the first 3 months
• Urethral catheter removed 48 hours after suprapubic tube • Lifelong regular follow-up
FIGURE 85.2 A funnel-shaped reservoir to urethra

anastomosis must be avoided because of the risk of
subsequent kinking and outlet obstruction.
substitute capacity of 500 mL should be prevented. tonus-regulating function of the autonomic nerves may lead to
O verdistention of the reservoir will result in a floppy pouch a dilation or rigidity of the urethra, resulting in intrinsic
unable to adequately empty, increased residual urine, and the sphincter deficiency. A denervated proximal urethra may
potential for urinary retention. result in ineffective active relaxation and/or kinking during
The time required to achieve continence depends on dili- voiding, and thus incomplete emptying, which necessitates
gent sphincter training, the age of the patient, and achieving self-catheterization.
intraoperative neural preservation to the urethra and pelvic Urethral length is also important in the genesis of urinary
floor (if oncologically safe). A postvoid dribble incontinence incontinence, as demonstrated by the following formula: con-
can be prevented by instructing the patient to milk the urethra tinence urethral length closing urethral pressure (12). In
at the end of each void (1). Daytime continence rates of up to female sheep, Strasser et al. (9) showed that maximal urethral
90% and nocturnal rates of 80% at 12 months can be closure pressure was markedly decreased in sheep with dener-
achieved (6). vated urethra (18 cm H 2 O compared to baseline of 49 cm
H ypercontinence tends to be a problem primarily for H 2 O ). If the autonomic nerves are compromised, closing ure-
female bladder substitute patients. H aving an unobstructed thral pressure cannot compensate for a shortened urethral
outlet with prevention of kinking of the urethra or reservoir length. Theoretically, after resection of the proximal urethra,
can help avoid this concern (Fig. 85.2). The contribution to patients may not leak with increased intra-abdominal pressure
sphincter function of the intrapelvic pudendal somatic nerves because of the intact pudendal nerve pathway but may leak
and autonomic branches of the pelvic plexus has not been when walking, particularly with a full bladder, because of re-
fully established, but animal studies have demonstrated a pres- duced functional urethral length. Also, sensory innervations of
sure increase in the distal urethra after pudendal nerve stimu- the proximal urethra may influence urinary continence.
lation and in the proximal urethra after stimulation of the Division of these nerves may result in loss of the afferent limb
pelvic plexus (3). This suggests that nerve sparing has func- of the external sphincter guarding reflex stimulated by urinary
tional significance for both continence and voiding ability. leakage into the proximal urethra.
Using the female sheep model, Strasser and colleagues (9)
found marked degeneration of the smooth muscle cells of the
proximal urethra after bilateral denervation of an isolated ure- Me t ab o lic Manag e me nt
thra, which reflects the situation in bladder substitute patients.
Thus complete autonomic denervation of the urethra in After catheter removal, the patient is at an increased risk for
patients undergoing cystectomy and bladder substitute may metabolic acidosis, particularly if there is residual urine. In
result in long-term smooth muscle dysfunction. Absence of the fact, this is the most frequent yet most often underdiagnosed
complication associated with bladder substitutes. Jagenburg TA B LE 8 5 . 5

et al. (4) reported that the iso-osmolality between urine in the
reservoir and serum is established within 2 to 6 hours. This SYMPTOMS OF METABOLIC ACIDOSIS IN PATIEN TS
explains why, initially, when the urine is hypo-osmolar, the WITH BLADDER SUBSTITUTES
bladder substitute will secrete sodium chloride, resulting in a • Fatigue
salt-losing syndrome, hypovolemia, and metabolic acidosis. • Anorexia
The resultant dehydration and anorexia may lead to a rapid
• Dyspepsia and heartburn
decrease in body weight; therefore, daily postoperative weight
• N ausea and vomiting
assessment is essential. To prevent this metabolic cascade, pa-
tients should increase salt intake (pretzels, chips, etc), primar- • Weight loss
ily because they are also encouraged to consume 2 to 3 L of
fluids a day to prevent a metabolic acidosis resulting from
highly concentrated acidotic urine (7). With time, the villi will
atrophy and this syndrome will become less pronounced. O UTCO MES
Both the urologist and the patient should be aware of
the symptoms that may arise with a metabolic acidosis (Table Lo ng -Te rm Fo llo w -up
85.5). The base excess can be monitored with a venous blood
gas analysis. A negative base excess needs to be corrected. M eticulous lifelong follow-up is essential for optimal reservoir
This is usually accomplished with sodium bicarbonate 2 to 6 g function and prevention of long-term complications. A sug-
daily for ileal bladder substitutes and with potassium citrate gested schema is illustrated (Table 85.6). A bladder substitute
for colonic bladder substitutes. should have no infection, no incontinence, no acidosis, and no
TA B LE 8 5 . 6
FOLLOW-UP SCHEDULE FOR PATIEN TS WITH ILEAL BLADDER SUBSTITUTE
MON THS AFTER SURGERY 3 6 12 18 24 30 36 42 48 54 60
Clinical examination X X X X X X X X X X X
Urine dipstick, urine culture X X X X X X X X X X X
Weight, blood pressure X X X X X X X X X X X
Basic blood tests X X X X

(H b,Cl,Bic,creat,alk.phos.)a
Extended blood tests X X X X X X X
(H b,N a,K,Ca,Cl,alk.phos.,LDH ,
M g,Bic,urea,creat,ALAT, GT)a
PSA (only in patients with X X X
prostate cancer)
Folic acid, vitamin B12 X X X X
Chest X-ray (only if Ca) X X X X X X X

Bone scan (only if pT3 and X X
any pN )
Pelvic/abdominal CT scan X X
(only if pT3 and any pN )
IVUb with tomography X X X X
(only in patients with multifocal
and/or carcinoma in situ)
Ultrasound of kidneys X X X X X X X
Ultrasound for residual urine X X X X X X X X X X X
Urethral lavage X X X X X X X
M icturition protocol X X X X X X
Voiding questionnaire X X X X X
aH b,hemoglobin; Cl, chlorine; Bic, ; creat., creatinine; alk.phos., alkaline phosphatase; N a, sodium; K, potassium; Ca, calcium; LDH , L-lactate
dehydrogenase; M g, magnesium; ALAT, alanine aminotransferase; GT, .
b IVU, intravenous urogram.
Chap t e r 86: O rthotop ic Urinary Dive rsion Using an Ile al Low-Pre ssure Re se rvo ir with an Affe re nt Tub ular Se g me nt 561
or minimal postvoid residual urine. Intravenous urogram (IVU) residual prostatic tissue, and urethral anastomotic strictures.
and lavage cytology are used to follow the upper tract and All of these can be managed endoscopically. Permanent in-
urethra, respectively, for recurrences. dwelling catheters and intermittent straight catheterizations
Residual urine should be monitored, recognized early, and are not adequate therapies and should only be reserved for pa-
promptly managed. The most common reasons for residual tients with personal preferences or for nursing purposes.
urine are protrusion of ileobladder mucosa into the urethra,
References
1. Bader P, H ugonnet CL, Burkhard F, et al. Inefficient urethral milking sec- 7. M ills RD, Studer UE. M etabolic consequences of continent urinary diver-
ondary to urethral dysfunction as an additional risk factor for incontinence sion. J Urol 1999;161:1057.
after radical prostatectomy. J Urol 2001;166(6):2247–2252. 8. Stenzl A, Jarolim L, Coloby P, et al. Urethra-sparing cystectomy and ortho-
2. Freeman JA, Thomas A, Esrig D, et al. Urethral recurrence in patients with topic urinary diversion in women with malignant pelvic tumors. Cancer
orthotopic ileal neobladders. J Urol 1996;156(5):1615–1619. 2001;92(7):1864–1871.
3. H ubner WA, Trigo-Rocha F, Plas EG, et al. Urethral function after cystec- 9. Strasser H , N inkovic M , H ess M , et al. Anatomic and functional studies of
tomy: a canine in vivo experiment. Urol R es 1993;21:45. the male and female urethral sphincter. W orld J Urol 2000;18(5):324–329.
4. Jagenburg R, Kock N G, N orlén L, et al. Clinical significance of changes in 10. Studer UE, Burkhard FC, Danuser H , et al. Keys to success in orthotopic
composition of urine during collection and storage in continent ileum bladder substitution. Can J Urol 1999;6(5):876.
reservoir urinary diversion. Scan J Urol N ephrol 1978;49[Suppl]:43–48. 11. Studer UE, Siegrist T, Casanova GA. Ileal bladder substitute: antireflux
5. Kessler TM , Burkhard FC, Perimenis P, et al. Attempted nerve sparing nipple or afferent tubular segment? Eur Urol 1991;20(4):315–326.
surgery and age have a significant effect on urinary continence and erectile 12. Weil A, Reyes H , Bischoff P, et al. M odification of the urethral rest and
function after radical cystoprostatectomy and ileal orthotopic bladder sub- stress profiles after types of surgery for urinary stress incontinence. Br J
stitution. J Urol 2004;172(4, Pt 1):1323–1327. O bstet G ynaecol 1984;91:46–45.
6. M adersbacher S, M öhrle K, Burkhard F, et al. Long-term voiding pattern
of patients with ileal orthotopic bladder substitutes. J Urol 2002; 167(5):
2052.
CHAPTER 86 ■ O RTHO TO PIC URINARY

DIVERSIO N USING AN ILEAL LO W-PRESSURE
RESERVO IR WITH AN AFFERENT TUBULAR
SEGMENT
STEPHAN JESCHKE AND URS E. STUDER
An ileal low-pressure orthotopic bladder substitute offers sev- In cases of complicated urethral strictures or urethral tumor re-
eral significant advantages over other forms of orthotopic di- currence, the afferent tubular segment can easily be trans-
version. O ne is the ease of surgery, as the operation can be formed into an ileal conduit. By slightly modifying this reservoir,
performed by any urologist experienced in performing a radi- one can also use it for bladder augmentation following sub-
cal prostatectomy or a cystectomy and ileal conduit (1). The total cystectomy in patients with benign bladder pathology.
short ileum segment, approximately 55 cm long, that is used
to construct this bladder substitute minimizes intestinal mal-
absorption. The terminal ileum, as well as the ileocecal valve, DIAGNO SIS
is preserved. The reservoir is spherical, achieving a maximum
volume-to-surface area ratio with maximum capacity from Patients undergoing orthotopic bladder substitution will gen-
a given bowel segment (2). Another advantage is the iso- erally have the diversion as part of a cystectomy for bladder
peristaltic tubular afferent segment with the end-to-side cancer. A full metastatic workup to stage the cancer is impor-
ureteroileal anastomosis at its proximal end. This allows re- tant, as well as a cystoscopy to determine the extent of the
section of the distal ureters, including the paraureteral lym- cancer in the urethra. As is true for all bladder substitutes, spe-
phatics, at a safe distance from the bladder cancer and reduces cific criteria for selection are related to the disease stage, the
the risk of leaving distal ureters behind that may contain car- renal and liver function, and the patient’s willingness to comply
cinoma in situ. Furthermore, the shorter the ureters are, the with routine follow-up. These criteria are summarized in table
better the blood supply at their distal end and the lower the risk 86.1. Adequate renal function as defined by serum creatinine
of ischemic stricturing of the distal ureter. The peristalsis of the 1.5 mg per dL precludes the need for lifelong bicarbonate
afferent ileal segments acts as a dynamic antireflux mechanism. supplementation.
TA B LE 8 6 . 1
PATIEN T SELECTION CRITERIA FOR CON TIN EN T
URIN ARY DIVERSION
• N on-metastatic disease
• N egative biopsies from prostatic urethra (m)/bladder neck (f)
• Adequate renal function (serum creatinine 1.5 mg/dL)
• N ormal liver function
• N o active inflammatory bowel disease or previous
extensive bowel resection
• Physical and mental ability to live with a bladder substitute
• Compliance to routine follow-up
INDICATIO NS FO R SURGERY FIGURE 86.1 The 55-cm-long ileal segment for the bladder substi-
tute is isolated 25 cm proximal to the ileocecal valve. N ote the differ-
O rthotopic diversion may now represent the procedure of ent incision depth of the mesoileum proximally and distally, to
choice in the properly selected patient undergoing cystectomy. preserve the blood supply.
H owever, as with all bladder substitutes, the cancer operation
must not be compromised by the orthotopic reconstruction. out of the donut-shaped apex. The neurovascular bundles
In addition, the external rhabdosphincter and internal lis- located dorsolateral to the prostate are also preserved on the
sosphincter complex and corresponding innervations must be non–tumor-bearing side.
functionally intact. The ileal orthotopic bladder substitute is
also particularly well suited for patients in whom the sequelae
of ileocecal resection should be avoided. Pre p arat io n o f t he Ile um Se g me nt fo r t he
Blad d e r Sub st it ut e
ALTERNATIVE THERAPIES For construction of the reservoir, an ileal segment approxi-
mately 55 cm long is isolated 25 cm proximal to the ileocecal
Alternatives to the ileal orthotopic bladder include other valve and bowel continuity is restored (Fig. 86.1). The length
forms of diversion, including ileal and colon conduits, conti- of the ileum segment is measured with a ruler in portions of
nent urinary diversions, and other orthotopic diversions. 10 cm along the border of the mesoileum without stretching
the bowel. Irritation of the bowel as well as epidural anesthe-
sia with local anesthetics should be avoided since this can
SURGICAL TECHNIQ UE increase smooth muscle tone and activity and “ shorten” the
length of the bowel, which will then be too long after muscle
Cyst e ct o my relaxation. The distal mesoileum incision transects the main
vessels, whereas the proximal mesoileum incision must be
Pelvic lymphadenectomy and cystectomy are performed ac- short in order to preserve the main vessels perfusing the future
cording to standard technique, with slight modifications (3). reservoir segment (Fig. 86.1). The mesoileum borders are
The external iliac vessels, the obturator fossa, and the hy- adapted with a running suture (2-0 polyglycolic acid) in which
pogastric vessels are freed of all lymphatic, fatty, and connec- the mesoileum of the bladder substitute is included (Fig. 86.2).
tive tissue. H aving divided the dorsolateral bladder pedicles The sutures must be applied superficially, taking care to pre-
containing the superior and inferior vesical vessels along the serve the blood supply to the bladder substitute. Both ends of
hypogastric arteries, the pelvic floor fascia is incised and the the isolated ileal segment are closed by seromuscular running
Santorini plexus is ligated. If possible, the prostatic vessels sutures (4-0 polyglycolic acid). The distal end of the ileal seg-
should be preserved on the non–tumor-bearing side to ensure ment, approximately 42 to 45 cm long, is opened along its an-
adequate blood supply to the pelvic plexus and neurovascular timesenteric border (Fig. 86.2), leaving a 10- to 12-cm afferent
bundle. tubular limb for anastomosing the ureters.
The ureters are divided where they cross the iliac vessels.
This allows en bloc removal of the distal ureters and para-
ureteral lymphatic vessels, together with the cystectomy specimen. Ure t e ro ile al End -t o -Sid e Anast o mo sis
The dorsomedial pedicle is resected along the pararectal-
presacral plane on the tumor-bearing side. Whenever possible, The left ureter is mobilized up to the lower pole of the kidney,
care is taken to preserve the hypogastric fibers and the pelvic with care taken to maintain its surrounding blood supply and
plexus situated dorsolaterally to the seminal vesicle on the thereby prevent ischemia. It is then brought without tension to
contralateral non–tumor-bearing side. O n this side the dissec- the right side of the abdomen retroperitoneally by crossing the
tion along the dorsolateral wall of the seminal vesicle is aorta slightly above the inferior mesenteric artery. N ote: If the
stopped at the base of the prostate. The Santorini plexus is ureters need to be resected close to the kidney (e.g., if there is
then divided, and the membranous urethra is transected as carcinoma in situ, compromised vascular supply, or previous
close as possible to the apex of the prostate by excavating it radiation history), a longer afferent ileal segment can be harvested
Co nst ruct io n o f t he Blad d e r Sub st it ut e

and Anast o mo sis t o t he Ure t hra
To construct the reservoir itself, the two medial borders of the
opened U-shaped distal part of the ileal segment are oversewn
with a single continuous seromuscular layer of 2-0 polyglycolic
acid suture (Fig. 86.4). The bottom of the U is folded over
between the two ends of the U (Fig. 86.4), resulting in a spher-
ical reservoir consisting of four cross-folded ileal segments.
After closure of the lower half of the anterior wall and part
of the upper half (Fig. 86.5), the surgeon’s finger is intro-
duced through the remaining opening to determine the most
caudal part of the reservoir. At this point, a hole 8 to 10 mm in
diameter is cut out of the pouch wall, outside the suture line
(Fig. 86.6). Importantly, although it may appear easier to per-
form, it is imperative that the anastomosis of the urethra to
the neobladder is not to the funnel-shaped end of the reservoir.
FIGURE 86.2 Closure of the mesoileum incision. Avoid deep sutures
in the area joining the mesoileum of the terminal ileum to the
mesoileum of the bladder substitute, in order not to compromise circu-
lation. Transpose the afferent ileal segment as shown by the arrow .
to bridge the necessary distance. The ureters are spatulated

over a length of 1.5 to 2.0 cm. Incisions (2 cm) are made along
the paramedian antimesenteric border of the afferent tubular
ileal segment by running sutures using the N esbit technique in
an open end-to-side fashion (Fig. 86.3). The anastomoses are
placed paramedial to the antimesenteric border at the most
proximal portion of the afferent tubular segment. To prevent
bowel ischemia between the ureteral anastomosis, the right
ureter is placed approximately 1 cm distal to the left ureter.
The ureters are stented with 7Fr or 8Fr catheters. To pre-
vent dislocation of the catheters, a rapidly absorbable suture
(5-0 polyglycolic acid) is placed through the ureter and
catheter together 3 to 4 cm proximal to the anastomosis. It is
tied loosely, to not compromise the ureteral blood supply. The
most distal periureteral tissue is sutured to the afferent ileal
FIGURE 86.4 The two medial borders of the antimesenteric opened
segment to remove tension on the anastomosis and to cover it.
U-shaped distal ileum segment are oversewn with a single-layer sero-
The ureteric catheters are passed through the wall of the most muscular running suture. The bottom of the U is folded over and tied
distal end of the afferent tubular segment, where it is covered between the two ends of the U.
by some mesoileum. This provides a “ covered” canal in the
reservoir wall when withdrawing the ureteric splints 4 to 7
days postoperatively.
FIGURE 86.5 The caudal half of the remaining reservoir opening is

FIGURE 86.3 A ureteroileal anastomosis using a simple end-to-side closed completely, and the cranial half partially by a running seromus-
N esbit technique with a 4-0 running suture ensures a low stricture rate. cular suture.
FIGURE 86.6 The surgeon’s finger is introduced to determine the

most dependent part, and a 8 to 10 mm-diameter hole is excised.
FIGURE 86.8 Six 2-0 Vicryl sutures anastomose the previously made
hole in the bladder substitute to the urethra.
FIGURE 86.7 Anastomosis of the urethra to the neobladder is not

made using the funnel-shaped end of the reservoir.
FIGURE 86.9 After insertion of a cystostomy tube into the reservoir,
This error would increase the risk of kinking and obstruction the pouch is closed completely.
at the anastomotic site when the reservoir is full (Fig. 86.7). To
achieve optimal voiding, the anastomosis must sit broadly on Before complete closure of the reservoir, a cystostomy tube
the pelvic floor. After placement of a silicone 18Fr Foley ure- is passed through the bladder substitute wall and its exit site is
thral catheter, six 2-0 Vicryl sutures anastomose the previ- covered with mesenteric fat (Fig. 86.9). The cystostomy tube
ously made hole in the bladder substitute with the urethra is withdrawn 10 days postoperatively after exclusion of any
(Fig. 86.8). Two posterior sutures are passed through the leakage by a “ pouchography.” The indwelling catheter is left on
Denonvilliers fascia and medial to the neurovascular bundles, continuous drainage for 2 more days before removal to allow
two anterolaterally to them through the lateral portion of the for closure of the cystostomy canal in the reservoir wall.
urethra, and two anteriorly, taking only a little of the urethra
but also through the ligated Santorini plexus. When the ure-
thral sutures are placed, the needle incorporates 3 to 4 mm of Surg ical Mo d ificat io ns fo r O b e se Pat ie nt s
the sphincter but exits at the mucosal edges, thereby bringing
them close to the mucosal edges of the reservoir. This mini- An ileal neobladder can successfully be constructed and
mizes tension on the anastomosis and shortening of the ure- brought down into the pelvis of obese patients. A measure of
thral length, and it also reduces the incidence of anastomotic whether the reservoir will work in obese patients is if the
strictures. If necessary, the operating table is now flexed to re- bowel at 12 cm from the distal harvested end is able to reach
duce the distance between the bladder substitute and the ure- the base of the penis. To ensure this will happen, the following
thra. In situations where the mesentery is short and the steps should be employed. First, extend the distal mesenteric
anastomosis between the reservoir and urethra is under ten- division deeper into the mesentery; this will provide for in-
sion, careful superficial incisions of the neobladder mesentery creased mobility (Fig. 86.10). In addition, unflex the operating
will provide for further length. Sutures are loosely tied to pre- table as much as possible, and if necessary make superficial
vent cutting, ischemia, and stenosis. Rarely, to prevent undue transverse incisions of the serosa. If there is still tension, then,
traction on the anastomosis, two stitches placed lateral to the 12 cm from the distal end, transect a vessel proximal to the
urethra can fix the bladder substitute to the pelvic floor. Riolan arch (Fig. 86.11). Provided collateral vessels are left
increasing intra-abdominal pressure. At night, they are in-

structed to use an alarm clock to void every 3 to 4 hours.
Initially, the urine is often hypo-osmolar; consequently, the
bladder substitute will secrete sodium chloride, resulting in a
salt-losing syndrome and therefore hypovolemia and meta-
bolic acidosis. To prevent this series of metabolic events,
patients are instructed to consume 2 to 3 L of liquid a day and
to increase salt intake, and they are prophylactically placed on
sodium bicarbonate (2 to 6 g per day) after ureteral stent
removal. These patients are carefully followed with regular
assessments of blood gas and body weight.
Patients without metabolic acidosis (no negative base excess)
or those managed appropriately with oral intake of sodium
bicarbonate are instructed to retain urine for 3 and later for
4 hours in order to obtain a bladder capacity of up to 500 mL.
During this exercise, increased pouch pressures may result in in-
continence, but the elevated pressures are essential to increase
the reservoir’s capacity. Therefore, patients are advised to not
FIGURE 86.10 The distal mesenteric division should be extended void when they experience such incontinence; otherwise the
deeper into the mesentery.
bladder substitute will never achieve the desired capacity.
With increasing capacity, nighttime continence will im-
prove; on the other hand, a reservoir capacity of 500 mL
should be prevented. O verdistention of the reservoir will re-
sult in a floppy pouch that is unable to adequately empty, in-
creased residual urine, and the potential for urinary retention.
Residual urine should be monitored, recognized early, and
promptly managed. The cause of residual urine needs to be
addressed (urethroscopy), and any evidence of outlet obstruc-
tion needs to be incised or resected. In addition, bacteriuria
should also be appropriately treated. O ur patients are fol-
lowed regularly at every 6 months for 5 years and then at
yearly intervals.
O UTCO MES
Co mp licat io ns
We recently published our 20-year experience with the ileal
FIGURE 86.11 A vessel proximal to the Riolan arch is transected.
neobladder (4). In our experience, early diversion-related
complications (within 30 days) occurred in 13% of patients.
on either side, this will not compromise vascular supply to the Pyelonephritis was the predominant complication noted
reservoir. (5.8% ). Diversion-related late complications ( 30 days) that
required rehospitalization were metabolic acidosis, pyelonephri-
tis, and sepsis in 4.4% , 3.9% , and 2.1% , respectively, and uri-
Po st o p e rat ive Care nary retention due to infection and consequent mucus
production in 4.5% . Typical late complications requiring
Critical components to good long-term results include the surgery were bladder substitute outlet obstruction in 12% and
ability to create a high-compliance, low-pressure reservoir incisional or inguinal hernias in 10% .
with an adequate continence mechanism, as well as patient
compliance and meticulous postoperative care. Ureteral stents
are removed 5 to 7 days after surgery. At 8 to 10 days postop- Re sult s
eratively and after pouchography documents no evidence of
urinary leakage, the cystostomy tube is removed. The Foley After 20 years’ experience and a median follow-up of 32
catheter remains for an additional 2 days to provide adequate months in 482 patients, our results are promising. In this se-
time for closure of the cystostomy tube exit site from the reser- ries, 93% could void spontaneously at the last visit, and 90%
voir wall. Although our patients are on antibiotics, all drains had daytime and 78% nighttime continence with 3- to 4-hour
are removed as early as possible to prevent infections. After voiding intervals. The remaining 7% were on intermittent
the patient is drain-free, any bacteriuria is treated with antibi- self-catheterization or had an indwelling catheter for nursing
otics until the urine is sterile. home reasons. In addition to the correct performance of the
Patients are carefully instructed on how to void. Initially, above detailed surgical technique, success with this method
they are taught to empty the pouch every 2 hours during the of substitution demands meticulous postoperative care and
daytime in a sitting position by relaxing the pelvic floor and follow-up.
References
1. Benson M C, Seaman EK, O lsson CA. The ileal ureter neobladder is associ- 3. Skinner DG. Technique of radical cystectomy. Urol Clin N orth A m
ated with a high success and low complication rate. J Urol 1996;155: 1981;8:353.
1585. 4. Studer UE, Burkhard FC, Schumacher M , et al. Twenty years experience
2. Casanova GA, Springer JP, Gerber E, et al. Urodynamic and clinical aspects with an ileal orthotopic low pressure bladder substitute: lessons to be
of ileal low pressure bladder substitutes. Br J Urol 1993;72:728. learned. J Urol 2006;176(1):161–166.
CHAPTER 87 ■ ILEAL NEO BLADDER

RICHARD E. HAUTMANN
During the last 20 years orthotopic reconstruction evolved obstruction or chronic renal failure, with serum creatinine
from “ experimental surgery” over “ standard of care at larger 150 to 200 mol per L. Severe hepatic dysfunction is also a
medical centers” to the “ preferred method of urinary diver- contraindication to continent diversion. Patients with com-
sion” in both sexes. During the last decade the time-honored promised intestinal function, in particular inflammatory
conduit has given way to the increasingly frequent use of bowel disease, may be better served by a bowel conduit.
orthotopic reconstruction. Absolute contraindications to orthotopic reconstruction are
The goal of patient counseling about urinary diversion all patients who are candidates for simultaneous urethrectomy
should be to find the method that will be the safest for cancer based on their primary tumor (1–3). The role of relative con-
control, has the fewest complications in both the short and traindications and comorbidity is steadily decreasing. H owever,
long term, and provides the easiest adjustment for the patient’s some of them—like mental impairment, external sphincter
lifestyle that is supporting the best quality of life. The para- dysfunction, or recurrent urethral strictures—deserve serious
digm for choosing a urinary diversion has changed substan- consideration.
tially, and the proportion of cystectomy patients receiving a In many cases, the patient’s main motivation is to “ get out
neobladder has increased at medical centers to 50% . of the hospital as soon as possible” and resume normal, rather
sedentary activities. M any frail patients undergoing cystec-
tomy will have less disruption of normal activities with a
well-functioning conduit than with an orthotopic reservoir
DIAGNO SIS associated with less-than-ideal continence. Patients who have
no concern about body image may also be better served with
This procedure is used as an adjunct for reconstruction of the
an ileal conduit.
urinary tract, usually following cystectomy. The diagnostic
In addition to the above contraindications, patients under-
modalities therefore are relevant only to the primary diagnosis
going cystectomy for cancer have concerns regarding com-
that resulted in the plan for the cystectomy. This reconstruc-
pletely resecting the cancer versus preserving the rhab-
tive technique is performed following cystectomy, usually for
dosphincter. O ne of the initial deterrents to orthotopic
malignant disease. As such, proper diagnostic studies for the
diversion is the risk for urethral recurrence of cancer. The best
underlying disease are important.
predictor of the risk for urethral disease is the presence and
extent of carcinoma in situ (CIS) in the prostatic urethra,
ducts, or stroma. If there is diffuse CIS in the ducts and inva-
INDICATIO NS FO R SURGERY sion of the stroma, the risk for urethral disease has historically
been 25% to 35% , thus discouraging the use of the urethra.
The primary determining factor for a neobladder is the Lesser amounts of CIS confer a lesser degree of risk. O ur
patient’s desire for the procedure. The patient needs a certain aggressive approach for neobladder diversion relies only on a
motivation to tolerate the initial and sometimes lasting incon- frozen section of the urethral margin at the time of surgery. A
veniences of the nocturnal incontinence associated with a conservative approach would disqualify a patient with any
neobladder. M ost patients readily accept some degree of noc- prostatic involvement. In our view, neither multifocal bladder
turnal incontinence for the benefit of avoiding an external tumors nor CIS of the bladder is an indication for urethrec-
stoma; but not all patients do, and realistic expectations of the tomy. The frequency of urethral recurrence after orthotopic
functional outcome are essential for both the surgeon and the diversions is much less than anticipated. Increasing experience
patient. The psychologically damaging stigma to the patient with orthotopic reconstruction has made patient selection
who enters surgery expecting a neobladder but awakens with based on tumor stage less restrictive. Should extensive pelvic
a stoma plays an increasing role in today’s surgery. disease, a palpable mass, or positive but resectable lymph nodes
An absolute contraindication to continent diversion of any preclude a neobladder because of the high propensity for a
type is compromised renal function as a result of long-standing pelvic recurrence or distant relapse?
Chap t e r 87: Ile al Ne ob lad d e r 567
There is no convincing evidence that a patient with an or-

thotopic diversion tolerates adjuvant chemotherapy less well
or that a pelvic recurrence is any more difficult to manage
with a neobladder than after an ileal conduit. Patients can an-
ticipate normal neobladder function until the time of death.
N evertheless, our philosophy respects the patient’s desire for a
neobladder; if the patient is strongly motivated, he or she gets
a neobladder. Even though the patient has a poor prognosis
and relapse is likely to occur, we still try to construct the di-
version he or she wants. H owever, all patients should be in-
formed that diversion to the skin either by a continent
reservoir or ileal conduit may be necessary due to unexpected
tumor extent, and there should be an appropriate stoma site
marked on the abdominal wall beforehand.
ALTERNATIVE THERAPY
The alternatives to orthotopic urinary diversion (neobladder
construction) are incontinent cutaneous urinary diversion FIGURE 87.1 M odified pelvic lymph node dissection has been com-
(percutaneous nephrostomy, pyelostomy, ureterostomy, and pleted. Ureters are exposed extraperitoneally. The peritoneum over
bowel conduit urinary diversion), ureterosigmoidostomy, and the bladder is bisected to create two large peritoneal flaps for later
continent cutaneous urinary diversion. The patient must un- total extraperitonealization of the ileal neobladder.
derstand that the choice of a particular form of urinary diver-
sion is primarily a quality-of-life decision and has essentially
no impact on the course of the disease necessitating bladder dissected from the anterior abdominal wall, from the ileop-
replacement. It is the responsibility of the surgeon who under- soas region, and from the internal ring. The spermatic cord is
takes urinary reconstruction to fully educate the patient about freed and looped out of the way with a vessel loop. The dis-
all available forms of reconstruction and their relative benefits section is carried distally far enough to reach and resect the
and risks. H aving been so educated, the patient is prepared to large medial retrocrural lymph node of Cloquet near the in-
make a truly informed decision. guinal canal. The surgeon should stop at the circumflex iliac
vein and clear the tissue from the posterolateral aspect of the
common and external iliac veins. The bladder is retracted me-
SURGICAL TECHNIQ UE dially to dissect in the obturator fossa, and the important
nodal tissue and fat are gently pulled out, clearly exposing ob-
N o particular bowel preparation is necessary. Intravenous an- turator vessels and nerves. The peritoneum is mobilized
tibiotic coverage is indicated at the time of surgery. H eparin is bluntly in a cephalad direction to expose the anterior surface
given subcutaneously peri- and postoperatively as thrombosis of the ureter.
prophylaxis.
Ure t e ral Mo b ilizat io n

Cyst e ct o my
The standard vertical incision lateral to the sigmoid meso-
M odifications of pelvic lymphadenectomy and the approach colon should not be used. The peritoneal sac should be mobi-
to the pelvic ureter are made to allow for optimum ileal lized medially on both sides. The surgeon should continue
neobladder construction (4). Pelvic lymphadenectomy and to locate the ureter extraperitoneally, realizing that it is dis-
cystectomy are performed according to standard technique placed during exposure because it adheres to the peritoneum
with slight modifications. Ideally, the ileal neobladder (Fig. 87.1). The ureters are mobilized with sufficient peri-
anatomically replaces the native bladder (i.e., it is located ex- ureteral adventitia in a cephalad direction on both sides. A
traperitoneally in the pelvic cavity) and ileourethral anasto- plane is established between the ureter and the lateral pedicles
moses are located extraperitoneally. Depending on tumor of the bladder. As the ureter and bladder are retracted medi-
stage and location, this goal can be easily achieved by the cre- ally, the lateral pedicle is exposed. Finally, the ureter is
ation of two large peritoneal flaps obtained from the visceral clamped distally. Fine-traction sutures are inserted in the
pelvic peritoneum (Fig. 87.1). proximal surface of the ureter, and it is divided against the
clamps with scissors. Then, the ureter is dissected proximally
so that about 6 to 9 cm is free.
Mo d ifie d Pe lvic Lymp h No d e Disse ct io n Depending on tumor stage and location, the bladder is
Fo llo w ing a St and ard Lap aro t o my completely extraperitonealized and the peritoneum is bisected
over the bladder (Fig. 87.1). If this cannot be done safely, an
Following a standard laparotomy via a lower midline incision, incision in the peritoneum is made high on the base of the
the prevesical space is entered. The space between the bladder bladder, leaving a peritoneal patch on the posterior bladder
and the iliac vessels is opened. The peritoneum is sharply wall.
A 1-0 absorbable suture is then placed under direct vision

Ap p ro ach t o t he Me mb rano us Ure t hra anterior to the urethra (distal to the apex of the prostate)
in t he Male Pat ie nt around the gathered venous complex (Fig. 87.3A and B). This
suture is best placed with the surgeon facing the head of the
Urethral preparation with preservation of the continence table and holding the needle driver perpendicular to the pa-
mechanism is of critical importance when orthotopic diver- tient. This maneuver avoids the unnecessary passage of any in-
sion is anticipated. Attention to surgical detail is important struments between the dorsal venous complex and the
and deserves special mention. The author believes that the rhabdosphincter, which could potentially injure these struc-
continence mechanism in men may be maximized if dissection tures and compromise the continence mechanism.
in the region of the anterior urethra is minimized. This has led After the complex has been ligated, it can be sharply
to a slight modification in the technique of the apical dissec- divided with excellent exposure to the anterior surface of the
tion in the male patient undergoing orthotopic reconstruction. urethra (Fig. 87.4). O nce the venous complex has been sev-
All fibroareolar connections between the anterior bladder ered, the suture can be used to further secure the complex.
wall, prostate, and undersurface of the pubic symphysis are The suture is then used to suspend the venous complex ante-
divided. The endopelvic fascia is incised adjacent to the riorly to the periosteum to help re-establish anterior fixation
prostate, and the levator muscles are carefully swept off the of the dorsal venous complex and puboprostatic ligaments.
lateral and apical portions of the prostate (Fig. 87.2A). This may enhance recovery of continence. The anterior ure-
With tension placed posteriorly on the prostate, the pubo- thra is now exposed. Regardless of the technique, the urethra
prostatic ligaments are identified and slightly divided just be- is then incised 180 degrees, just beyond the apex of the
neath the pubis and lateral to the dorsal venous complex that prostate (Fig. 87.5). Six 2-0 polyglycolic acid sutures are
courses between these ligaments (Fig. 87.2A). Care should be placed in the urethra circumferentially, carefully incorporat-
taken to avoid any extensive dissection in this region. The ing only the mucosa and submucosa of the striated urethral
puboprostatic ligaments should only be incised enough to al- sphincter muscle anteriorly. The urethral catheter is clamped
low for proper apical dissection of the prostate (Fig. 87.2B). and divided distally. Two sutures are placed, which should
The apex of the prostate and membranous urethra becomes incorporate the rectourethrales muscle posteriorly or the cau-
palpable. Several methods can be performed to properly con- dal extent of the Denonvillier fascia (Fig. 87.6). Following
trol the dorsal venous plexus. An angled clamp may be passed this, the posterior urethra is divided and the specimen is
carefully beneath the dorsal venous complex, anterior to the removed.
urethra (Fig. 87.3A and B). The venous complex can then be
ligated with a 2-0 absorbable suture and divided close to the
apex of the prostate. If any bleeding occurs from the tran- Co nst ruct io n o f t he Re se rvo ir
sected venous complex, it can be oversewn with 2-0 polygly-
colic acid sutures in a slightly different fashion; the dorsal The light behind the mesentery should be adjusted, and a 60-
venous complex may be gathered at the apex of the prostate to 70-cm-long ileal segment should be selected 10 to 20 cm
with a long Allis clamp (Fig. 87.2B). proximally from the ileocecal valve (6,9,10). Spasticity of the
FIGURE 87.2 A: The endopelvic fascia adjacent to

the prostate is incised. N ote that care should be
taken not to perform excessive dissection along the
pelvic floor levator musculature, which could injure
the innervation to the rhabdosphincter. The pubo-
prostatic ligaments are slightly divided, providing
excellent exposure to the apex of the prostate and
the membranous urethra. B: The dorsal venous com-
plex should be gathered with an Allis clamp near the
B apex of the prostate or with a stitch.
A B
FIGURE 87.3 A: The dorsal venous complex may be controlled by carefully passing a clamp between the
venous complex (anterior) and the urethra (posterior). B: A suture is carefully placed anterior to the ure-
thra and around the gathered venous complex.
FIGURE 87.4 The venous complex is divided. The

previously placed suture can then be used to further
secure the dorsal venous complex if any bleeding
occurs. The complex is then fixed anteriorly to the
periosteum.
FIGURE 87.5 The anterior urethra is incised 180 degrees just beyond FIGURE 87.6 Placement of urethral sutures and division of the poste-
the prostate apex. rior urethral wall.
FIGURE 87.7 Selection of the ileal segment with an ap-

propriate vascular supply and antimesenteric incision of
ileum, except for the small chimneys on both sides of the
W and the intended site of the ileourethral anastomosis
(brok en line).
bowel or a thick, short mesentery may lead to more bowel

than necessary, thus increasing the reservoir capacity. It is
helpful to place two temporary stay sutures at the intended
resection lines. They can be moved several times if necessary.
The most dependable part of the segment should be long
enough to reach the top of the symphysis pubica in the skin
level. That point should be marked with a suture. This ma-
neuver guarantees that the reservoir will reach the urethral
remnant without difficulty. The distal division of the mesen-
tery along the avascular region between the ileocolic artery
and the terminal branches of the superior mesenteric artery
should extend to the base of the mesentery to provide maxi-
mum mobility and sufficient length to reach the membranous
urethra. The proximal incision of the mesentery is made as
short as possible to provide maximum vascular supply to the
ileal segment. The ileum is then divided between bowel
clamps. A standard bowel anastomosis is performed and the
mesenteric trap is closed. The isolated bowel segment is thor-
oughly cleaned or rinsed with saline or an iodine solution
(Fig. 87.7).
Four lengths of ileum are arranged in the shape of a W with
3- to 5-cm-long chimneys on each side of the W using five to
six Babcock clamps. O ther than the two chimneys, the bowel
is opened on the antimesenteric border except for a 5- to 7-cm
section centered around the marking suture, which is opened FIGURE 87.8 W-shaped reconfiguration of the intestinal segment
to close to the antimesenteric border to create a U-shaped flap. after detubularization and asymmetrical incision of the ileal wall
Two to 3 cm from the tip of that flap, a buttonhole of all lay- at the site of the anastomosis to the urethra, forming a U-shaped
ers is excised from the ileal plate. An ileal plate is formed by flap.
sewing together the cut edges of the antimesenteric borders
of the W using 2-0 synthetic absorbable sutures (SASs) on a
straight needle (Fig. 87.8). anastomosis so that mucosa is in direct contact with urethral
A 22Fr catheter is placed through the buttonhole. For the epithelium. N ext, under gentle traction on the transurethral
actual anastomosis, six previously placed double-armed sutures catheter, the ileal plate is manipulated down to the urethral
using 3-0 SAS in the urethra are used. The inner sutures are remnant and the knots are tied inside the bowel (Fig. 87.10).
passed through the neobladder outlet in the ileal plate without The cut edges of the 5- to 7-cm U-shaped flap are sewn to-
grasping the ileum, and the corresponding outer sutures grasp gether over the catheter. The lower third of the anterior wall
the entire ileal wall 5 to 8 mm lateral to the neobladder outlet of the neobladder is closed, beginning inferiorly with inter-
(Fig. 87.9). This guarantees a wide, ideal, funnel-shaped rupted 3-0 SAS (Fig. 87.11).
FIGURE 87.9 Ileourethral anastomosis, anterior view.
In 10% of patients, the ileourethral anastomosis may cause or continent diversion. The rationale for implanting the
some difficulties. Some or all of the following tricks are help- ureters in an antireflux fashion into orthotopic bladder substi-
ful to overcome this dilemma (Fig. 87.12A and B): loosening tutes or continent reservoirs is to prevent the upper urinary
the retractor, straightening the operating table, removing the tract from retrograde hydrodynamically transmitted pressure
sacral cushion, neutralizing the extended position of the peaks and from ascending bacteriuria. H owever, the routine of
patient, bringing up the perineum with a sponge stick, freeing antireflux ureter implantation into intestinal urinary reser-
the cecum and descending colon as in retroperitoneal lymph voirs was born in the era before the creation of designated
node dissection (RPLN D), moving up the neobladder outlet to low-pressure reservoirs. Reflux prevention in neobladders is
the tip of the U-shaped flap, or performing an end-to-end even less important than in a normal bladder because there are
anastomosis after tubularization of the U-shaped flap (Fig. no coordinated contractions during micturition and there is a
87.13). Any incisions into the mesentery of the neobladder simultaneous pressure increase in neobladder, abdomen, and
should be avoided. The neobladder mesentery should not be kidney pelvis during the Valsalva maneuver. Using nonreflux-
pulled roughly to the pelvic floor. ing techniques, the risk of obstruction is at least twice that fol-
lowing a direct anastomosis, irrespective of type of bowel
segment used, and half of these strictures require secondary
Re fluxing Ile o ure t e ral Anast o mo sis procedures.
Since 1996 we have been using a freely refluxing, open,
Controversy exists about the importance of an antireflux end-to-side ureteroileal anastomosis, which is the simplest
mechanism, and the benefits are not easy to define in adults small-bowel surgery and which has reduced our stenosis rate
undergoing urinary diversion. It is clear that the need for reflux from 9.5% to 1.0% . Further advantages of this chimney mod-
prevention is not the same as in ureterosigmoidostomy conduit ification are the extra length to reach the ureteral stump, the
FIGURE 87.10 Lateral aspect of the ileourethral anastomosis.

The sutures are tied from inside the ileal bladder.
ease of surgery far outside the pelvic cavity, a tension-free

anastomosis, no risk of ureteral angulation with neobladder
filling, and a simplified flank access for revisional surgery.
O n each side, the ureters are trimmed as appropriate for
their chimney (Fig. 87.14). The ureterointestinal anastomosis
can be done extraperitoneally above the common iliac vessels
using a Bricker or Wallace (our choice) technique without
competing with the bowel mesentery for an anastomotic site
(Fig. 87.14). After appropriate ureteral stents are placed, they
are brought through the anterior neobladder suture line. The
remaining anterior neobladder wall is closed in a T shape with
running 3-0 SASs. N o cystostomy tube is placed. Two 20Fr sil-
icone drains are placed into the small pelvis.
Using the two large peritoneal flaps from the visceral pelvic
peritoneum, this goal can easily been reached (Fig. 87.1). Both
flaps are sewn together, except for the portion where the
mesentery of the neobladder runs through them. The peri-
toneal cavity is closed in a standard fashion (Fig. 87.15).
Alternatively, the flaps can be sewn to the posterior wall of the
neobladder.
Excessive mucus production of the ileal bladder may rarely
cause a problem by obstructing the urethral catheter in the
postoperative course. Therefore, the ileal bladder is rinsed via
the cystostomy with 50 to 100 mL of saline twice a day, starting
on postoperative day 5. Routinely, the ureteral stents are re-
FIGURE 87.11 Closure of reservoir. moved between postoperative days 7 and 14.
A B
FIGURE 87.12 M ethods to get the ileal neobladder to the pelvic floor. A: Changing the extended position
of the patient to slightly supine and removing the sacral cushion rotate the pelvic floor upward. B: Pushing
up the perineum with a sponge stick or finger approximates the urethral remnant and neobladder.
FIGURE 87.14 Refluxing ileoureteral anastomosis using chimneys of

a 3- to 5-cm afferent limb on each side.
FIGURE 87.13 M oving the neobladder outlet closer to the tip of the
U-shaped flap of ileal plate. If this still does not allow tension-free
anastomosis, one should tubularize the U-shaped form and perform
direct (end-to-end) anastomosis.
As soon as the urine is in contact with the ileal bladder mu-

cosa, reabsorption of urine electrolytes may occur. Therefore,
the base excess is checked at weekly intervals for the first 4
weeks and monthly thereafter. Approximately 50% of all pa-
tients need temporary alkalinizing therapy.
The urethral catheter is removed between postoperative
days 14 and 21, after a cystogram has demonstrated complete
healing of the ileourethral anastomosis. Rarely, there is still
leakage from the anastomosis. When this is occurs, it is
treated by prolonged catheter drainage until the leak has
closed spontaneously.
FIGURE 87.15 Completely extraperitoneal localization of the

O UTCO MES neobladder as well as ileourethral and ileoureteral anastomoses.
Co mp licat io ns
Reoperation for early complications overall occurred in 3% of
The complications of both continent catheterizable reservoirs continent catheterizable reservoirs and 7% of orthotopic blad-
and orthotopic bladder substitutes in the hands of the most der substitutions. Reoperation for late complications overall
experienced surgeons have been considered in detail (4,7,8). occurred in about 30% of continent catheterizable reservoirs
and in 13% of orthotopic bladder substitutions (4,7,8). We emptying. Physicians must be aware of the risk of rupture.
believe that the morbidity of orthotopic bladder substitutes is Patients must be encouraged to void regularly, especially at
actually similar to, or lower than, the true rates of morbidity bedtime, and perform clean intermittent self-catheterization to
after conduit formation, contrary to the popular view that avoid chronic reservoir overdistention. In the event of anesthe-
conduits are simple and safe. sia, proper bladder drainage should be performed.
There are several new complications unknown during the
conduit era, including incisional hernias, as a consequence of
the Valsalva maneuver: neobladder-intestinal and neobladder-
cutaneous fistulas, mucus formation, and neobladder rupture. Re sult s
The secretion of mucus can be dramatically increased.
Spontaneous late rupture of neobladders is a rare but In some studies, perioperative death occurred in 3% of patients.
potentially life-threatening complication. In the majority of N eobladder-related early and late complications occurred in
cases it is secondary to acute or chronic overdistention and 15% and 23% of patients, respectively. N eobladder-related
bacterial infection. O ther factors are minor blunt abdominal early and late abdominal reoperation rates were 0.3% and
trauma or urethral occlusion. Chronic ischemic changes of the 4% , respectively. Perioperative neobladder-unrelated early
neobladder’s wall, possibly facilitated by detubularization and complications were observed in 33% , and 12% of patients re-
the variability of the mesenteric circulation, are additional fac- quired operative treatment. Late postoperative complications
tors that lead to perforation. The rupture site is typically the unrelated to the neobladder occurred in 12% of patients, and
upper part of the right side of the reservoir. This is the most 5% required open surgical revision. N inety-six percent of pa-
mobile part of the reservoir and undergoes the most marked tients voided spontaneously, 4% performed clean intermittent
distention during overfilling, which may constitute an addi- catheterization in some form, and 1.7% performed regular in-
tional factor for perforation in this location. There is no reliable termittent catheterization. Thirty percent to 40% of women
procedure to establish the diagnosis. Cystography is mislead- required some form of intermittent catheterization to com-
ing in three of four patients with neobladder rupture. A high pletely empty their neobladder (6–8). Daytime and nighttime
index of suspicion and early aggressive operative treatment in continence was reported as good by 96% and satisfactory by
patients suspected of having a neobladder rupture are instru- 95% of patients. Unacceptable daytime continence requiring
mental in providing a successful outcome. Prevention of more than one pad per day occurred in only 4% of patients,
neobladder rupture comprises careful monitoring of neobladder and only 5% were wetting more than one pad per night.
References
1. H autmann RE. The ileal neobladder to the female urethra. Urol Clin 7. H autmann RE, Volkmer BG, Schumacher M C, et al. Long-term results of
N orth A m 1997;24:827–835. standard procedures in urology: the ileal neobladder. World J Urol 2006;
2. H autmann RE. The ileal neobladder. A tlas Urol Clin N orth A m 2001;9: 24:305–314.
85–108. 8. H autmann RE, Abol-Enein H , H afez K, et al. Urinary diversion. Urology
3. H autmann RE. Urinary diversion: ileal conduit to neobladder [Review]. J 2007;69 [Suppl 1A]:17–49.
Urol 2003;169:834–842. 9. Skinner DG, Studer UE, O kada K, et al. Which are suitable for continent
4. H autmann RE, de Patriconi R, Gottfried H -W, et al. The ileal neobladder: diversion or bladder substitution following cystectomy or other definitive
complications and functional results in 363 patients after 11 years of fol- local treatment? Int J Urol 1995;2[Suppl 2]:105.
lowup. J Urol 1999;161:422–428. 10. Studer UE, H autmann RE, H ohenfellner M , et al. Indications for continent
5. H autmann RE, Egghart G, Frohneberg D, et al. The ileal neobladder. J diversion after cystectomy and factors affecting long-term results. Urol
Urol 1988;139:39–43. O ncol 1998;4:172.
6. H autmann RE, Paiss T, de Petriconi R. The ileal neobladder in women: 9
years of experience with 18 patients. J Urol 1996;155:76–81.
CHAPTER 88 ■ THE PADUA ILEAL BLADDER

FRANCESCO PAGANO AND PIERFRANCESCO BASSI
The Padua ileal bladder (VIP, or “ vescica ileale Padovana” ) Large and small bowel nondetubularized segments used as
was developed as a practical application of the concepts ex- bladder substitutes have been shown to generate significant
pressed by Camey (3), Bramble (2), Kock (5), and H inman (4) intraluminal pressures (4,5) and subsequently cause urinary
for the construction of a urinary reservoir employing an in- incontinence and/or renal failure. Disrupting directional peri-
testinal segment: detubularization, reconfiguration, and stalsis by opening the antimesenteric border of the bowel
search for a spherical pouch of adequate capacity. (detubularization) and folding (reconfiguration) has been
Chap t e r 88: The Pad ua Ile al Blad d e r 575
proven to significantly decrease intraluminal pressure by bladder cancer (T3 to T4) or with nodal involvement and can-
making ineffective the bowel contractions. H owever, a single didates for adjuvant systemic chemotherapy are also suitable
folding of the intestinal detubularized segment incompletely for the procedure.
suppresses the peristaltic activity, as Kock demonstrated: a
double folding is necessary for this aim (5). As a consequence,
the double-folding Kock principle is the gold standard in ALTERNATIVE THERAPIES
constructing a spherical reservoir from a cylindrical bowel
segment. O ther urinary diversions, including ileal and colonic conduits,
The capacity and the intraluminal pressure of a reservoir continent urinary diversions, and other forms of orthotopic
also depend on the geometric configuration, as demonstrated bladders, are possible alternatives. The patient’s health, moti-
by H inman (4) with geometric considerations: the larger the vation, and desires, together with the abdominal anatomy,
radius, the larger the volume. From the surgical standpoint, will determine the optimal diversion.
this explains why the double folding produces the largest vol-
ume from the same initial intestinal length. Coupling the dou-
ble folding with the spherical configuration also offers a
relevant feature: at the same endoluminal pressure, the larger SURGICAL TECHNIQ UE
diameter accommodates a larger volume, according to the
Laplace and Pascal laws. Cyst e ct o my
In men, the membranous urethra is managed as in radical
GO ALS prostatectomy and is incised as close as possible to the prostatic
apex to preserve the distal urethral sphincter. In selected patients,
Following the above-mentioned principles, the functional re- the nerve-sparing cystoprostatectomy can be performed.
quirements of the Padua ileal bladder were identified in 1990 In women, the ureters are dissected and divided distally
(6): adequate capacity (300 to 500 mL), low-pressure storage and the uterine vessels ligated and divided. The peritoneum
phase ( 40 cm of water ), no reflux to upper urinary tract, is circumferentially incised just below the vaginal fundus.
daytime and nighttime continence, and voluntary as well as The uterus is lifted posteriorly, and the plane between the
easy and complete voiding “ per urethram.” An intestinal anterior vaginal wall and bladder is developed toward the
reservoir respecting these requirements should allow the long- bladder neck (Fig. 88.1). In this phase the bladder vessels are
term preservation of renal function and provide a reliable con- ligated and divided with respect of the autonomic nerves
trol of continence and voiding with satisfactory patient that originate from the pelvic plexus and run along the lat-
acceptance. eral vaginal wall toward the urethra. The bladder neck is
Further features have also been considered. Because urine identified by filling the catheter balloon to 20 cc and using a
absorption throughout the intestinal wall is unavoidable, the slight outward traction. Before the bladder neck incision,
shortest intestinal segment must be selected to minimize sec- a Satinsky clamp is cranially placed to avoid the spilling of
ondary metabolic disorders. An easy-to-perform and quick urine and tumor cells. The urethral margin is sent for patho-
procedure with a short learning curve is considered highly logical evaluation.
desirable. Last but not least, from the oncologic standpoint, Thereafter the uterus with the ovaries is removed and the
the neobladder must not interfere with the natural history of vaginal fundus accurately sutured. A 2- by 15-cm strip of
the disease and the related treatment(s).
DIAGNO SIS
N ormal renal function is compulsory: however, a dilated up-
per urinary tract(s) per se does not represent a contraindica-
tion to the procedure. A normal urethral closure pressure,
evaluated by the urethral pressure profile and the tumor site
far from the trigone and the posterior bladder wall, is re-
quested in female patients. To benefit from the procedure, the
patient must have intelligence, maturity, and motivation.
Any patient, male or female, who is a candidate for a conduit
diversion is potentially suitable for bladder substitution as
long as an adequate ileal segment is available. Surgical indica-
tions include bladder cancers, neurogenic bladder, congenital
abnormalities, and refractory interstitial cystitis. From the
oncologic standpoint, the only contraindication is a posi-
tive urethral margin biopsy: patients with locally advanced FIGURE 88.1 Creation of lower funnel
FIGURE 88.2 Detubularization and reconfiguration (scheme).

FIGURE 88.4 First folding maneuver.
abdominal fascia is dissected from the laparotomic incision

and bilaterally fixed to the sacrum promontory with non-
absorbable sutures and to the vaginal fundus with 2-0
polyglactin sutures, respectively (Fig. 88.2).
Cre at io n o f t he Pad ua Ile al Blad d e r

A 40-cm ileal segment is isolated, starting at a convenient
point 15 to 20 cm proximal to the ileocecal valve (Fig. 88.3).
The distal (aboral) mesenteric incision is deepened at the level
of the ileocolic artery to obtain better mobility and to allow a
tension-free urethrointestinal anastomosis. O n the contrary,
the proximal (oral) mesenteric incision can be short because it
does not contribute to the mobility of the reservoir. The in-
testinal continuity is restored by an end-to-end anastomosis
with surgical staplers.
The entire ileal segment is split open along the antimesen-
teric border (Fig. 88.4). A lower funnel is created by means of
two running sutures, posteriorly and anteriorly, about 5 cm in
length in order to make the urethrointestinal anastomosis eas- FIGURE 88.5 Ureteral reimplantation: serous-lined intestinal troughs.
ier and tension-free (Fig. 88.5). The ileal anastomotic hole is
placed at the lowest edge of the funnel: the eversion of the ileal
mucosa in the anastomotic hole is recommended. M edially,
the proximal loop is folded on itself in a reversed U shape, and
the inner opposite borders are sutured side to side to create an
upper ileal cup (Fig. 88.6).
FIGURE 88.3 Isolation of a 40-cm segment of distal ileum. FIGURE 88.6 Ureteral reimplantation: final view.
Chap t e r 88: The Pad ua Ile al Blad d e r 577
pouch catheter stays in. The rectal and the gastric tubes are
left in place for 3 to 4 days or until bowel contractions begin.
The ureters are drained by 6Fr to 8Fr or more stents and are
removed after 10 days. Radiologic evaluation of the pouch is
performed after 12 days. Special attention is paid to train the
patient to completely empty the reservoir by abdominal strain-
ing and simultaneous perineal relaxation and to develop alter-
natives to the normal voiding desire.
O UTCO MES
Re sult s
The Padova small bowel neobladder procedure was first per-
formed in 1987 (6). Since its first applications, some changes
have been sequentially introduced to simplify and shorten the
procedure. Initially, the sequence was as follows: ileourethral
FIGURE 88.7 Second folding maneuver and final view. anastomosis, detubularization, lower funnel, ureteral reim-
plantation according to the LeDuc technique, posterior recon-
The ureteroileal anastomosis with serous-lined extramural figuration, and anterior reconfiguration. The length of the
reimplantation according to the Abol-Eneim and Ghoneim ileal segment was progressively reduced from between 50
technique (1) is carried out bilaterally. The edges of two me- and 60 cm to 40 cm. Recently the sequence of maneuvers
dial intestinal flaps are joined by a running through-and- has been established as follows: detubularization, construc-
through suture of 3-0 polyglactin, resulting in the creation of tion of the lower funnel, posterior reconfiguration, bilateral
two oblique serous-lined intestinal troughs (Fig. 88.7). The ureteral reimplantation, incomplete anterior reconfiguration,
left ureter is brought medially through a suitable mesenteric ileourethral anastomosis, complete reconfiguration, and ex-
window in the left mesocolon, providing a downward smooth traperitonealization of the reservoir. This sequence allows the
curve without kinking. Each ureter is then laid into its corre- surgeon to perform the major part of the procedure on the
sponding trough. A mucosa-to-mucosa anastomosis between surface of the surgical field, thus reducing the operative time
the stented (6Fr) and spatulated end of the ureter and the ileal (at present about 2 hours). Because of the unsatisfactory rate
flaps is performed using 4-0 polyglactin suture. The implanted of ureterointestinal anastomosis stenoses (7), the LeDuc
ureters are then covered by approximation and an interrupted ureteral reimplantation technique has been abandoned and
3-0 polyglactin suture is inserted. favorably replaced with the serous-lined extramural reimplan-
When appropriate, a direct non-antirefluxing ureteroileal tation according to the Abol-Eneim and Ghoneim procedure
anastomosis is performed monolaterally or bilaterally: in this (1). The procedure can be easily performed in women with
case the neobladder is also fixed with 3-0 polyglactin sutures to satisfactory functional results provided the vaginal axis is
the ipsilateral psoas muscle. The ureteral stents are fixed to the respected by a colpopexy.
pouch mucosa close to the ureteral hiatus and secured to their
exits (made by stabbing through the anterior wall of the reser-
voir) using a 4-0 polyglactin suture. The urethroileal anasto- CO NCLUSIO NS
mosis is performed with six to eight 3-0 polyglactin sutures.
The closure of the reservoir is completed at the anterior as- The Padua ileal bladder (VIP, or “ vescica Ileale Padovana” ) is a
pect by folding downward the upper edge of the ileal cup to ob- simple, quick procedure with a short learning curve for the urol-
tain a spherical reservoir. A running suture of 3-0 polyglactin is ogist who is accustomed to performing radical cystoprostatec-
employed for all the suturing of the reservoir. The reservoir is tomy, ileal conduit, and antireflux procedures. The procedure
drained by a transurethral 22Fr or 24Fr hematuria catheter. provides both sexes a good-capacity, low-pressure, nonreflux-
Parenteral alimentation is supplied until normal bowel ing, and continent reservoir by employing only a 40-cm ileal
function resumes. Wide-spectrum antibiotics are given for segment in both men and women. The procedure can be easily
7 days; then quinolones are administered orally as long as the customized according to anatomical and oncologic needs.
References
1. Abol-Eneim H , Ghoneim M A. A novel uretero-ileal reimplantation tech- 5. Kock N G. The development of the continent ileal reservoir (Kock pouch)
nique: the serous lined extramural tunnel. A preliminary report. J Urol and application in patients requiring urinary diversion. In: King LR, Stone
1995;151:1193–1197. AR, Webster GD, eds. Bladder reconstruction and continent urinary diver-
2. Bramble FG. The treatment of adult enuresis and urge incontinence by sion. Chicago: Year Book M edical Publishers, 1987.
enterocystoplasty. Br J Urol 1982;54:693. 6. Pagano F, Artibani W, Ligato P. Vescica ileale Padovana: a technique for
3. Camey M , Richard F, Botto H . Bladder replacement by ileocystoplasty. In: total bladder replacement. Eur Urol 1990;17:149–154.
King LR, Stone AR, Webster GD, eds. Bladder reconstruction and conti- 7. Pagano F, Bassi P, Artibani W. The Padua ileal bladder (V.I.P., vescica ileale
nent urinary diversion. Chicago: Year Book M edical Publishers, 1987. Padovana). A cta Urol Ital 1996;10(2):79–83.
4. H inman F Jr. Selection of intestinal segments for bladder substitution:
physical and physiological characteristics. J Urol 1988;139:519–524.
CHAPTER 89 ■ THE T-PO UCH ILEAL
NEO BLADDER
JO HN P. STEIN AND DO NALD G. SKINNER
The goals of urinary diversion have evolved from simply di- (6). The orthotopic neobladder resembles the original bladder
verting the urine and protecting the upper urinary tracts. in location and function. An orthotopic form of recon-
Contemporary objectives of urinary diversion should also struction eliminates the need for a cutaneous stoma and a
include a form of reconstruction that provides a safe and cutaneous collection device, and it relies on the patients’ intact
continent means to store and eliminate urine, with efforts to rhabdosphincter continence mechanism (external striated
improve the quality of life of the patient requiring cystectomy sphincter muscle), thus eliminating the need for inter-
(6). Currently, four reasonable options regarding lower- mittent catheterization in most cases and the often plagued
urinary-tract reconstruction exist: (a) an incontinent cutaneous efferent limb of the continent cutaneous reservoir. Voiding is
diversion: the ileal or colon conduit; (b) a continent cutaneous effectively accomplished by concomitantly increasing intra-
reservoir, requiring catheterization of a cutaneous stoma; (c) a abdominal pressure (Valsalva) with relaxation of the pelvic
continent rectal reservoir, with storage and elimination of floor musculature.
urine via the rectum; and (d) the orthotopic bladder substitute O rthotopic reconstruction was initially applied to carefully
(neobladder), with reconstruction to the native intact urethra. selected male patients in the mid 1980s with excellent clinical
The evolution of urinary diversion and lower-urinary-tract and functional results (6). The positive experience in men sub-
reconstruction over the past 60 years has been remarkable. sequently stimulated interest in applying orthotopic recon-
Progress should be attributed to advances in medical and sur- struction to women (7). After neuroanatomical dissections
gical improvements but should also be credited to thoughtful provided a better understanding of the continence mechanism
and creative surgeons looking to improve upon existing forms in women and defined pathologic guidelines allowed for
of urinary diversion. In 1950, Bricker (2) introduced the ileal proper patient selection from a cancer perspective in women,
conduit, which established a technically simple and reliable orthotopic reconstruction was subsequently and successfully
form of urinary diversion. The ileal conduit remains even to- applied to women in the early 1990s. The majority of both
day a commonly performed urinary diversion and a standard male and female patients undergoing cystectomy today are ap-
to which other forms of urinary reconstruction are compared. propriate candidates for orthotopic reconstruction (6).
Concurrent with Bricker’s introduction of the ileal conduit, From 1982 to 1997, the primary form of urinary diversion
Gilchrist (3) independently reported on a continent cutaneous at the University of Southern California (USC) was the conti-
form of diversion utilizing the ileocecal valve as the continence nent Kock ileal reservoir (Kock pouch) (4,5). The intussus-
mechanism and the terminal ileum as a catheterizable stoma. cepted nipple valve provided the continence and antireflux
For various medical reasons, Gilchrist’s ileocecal reservoir gar- mechanism in the Kock ileal reservoir. The principles of the
nered little support, and the technically simpler Bricker ileal continent Kock ileal reservoir (cutaneous and orthotopic
conduit became the urinary diversion of choice for the next forms) are sound; however, complications can occur (8). M ost
several decades. complications associated with the Kock ileal reservoir relate to
The concept of a continent cutaneous urinary diversion the intussuscepted limb, either the antireflux (afferent limb) or
was eventually reintroduced and popularized in the early the continent catheterizable (efferent limb) nipple.
1980s, revolutionizing urinary diversion to a continent cuta- A review of our large experience at USC with the Kock ileal
neous form of diversion (4). Although patients were relieved reservoir subsequently revealed a 10% complication rate asso-
from the issues of an external collection device, catheteriza- ciated with the afferent intussuscepted antireflux nipple in
tion of the continent abdominal stoma was required. The con- over 800 patients (including the continent cutaneous and
tinent cutaneous urinary diversion was considered a step orthotopic Kock ileal reservoir) (8). The three most common
forward and an improvement on the standard ileal or colon complications associated with the intussuscepted afferent nip-
conduit. These continent reservoirs, however, are technically ple include (a) stone formation (associated with exposed sta-
more challenging, take significantly longer to construct, and ples that secure the afferent nipple valve), seen in 5% ; (b)
are associated with a reoperation rate, particularly the efferent afferent nipple stenosis (thought to be caused by ischemic
catheterizable limb. Despite the benefits of the continent cuta- changes resulting from the mesenteric stripping required to
neous reservoir over an ileal conduit, these aforementioned maintain the intussuscepted limb), seen in 4% ; and (c) extus-
issues even today have limited the widespread application of susception (prolapse of the afferent limb), seen in 1% of
this form of urinary diversion. patients. Although the majority of these afferent nipple valve
A natural progression from the continent cutaneous complications (60% ) can be managed with endoscopic tech-
urinary diversion was the orthotopic bladder substitute niques, they nonetheless may result in some morbidity.
(neobladder) connected directly to the native intact urethra Approximately 3% of all patients undergoing a continent
578
Chap t e r 89: The T-Pouch Ile al Ne ob lad d e r 579
Kock ileal reservoir will require an open surgical revision to evidence of tumor on this biopsy and no other contraindica-
repair an afferent nipple complication (8). tions exist, an orthotopic diversion is performed.
The need to improve upon the intussuscepted Kock nipple
valve became increasingly obvious. Based on reports from
Ghoneim’s group in M ansoura, Egypt, employing a ureteral ALTERNATIVE THERAPY
serous-lined, extramural tunnel (1), as well as our initial expe-
rience with the M itrofanoff appendiceal subserosal tunnel at O ther forms of urinary diversion may be performed, including
USC, we subsequently developed and reported our initial ex- various incontinent reservoirs (ureterostomy, conduits), conti-
perience with a flap-valve technique called the “ T-mecha- nent cutaneous reservoirs, continent rectal reservoirs, and
nism” (9). The T-mechanism is a versatile technique that can other orthotopic neobladders.
be applied as an antireflux mechanism as well as a continent
mechanism in a cutaneous reservoir (10). Since 1997, we have
utilized the T-mechanism as an important modification to the SURGICAL TECHNIQ UE
Kock ileal reservoir (11).
The T-mechanism was first successfully incorporated as The terminal portion of the ileum is used to construct the or-
the afferent antireflux limb of an orthotopic reservoir thotopic T-pouch ileal neobladder (Fig. 89.1). The distal
(T-pouch) (9,11) and subsequently into an afferent antireflux mesenteric division is best made along the avascular plane of
and efferent continence limb of a cutaneous reservoir (double- Treves between the ileocolic artery and terminal branches of
T-pouch) soon after (10). We believe the flap-valve the superior mesenteric artery. This division extends deep into
T-mechanism has eliminated the complications associated the avascular portion of the mesentery, which is essential for
with the intussuscepted nipple valve while maintaining an adequate mobility of the reservoir. The proximal mesenteric
effective antireflux or continence mechanism. The surgical division, however, is short and provides a broad vascular
technique of the orthotopic T-pouch ileal neobladder will be blood supply to the reservoir. In addition, a small window of
described herein. mesentery and a 5- to 7-cm portion of small bowel most prox-
imal to the overall ileal segment are discarded. This helps en-
sure mobility to the pouch and small bowel anastomosis.
DIAGNO SIS The T-pouch reservoir is created from a 44-cm segment of
distal ileum placed in an inverted V configuration. Each limb
Indications for an orthotopic diversion are related to a func- of the V measures 22 cm. A proximal 8- to 10-cm segment of
tional loss of the bladder for either benign or malignant ileum (afferent limb) is used to form the afferent antireflux
causes. In the United States, the most common cause is related T-mechanism. N ote: If ureteral length is short or compro-
to bladder cancer requiring radical cystectomy. All diagnostic mised, a longer afferent ileal segment (proximal ileum) may be
tests are related to the underlying disease and indication for harvested to bridge the ureteral gap.
cystectomy. The ileum is divided between the proximal afferent ileal
segment and the 44-cm ileal segment that will form the reser-
voir portion of the neobladder. The mesentery between these
INDICATIO NS FO R SURGERY ileal segments does not need to be incised; this could poten-
tially compromise the blood supply to the afferent limb. There
Any patient who is an appropriate candidate for orthotopic is generally adequate mobility of the afferent ileal segment,
diversion may undergo this procedure. If a patient has a his- which will ultimately be advanced into the serous-lined ileal
tory of bladder cancer, the authors recommend intraoperative trough formed by the base (cephalad) of the two adjacent
frozen section analysis of the proximal urethra. If there is no 22-cm segments of ileum.
FIGURE 89.1 Designated segments of terminal ileum

for construction of the orthotopic T-pouch ileal neoblad-
der. N ote that the distal mesenteric division is made be-
tween the ileocolic and terminal branches of the superior
mesenteric artery, which extends into the avascular plane
of the mesentery. In addition, a small window of mesen-
tery and a 5- to 7-cm segment of most proximal small
bowel is discarded to allow mobility to the pouch and
small bowel anastomosis.
The antireflux (flap-valve) T-mechanism is then created by

anchoring the distal 4 cm of the afferent ileal segment into the
serous-lined ileal trough formed by the two adjacent 22-cm
ileal segments. First, mesenteric windows of Deaver are
opened between the vascular arcades (carefully excising
mesenteric fat adjacent to the serosa of the ileum, which facil-
itates the development of these mesenteric windows) for 4 cm
proximal to the distalmost portion of the isolated afferent ileal
segment (Fig. 89.3). Preserving these arcades (blood vessels)
maintains a well-vascularized afferent limb and allows perma-
nent fixation of this portion of the limb into the serous-lined
ileal trough with complete preservation of the mesentery and
blood supply. N ote: Placement of small Penrose drains through
each mesenteric window helps identify and facilitates passage
of suture through each window.
N ext, a series of 3-0 silk sutures are then used to approxi-
mate the serosa of the two adjacent 22-cm ileal segments at the
base of the V. N ote: These sutures are passed through the previ-
ously opened windows of Deaver in the afferent ileal limb. This
will anchor the 4-cm segment of afferent limb into the serous-
lined ileal trough. Specifically, a silk suture is placed into the
seromuscular portion of the bowel (adjacent to the mesentery)
at the base (most cephalad portion of the V) of one of the 22-cm
ileal segments (Fig. 89.4A). The suture is then passed through
FIGURE 89.2 The T-pouch is constructed from an isolated 44-cm the most proximal window of Deaver opened in the afferent
ileal segment (laid out in an inverted V configuration) that forms the ileal limb (Fig. 89.4B) and placed in a corresponding seromus-
reservoir portion of the pouch, and a proximal 8- to 10-cm segment of cular site of the bowel (next to mesentery) of the adjacent
ileum to form the antireflux limb. The mesentery between the afferent 22-cm ileal segment (Fig. 89.4C). The suture is brought back
ileal segment and the proximal portion of the 44-cm ileal segment is
carefully incised (2 cm) with preservation of the major vascular arcades. through the same window of Deaver and tied down (Fig.
N ote the serous-lined ileal trough created at the base of the two 22-cm 89.4D). Generally, two to three silk sutures are placed within
ileal segments where the afferent limb will be advanced (arrow ). each window of Deaver to ensure that the back wall of the
reservoir (serous-lined ileal trough) is anchored and does not
The proximal end of the isolated afferent ileal segment is separate. This process is repeated through each individual win-
closed with a running Parker-Kerr suture of 3-0 chromic, and dow of Deaver until the distal 4 cm of the afferent segment is
a third layer of interrupted 4-0 silk sutures. A standard small permanently fixed in the serous-lined ileal trough. We have
bowel anastomosis is performed to re-establish bowel continu- found that placement of small (1/4–in.) Penrose drains through
ity, and the mesenteric trap is closed. each window of Deaver facilitates passage of the silk suture
The isolated 44-cm ileal segment is then laid out in an in- back and forth through the mesentery without difficulty. The
verted V configuration, with the apex of the V lying caudally Penrose drains are systematically removed as the afferent limb
toward the feet and with a suture marking a point between the is fixed within the serous-lined ileal trough.
two 22-cm adjacent segments of ileum (Fig. 89.2). The opened In our early experience with the T-pouch, the previously
end (base) of the V is directed in a cephalad manner toward anchored portion of the afferent ileal segment (distal 4 cm) was
the head. N ote the serous-lined ileal trough formed at the base consistently tapered on the antimesenteric (anterior) border
of the 44-cm segment. over a 30Fr catheter (Fig. 89.5). Tapering this portion of the
FIGURE 89.3 Creation of the antireflux mechanism.

First, four mesenteric windows of Deaver are opened
(adjacent to the serosa of the ileum) at the distal 4 cm
of the isolated afferent ileal segment. Placement of
small Penrose drains through each mesenteric win-
dow helps identify and facilitates passage of suture
through each (insert w ith arrow s). The distal 4 cm of
the afferent segment will be anchored into the serous-
lined ileal trough formed by the base of the two adja-
cent 22-cm ileal segments.
A B
C D
FIGURE 89.4 A: A series of interrupted silk sutures are used to approximate the serosa of the base of the two adjacent
22-cm ileal segments. N ote that these sutures are brought through the windows of Deaver, facilitated by the use of the
Penrose drains. After the silk suture is passed through the window of Deaver (B), it is placed in a corresponding site on
the adjacent 22-cm ileal segment (C). D: This suture will then be brought back through the same window of Deaver and
tied down.
FIGURE 89.5 The previously anchored distal 4-cm affer-

ent ileal segment is tapered over a 30Fr catheter on the
antimesenteric border. Since the initial description of the
T-pouch, we now selectively taper the afferent limb only
in those cases where there is clearly a large diameter of
ileum.
After the distal 4 cm of the afferent ileal segment has been

anchored into the serous-lined tunnel, the remaining portions
of the adjacent 22-cm ileal segments are approximated to-
gether with a side-to-side 3-0 polyglycolic acid suture. This su-
ture line simply reapproximates the two ileal limbs and is
placed adjacent to the mesentery (Fig. 89.6). This can be per-
formed in a running or interrupted fashion.
N ext, starting at the apex of the V, the ileum is opened im-
mediately adjacent to the previously placed serosal suture line
using electrocautery. This incision is carried upward toward
the ostium of the afferent limb where the afferent limb is an-
chored (Fig. 89.7A). O nce this incision reaches the level of the
afferent ostium, the incision is then extended directly lateral to
the antimesenteric border of the ileum and carried upward
(cephalad) to the base of the ileal segment. An incision is made
in similar fashion on the contralateral 22-cm ileal segment
(Fig. 89.7B). O nce completed, these incisions provide wide
flaps of ileum that will ultimately be brought over and cover
the anchored afferent ileal segment to create the antireflux
mechanism in a flap-valve technique (Fig. 89.7C).
The previously incised ileal mucosa is then oversewn with
FIGURE 89.6 The two 22-cm ileal segments are joined by a running two layers of a running 3-0 polyglycolic acid suture starting at
3-0 polyglycolic acid continuous suture. N ote that this suture is the apex and running upward toward the ostium of the affer-
placed adjacent to the mesentery and runs from the apex up to the ent limb (Fig. 89.8). O nce the ostium of the afferent limb is
ostium of the afferent ileal segment. The serosa of the two 22-cm ileal reached, the running suture is tied. An interrupted mucosa-to-
segments is reapproximated.
mucosa anastomosis is then performed between the ostium of
the afferent ileal limb and the incised intestinal ileal flaps with
3-0 polyglycolic acid sutures (Fig. 89.9). The mucosal edges of
afferent ileal segment reduces the bulk and lumen of the affer- the ileal flaps are then approximated over the tapered portion
ent limb and facilitates later coverage of the anchored afferent of the afferent ileal limb (4 cm) with a running suture in two
limb with ileal flaps. In addition, this tapering of the afferent layers (Fig. 89.10). This suture line completes the posterior
limb increases the ratio of the tunnel length to the lumen wall of the reservoir and creates the effective flap-valve
diameter, theoretically providing a more effective flap-valve T-mechanism: the serous-lined ileal antireflux limb.
mechanism. H owever, we have found that with longer follow- The reservoir is then closed by folding the ileum in half in
up this tapering may contribute, in a small percentage of an opposite direction to which it was opened (Fig. 89.11).
patients, to some narrowing and even stenosis at the ostium. This effectively creates a low-pressure, high-capacity urinary
Currently, tapering of the afferent limb on the antimesenteric reservoir. The anterior wall is closed with a running, two-layer
boarder is only performed when the ileum has an obviously 3-0 polyglycolic acid suture that is watertight (Fig. 89.12).
large diameter. This anterior suture line is stopped just prior to the end of the
FIGURE 89.7 A: The two 22-cm ileal seg-

ments are opened immediately adjacent to
the serosal suture line beginning at the
apex and carried upward to the ostium of
the afferent segment. N ote: O nce this inci-
sion reaches the ostium, it is then directed
lateral (to the antimesenteric border) and
cephalad to the base. The dotted line depicts
the incision line. B: Completing the inci-
sion of the bowel. C: The incision provides
wide flaps of ileum that can easily be
brought over and that cover the tapered
distal afferent ileal segment to form the
antireflux mechanism in a flap-valve tech-
nique.
FIGURE 89.8 The incised ileal mucosa is oversewn in two layers beginning
at the apex and continuing toward (cephalad) the ostium of the afferent
ileal segment.
FIGURE 89.9 A mucosa-to-mucosa, ileal-

to-ileal anastomosis is performed between
the ostium of the afferent segment and the
edges of the ileal flaps. N ote that this is per-
formed with interrupted 3-0 polyglycolic
acid suture with completion of the ileal-to-
ileal anastomosis.
FIGURE 89.10 A: The mucosal edges of the ileal flaps

are brought over the tapered distal portion of the afferent
ileal segment. B: Completion of the posterior suture line
covering the afferent segment with the ileal flaps. N ote:
This will exclude the staple line from the reservoir.
reservoir, and the ureteral stents are secured to the end of the
urethral catheter with a 3-0 nylon suture. This step facilitates
removal of the stents at approximately 3 weeks along with the
urethral catheter. A tension-free mucosa-to-mucosa urethroileal
anastomosis is performed.
O UTCO ME AND CO MPLICATIO NS

From N ovember 1996 through M ay 2000, 209 patients (169
men [79% ], 40 women), with a mean age of 69 years (range,
33 to 93 years) underwent an orthotopic T-pouch ileal
neobladder following cystectomy (11). The indication for cys-
tectomy included bladder cancer in 198 patients (95% ). The
median follow-up for the entire cohort is 33 months (range, 0
to 69 months). Data were analyzed according to perioperative
mortality, early (within 3 months) and late diversion-related
and diversion-unrelated complications, radiographic evalua-
tion of the upper urinary tract and urinary reservoir, and de-
termination of renal function.
FIGURE 89.11 The T-pouch is folded (arrow s) and closed in the
opposite direction to which it was opened. This manner of folding will Three patients (1.4% ) died during the perioperative period.
create a low-pressure, large-capacity spherical reservoir. A total of 63 (30% ) early complications occurred, including
53 (25% ) diversion-unrelated and 10 (5% ) diversion-related.
The most common early diversion-unrelated complication
right side to allow insertion of an index finger. This is the most was dehydration (10 patients). The most common early diver-
mobile and dependent portion of the reservoir and will later sion-related complication was urine leak in 6 patients. There
be anastomosed to the urethra. were no early complications directly related to the antireflux-
O nce the pouch has been closed, each ureter is spatulated ing T-limb. Late complications occurred in a total of 66 (31% )
and a standard, bilateral end-to-side ureteroileal anastomosis patients, including 30 (14% ) diversion-unrelated and 38 (17% )
is performed to the proximal portion of the afferent limb diversion-related. The most common late diversion-unrelated
using interrupted 4-0 polyglycolic acid suture. These anasto- complication was incisional hernia in 16 patients. O f the 38 late
moses are stented with no. 8 infant feeding tubes that are di- diversion-related complications, the most common were pouch
rected from the ipsilateral renal pelvis (kidney), across the calculi in 17 patients and ureteroileal obstruction in 9 patients.
ureteroileal anastomosis through the afferent limb into the The only late complication directly related to the T-limb was
reservoir and out the neourethra. A 24Fr hematuria catheter afferent ostial stenosis seen in 4 patients, 3 of whom received
is placed per urethra to provide adequate drainage of the adjuvant pelvic radiation.
A B
FIGURE 89.12 A: The anterior suture line is completed with two layers of a continuous 3-0 polyglycolic acid suture.
N ote that the anterior suture line is stopped just short of the right side to allow insertion of an index finger, which will
be the neourethra. B: Completion of the T-pouch. N ote that the most mobile and dependent portion of the reservoir
will be anastomosed to the urethra following the ureteroileal anastomosis to the proximal portion of the afferent limb.
A total of 181 patients had radiographic evaluation of the unexpected patient who requires intermittent catheterization
upper urinary tract, including 162 (90% ) with a normal radi- to completely empty the neobladder (which is unpredictable)
ographic study or evidence of decompression postoperatively. can also be expected to have colonized bacteriuria with the
An abnormal upper-tract study was seen in 18 patients (10% ), risk of upper-tract deterioration.
including 9 patients with ureteroileal obstruction and 4 with Reflux prevention following orthotopic diversion may be-
afferent T-limb stenosis. Gravity cystography of the neoblad- come more important as the comprehensive therapy (medical
der was normal in 143 of 158 (90% ) evaluable patients. and surgical) for pelvic malignancies improves and patients’
Reflux was seen in 15 patients (10% ). Renal function as de- life expectancy increases following exenteration and urinary
termined by serum creatinine was stable or improved in 96% diversion. This may then place patients at further risk for
of patients. renal deterioration in the future. Subsequently, several novel
Good daytime and nighttime continence was reported in antireflux mechanisms have been developed to improve on ex-
87% and 72% of evaluable patients, respectively. O verall, isting techniques and to eliminate or reduce the complications
75% of patients completely voided, while 25% required some associated with previous antireflux mechanisms, particularly
form of intermittent catheterization to completely empty their obstruction (9,11). Longer follow-up will be required to accu-
neobladder, including 20% of men and 43% of women. rately evaluate the isoperistaltic afferent limb, as well as these
more recent antireflux techniques, to determine if reflux pre-
vention in patients undergoing orthotopic diversion is truly
DISCUSSIO N necessary.
From 1982 to 1997, we incorporated the intussuscepted
The development of orthotopic reconstruction was a signifi- nipple valve as an antireflux mechanism in all forms of conti-
cant improvement in the evolution of urinary diversion. The nent urinary diversion at USC and as an efferent continence
importance of preventing the reflux of urinary constituents mechanism in patients undergoing a cutaneous Kock ileal
following orthotopic reconstruction is a controversial subject reservoir (4,5,7). The basic surgical premise and structural
and remains a topic of significant debate. The authors have characteristics of the Kock ileal reservoir are sound: a low-
been, and continue to be, strong proponents of reflux preven- pressure, large-capacity reservoir, employing an antirefluxing
tion in patients undergoing lower-urinary-tract recon- and continent nipple valve. The Achilles heel of the Kock ileal
struction. It is emphasized that the complications or risks reservoir, however, remained the intussuscepted nipple valve.
associated with incorporating an antireflux mechanism (i.e., Despite several surgical modifications to improve upon the
obstruction) should not outweigh the theoretical advantage of construction of the intussuscepted nipple valve, there re-
reflux prevention. To meet this end, we have been diligent to mained complications and a reoperation rate (8). The intus-
critically evaluate our antireflux techniques and continually suscepted nipple valve needed to be improved.
improve upon existing ideas and methods. This evaluation The so-called T-mechanism is a flap-valve technique that
process has subsequently stimulated a change from the intus- can be applied as an antireflux and continence mechanism in
suscepted nipple of the Kock pouch to the development of the lower-urinary-tract reconstruction (9–11). In general, all flap-
flap-valve T-mechanism, incorporated as an antireflux limb in valve techniques rely on the dynamic principle that the chan-
the orthotopic T-pouch ileal neobladder as well as a rectal neled segment (appendix, ureter, intestine) is fixed and
reservoir (9,11). This technique provides an effective antire- tunneled along the inner wall of the reservoir. As reservoir fill-
flux mechanism without the complications associated with the ing occurs, the channeled segment is compressed against the
intussuscepted nipple. Furthermore, the T-mechanism has been wall of the pouch and continence or reflux prevention is
successfully applied as a catheterizable continent mechanism achieved. This technique is based on similar principles for
in cutaneous reservoirs, as discussed elsewhere (10). reimplantation of the ureter into the bladder. Keys to success
M any antireflux techniques exist today. The inclusion of of the flap-valve technique include an appropriate ratio of
an antireflux mechanism in the chronically infected, continent tunnel length to lumen diameter. Furthermore, the back wall
cutaneous reservoir (requiring intermittent catheterization) is of the reservoir must be sufficiently capable to allow compres-
still thought to be important and not a source of considerable sion of the tunneled channel as the pouch fills.
debate. With increasing popularity and further application of The unique aspect of the T-mechanism (antireflux and con-
the low-pressure orthotopic reservoir, the issue of reflux pre- tinence) is the ability to create a reliable and effective flap-
vention has regained attention. Studer and associates (12) ad- valve system. M aintenance of the vascular arcades (opening
vocate a long (20-cm), dynamic, isoperistaltic ileal segment as the windows of Deaver) provides complete preservation of the
an afferent limb of an orthotopic neobladder reservoir. mesentery and blood supply to the entire limb, thus eliminat-
Proponents of the isoperistaltic afferent ileal limb argue that ing problems with ischemia or stenosis of the bowel segment.
radiographic evidence of reflux in a sterile, low-pressure reser- Permanent fixation of the limb into the serous-lined ileal
voir may not have the same importance and clinical conse- trough should also eliminate issues associated with prolapse
quence. Furthermore, the complications of late stenosis from or extussusception of the limb. Importantly, no exposed
the various antireflux techniques could potentially outweigh metallic staples exist within the reservoir, which should reduce
their theoretical advantage of protecting the upper urinary the incidence of stone formation, typically associated with ex-
tract. O thers, however, argue that antireflux procedures are posure of metallic foreign bodies to urine. Furthermore, if nec-
not only theoretically inherent in humans but are also critical essary, the proximal portion of the afferent limb can be easily
to preserve or maintain renal function and important in all lengthened when there is shortened or compromised ureters. A
forms of lower-urinary-tract reconstruction, even orthotopic longer proximal afferent segment may be harvested to bridge
diversion. Reasons include the fact that patients, even with an any ureteral defect and maintain a tension-free ureteroileal
orthotopic neobladder, may have colonized bacteriuria. The anastomosis.
Several technical points regarding the specifics of the ileal neobladder (11). This effectively increases the ratio of the
construction of the flap-valve T-mechanism (antireflux, con- tunnel length to the lumen diameter and has provided an
tinence) deserve mentioning. An effective afferent antireflux excellent efferent continence mechanism. H owever, several
valve can be created from 4 cm of ileum anchored within patients (2% ) with longer follow-up developed some narrow-
the serous-lined ileal trough. Permanently anchoring the ing of the ostium and even stenosis that may be attributed to
portion of ileum in the serous-lined ileal trough is critical to either some postoperative radiation to the reservoir or possi-
fix the limb and prevent any valve slippage or prolapse. In bly to the antimesenteric tapering. We subsequently tapered
addition, the silk sutures used to anchor the valve (passed the T-limb only in those patients with a large ileal diameter
through the windows of Deaver) should be placed adjacent and have found that it does not appear to compromise the
to the mesentery and should incorporate a generous portion antireflux mechanism; to date, we have not observed any
of the seromuscular ileum to prevent separation of the further issues with stenosis of the afferent limb.
serous-lined ileal trough. This trough forms the so-called The flap-valve T-mechanism in the T-pouch provides an
“ backboard” (posterior wall to the reservoir) of the flap- effective and reliable antireflux mechanism. The long-term
valve technique, which is critical to antireflux prevention as results of the T-pouch are yet to be determined; however,
the reservoir fills. Placement of two to three sutures within the initial and intermediate results have been promising.
each window of Deaver should prevent separation of this Furthermore, we believe that this technique can be easily
trough. learned with a little experience. The T-mechanism is a very
The antimesenteric tapering of the valve was initially de- versatile flap-valve technique that can also be applied as a con-
scribed and performed on all patients with this technique. tinent mechanism in a cutaneous reservoir (double-T-pouch).
Tapering the afferent limb over a 30Fr catheter was effective We believe that reconstructive surgeons interested in lower-
in preventing reflux of urinary constituents and in protecting urinary-tract reconstruction should understand this concept
the upper tracts in patients undergoing an orthotopic T-pouch and technique to broaden their surgical armamentarium.
References
1. Abol-Enein H , Ghoneim M A. Further clinical experience with the ileal ureteroileal urethrostomy: initial clinical experience. J Urol 1994;152:
W-neobladder and a serous-lined extramural tunnel for orthotopic substi- 1404–1408.
tution. Br J Urol 1995;76:558–564. 8. Stein JP, Freeman JA, Esrig D, et al. Complications of the afferent antire-
2. Bricker EM . Bladder substitution after pelvic evisceration. Surg Clin N orth flux valve mechanism in the Kock ileal reservoir. J Urol 1996;155:
A m 1950;30:1511–1521. 1579–1584.
3. Gilchrist RK, M erricks JW, H amlin H H , et al. Construction of a substitute 9. Stein JP, Lieskovsky G, Ginsberg DA, et al. The T pouch: an orthotopic
bladder and urethra. Surg G ynecol O bstet 1950;9:752–760. ileal neobladder incorporating a serosal lined ileal antireflux technique.
4. Skinner DG, Boyd SD, Lieskovsky G. Clinical experience with the J Urol 1998;159:1836–1842.
Kock continent ileal reservoir for urinary diversion. J Urol 1984;132: 10. Stein JP, Skinner DG. T-mechanism applied to urinary diversion: the ortho-
1101–1107. topic T-pouch ileal neobladder and cutaneous double-T-pouch ileal reser-
5. Skinner DG, Boyd SD, Lieskovsky G, et al. Lower urinary tract reconstruc- voir. Tech Urol 2001;7:209–222.
tion following cystectomy: experience and results in 126 patients using the 11. Stein JP, Dunn M D, Q uek M L, et al. The orthotopic T pouch ileal neoblad-
Kock ileal reservoir with bilateral ureteroileal urethrostomy. J Urol 1991; der: experience with 209 patients. J Urol 2004;172:584–587.
146:756–760. 12. Studer UE, Danuser H , Thalmann GN , et al. Antireflux nipples or afferent
6. Stein JP, Skinner DG. O rthotopic bladder replacement. In: Wein AJ, tubular segments in 70 patients with ileal low pressure bladder substitutes:
Kavoussi LR, N ovick AC, et al., eds. Cam pbell-Walsh urology, 9th ed. WB long-term results of a prospective randomized trial. J Urol 1996;156:
Saunders, 2006:2613–2649. 1913–1917.
7. Stein JP, Stenzl A, Esrig D, et al. Lower urinary tract reconstruction follow-
ing cystectomy in women using the Kock ileal reservoir with bilateral
CHAPTER 90 ■ CO LO NIC O RTHO TO PIC

BLADDER SUBSTITUTIO N
JO ACHIM W. THÜRO FF AND LUDGER FRANZARING
O rthotopic bladder substitution can be realized from ileum a urinary reservoir from bowel segments generally means
only or from colonic segments either alone or in combination transformation of a cylinder into a sphere. The length of
with small bowel segments as a composite reservoir. The ratio- bowel to be excluded from the intestinal tract for formation of
nale of using large bowel for urinary diversion is based on a reservoir of a given capacity depends only on bowel diame-
anatomical and functional considerations. Surgical creation of ter. Since in the volume formula of a cylinder (V r 2 · l) the
Chap t e r 90: Colonic O rthotop ic Blad d e r Sub stitution 587
radius determines the volume by its second power, the wider same time. This translates into higher capacity and lower pres-
the bowel diameter, the less the bowel length required. Thus, sure of the cecum and ascending colon as compared to the de-
large bowel with its wider diameter can contribute a signifi- scending and sigmoid colon. The surgical technique of the
cant capacity to a continent reservoir while excluding only a M ainz ileocecal pouch as described following in detail may in
short length of a functional segment. this context serve as a general example of construction of an
Physiologically, fat-soluble vitamins such as vitamin B12 ileocolonic composite pouch.
and folic acid as well as biliary acids are absorbed from the en- H owever, one single technique of continent urinary diver-
tire ileum, but not from colon. Consequently, possible malab- sion does not fit all patients and all pathologies. Thus, modern
sorption syndromes are related only to resection of ileum but concepts of intestinal urinary diversion require surgical versatil-
not to colon resection. The critical length of ileum resection is ity instead of stereotypic repetition of fixed surgical strategies.
40 cm, at which the risk of secondary malabsorption syn-
dromes starts to increase. These facts should influence choice
of bowel segments for reservoir formation in favor of reducing
the length of ileum segments for a composite reservoir or of
DIAGNO SIS
avoiding ileum entirely in an all-colon reservoir. The scope of diagnostic studies is determined by the underly-
H owever, the large bowel is less distensible than small ing disease because of which the native bladder has to be sub-
bowel. Although at first this may be regarded as a disadvan- stituted. For continent urinary diversion as compared to
tage, it may be advantageous, specifically for spontaneous incontinent diversion, the most important assessment is renal
evacuation of an orthotopic bladder substitute in the long run. morphology and function. Grossly dilated upper urinary
Intestinal urinary reservoirs start their life at a surgically detracts may not drain as well into a continent urinary reservoir
termined volume that increases over time by gradual disten- as into a conventional zero-pressure conduit diversion. Every
tion. During this process, large bowel segments have the intestinal urinary reservoir reabsorbs hydrogen and chloride
advantage that the longitudinal arrangement of taeniae pre- ions. The resulting metabolic acidosis is generally balanced by
vents the development of a decompensated substitute mega- respiratory compensation and by an increased renal secretion.
cystis as has been described for ileum reservoirs. In addition, As a consequence, renal reserve must be sufficient as judged
large bowel segments, especially cecum and ascending colon, by a glomerular filtration rate better than a minimum of 50%
offer several alternatives for safe and effective antirefluxive of the age-related normal global renal function.
ureteral implantation. The intestinal tract must be evaluated in order to avoid sur-
The downsides of using large bowel for creation of an or- gical or postoperative problems. Concerning patient history,
thotopic reservoir have to be weighed against the advantages special attention must be paid to inflammatory bowel disease,
of large capacity, less malabsorption, less overdistention, and prior abdominal surgery or radiation, and related abnormali-
reliable antireflux techniques. ties of stool and defecation. When large bowel segments are
First, many urologic surgeons are not familiar with large used for continent diversion, contrast enema or coloscopy are
bowel surgery and feel uncomfortable with it, specifically mandatory to exclude asymptomatic diverticulosis or tumors
when mobilizing the large bowel and performing the bowel of the large bowel.
anastomosis after resection of the segments for the urinary
reservoir. H owever, generous mobilization of segments as well
as rotation of segments may be required to allow a tension-
free transposition as an orthotopic reservoir in patients with a INDICATIO NS FO R SURGERY
deep true pelvis. Surgical techniques using large bowel may
also be more time-consuming because adhesions with the The indications for a colonic orthotopic bladder substitute or
greater omentum have to be freed and the bowel anastomosis a composite reservoir of ileum and colon are not different
after exclusion of the segments for urinary diversion has a sig- from those for ileal orthotopic bladder substitution. H owever,
nificantly larger circumference to be sutured than in a small in patients with neurogenic bowel and anal sphincter incom-
bowel anastomosis. petence, any change in stool consistency secondary to bowel
Finally, the use of large bowel segments may have func- resection bears the risk of worsening pre-existing anal inconti-
tional sequaelae as well. All reservoirs that use the ileocecal nence. Another aspect of all forms of orthotopic bladder sub-
segment and thus require resection of the ileocecal valve may stitution, specifically in women, is the risk of urinary retention
allow retrograde colonization of the ileum if the ileocecal requiring emptying of the reservoir by intermittent catheteri-
valve is not reconstructed by an antirefluxing technique of the zation. Thus, the willingness and ability to perform intermit-
ileoascendostomy anastomosis. tent self-catheterization have to be determined and possibly
The different techniques of constructing an orthotopic practiced preoperatively. This is of special importance in
reservoir, either from large bowel only or in combination with women, patients with neurogenic bladder, and children.
small bowel segments as a composite reservoir, refer to the Generally, children can perform intermittent self-catheterization
very same principles of continent urinary diversion: detubular- of the urethra from about 6 years of age.
ization and spherical reconfiguration. Thus, the success of or-
thotopic bladder substitution is not confined to selection of
small bowel segments; good results have been reported with ALTERNATIVE THERAPY
the ileocecal segment, the right colon, and the sigmoid colon.
H owever, in general, large bowel segments have physiologi- Alternatives to orthotopic bladder substitution with colonic
cally decreasing capacity and compliance from proximally to segments are orthotopic ileal neobladders. Alternatives to con-
distally, while wall tension and pressure are increasing at the tinent orthotopic bladder substitution are continent cutaneous
urinary diversion (e.g., M ainz Pouch I, Indiana Pouch) or con- The ileocecal segments may also be used for creating an or-
tinent anal urinary diversion (M ainz Pouch II). Alternatives to thotopic pouch in the “ Le Bag” technique (Fig. 90.3). The
continent urinary diversion are incontinent conduit diversions right colonic pouch is constructed from cecum and ascending
(ileal conduit, sigmoid conduit, transverse colonic conduit). colon (Fig. 90.4). The blood supply of ileocecal reservoirs is
based on the ileocolic artery, which always allows tension-free
anastomosis to the urethra, specifically if a 180-degree coun-
terclockwise rotation of the pouch around the “ insertion” of
SURGICAL TECHNIQ UE the ileocolic vessels is performed. In right colonic pouches,
with additional blood supply from the right colonic artery,
The day before surgery the bowel is cleansed either by oral ad- reaching down to the urethral stump may sometimes be more
ministration with 4 to 6 L of a hyperosmotic nonabsorbable difficult. The blood supply of the sigmoid colon is from the in-
solution (e.g., macrogol) or by irrigation with 8 to 10 L of iso- ferior mesenteric and superior rectal arteries (Fig. 90.5).
tonic saline with a total of 50 mval of potassium chloride Sigmoid reservoirs thus always easily reach down to the ure-
added through a nasogastric tube. After irrigation, serum elec- thral stump (Fig. 90.6).
trolyte concentrations have to be checked and, if necessary, in-
travenously substituted.
During surgery, the small and large bowel segments that Ure t e ral Imp lant at io n
have been excluded for construction of the intestinal urinary
reservoir are intubated with a Foley catheter and antegradely A variety of techniques reflects the surgical challenge to create
flushed with saline until the irrigation fluid turns out clear bean antireflux mechanism without obstruction of the ureter.
fore they are opened antimesenterically. Perioperative par- This challenge may be heightened by a number of pathological
enteral antibiotic therapy with broad-spectrum antibiotics conditions in the individual patient. Ureters may be dilated, fi-
should include antianaerobic activity. The antibiotics are ad- brotic, or ischemic secondary to obstruction, previous surgery,
ministered 1 hour before surgery and continued until the fifth or irradiation. Bowel segments may be altered from inflamma-
to seventh postoperative day. tion, dilatation, or ischemia secondary to inflammatory bowel
The patient is positioned supine on the operating table. disease, previous surgery, or irradiation. M echanical factors
Radical cystoprostatectomy should adhere to the same princi- (e.g., position changes of the reservoir) or biochemical factors
ples as radical prostatectomy: that is, to preserve maximum (e.g., effects of urine on the ureteral adventitia or on the intesti-
urethral length and, if possible and indicated, to preserve the nal mucosa) may have long-term effects on the whole system.
neurovascular bundles. The rationale of implanting the ureters by an antirefluxive
For ileocecal orthotopic bladder substitution, the cecum technique into an orthotopic bladder substitute is to protect
and ascending colon are mobilized beyond the right colonic the upper urinary tracts from retrogradely transmitted pres-
flexure. Extended mobilization is helpful for later sliding the sure peaks and from ascending bacteriuria. H owever, the stan-
pouch easily into the small pelvis. dard technique of antirefluxive ureteral implantation into
Ten to 15 cm of cecum and ascending colon and about large bowel was conceived from ureterosigmoidostomy, which
20 to 30 cm of distal ileum are marked by stay sutures means diverting urine into a high-pressure reservoir. The de-
and isolated from bowel continuity. An ileoascendostomy is bate about the necessity of antirefluxive ureteral implantation
accomplished either as a sutured single-row, dual-layer (sero- into orthotopic low-pressure reservoirs is still not concluded.
muscularis), running end-to-end anastomosis after antimesen- O ne argument is that, in contrast to most forms of continent
teric spatulation of the ileum for adjustment of bowel cutaneous diversion, orthotopic reservoirs have the pop-off
diameter or as stapled mechanical end-to-side anastomosis of valve of urethral incontinence when overfilled. Another argu-
ileum to ascending colon using EEA and TA-55 staplers. The ment is a supposedly lower bacterial contamination rate as
isolated ileocecal segment is intraoperatively irrigated with compared to reservoirs that require intermittent catheteriza-
isotonic saline for further cleansing. tion. N evertheless, antirefluxive ureterointestinal reimplanta-
Ascending colon, cecum, and ileum are split open at their tion is still the method of choice for colonic reservoirs. A
antimesenteric borders. The posterior wall of the pouch is variety of surgical techniques is based on different antireflux
completed by side-to-side anastomosis of the ascending colon mechanisms, which have been described, although two general
with the terminal ileal loop and of the latter with the next types exist. In one type, the ureter itself is part of the antire-
proximal segment. The anastomosis is performed by single- flux mechanism, while in the other a bowel-derived antireflux
row, all-layer running sutures of 4-0 polydioxanone with a mechanism is interposed between ureter and reservoir.
straight needle. The still open pouch is slid into the small In any case, for implantation of the ureters into cecum or
pelvis. For bladder substitution to the bladder neck (benign ascending colon, the left ureter has to be brought into the right
disease), the pouch is anastomosed with the posterior bladder retroperitoneum behind the mesentery of the descending colon
wall using single-row, all-layer running sutures of 4-0 poly- as for ileal conduit diversion.
dioxanone. For bladder substitution to the urethra after cys- Antirefluxive ureteral implantation techniques in which the
tectomy, a small vertical buttonhole incision is made at the ureter becomes part of the antireflux mechanism mostly fol-
lowest aspect of the cecal pole and the opened mucosa is low the “ flap-valve” principle: An oblique entry of the ureter
everted with a few 5-0 absorbable stitches before anastomosis into the reservoir is created with a “ tunnel” course that allows
to the membranous urethra is performed by eight interrupted transmission of the reservoir pressure onto the ureter and
sutures of 4-0 glykonat (Fig. 90.1). Alternatively, the ileocecal against the seromuscularis of the reservoir. This pressure
pouch may be created by using G1A staplers with reab- transmission passively compresses the ureter with rising reser-
sorbable staples (Fig. 90.2). voir pressures. The most frequently utilized principles to
FIGURE 90.1 Construction of the M ainz ileo-

cecal reservoir. A: Isolation of the ileocecal seg-
ment consisting of 20 to 30 cm of ileum and 10
to 15 cm of cecum and ascending colon. B:
Antimesenteric opening of the intestinal seg-
ments. C: Detubularization and reconfiguration
of the ileal segment. N ote: The ileocecal valve
may be left intact. D: Submucosal tunnel im-
plantation of the ureters in “ open-end” tech-
nique into the colonic segment. The term open
end describes the ureters entering the submu-
cosal tunnel from the resection margin. E:
Completion of the posterior wall of the pouch
by anastomosing the medial margin of the
colonic segment to the right margin of the ileal
plate. The lowest part of the pouch is anasto-
mosed to the urethra. F: Completion of the ante-
rior wall of the pouch by anastomosing the
lateral margin of the colonic segment to the left
margin of the ileal plate. Drainage of the pouch
is secured by a transurethral Foley catheter and
a percutaneous pigtail pouchostomy catheter.
transmit the reservoir pressure to the ureter are the submu- Ureters are anchored with 6-0 glykonat sutures to the muscu-
cosal tunnel technique and the seromuscular extramural tun- laris of the bowel wall, and the neo-orifices are established by
nel technique. 6-0 glykonat or 7-0 polyglycolic acid ureteromucosal sutures.
In the submucosal tunnel technique, both ureters are im- The most common technique of interposition of an antire-
planted into the colon with a 2- to 3-cm submucosal tunnel. fluxive mechanism between the urinary reservoir and the ureters
A C
Zoekum
IIeum
Rotation
180˚
D
E
FIGURE 90.2 Construction of an ileocecal reservoir utilizing reabsorbable staples. A: Isolation of the ileocecal segment
comprising 15 cm of large bowel with 10 cm of prevalvular terminal ileum and an additional 15 cm of ileum. B:
Alignment of cecum or ascending colon and the separated segment of 15 cm of ileum and one-step antimesenteric open-
ing and side-to-side anastomosis of the large bowel segment and the ileal segment, with the GIA-75 (Autosuture) sta-
pler applying on either side two rows of polyglycolic absorbable staples (copolymer Lactomer). C: Eversion of the
pouch wall and second stapler application (a third application in the very same way may be required). Gaps between
the staple lines are closed with a running 4-0 polydioxanone suture (insert). N ote: The 10-cm terminal prevalvular
ileum remains intact. D: The cranial aspect of the pouch is closed with a running seromuscular 4-0 polydioxanone su-
ture. Then the pouch is rotated 180 degrees counterclockwise. E: At the most dependent aspect of the pouch, a vertical
buttonhole incision is performed and the pouch is anastomosed to the urethral stump. The left ureter is pulled into the
right retroperitoneum above the inferior mesenteric artery, and the ureters are anastomosed to the terminal ileum in an
end-to-end (left ureter) and end-to-side (right ureter) technique.
is to take advantage of the antireflux function of the ileocecal pouchostomy catheter is removed at residual urine volumes
valve. The cecum with the ileocecal valve is incorporated in 50 mL. In neurogenic cases, patients are instructed in inter-
the pouch, and the ureters are anastomosed in an end-to-side mittent catheterization.
(N esbit) or spatulated end-to-end (Wallace) technique to the
terminal prevalvular ileum. Thus, the flow of urine is directed
from the ureters into the pouch through the ileocecal valve.
The ureters are intubated with 6Fr or 8Fr stents, and a O UTCO MES
10Fr pouchostomy pigtail catheter and a 20Fr transurethral
Foley balloon catheter are inserted into the reservoir. The Co mp licat io ns
closure of the anterior wall of the pouch is completed in the
same way as described previously. H owever, at the site of a In the early postoperative months, nonperistaltic contractions
submucosal ureteral tunnel implantation, the pouch is closed of the bowel segments of a M ainz pouch do occur but subside
by mucosal sutures only to prevent ureteral obstruction at the spontaneously with increasing capacity of the pouch. For per-
entry. A 20Fr gravity drain is placed each into the small pelvis sistent inadequate compliance or persistent contractions of the
and at the ureteral implantation site. pouch, antimuscarinics can be used for pharmacotherapy.
The ureteral stents are removed at day 10 and 11. The About 60% of patients postoperatively have an asympto-
transurethral catheter is removed at day 12 when a pouchogram matic metabolic acidosis as judged by blood gas analysis (base
has ruled out extravasation. Residual urine is checked via the excess below 2.5), which is balanced prophylactically by oral
pouchostomy catheter when patients void spontaneously. The alkali substitution (sodium/potassium citrate/bicarbonate).
FIGURE 90.3 “ Le Bag” procedure. A and B: Isolation of the ileocecal segment and antimesenteric opening,
leaving the oral end of the ileal segment intact. C and D: Detubularization and reconfiguration of the seg-
ments into a pouch. A 180-degree counterclockwise rotation brings the oral intact ileum segment down to
the urethra. E: Ileourethral anastomosis with the oral end of the ileal segment. F: Antirefluxive submucosal
tunnel ureter implantation through two separate incisions of the posterior pouch wall (buttonhole tech-
nique).
A, B
C, D
FIGURE 90.4 Construction of a right colonic reservoir. A and

B: Isolation of a colonic segment consisting of cecum, ascend-
ing colon, and the right colic flexure. C and D: O pening of the
segment through the taenia libera, leaving the cecum intact
and anastomosing it to the urethra. E and F: The ureters are
anastomosed into the colonic segment utilizing the “ button-
hole” submucosal implantation technique. This technique de-
scribes the ureters entering the submucosal tunnel via a
E, F buttonhole incision into the posterior wall of the pouch.
Reconfiguration is completed by folding the open cranial seg-
ment over the caudal segment and anastomosing both lateral
margins.
At present, the risk of secondary malignancies cannot be

comprehensively determined. Follow-up examinations must
include renal ultrasound and/or intravenous pyelogram, blood
gases, and, starting from the fifth postoperative year, pouch-
oscopy and evaluation of serum cobalamin.
Re sult s
In general, the outcome criteria for orthotopic bladder substi-
tution by intestine are (a) the function and morphology of the
upper urinary tracts, (b) frequency during day and night, (c)
continence, and (d) ability to void spontaneously. H owever,
one has to keep in mind that especially continence and the abil-
ity for spontaneous micturition may significantly be influenced
by the type and quality of surgery preceding the orthotopic sub-
stitution itself. Related factors are, for example, preparation of
the bladder neck and urethra, sparing of the autonomous
nerves, and measures to prevent pouch displacement or kink-
ing. Therefore, functional results attributed to specific kinds of
reservoirs actually rely on more factors than the segment(s) of
intestine chosen. For ileocecal reservoirs, a ureterointestinal
obstruction rate of up to 7% is reported. Continence rates for
ileocecal reservoirs vary between 75% and 88% during the day
and 67% during the night (6,11). Continence rates for sigmoid
FIGURE 90.5 Vascular supply of the left colon and rectosigmoid. colon reservoirs are significantly lower, at 50% (11).
FIGURE 90.6 Construction of a sigmoid

colon reservoir (Reddy). A: Isolating a
segment of about 30 cm of sigmoid
colon. B: Submucosal tunnel ureteral im-
plantation. C and D: Detubularization,
U-shaped reconfiguration of the segment,
and side-to-side anastomosis of the back
wall of the pouch. E and F: Completion
of the anterior wall of the pouch and
anastomosis to the urethra.
References
1. Ali-El-Din B, El-Sobky E, H ohenfellner M , et al. O rthotopic bladder sub- 10. Reddy PK. The colonic neobladder. Urol Clin N orth A m 1991;18:
stitution in women: functional and urodynamic evaluation. J Urol 1999; 609–614.
161:1875–1880. 11. Riedmiller H , Thuroff J, Stöckle M , et al. Continent urinary diversion and
2. El-M ekresh M , Franzaring L, Wöhr M , et al. Simplified orthotopic ileoce- bladder augmentation in children: the M ainz pouch procedure. Pediatr
cal pouch (M ainz pouch) for bladder substitution. A k tuelle Urol 2003; N ephrol 1989;3:68–74.
34:226–230. 12. Santucci R, Park C, M ayo M , et al. Continence and urodynamic parame-
3. H inman FJ. Selection of intestinal segments for bladder substitution: phys- ters of continent urinary reservoirs: comparison of gastric, ileal, ileocolic,
ical and physiological characteristics. J Urol 1988;139:519–523. right colon, and sigmoid segments. Urology 1999;54:252–257.
4. H ohenfellner M , Black P, Linn J, et al. Surgical treatment of interstial cysti- 13. Stein R, Fisch M , Beetz R, et al. Urinary diversion in children and young
tis in women. Int Urogynecol J Pelvic Floor D ysfunct 2000;11:113–119. adults using the M ainz pouch I technique. Br J Urol 1997;79:354–361.
5. H ugonnet C, Danuser H , Springer J, et al. Urethral sensitivity and the im- 14. Stenzl A, Colleselli K, Poisel S, et al. Rationale and technique of nerve spar-
pact on urinary continence in patients with an ileal bladder substitute after ing radical cystectomy before an orthotopic neobladder procedure in
cystectomy. J Urol 2001;165:1502–1505. women. J Urol 1995;154:2044–2049.
6. Kolettis PN , Klein EA, N ovick AC, et al. The Le Bag orthotopic urinary 15. Thüroff JW, Alken P, Riedmiller H , et al. The M AIN Z pouch (mixed aug-
diversion. J Urol 1996;156:926–930. mentation ileum and cecum) for bladder augmentation and continent di-
7. Leissner J, Stein R, H ohenfellner R, et al. Radical cystoprostatectomy com- version. J Urol 1986;136:17–26.
bined with M ainz pouch bladder substitution to the urethra: long-term 16. Thüroff JW, M attiasson A, Andersen JT, et al. Standardization of terminol-
results. BJU Int 1999;83:964–970. ogy and assessment of functional characteristics of intestinal urinary reser-
8. Light JK, Engelmann UH . Le Bag: total replacement of the bladder using voirs. N eurourol Urodyn 1996;15:499–511.
an ileocolonic pouch. J Urol 1986;136:27–31. 17. Turner W, Danuser H , M oehrle K, et al. The effect of nerve sparing cystec-
9. Linn JF, H ohenfellner M , Roth S, et al. Treatment of intersitial cystitis: tomy technique on postoperative continence after orthotopic bladder sub-
comparison of subtrigonal and supratrigonal cystectomy combined with stitution. J Urol 1997;158(6):2118–2122.
orthotopic bladder substitution. J Urol 1998;159:774–778.
CHAPTER 91 ■ CO NTINENT CATHETERIZABLE

RESERVO IR MADE FRO M ILEUM
HASSAN ABO L-ENEIN AND MO HAMED A. GHO NEIM
A substantial number of techniques have been described for appendix (10), fallopian tubes (12), parts of ileum (13), or
the creation of continent cutaneous urinary reservoirs. For tubularized cecal segments (9). M ultiplicity of techniques im-
construction of such systems three elements are required: a plies that none is optimal. M any of the above techniques rely
low-pressure compliant reservoir, an antirefluxive ureteroin- on an inert or even unphysiologic mechanism, and problems
testinal anastomosis, and a continent stoma that allows easy and malfunctions soon appear.
catheterization. In our proposed technique, we have utilized the ileum for
To create a reservoir with high capacity at low pressure, construction of the low-pressure reservoir and a serous-lined
various segments of bowel have been utilized: the ileum, the tunnel to provide an antirefluxive mechanism (1) as well as to
ileocolonic region, the ascending colon, and the transverse create a reliable continent outlet (2).
colon. Regardless of the selected bowel segment, detubulariza-
tion and double folding are basic prerequisites to achieve this
goal.
A reliable antirefluxive ureterointestinal anastomosis is nec- INDICATIO NS FO R SURGERY
essary, since bacteriuria is a constant feature in these systems
Any patient who requires bladder replacement is a potential
and results from intermittent catheterization. The technique
candidate for this operation. The indications of continent cu-
employed should provide a unidirectional but nonobstructed
taneous urinary diversion include the following:
flow. The antirefluxing mechanism should not be at the ex-
pense of a higher incidence of obstructive complications. 1. Pelvic malignancies: In patients for whom cystectomy is
H inman (7) classified continent outlets into four categories indicated for bladder cancer or those requiring an anterior
according to the mechanism of their action. These included an pelvic exenteration for other pelvic malignancies.
antiperistaltic ileal segment (6); imbricated or tapered ileal 2. Benign indications: These include neuropathic bladders
segments resulting in passive tubular resistance (11); outlets when conservative measures fail, extensive urethral stric-
using the pressure equilibration principle, including an ileal tures with damaged urethral sphincter, contracted blad-
spout valve (3), flutter valve (4), inkwell hydraulic valve, in- ders with compromised urinary continence, complex
tussusception nipple (5), or ileal servomechanism sphincter urinary fistulas affecting the sphincteric mechanism, and
(8); and flap valves, which are created by the incorporation of some cases of bladder exstrophy with failed attempts of
tubular structures within the wall of the reservoir, such as the primary repair.
Chap t e r 91: Contine nt Cathe te rizab le Re se rvoir Mad e from Ile um 595
3. Urinary conversion: Conversion from other types of uri- ation of the abdominal muscles, facilitate retraction, and
nary diversion, such as ileal conduits in young healthy provide wider exposure. If total urethrectomy is planned, the
patients, for patients who develop isolated urethral recur- patient is put in a slight lithotomy position for access to the
rence following radical cystectomy and orthotopic bladder perineum. The surgical area to be sterilized and draped ex-
substitution, and in some cases of ureterosigmoidostomy tends from the lower chest down to the upper thighs.
suffering from intractable metabolic acidosis. A midline incision from the pubis inferiorly to a point
halfway between the umbilicus and xyphoid process of the
sternum superiorly is generally employed. The incision is en-
circling the umbilicus by 2 to 3 cm to the left.
PATIENT SELECTIO N AND The bowel is examined, and a 60-cm-long segment of
EVALUATIO N the terminal ileum is isolated. Backlight transillumination
of the mesenteric attachment greatly helps the identification
Suitable candidates should have reasonable manual dexterity. of the arterial arcades supplying the selected segments. The
M otivation to carry out clean intermittent catheterization at bowel is divided 15 to 20 cm proximal to the cecum in the
regular intervals is necessary. Furthermore, a good prognosis avascular window of Treves between the ileocolic artery and
might be expected if the indication to diversion was a pelvic the terminal branch of the superior mesenteric artery. The
malignancy. Patients who are unfit for prolonged surgery and ileum is divided proximally in a suitable avascular plane be-
those with a history of previous bowel resection, short bowel tween the superior mesenteric arcades. Continuity of the
syndrome, or heavily irradiated bowel are among the con- bowel is re-established by end-to-end anastomosis. The use of
traindications for this procedure. Patients with impaired an automatic stapler or a hand-sewn technique is a matter of
renal function (serum creatinine equal to or 1.8 mg per dL surgeon’s preference. The isolated bowel segment is subse-
and or creatinine clearance equal to or 40 mL per minute) quently subdivided into three parts. The middle 40-cm seg-
are unsuitable candidates since metabolic acidosis would be ment is used for construction of the reservoir, the 10-cm oral
inevitable. segment is used for creation of the antireflux mechanism, and
the distal 10-cm caudal segment is used for creation of the
outlet valve (Fig. 91.1). Great attention is paid to preserving
an adequate blood supply for the oral and caudal small
ALTERNATIVE THERAPY bowel segments.
The middle segment is arranged in a W configuration, and
Alternative techniques of urinary diversion should be discussed its antimesenteric border is incised by a diathermy knife. The
with the patient when orthotopic bladder substitution or con- edges of the two medial flaps are joined by a single layer of
tinent cutaneous reservoirs are contraindicated or unfeasible. continuous 3-0 polyglactin sutures. The two lateral limbs are
These include conduit diversion and anal sphincter–controlled left to serve as serous-lined troughs. The oral and caudal short
bladder substitutes. The potential postoperative complications,
changes in future lifestyle, and long-term sequelae should be
clearly explained to the patients.
SURGICAL TECHNIQ UE
Pre o p e rat ive Pre p arat io n
Since the small bowel is utilized, no specific preparation is
necessary. The only requirement is fasting overnight with ad-
ministration of intravenous fluids to ensure good hydration.
Patients with histories of thromboembolic disease or vari-
cose veins should receive a prophylactic dose of heparin
(5,000 U subcutaneously) the night before the operation and
every 12 hours thereafter until ambulation. Compression leg
stockings are also advised. Although the intention is to use a
concealed umbilical stoma, a stoma therapist should exam-
ine the patient and determine a suitable site for an abdomi-
nal stoma. A parenteral broad-spectrum antibiotic is given
just before induction of anesthesia and continued postopera-
tively for 3 days.
FIGURE 91.1 A 60-cm-long ileal segment is isolated; the 40-cm mid-

O p e rat ive Te chniq ue dle segment is arranged in a W configuration and used for construc-
tion of the body of the reservoir, the 10-cm oral segment is used for
The patient is put in the supine position with a Trendelenberg the antireflux mechanism, and the caudal segment is used for the out-
tilt. Slight flexion of the knees will further help in the relax- let valve.
FIGURE 91.2 The bowel segment is incised at the antimesenteric bor-

der. The medial flaps are approximated with continuous 3-0
polyglactin sutures. The oral and caudal segments are tapered around
a 20Fr catheter. The proximal one-third of the inlet segment is kept
untapered. The created mesenteric windows are marked by a strip of
vessel loops.
FIGURE 91.3 The tapered ileal seg-
ments are fixed and embedded within
the serous-lined extramural troughs.
The bulky mesentery of the embedded
segments are tapered around a 22Fr catheter. Bowel tapering segments is excluded behind the
could be performed either by simple excision and hand-sewn pouch.
technique or by using a one-step technique with an automatic
gastrointestinal stapler. The proximal one-third of the inlet
segment is kept untapered for ureteral anastomosis. Three to
four small mesenteric windows close to the mesenteric border
are created in between the arterial arcades supplying these seg-
ments. Each mesenteric window is marked by a small strip of
rubber vessel loop. This step will facilitate easy passage of su-
tures through the mesenteric window (Fig. 91.2).
Each tapered segment is inlaid in its corresponding serous-
lined trough. The two adjacent limbs of each trough are ap-
proximated using 3-0 silk seromuscular suture passing
through the mesenteric windows and guided by the inserted
strips of vessel loops. The tapered ileal segments are fixed and
embedded within the serous-lined extramural troughs. Thus,
the bulky mesentery of the embedded segments is excluded be-
hind the pouch (Fig. 91.3). The spatulated distal ends of the
tapered segments are anastomosed to the tunnel flaps, and the
ileal trough is closed in front of the embedded segment using
interrupted 4-0 polyglactin sutures (Fig. 91.4).
Two soft siliconized 8Fr to 10Fr stents are threaded
through the inlet segment and secured in place by 4-0 chromic
gut sutures. The pouch plate is then closed by approximation
of the most lateral ileal flaps anteriorly and to the shoulder
flap between the inlet and outlet segments (Fig. 91.5).
The skin of the umbilical funnel is raised and separated from
the underlying rectus fascia in the midline. A fascial cruciate in-
FIGURE 91.4 The spatulated distal ends of the tapered segments are
cision is made that can admit a 20Fr to 24Fr catheter. The anastomosed to the tunnel flaps, and the ileal trough is closed in front
invaginated umbilical skin funnel is identified and a suitable of the embedded segment using interrupted 4-0 polyglactin sutures.
button hole is excised. The distal end of the outlet segment is Two siliconized stents are threaded through the inlet segment.
Chap t e r 91: Contine nt Cathe te rizab le Re se rvoir Mad e from Ile um 597
The reservoir is drained by an 18Fr to 20Fr Foley balloon

siliconized catheter fixed through the stoma.
Both ureters are prepared and oriented toward the inlet
segment according to the final position of the pouch. The left
ureter is passed from left to right through a high, wide
enough mesenteric hole created in the left mesocolon. The
right ureter comes from right to left in front of the common
iliac artery behind the mesentery of the pouch. Tension-free,
widely spatulated, stented implantation of the ureters into the
inlet segment is then performed. A Wallace, N esbit, or end-to-
end anastomosis could be utilized according to surgical needs,
using 4-0 or 5-0 polyglactin sutures.
The ureteral stents are exteriorized through the anterior
wall of the reservoir to which they are secured. This will pro-
vide almost a dry reservoir during the healing stage.
The pelvic cavity is drained by two 18Fr fenestrated
tubes. O nly straight gravity drainage is used. Gastric
drainage is established using either a nasogastric tube or
open gastrostomy.
FIGURE 91.5 The pouch plate is closed by approximation of the

most lateral ileal flaps anteriorly and to the shoulder flap between the
inlet and outlet segments.
An Alt e rnat ive : Ut ilizat io n
o f t he Ap p e nd ix
If the appendix is suitable to serve as an outlet, the ileocecal
junction is mobilized sufficiently to ensure a tension-free im-
plantation of the appendix. The appendix is mobilized and de-
tached at its base. The isolated appendix is cut and spatulated
at its tip. The lumen is then dilated up to 16Fr to 18Fr using
straight dilators. Four windows are created in the mesoappen-
dix. The windows are labeled by rubber vessel loops. The ap-
pendix is embedded in the serous-lined trough as described
previously (Fig 91.7).
FIGURE 91.6 The edge of the outlet is fixed to the edge of the umbil-
ical skin funnel using interrupted sutures including the rectus fascia.
pulled through the rectus fascia aperture. The edge of the in-
testinal outlet is fixed to the edge of the umbilical skin funnel
using interrupted monofilament 4-0 or 3-0 monocryl sutures
including the rectus fascia (Fig. 91.6).
The body of the reservoir wall around the outlet segment
is then fixed to the inner aspect of the abdominal wall.
Attention is paid to avoid twisting and/or angulation of the FIGURE 91.7 The appendix is isolated and spatulated at its tip. Four
outlet segment. This would avoid difficulties in catheteriza- windows are created at the mesoappendix. The appendix is fixed and
tion later. embedded in the serous-lined trough as previously described.
stenotic area using a wedge skin flap technique. In one child it

PO STO PERATIVE CARE was impossible to pass a catheter into the pouch due to
overdistention resulting in angulations of the outlet tract.
Parenteral fluids are maintained until bowel habit resumes. Under ultrasound guidance, percutaneous insertion of a pig-
Prophylactic antibiotics are given routinely for 5 days. Low- tail catheter was carried out. O nce the pouch became empty,
molecular-weight heparin is given for 10 days. The draining outlet catheterization again was easy. Rupture of the pouch
tubes are removed when the drainage ceases. The reservoir is was observed in one patient following blunt abdominal
irrigated with 30 to 60 mL of normal saline every 8 hours to trauma. Laparotomy was necessary, and the pouch tear was
prevent mucus retention. The ureteric stents are removed after adequately repaired. Pouch stones were observed in 5% of the
10 to 12 days postoperatively. The pouch is drained for patients. All of them were amenable for endoscopic manipula-
21 days before training by intermittent catheter clamping. tions, but one patient required open pouchlithotomy. The inci-
All patients start self-catheterization 2 days before discharge dence of upper-tract dilatation due to anastomotic stricture
from the hospital. A 2-hour interval is allowed in week 1, was minimal (1% ); the stricture was treated by antegrade bal-
which is increased gradually until the pouch matures. By the loon dilatation. O ne patient required left nephrouretectomy
end of week 6 most of the patients evacuate the pouch every 3 years following cystectomy due to a renal pelvis tumor.
4 to 5 hours. Gravity pouchography demonstrated reflux in three patients
(3% ). Reflux was asymptomatic in all, and the patients were
kept on prophylactic antimicrobial suppressive therapy. N one
O UTCO MES of the operated patients developed metabolic acidosis. All
patients were advised to use oral alkali therapy.
Co mp licat io ns
In our experience with 101 patients, early complications were Re sult s
observed in 15% . These included urinary leakage (2% ), pelvic
collections (8% ), ureteroileal obstruction (1% ), ileus (3% ), Patients regained their normal lifestyle once healing was
and wound complications (3% ). Small nonsymptomatic pelvic completed. N inety-five percent of our patients were com-
collections need no treatment. Sizable and/or infected sympto- pletely dry day and night. The catheterization interval was
matic ones are usually treated by ultrasound-guided needle as- every 4 to 5 hours during daytime and every 1 to 2 hours at
piration with or without an indwelling tube drain. N one of night. The average capacity at 6 months postoperatively was
these pelvic collections required open drainage. Urinary leak- 550 130 mL.
age was an infrequent complication in our series (2% ). This Five patients (5% ) had a frequently wet stoma due to failure
complication was due to pouch perforation during catheteri- of the continence mechanism. Two patients were revised. O ne
zation training. Prolonged pouch drainage was required for an underwent revision of the continent outlet, and augmentation
additional 2 weeks until healing of the injury occurred. Early ileopouchoplasty was required to increase pouch capacity in
evidence of ureteroileal obstruction was observed in one the other. Two patients preferred frequent catheterization to
patient. Antegrade fixation of a double-J stent was done for avoid leakage. The remaining patient fixed a collection device
6 weeks. The stent was removed by pouchoscopy carried out during nighttime and refused further intervention.
through the umbilical stoma. Gastrointestinal and wound Patients have to understand that they have a neobladder
complications were similar to those for other urinary diver- constructed from the bowel and that this bladder is different
sion procedures. from the native one. The usual desire to micturate and the
Late complications included stomal stenosis at the skin familiar micturition mechanism no longer exist. H owever, all
level with catheterization difficulties in 6% of the patients. Two- patients with a dry, continent outlet stoma enjoy an excellent
thirds of them had an appendix stoma. H alf of these patients lifestyle, normal social activities, an accepted body image, and
required revisional surgery to widen the mucocutaneous personal satisfaction.
References
1. Abol-Enein H , Ghoneim M A. A novel uretero-ileal reimplantation tech- 8. Koff AS, Cerulli C, Wise H A. Clinical and urodynamic features of a new
nique: the serous lined extramural tunnel. A preliminary report. J Urol intestinal urinary sphincter for continent urinary diversion. J Urol
1994;151:1193–1197. 1989;142:293–296.
2. Abol-Enein H , Ghoneim M A. Serous-lined extramural ileal valve: a new 9. Lample A, H ohenfellner M , Schultz-Lample D, et al. In situ tunneled bowel
continent urinary outlet. J Urol 1999;161:786–791. flap tubes: 2 new techniques of a continent outlet for M ainz Pouch cuta-
3. Ashken M H . An appliance free ileocecal urinary diversion: preliminary neous diversion. J Urol 1995;153:308–315.
communication. Br J Urol 1974;46:631–634. 10. M itrofanoff P. Cystostomie continente trans-appendicularie dans la traite-
4. Askhen M H . Urinary reservoirs. In: Urinary diversion. Berlin: Springer- ment des vessies neurologiques. Chir Pediatr 1980;21:297–300.
Verlag, 1982:112. 11. Rowland RG, M itchell M E, Bihrle R. The cecoileal continent urinary reser-
5. Benchekroun A. Continent caecal bladder. Eur Urol 1987;3:248–251. voir. World J Urol 1985;3:185–190.
6. Gilchrist RR, M erricks JW, H amlin H H , et al. Construction of a substitute 12. Woodhouse CRJ, M alone PR, Cummning J, et al. The M itrofanoff princi-
for bladder and urethra. Surg G ynecol O bstet 1950;90:752–760. ple for continent urinary diversion. Br J Urol 1989;63:53–57.
7. H inman F Jr. Functional classification of conduits for continent diversion. 13. Z inman L, Libertino JA. Ileocecal conduit for temporary or permanent uri-
J Urol 1990;44:27–30. nary diversion. J Urol 1975;113:317–323.
CHAPTER 92 ■ CO NTINENT CATHETERIZABLE
RESERVO IR MADE FRO M CO LO N
HUBERTUS RIEDMILLER AND ELMAR W. GERHARZ
O ver the past 15 years there has been an increasing interest in fistulas, continent cutaneous reservoirs provide excellent re-
alternatives to the Bricker ileal conduit as a form of urinary sults even in extremely complex cases.
diversion. A wide range of techniques are currently available, Until recently, renal transplant patients were excluded from
including orthotopic bladder substitution and continent cuta- the benefits of continent urinary diversion. Several authors
neous and rectal bladder diversion. The current body of pub- have, however, reported encouraging experiences with kidney
lished literature is insufficient to conclude that there is a transplantation into continent urinary intestinal reservoirs as
superior form of urinary diversion in terms of evidence-based a planned two-stage procedure in patients with functional or
medicine. It is quite clear, however, that not all patients are morphologic bladder loss (see below) (9).
candidates for one type of diversion. The best results are ob- O ther factors to consider when deciding on the type of uri-
tained when a comprehensive concept is tailored to the indi- nary diversion include patient age, prognosis of underlying dis-
vidual patient at a high-volume center with experience in all ease, comorbidity, urinary and anal sphincter competence,
major types of diversion techniques (4). manual dexterity, renal function and upper-urinary-tract con-
figuration, and subjective criteria (motivation, compliance, ex-
pectation of social support, emotional capability of dealing with
DIAGNO SIS clean intermittent catheterization). Patient priorities are consid-
ered whenever medically justifiable and technically feasible.
The most common indication for continent cutaneous diver- Contraindications of continent urinary diversion include
sion is a bladder replacement after anterior pelvic exenteration impaired renal function with serum creatinine 2 mg per L,
for malignant disease, followed by functional or morphologic inflammatory bowel disease, large bowel malignancy, or pre-
bladder loss for other reasons. Diagnostic modalities therefore vious history of multiple bowel ablative procedures, with or
should be directed at the underlying pathology and definitive without a history of diarrhea.
treatment.
ALTERNATIVE THERAPY
Alternatives to catheterizable colonic reservoirs include
Despite the recent trend toward orthotopic substitution, conti- pouches made from ileum (Kock), ileal or colonic conduits,
nent catheterizable urinary reservoirs remain a good form of classic and modified ureterosigmoidostomy (e.g., sigma-
diversion. Whereas previous or synchronous urethral transi- rectum pouch/M ainz pouch II), or orthotopic neobladder
tional cell carcinoma (TCC) is an absolute contraindication to (Camey II, Kock, H autmann, Studer).
urethral preservation, the role of multifocality, associated car-
cinoma in situ and of bladder neck and prostatic involvement
on urethral recurrence is less well defined. In these cases, con- SURGICAL TECHNIQ UE
tinent cutaneous diversion is still a safe alternative in the
appropriate patient. While there is a broad consensus among reconstructive urolo-
Advanced age ( 70 years) with its physiologic deteriora- gists regarding detubularization and spheric reconfiguration
tion of sphincter competence is another relative contraindica- of bowel as a basic principle in the creation of a low-pressure,
tion for orthotopic reconstruction; older patients who are high-capacity reservoir, the issues of reflux prevention (affer-
otherwise physically fit may well benefit from a continent cu- ent limb) and continence (efferent limb) are more controver-
taneous reservoir. sial. The still-growing number of techniques described for
Whenever the native sphincter mechanism is lacking, de- achieving continence in urinary reconstruction indicates that a
stroyed, or dysfunctional or urethral catheterization is painful universally applicable procedure with a low complication rate
or technically impossible, cutaneous diversion is the only has not yet evolved. The principal methods for construction of
alternative to modified ureterosigmoidostomy and ileal loop. a continence mechanism depend on the formation of a nipple
As a salvage procedure in failed exstrophy reconstruction, in valve, utilization of the ileocecal valve, or construction of a
other complicated congenital abnormalities of the urinary flap valve. Among the different techniques, the versatile
tract, in neurogenic bladder dysfunction (wheelchair-bound M itrofanoff principle (6) has acquired significant popularity,
myelomeningocele patients), and in patients with intractable predictably providing continence and allowing easy catheteri-
urinary incontinence, severe pelvic traumas, and complicated zation in 90% of cases. In 1990, Riedmiller et al. introduced
599
the M itrofanoff theme to the ileocecal reservoir, significantly of distal ileum. If the vermiform appendix is absent, as in cloa-
facilitating the M ainz pouch procedure (8,12). cal exstrophy, completely obliterated, immobile, insufficient in
When performing a M itrofanoff, the method of attaching diameter and length, or has been removed beforehand, we
the appendix to the reservoir (reversed, in situ: imbricated, em- usually isolate an additional portion of ileum measuring 8 to
bedded, unaltered), the location of the stoma (umbilicus, lower 10 cm (Fig. 92.1A). While the latter is left tubularized, the re-
abdomen), and appropriate alternatives are controversial. It is maining bowel segment is split antimesenterically. These three
known that the success of the M itrofanoff principle is not de- opened bowel loops are folded in the form of an incomplete
pendent upon the underlying pathologic condition, the type of W, and their posterior aspects are sutured to one another to
tube and its possible peristalsis, the type and configuration of form a broad posterior plate (Fig. 92.1B). Both ureters are im-
the reservoir, or the patient’s age, but rather on the mainte- planted into the large bowel segment of the pouch plate, form-
nance of a pressure gradient between channel lumen and the ing submucosal tunnels for reflux prevention (Fig. 92.1C).
reservoir. It is therefore the availability of the required material The midportion of the intact ileal segment is freed of its
and the simplicity of a technique that determine its popularity. mesentery up to a distance of 4 to 5 cm to allow its intussus-
Recent variations of the M itrofanoff theme have aimed at its ception (Fig. 92.1D and E). O ne row of staples is applied to
simplification and at reduction of long-term complications. stabilize the intussusception itself (Fig. 92.1F). Thereafter, the
intussuscepted nipple is pulled through the intact ileocecal
valve and two additional rows of staples are applied to attach
Ile o ce cal Po uch (Mainz Po uch I) the nipple to the ileocecal valve. After the mucosa has been re-
moved from the rim of the intussuscepted nipple and the
Int ussusce p t e d Ile al Nip p le colonic aspect of the ileocecal valve, their circumferences are
After mobilization of cecum, ascending colon, and the right sewn together with a running suture.
colonic flexure, the mesentery is divided between the right The bowel is then folded on itself in a side-to-side fashion,
colic and the ileocolic arteries. A 13-cm segment of cecum and thus creating a low-pressure, high-capacity reservoir. Ureteral
ascending colon is isolated along with two equal-sized limbs stents (6Fr or 8Fr) and a 10Fr pouchostomy are led through
FIGURE 92.1 Ileocecal pouch (M ainz pouch I) with intussuscepted

ileal nipple valve. A: Isolation of cecum or ascending colon (13 to 15 cm),
two equal-sized ileal loops (13 cm each) for reservoir formation, and
an additional ileal segment (8 to 10 cm) for nipple formation.
Antimesenteric splitting of the bowel. B: Side-to-side anastomosis of
the terminal and next proximal ileal loop with subsequent detubular-
ization of the ascending colon. C: Antirefluxing ureteral implantation
into the colonic portion of the pouch plate using submucosal tunnels
(3 cm length) and insertion of 6Fr ureteral stents.
B (continued on nex t page)
Chap t e r 92: Contine nt Cathe te rizab le Re se rvoir Mad e from Colon 601
FIGURE 92.1 (continued) D: Removal of mesentery

(4 to 5 cm) in the midportion of the oral ileal segment
in preparation for intussusception. E: Intussusception
of the ileal segment and stabilization by applying one
row of staples. F: The intussuscepted ileal nipple is
pulled through the ileocecal valve and two additional
rows of staples are used to attach the nipple to the valve.
F (From Thieme Stuttgart, N ew York, with permission.)
the abdominal wall at separate sites. The entire pouch is excessive fatty tissue. Windows in the mesoappendix are ex-
rotated to bring the efferent limb to the region of the umbilicus. cised between the branches of the appendicular artery without
A small button of skin is removed from the depth of the um- compromising the blood supply (Fig. 92.2B). Anatomic varia-
bilical funnel. The pouch is carefully attached to the posterior tions of the appendicular artery have to be respected, and an
fascia with interrupted nonabsorbable sutures to prevent the additional branch of the anterior or posterior cecal artery sup-
pouch from rotating and kinking. The efferent limb is then plying the base of the appendix should be preserved. After the
connected to the umbilical funnel with interrupted absorbable appendix is correctly positioned, the seromuscular layer is
sutures. In the absence of an umbilicus (as in the case of closed over the embedded in situ appendix with interrupted 4-0
exstrophy), it is created by tubularizing a V-shaped cutaneous polydioxanone sutures. A short mobile portion of the distal
flap and connecting it to the appendicular stump (12). appendix remains for the creation of the appendicoumbilical
A vigorous washout regimen is started early in the postop- stoma (Fig. 92.2C). Formation of the pouch plate, the
erative course. Ureteric stents are removed after 10 to 14 days. ureterointestinal anastomosis, and the attachment to the um-
Clean intermittent catheterization is usually started at the end bilicus follows the same procedure as that for a pouch with an
of the third postoperative week after leakage and reflux have intussuscepted nipple (8).
been ruled out by pouchogram.
Alt e rnat ive Te chniq ue s fo r Co nst ruct io n
Ap p e nd ix St o ma o f Co nt ine nce Me chanism
If the appendix is present and can be dilated to accommodate M ore recent alternative techniques use a small-caliber conduit
a 16Fr to 18Fr catheter, it is ideally our first choice as the fashioned from the cecal wall. O ne technique uses a full-thick-
efferent segment for construction of a continence mechanism. ness tube lined by mucosa (Fig. 92.3) and the other a seromus-
In this case, a 15-cm segment of cecum and ascending colon is cular tube lined by serosa (Fig. 92.4) (5). O ther authors have
isolated along with two equally sized limbs of distal ileum described transversely retubularized ileum (Fig. 92.5) to create
(12 to 13 cm each). The lower 5 cm of the cecum (cecal pole) a tunneled access into the right colon (7).
is left tubularized and intact. The seromuscular layer of the
intact cecal pole is divided along the tenia down to the mucosa Alt e rnat ive Te chniq ue s fo r Ure t e ral Imp lant at io n
in a manner analogous to the Lich-Gregoir procedure for vesi- In dilated, irradiated, or otherwise compromised ureters,
coureteral reflux (Fig. 92.2A). By careful dissection of the ureterointestinal anastomosis may be performed according to
seromuscular tissue, a broad submucosal bed (5 cm) is created a technique that has been described by Abol Enein and
for the appendix. The appendicular mesentery is freed of its Ghoneim (serous-lined extramural tunnel) (Fig. 92.6) (1).
FIGURE 92.2 Ileocecal pouch (M ainz pouch I) with appendix stoma. A: Seromuscular layer
of the intact cecal pole is split along the tenia down to the mucosa, and a broad submucosal
bed (5 cm in length) for the appendix is created. B: Windows in the mesoappendix are
excised between the branches of the appendicular artery without compromising the blood
supply. C: After the appendix is correctly positioned, the seromuscular layer is closed over
A the embedded in situ appendix. (From Thieme Stuttgart, N ew York, with permission.)
A B
FIGURE 92.3 Full-thickness bowel flap tube. A: U-shaped incision (3 6 cm) of all layers of bowel wall,
resulting in pedicled bowel flap at lower pole of cecum. B: Tubularization of pedicled flap over 18Fr
Foley catheter and incision of seromuscularis of tenia omentalis (5 cm) for submucosal embedding, start-
ing at pedicle of bowel flap tube. (From Thieme Stuttgart, N ew York, with permission.)
valve area is plicated with five to seven Lembert stitches of 3-0

Rig ht Co lo n Po uche s w it h Int ussusce p t e d silk suture (Fig. 92.8C). Care is taken to avoid having the su-
o r Tap e re d Te rminal Ile um tures enter the lumen of the bowel. Each Lembert suture is
progressively wider than the last. This has the effect of nar-
Several other authors use the ileocecal region in continent rowing the ileocecal valve by wrapping cecal wall over the an-
cutaneous urinary diversion. In contrast to the M ainz tech- gled staple line. The tightness of the plication sutures is tested
nique, they employ the ileum for construction of the conti- by passing an 18Fr catheter through the efferent limb. O nce the
nence mechanism but not for creation of the reservoir itself. efferent limb and continence mechanism have been completed
O ther colon pouches using nipple valve configuration for the and a M alecot catheter has been placed as a cecostomy tube in
continence mechanism include modifications from many other the dependent portion of the cecum, the reservoir is closed.
centers and differ from one another by only a few features, Both ureters are led in such a manner as to allow alignment
predominantly related to the technique employed for stabiliz- with a tenia. A tenial incision is made for each ureter. The ureter
ing the nipple valve. For example, in the “ Tiflis” technique, is cut obliquely or spatulated, and the site for the ureteral ori-
the continence mechanism is created by tapering and submu- fice is created by incising the bowel mucosa. The ureteromu-
cosally embedding the terminal ileum (Fig. 92.7) (2). cosal anastomosis is performed with interrupted sutures of 5-0
synthetic absorbable monofile material. The tenia is reapprox-
imated over the ureter with a nonabsorbable 5-0 suture.
Ind iana Po uch
Between 25 and 30 cm of cecum and ascending colon and 8 to Co lo n Po uch (Mainz Po uch III)
10 cm of terminal ileum are isolated (10). The entire colonic
segment will be detubularized by incising it along its antime- Between 15 and 17 cm of transverse colon and either ascend-
senteric surface. If an appendix is present, it is removed at this ing [transverse-ascending pouch (TAP)] or descending colon
time. Reconfiguration of the opened bowel segment by folding [transverse-descending pouch (TDP)] (Fig. 92.9A) are re-
the cephalad end down to the apex of the antimesenteric inci- quired to create a pouch of adequate capacity (350 to 400 mL).
sion allows the creation of a spheric reservoir (Fig. 92.8A). Complete mobilization of the right or left colic flexure should
For construction of the efferent limb and continence mecha- be performed to gain adequate colon length for the pouch.
nism, metal staples are applied sequentially to narrow the ef- The greater omentum is dissected from the transverse colon
ferent limb over a 12Fr straight catheter (Fig. 92.8B). Any from right to left in the TAP and vice versa in the TDP.
excess antimesenteric ileum is then removed. The last row of The bowel segment is detubularized antimesenterically, leav-
staples is placed at an angle to prevent stapling into the wall of ing 5 to 6 cm of the oral or aboral end intact for construction
the cecum. After narrowing the efferent limb, the ileocecal of the efferent limb. The terminal segment is tapered over a
A B
FIGURE 92.4 Seromuscular bowel flap tube. A: U-shaped incision

(3 5 cm) of seromuscular layer at lower pole of cecum and trans-
verse incision of mucosa (0.5 cm) at the oral end of flap for insertion
of 18Fr Foley catheter into lumen of reservoir. B: Tubularization of
seromuscular bowel flap over 18Fr Foley catheter. C: Suturing of ante-
rior circumference of seromuscular tube to margin of mucosa (inset).
C (From Thieme Stuttgart, N ew York, with permission.)
18Fr silicone catheter, thus creating a neoappendix (Fig. 10Fr pouchostomy are led through the abdominal wall at sep-
92.9B). The mucosa is sewn with polyglycol suture and the arate sites.
seromuscular layer with a nonabsorbable running suture. Easy The pouch is closed and the efferent segment is established.
insertion of the catheter is important, as a shrinkage of ap- Windows are dissected in the mesentery of the tapered colon
proximately 30% has to be allowed for. After the pouch plate between the vessels. The efferent limb is then placed in the
is created, antirefluxing ureterointestinal implantation accord- suture line, and the seromuscular layer of the anterior wall is
ing to Goodwin is performed on both sides of the suture line approximated through the windows in the mesentery (Fig.
(Fig. 92.9C). For refluxing ureteral implantation, about 1 cm 2 92.9D). O ur favorite technique comprises isolation of a short
of the bowel mucosa is excised and the seromuscular layer is segment of jejunum or ileum, which is tapered over a 18Fr
incised in the shape of a cross. After anchor sutures at the 5 Foley catheter and embedded submucosally after incising the
and 7 o’clock positions are placed, a watertight anastomosis tenia of a tubularized portion of the colonic segment. Sutures
with 5-0 M onocryl sutures is performed. Ureteral stents and a are led through windows in the ileal mesentery (Fig. 92.10).
FIGURE 92.5 Yang-M onti technique. A: An ileal segment 2.0 to 2.5 cm

long is excised and opened longitudinally about 1 cm from mesentery.
B: The resulting pedicled rectangle (2 6 to 7 cm). C:
Retubularization in transverse direction using interrupted sutures (4-0
chromic catgut or 5-0 polydioxanone), resulting in a small-caliber
tube (neoappendix) that is divided by mesentery into a short branch
(stoma formation, anastomosis with umbilical funnel) and long
branch (for submucosal embedding). (From Thieme Stuttgart, N ew
York, with permission.)
A B
C D
The umbilicointestinal anastomosis is performed in the depending on the length of follow-up. Although stenosis rep-
same fashion as in the ileocecal pouch. Finally, the reservoir is resents a minor technical problem, the subsequent inability to
attached to the abdominal wall. The greater omentum is used insert the catheter is a distressing complication with poten-
to cover pouch and bowel. Ureteric stents are removed after tially serious consequences in patients in whom the
10 to 14 days. Clean intermittent catheterization is started 3 M itrofanoff channel is the only route of evacuation. In these
weeks postoperatively (11). cases the reservoir must be immediately emptied percuta-
neously, which is facilitated by fixation of the pouch to the
abdominal wall.
CO MPLICATIO NS Skin stenosis may be dilated, incised, or repaired by
open surgery, carefully removing fibrotic tissue. According
While continence using the appendix, once established, is to our experience, dilatation alone seldom produces a last-
durable with late-onset failure of 1% to 2% at about 4 years, ing improvement. We therefore tend to intervene early.
stomal stenosis is seen in between 8% to 28% of patients, Although revisions are usually successful, prevention of
FIGURE 92.6 Ileocecal pouch (M ainz pouch I) with serous-lined

implantation of ureters. A: In contrast to the original technique,
the pouch plate is not created by anastomosing the edges of
detubularized bowel segments, but by creating two serous-lined
extramural troughs. B: The ureters are placed into the serous-lined
tunnels and covered by approximating the margins of the detubu-
B larization. (From Thieme Stuttgart, N ew York, with permission.)
stenosis is desirable. Stomal stenosis can be avoided by in- unphysiologic exposure of the reconfigured bowel to urine.
corporation of a V-shaped flap of umbilical funnel into the Factors that affect solute absorption include the size and
spatulated appendix. To prevent recurrence, we have devel- segment of bowel used, the time of retention of urine, the con-
oped a cone-shaped metal dilator. Its effective length was centration of the solutes in the urine, renal function, and the
designed to cover only the known critical segment of the pH and osmolality of the fluid (3).
channel. Directly before inserting the catheter for evacua- The most common consequence of intestinal urinary diver-
tion of the reservoir, the stoma is gently dilated for a few sion is metabolic acidosis. Depending on definition, diagnostic
minutes once or twice daily. A similar effect might be pro- modality, reservoir characteristics, renal function, and length
duced by occasionally leaving the catheter in the pouch at of follow-up, it has been reported in 20% to 100% of patients
night. after ureterosigmoidostomy, bladder substitution, and conti-
M etabolic complications are due to either reduction of the nent diversion using ileal and/or colonic segments. There is no
absorptive bowel capacity through functional loss of those proven effect on either bone absorption or childhood growth
segments required for reservoir construction or the highly and development.
A B
FIGURE 92.7 Tiflis pouch. A: Tapering of terminal ileum over a 18Fr Foley catheter with removal of ex-
cessive bowel wall. B: Incision of seromuscular layers of the cecum adjacent to the terminal ileum in
preparation for submucosal embedding. (From Thieme Stuttgart, N ew York, with permission.)
A C
FIGURE 92.8 Indiana pouch. A: The cephalad end of the detubularized right colon segment is folded
caudally to the apex of the antimesenteric incision. A M alecot catheter is placed in the dependent portion
of the cecum prior to closing the reservoir. B: A stapler is used to trim away the excess bowel wall of the
ileal segment (tapering). C: A total of five to seven Lembert sutures are placed to plicate the ileocecal
valve.
A B
C D
FIGURE 92.9 Colon pouch (M ainz pouch III) with tapered colon as efferent limb. A: About 15 to 17 cm of nonirradi-
ated large bowel is isolated for reservoir creation. The oral end with a Foley catheter is used for construction of the
efferent limb. B: The colonic segment is detubularized and the pouch plate is formed. The oral end is tapered over an
18Fr Foley catheter and windows are made in the mesentery. C: The ureters are attached to the posterior pouch
wall through a submucosal tunnel. D: Pouch formation is completed by closing the anterior wall. The efferent segment
is embedded serosa-to-serosa by sutures led through mesenteric windows. (From Thieme Stuttgart, N ew York, with
permission.)
Intestinal urinary reservoirs have an increased propensity orthotopic ileal and ileocolonic bladder replacement, and
to form urinary calculi, predominantly in the lower tract, that in continent cutaneous reservoirs 4 weeks to 5 years after
tend to recur with an increasing incidence over time. Risk surgery.
factors include the presence of foreign material (e.g., staples), H ypovitaminosis is a well-studied sequela of bowel resec-
recurrent and chronic infection, the composition of the urine, tion, particularly of vitamin B12, in which patients may develop
mucus production, urinary stasis, and noncompliance with irreversible neurologic disease following an unrecognized defi-
irrigation and catheterization regimes. ciency. Substitution of vitamin B12 is simple and even less
Spontaneous rupture or perforation during catheteriza- expensive than regular analysis. Empirical supplementation
tion has been reported after bladder augmentation, after should therefore be considered.
B D
FIGURE 92.10 Colon pouch (M ainz pouch III) with tapered small bowel as efferent limb. A: The oral end of the large
bowel segment is closed and left intact. B: A 10-cm jejunal or ileal segment is isolated with careful preservation of its
mesenteric pedicle. C: The ileal segment is tapered over an 18Fr Foley catheter, trimming away the excess bowel wall.
The tube is formed using a running suture. Windows are created in between the vasculature of the mesentery. D:
Submucosal embedding of tapered ileum after incision of seromuscular layer of the tenia of the intact colonic segment.
Sutures are led through mesenteric windows. (From Thieme Stuttgart, N ew York, with permission.)
surgeons. The mean age of the patients at the time of surgery

O UTCO MES was 47.8 years. The most common indication for urinary
diversion was bladder replacement after anterior exenteration
Between 1985 and 2005, a continent cutaneous ileocecal for pelvic malignancies (69.9% ), followed by morphologic or
reservoir was created in 977 patients in two high-volume ter- functional bladder loss due to various benign conditions.
tiary referral centers (Departments of Urology, Johannes- M ean follow-up was 91.1 months (4.3 to 220.2 months). The
Gutenberg-University M edical School at M ainz, Bavarian vast majority of ureterointestinal anastomoses were performed
Julius-M aximilians-University M edical School at Würzburg, using a submucosal tunnel [1,470 renal units (RU)]. In 419 pa-
Germany) (12), reflecting the learning curves of numerous tients, the in situ appendix could be embedded submucosally
to form a M itrofanoff type of continence mechanism (43% ), Calculus formation was observed in 22 out of 396 patients
while an intussuscepted ileal nipple valve was established in (5.6% ) with an appendix stoma and in 48 out of 443 patients
491 patients (50% ). In 56 patients the outlet was created by (10.8% ) with an intussuscepted ileal nipple.
using other techniques (Figs. 92.3, 92.4, 92.5). Stoma stenosis Ureteral complications are mostly due to anastomotic stric-
was the most frequent outlet-related complication, affecting ture. O f 1,422 renal units with ureterointestinal reimplanta-
161 out of 839 patients (19.2% ). A reintervention was neces- tion by submucosal tunnel, 93 (6.5% ) developed obstruction
sary in 93 of 396 patients (23.5% ) with appendix stoma and at the anastomotic site. O f those, 74 renal units were reim-
in 68 of 443 patients (15.3% ) with an intussuscepted ileal planted by open surgical revision, and 7 renal units were
nipple. While stoma-related complications in patients with ap- treated endoscopically by balloon dilatation, incision with the
pendix stoma could be treated successfully by minor outpa- cold knife, or ureteral stent implantation. Eleven renal units
tient procedures in the vast majority of cases, management of had to be removed because of renal deterioration.
nipple complications more often required open revision such In 17 patients with an absent or dysfunctional lower uri-
as refixation of the nipple in the ileocecal valve or at the fas- nary tract, a continent urinary reservoir was created in prepa-
cia. Creation of a new outlet became necessary because of ration for renal transplantation (9). In a recent update,
ischemic outlet degeneration in 11 patients, including 8 with follow-up ranged from 3 months to 15 years after kidney
an appendix stoma and 3 with a nipple valve. transplantation, with serum creatinine values documented
Continence was reported in 96% of the patients with an between 0.9 and 2.0 mg per dL.
appendix stoma and in 89.5% of patients with a nipple valve.
References
1. Abol-Enein H , Ghoneim M A. A novel uretero-ileal reimplantation tech- 7. M onti PR, Lara RC, Dutra M A, et al. N ew techniques for construction of
nique: the serous lined extramural tunnel. A preliminary report. J Urol efferent conduits based on the M itrofanoff principle. Urology 1997;49:
1994;151:1193–1197. 112–115.
2. Chanturaia Z , Pertia A, M anagadze G, et al. Right colonic reservoir with 8. Riedmiller H , Bürger R, M üller S, et al. Continent appendix stoma: a mod-
submucosally embedded tapered ileum: “ Tiflis pouch.” Urol Int 1997;59: ification of the M ainz pouch technique. J Urol 1990;143:1115–1116.
113–118. 9. Riedmiller H , Gerharz EW, Köhl U, et al. Continent urinary diversion in
3. Gerharz EW, Turner WH , Kälble T, et al. M etabolic and functional conse- preparation for renal transplantation: a staged approach. Transplantation
quences of urinary reconstruction with bowel. BJU Int 2003;91:143–149. 2000;70:1713–1717.
4. Gerharz EW. Is there any evidence that one continent diversion is any bet- 10. Rowland RG. Right colon reservoir using a plicated tapered ileal outlet. In:
ter than any other or than ileal conduit? Curr O pin Urol 2007;17: Webster GD, Goldwasser B, eds. Urinary diversion, 1st ed. O xford: Isis
402–407. M edical M edia, 1995:229–235.
5. Lampel A, H ohenfellner M , Schultz-Lampel D, et al. In situ tunneled bowel 11. Stolzenburg JU, Schwalenberg T, Liatsikos EN , et al. Colon pouch (M ainz
flap tubes: 2 new techniques of a continent outlet for M ainz pouch cuta- III) for continent urinary diversion. BJU Int 2007;99:1473–1477.
neous diversion. J Urol 1995;153:308–315. 12. Wiesner C, Bonfig R, Stein R, et al. Continent cutaneous urinary diversion:
6. M itrofanoff P. Cystostomie continente transappendiculaire dans le traitement long-term followup of 800 patients with ileocecal reservoirs. W orld J
des ves-sies neurologiques. Chir Pediatr (Paris) 1980;21:297–305. Urol 2006;24:315–318.
CHAPTER 93 ■ URETERO SIGMO IDO STO MY:

MAINZ PO UCH II
MARGIT FISCH, RUDO LF HO HENFELLNER, JÖ RG SCHEDE, AND JO ACHIM W. THÜRO FF
Since the introduction of internal urinary diversion 140 years incontinence was reported to be high (7,10). Urodynamic in-
ago by Simon (11), 60 modifications of ureterosigmoidos- vestigations showed that bowel contractions with a pressure
tomy have been published. It remained the method of choice rise in the bowel/reservoir are responsible for the incontinence
for urinary diversion until the late 1950s, when electrolyte im- (7,10). By interrupting the circular contractions (antimesen-
balance and secondary malignancies arising at the ureteral im- teric opening of the bowel and reconfiguration), a low-pressure
plantation site were described. H owever, with increased reservoir can be created, thus improving continence rates and
follow-up, secondary malignancies were later reported in all protecting the upper urinary tract. The era of low-pressure
other forms of urinary diversion using bowel (2). The develop- anal reservoirs began.
ment of new absorbable suture material, modern ureteric Kock was the first to apply these principles to ureterosig-
stents, antibiotics, and alkalinizing drugs has solved many of moidostomy: By an antimesenteric opening of the rectosigmoid
the traditional shortcomings of ureterosigmoidostomy and and augmentation by an ileal patch, a low-pressure reservoir
has rekindled the interest in this technique. was created (10). To avoid metabolic disorders, a valve mech-
At this time continence became a more important issue. anism cranial to the augmentation was formed by invagina-
Frequency and urgency were often observed, and nighttime tion of the sigmoid colon. A temporary colostomy was needed
Chap t e r 93: Ure te rosig moid ostomy: Mainz Pouch II 611
to protect the invagination, and the advantage of the low- colon, polyposis, liver dysfunction, and a serum creatinine
pressure reservoir was, however, tempered by the complexity 1.5 mg/dL.
of the operative procedure. Reports on similar techniques of
augmenting the sigmoid segment with either ileal or ileocecal
segments followed. ALTERNATIVE THERAPY
At the M ainz M edical School, a more simple but equally
Alternatives to the sigmoid-rectal pouch are any other forms
effective operative procedure for the creation of a low-pressure
of urinary diversion, including bladder substitution, continent
rectal reservoir was developed, in which the sigmoid-rectal
cutaneous urinary diversion, and conduit diversion.
pouch was based on Kocher’s description in 1903 (5,6).
Although the standard technique describes ureteral implanta-
tion into the sigmoid-rectal pouch, the submucous tunnel rep- SURGICAL TECHNIQ UE
resents an excellent implantation technique for normal
undilated ureters with a low risk of stenosis or reflux. It is, For bowel preparation, oral administration of 4 to 7 L
however, associated with an increased complication rate when Fordtan solution can be used on the day before the operation
dilated or thick-walled ureters are present. For these ureters (alternatively, 8 to 10 L of Ringer lactate solution via a gastric
the serosa-lined extramural tunnel as published by Abol-Enein tube). M etronidazole in combination with a cephalosporin
and Ghoneim represents an alternative (1). The technique was (alternatively, piperacillin sodium) and an aminoglycoside is
first described for the ileal neobladder but is also applicable given at the beginning of surgery. A gastric tube or gastros-
for the sigmoid-rectal pouch. M ore recently, modifications of tomy and a rectal tube are placed. For parenteral nutrition a
the original technique have been described with good results. central venous catheter has to be inserted.
With the increased interest in minimally invasive procedures,
the technique of the sigmoid-rectal pouch, as with radical cys-
tectomy and urinary diversion, can be completely performed Classical Ure t e ro sig mo id o st o my
endoscopically (12). The bladder specimen can even be re-
After a median laparotomy, the peritoneum is incised lateral
moved transanally through the opened rectosigmoid during
to the descending colon and the left ureter is identified. A peri-
pouch creation, thus avoiding an additional incision. Today
toneal incision is made on the contralateral side lateral to the
the techniques of low-pressure anal reservoirs have completely
ascending colon and the right ureter identified. Both ureters
replaced classic ureterosigmoidostomy.
are dissected, respecting the longitudinal vessels running in-
side the Waldeyer sheet. The dissection is extended caudally to
the ureterovesical junction. The ureters are cut as distal as
DIAGNO SIS possible, and stay sutures are placed at the 6 o’clock position.
The ureteral stumps are ligated.
The anal sphincter function can be checked by a w ater tap en-
The colon is slightly elevated at the rectosigmoid junction
em a (perianal instillation of 200 to 300 mL saline, which the
by four stay sutures. After opening of the sigmoid colon over a
patients should keep for at least 3 hours) and a rectodynam ic
length of 4 cm by an incision of anterior teniae, four mucosal
investigation (no incontinence during measurement; anal
stay sutures are placed in the mucosa of the posterior aspect of
sphincter profile: resting closure pressure 60 cm H 2 O , clo-
the sigmoid (Fig. 93.1). The bowel mucosa is incised between
sure pressure under stress 100 cm H 2 O ). The upper tract
should be normal as proven by renal ultrasound and intra-
venous urography or renal function study. An enema with wa-
ter-soluble contrast medium should be performed to exclude
any rectal or sigmoidal anomalies.
The sigmoid-rectal pouch is suitable for primary urinary
diversion, revision of ureterosigmoidostomy, and conversion
of incontinent diversion. The procedure is indicated in patients
with functional or actual loss of the urinary bladder. O ur main
indications are urinary diversion in patients with bladder
exstrophy and incontinent epispadias or after radical cystec-
tomy for bladder cancer. The sigmoid-rectal pouch also has
been used for treatment of complex ureterovaginal and vesico-
vaginal fistula. It presents an excellent method of urinary
diversion, especially for countries in which catheters or any
stoma appliances are difficult to obtain. A competent anal
sphincter is a prerequisite for the sigmoid-rectal pouch, as it is
for ureterosigmoidostomy. There should be no renal insuffi-
FIGURE 93.1 O pen transcolonic ureterosigmoidostomy: Both ureters
ciency (creatinine maximum 1.5 mg per dL) or liver dysfunction. have been cut at its entrance into the bladder and mobilized. The sites
Contraindications are an incompetent anal sphincter, of the planned ureteral implantations in the posterior sigmoid wall are
irradiation of the pelvis, diverticulosis of the sigmoid outlined by stay sutures.
FIGURE 93.2 After incision of the mucosa and a buttonhole type of

excision of the posterior bowel wall site, the ureter is to be brought FIGURE 93.3 The ureter has been pulled into the bowel and through
through the intestinal wall; a subperitoneal tunnel is modeled bluntly a submucous tunnel reaching from the proximal to the distal stay
from this point to the left incision in the peritoneum. The curved sutures.
clamp is advanced precisely below the peritoneum
the proximal stay sutures, and a buttonhole type of excision of ureterointestinal anastomosis, an anchor suture is placed at
posterior bowel wall is performed. A straight or slightly the 6 o’clock position grasping intestinal mucosa and muscu-
curved clamp is advanced through the opening, and a tunnel is lature (5-0 polyglactin), and the anastomosis is completed by
created by blunt dissection below the visceral peritoneum of several ureteromucosal single stitches (6-0 polyglactin). A 6Fr
the mesosigmoid (Fig. 93.2). The ureter is pulled into the silastic stent is inserted into the ureter and fixed to the mucosa
lumen of the intestine. After creation of a submucosal tunnel by a polyglactin 4-0 suture (Fig. 93.4). The contralateral
of about 3 cm in length, the ureter is threaded through this ureter is implanted about 3 cm lateral and either proximal
tunnel, avoiding torsion of the ureter (Fig. 93.3). The anterior or distal to the first anastomosis using the same technique
wall of the ureter is spatulated for a length of 1 cm. For the (Fig. 93.5). The ureteral stents are inserted into the rectal tube
A B
FIGURE 93.4 Spatulation of the anterior wall of the ureter (A) and ureteromucosal anastomosis
between ureter and intestinal wall. The ureter is stented (B).
FIGURE 93.5 Identical implantation of the right ureter 3 cm lateral FIGURE 93.6 Identification of the rectosigmoid junction.
and proximal or distal of the first anastomosis.
and pulled out through the anus. Thereafter, the rectal tube is (Fig. 93.8). For ureteral implantation, four mucosal stay su-
reinserted. tures are placed parallel right and left to the medial running
The anterior sigmoid colon is closed in one layer using in- suture. The mucosa is incised, and the seromuscular layer is
terrupted sutures of 4-0 polyglactin or in two layers using run- excised between the two cranial stay sutures to create a wide
ning sutures (5-0 polyglactin for the mucosa and 4-0 buttonhole type of opening as an entrance of the ureter into
polyglactin for the seromuscularis). The peritoneal incisions
are closed. At the end of the operation separate fixations of
the rectal tube and ureteral stents to the skin of the anus are
performed (nonabsorbable material).
Sig mo id -Re ct al Po uch (Mainz Po uch II)

Access is gained by a median laparotomy as for ureterosigmoi-
dostomy. The rectosigmoid junction is identified and two stay
sutures are placed. The peritoneum is incised lateral to the de-
scending colon and the left ureter is identified. Another peri-
toneal incision is made lateral to the ascending colon and the
right ureter is identified. Both ureters are dissected down to
the ureterovesical junction, respecting the longitudinal vessels
running inside the Waldeyer sheet. The ureters are cut as distal
as possible, stay sutures are placed at the 6 o’clock position,
and the ureteral stumps are ligated.
For creation of the pouch, the intestine is opened at the
anterior tenia starting from the rectosigmoid junction over a
total length of 20 to 24 cm distal and proximal of this point
(Fig. 93.6). By placing two stay sutures in the middle of the in-
cision at the right side of the opened rectosigmoid, the intes-
tine is positioned in a shape of an inverted U. The posterior
wall of the pouch is closed by side-to-side anastomosis of the
medial margins of the U using two-layer running sutures of FIGURE 93.7 O pening of the rectosigmoid at the anterior tenia start-
4-0 polyglactin for the seromuscular layer and 5-0 polyglactin ing from the rectosigmoid junction over a total length of 20 to 24 cm
distal and proximal of this point. Side-to-side anastomosis of the me-
for the mucosa (Fig. 93.7). dial margins of the cut bowel edges by two-layer closure using run-
The left ureter is pulled through retromesenterically above ning sutures of absorbable synthetic suture material (4-0 for the
the inferior mesenteric artery from the left to the right side seromuscular layer and 5-0 for the mucosa).
FIGURE 93.9 The left ureter is pulled through retromesenterically to

the right side.
FIGURE 93.8 The left ureter is pulled through retromesenterically to
the right side.
sigmoid segment is outlined by stay sutures, with each limb of
10- to 12-cm length, resulting in a total length of 30 to 36 cm
the pouch. The dissection of the submucous tunnel starts from (Fig. 93.13). After antimesenteric opening of the S-shaped sig-
this incision downward over a length of 2.0 to 2.5 cm. The moid colon (Fig. 93.14) in the area of the anterior tenia, a
mucosa is incised at the distal end of the tunnel and the ureter
is pulled into the tunnel. After having resected the ureter to an
adequate length, implantation is completed by placing an an-
chor suture at the 6 o’clock position (5-0 polyglactin) and sev-
eral interrupted ureteromucosal sutures (6-0 polyglactin). The
cranial mucosal incision is closed by a running suture with
polyglactin 4-0, which has a short reabsorption time. The con-
tralateral ureter is implanted in the same manner (Fig. 93.9).
N ext, 6Fr ureteral stents are inserted into the ureters and are
pulled out through the anus with the rectal tube, which is af-
terwards reinserted. The pouch is fixed to the anterior longitu-
dinal band at the sacral promontory in the region of the
proximal end of the posterior medial running sutures by two
Bassini sutures of 3-0 nonabsorbable suture material (Fig.
93.10). Closure of the anterior pouch wall is performed in
two-layer sutures (5-0 polyglactin for the seromuscular and
4-0 polyglactin for the mucosal layer). Alternatively, single-
layer closure using interrupted stitches can be used (Fig. 93.11).
The peritoneal incisions are closed and the anastomotic site of
the pouch is covered by omentum. The rectal tube and the
ureteral stents are separately fixed to the skin of the anus
(nonabsorbable material).
Se ro sa-Line d Ext ramural Tunne l

Ure t e ral Imp lant at io n
FIGURE 93.10 After a 6Fr stent is inserted in each ureter, which are
M obilization of the bowel includes the left colonic flexure (in pulled out through the anus with the rectal tube, the pouch is fixed to
cases of a short sigmoid segment). Dissection of the ureters is the anterior longitudinal band of the spine in the region of the proximal
identical to the standard technique (Fig. 93.12). An S-shaped end of the posterior medial running sutures by two Bassini sutures.
FIGURE 93.11 Closure of the anterior pouch wall by seromuscular

single stitches with 4-0 absorbable synthetic suture material. Closure
of the peritoneal incisions. FIGURE 93.13 S-shaped sigmoid segment is outlined by stay sutures.
The length of each segment is 10 to 12 cm, starting at the rectosig-
moid junction (standard technique), adding another segment of 10 to
12 cm of ascending colon.
FIGURE 93.12 Right and left paracolonic incision; identification and

dissection of the ureters.
side-to-side adaptation of the seromuscularis of both limbs is FIGURE 93.14 The marked segments are opened in the area of the
obtained by single-stitch sutures close to the mesentery (non- anterior tenia. Excision of a mesenteric window for pull-through of
absorbable suture), thereby creating two serosa-lined chan- the left ureter.
nels. O n the right side an entrance for the right ureter is left at
the cranial aspect of the running suture. The mesentery cranial the ureter with a running suture incorporating all layers, thus
to the left running suture is incised and the left ureter pulled converting the channel into a tunnel. The length of the tunnel
through. The ureters are placed in their respective channels should be four times the diameter of the ureter. For implanta-
(Fig. 93.15), and the cut edges of the bowel are sutured above tion, the ureter is cut at its required length and spatulated.
FIGURE 93.15 Side-to-side adaptation of the seromuscularis of FIGURE 93.16 Ureteral implantation in the area of the continuous
the limbs of the S by two interrupted sutures close to the mesentery suture line. Insertion of ureteral stents.
(4-0 nonabsorbable suture), thereby creating two serosa-lined chan-
nels. O n the right side, an entrance for the right ureter is left at the
cranial aspect of the running suture and the ureter is pulled through.
O ne ureter is placed in each channel created between the segments of
the S.
Four anchor sutures are placed at the 11 and 1 o’clock and the
5 and 7 o’clock positions through all layers of the ureter as
well as all layers of the bowel wall (4-0 polyglactin).
Ureteromucosal sutures are placed in between the anchor
sutures to complete the anastomosis (5-0 polyglactin) (Fig.
93.16). Two ureteral stents are inserted and pulled out
through the anus with the rectal tube after having been fixed
to the bowel mucosa (4-0 polyglactin). The anterior pouch
wall is closed by interrupted seromuscular sutures (4-0
polyglactin) (Fig. 93.17).
Surg ical Tricks (Sig mo id -Re ct al Po uch)

When the anastomosis reaches deep down to the rectum, it is
easier to suture the pouch starting caudally, as the deepest
point of the anastomosis is the most critical part and can be
reached more easily at the beginning of the anastomosis.
To facilitate fixation of the pouch to the promontory, one
sutured end of the dorsal running suture can be pulled through
dorsally outside of the pouch and be tightened with the fixation
suture placed in the anterior band at the promontory.
A Bassini needle facilitates placement of the fixation suture
through the anterior band of the spine. FIGURE 93.17 The stents are pulled through the anus and the pouch
is closed.
During ureteral implantation, sufficient spatulation of the
ureters is of utmost importance to avoid a nipplelike protru-
sion of the ureters. The S-shaped sigmoid-rectal pouch as created for the
To drain an incidental hematoma of the submucous tunnel, ureteral implantation via a serosa-lined tunnel has an ideal
the mucosa covering the tunnel can be selectively incised at and stable position within the pelvis; therefore, no fixation to
different points. the promontory is needed.
of the ureter was required in 10 of 69 renal units (14.4% ), in

O UTCO MES 10.1% due to stenosis, and in 4.3% due to reflux. Early alkali
supplementation was initiated in 24 (69% ). N o secondary ma-
O f utmost importance for the outcome is patient selection. A lignancies were observed during follow-up.
functioning anal sphincter is a prerequisite. Also important Concerning quality of life, the M ainz pouch II serves as a
are technical details such as ureteral implantation, side-to-side satisfying continent urinary diversion for both sexes. N o sta-
anastomosis by two layers, and the fixation at the promontory tistically significant differences in functional and symptom
(classical technique). scales or global health status were detected between males and
Between 1990 and 1999 a sigmoid-rectal pouch was per- females. All scales but diarrhea showed good results, and the
formed in 123 patients (94 adults and 29 children). M ean age outcome was comparable to health-related quality of life in a
was 44 years (10 months to 73 years). Indications were malig- reference population (4).
nancy (n 92), bladder exstrophy and incontinent epispadias
(n 26), trauma (n 4), and sinus urogenitalis (n 1). A to-
tal of 102 of the 123 patients were followed, with a mean fol-
low-up of 46.2 months (1 to 9 years). Eight patients died CO MPLICATIO NS
during follow-up due to their primary malignant tumor; an-
other 2 died unrelated to the underlying disease. Eleven were The main complication is stenosis at the ureterointestinal
lost to follow-up. Four early pouch-related complications anastomosis. The incidence in our series was 7% in the whole
were encountered: two dislodged ureteral stents requiring collective and 10% in the children. H adzi-Djokic et al. (8) re-
temporary nephrostomy and one ileus treated by operative in- ported a stenosis in 11 out of 220 patients. H ammouda (9)
tervention. O ne patient developed severe complications as a used the serosa-lined extramural tunnel as well as the submu-
result of anastomotic leakage from a pouch fistula requiring cosal tunnel for ureteral implantation in 95 patients and
revision and colostomy. Stenosis at the ureteral implantation found reflux in 1.6% of renal units and stenosis in 5.3% .
site was the most common complication (7% , or 14 renal Balloon dilatation and endoscopic incision of the stenosis have
units). Eleven renal units required surgical reimplantation. been described to treat ureterointestinal anastomosis; however,
During follow-up, pyelonephritis was observed in 3% of pa- we would recommend open revision with reimplantation.
tients. N inety-nine of the 102 patients were completely conti- Pyelonephritis is described in our series (3,8,9) with an
nent postoperatively; nighttime continence was 95% . The incidence of 3.0% to 15.8% and should be treated with
majority of the patients (70 out of 102, or 69% ) used alkalin- antibiotics. O nly those patients with recurrent pyelonephritis
izing drugs to prevent metabolic acidosis. and a decrease in split renal function require ureteral neoim-
Between 1991 and 2004 a total of 38 children with a mean plantation.
age of 5 years underwent a M ainz pouch II procedure. O f About two-thirds of patients will develop an acidosis
these, 33 had bladder exstrophy or incontinent epispadias. with a negative base excess. Early correction (starting from a
In 14 children (37% ) urinary diversion was performed after base excess of 2.5) with alkali supplementation is recom-
failed primary reconstruction. Thirty-five children could be mended to avoid further complications, especially in children.
followed, with a mean follow-up of 112 months (range 5 to Incontinence is a rare complication but can be disastrous. In
147). All children were continent during daytime, but 3 (8.6% ) severe forms a conversion to another form of urinary diver-
suffered from nighttime incontinence requiring pads. Six chil- sion is required.
dren (15.8% ) had developed pyelonephritis, mostly with To discover secondary malignancies early, endoscopy is
stenosis of the ureterointestinal anastomosis. Reimplantation recommended starting from the fifth postoperative year.
References
1. Abol-Enein H , Ghoneim M A. A novel uretero-ileal reimplantation tech- 8. H adzi-Djokic JB, Basic DT. A modified sigma-rectum pouch (M ainz pouch
nique: the serous lined extramural tunnel. A preliminary report. J Urol II) technique: analysis of outcomes and complications on 220 patients. BJU
1994;151(5):1193–1197. Int 2006;97(3):587–591.
2. Austen M , Kälble T. Secondary malignancies in different forms of urinary 9. H ammouda H , Shalaby M , Adelelateef A, et al. M ainz II and double folded
diversion using isolated gut. J Urol 2004;172(3):831–838. rectosigmoid pouches. Experience with 95 patients. J Surg O ncol 2006;
3. Bastian PJ, Albers P, H anitzsch H , et al. The modified ureterosigmoidos- 93(3):228–232.
tomy (M ainz pouch II) as continent form of urinary diversion. Urologe A 10. Kock N G, Ghoneim M A, Lycke KG, et al. Urinary diversion to the aug-
2004;43(8):982–988. mented and valved rectum: preliminary results with a novel surgical proce-
4. Bastian PJ, Albers P, H anitzsch H , et al. H ealth-related quality-of-life fol- dure. J Urol 1988;140(6):1375–1379.
lowing modified ureterosigmoidostomy (M ainz Pouch II) as continent uri- 11. Simon J. Ectropia vesica (absence of the anterior walls of the bladder and
nary diversion. Eur Urol 2004;46(5):591–597. pubic abdominal parieties); operation for directing the orifices of the
5. Fisch M , H ohenfellner R. Der Sigma-Rektum Pouch: Eine M odifikation ureters into the rectum; temporary success; subsequent death; autopsy.
der H arnleiterdarmimplantation. A k t Urol 1991;I–IX. L ancet 1852;568.
6. Fisch M , Wammack R, M üller SC, et al. The M ainz pouch II (sigma rectum 12. Türk I, Deger S, Winkelmann B, et al. Complete laparoscopic approach for
pouch). J Urol 1993;149(2):258–263. radical cystectomy and continent urinary diversion (sigma rectum pouch).
7. Ghoneim M A, Shebab-El-Din AB, Ashamallah AK, et al. Evolution of Tech Urol 2001;7(1):2–6.
the rectal bladder as a method for urinary diversion. J Urol 1981;126(6):
737–740.
CHAPTER 94 ■ PALLIATIVE URINARY
DIVERSIO N
BURKHARD UBRIG AND STEPHAN RO TH
The word palliative derives from the Latin palliare, which fistula in one. All patients in whom the bladder was preserved
means “ to cover with a coat.” The term palliative therapy im- complained of severe symptoms that reduced the quality of
plies the impossibility of cure. The main goal of palliative uri- life of their remaining life span (7).
nary diversion is the control or the prevention of symptoms Radical cystectomy with urinary diversion is nowadays a
caused by incurable diseases of the urinary tract, usually can- routine procedure with acceptable risk in many urologic de-
cer. In addition to bladder and prostate cancer, advanced cer- partments. Recent reports have proven the feasibility of radi-
vical, ovarian, breast, or colorectal cancer may interfere with cal cystectomy with acceptable morbidity and mortality also
the urinary tract. in octogenarians (5). There is some evidence that radical cys-
Typical symptoms of locally progressive pelvic cancer with tectomy itself, if performed with minimal blood loss and in a
impairment of the urinary bladder include urgency, pelvic time-efficient manner, does not decisively increase the morbid-
pain, pyocystis, recurrent gross hematuria, ileus, and fistulas ity of the palliative urinary diversion (8,11).
(e.g., vesicovaginal, vesicorectal, cloacal) that may severely Therefore, in most palliative patients with acceptable sur-
compromise quality of life. In a broader sense, palliative treat- gical risk and good motivation for surgery, radical cystec-
ment for ureteral obstruction may also be considered in this tomy with urinary diversion will be the most suitable option.
chapter. N evertheless, the decision will be made on an individual
basis between the urologic surgeon and his or her patient. In
some borderline cases the risk of the surgical approach is
considered too high, either because of a poor general health
DIAGNO SIS condition (American Society of Anesthesiologists (ASA) score
3 and 4) or because the operation cannot be considered due
Diagnosis of incurable pelvic cancer is based on the diagnosis to advanced age and limited life expectancy.
of metastatic disease or local infiltration of adjacent pelvic
structures and organs. Diagnostic studies may depend upon
the underlying pathology. In general, the detection of distant
and locoregional metastases will be achieved with common ALTERNATIVE THERAPY
imaging procedures: computed tomography and/or magnetic
resonance imaging and bone scan. Urethrocystoscopy, rectal In most patients with locally advanced pelvic cancer, cystec-
digital examination, and bimanual palpation of the pelvis by tomy or complete pelvic exenteration is the standard option. In
the experienced pelvic surgeon aid in local staging of the pri- a select group of patients with high surgical risk, frozen pelvis,
mary tumor and reveal important information on resectability. and a short residual life expectancy, supravesical diversion
without exenteration may be a viable option that results in
good symptom control (12). Indications are infrequent, and re-
sults of this strategy have rarely been reported in the literature.
INDICATIO NS FO R SURGERY Further alternatives to radical cystectomy with urinary diver-
sion are observation, repeated transfusions, or indwelling
There are no prospective studies that compare bladder- catheters, depending upon the underlying disease process.
preserving strategy versus palliative cystectomy in locally ad-
vanced bladder cancer. H owever, the clinical course of patients
with advanced muscle-infiltrating bladder cancer under a
bladder-preserving strategy is often dismal. In a recent study, SURGICAL TECHNIQ UE AND
24 patients with muscle-infiltrating bladder tumor (mean age O UTCO MES
81 years) were treated with bladder preservation for a mean
22.6 months (7). All complained of frequency, urgency, and Palliative urinary diversion will usually be performed with the
severe nocturia. The mean hospital readmission rate was lowest risk options that are acceptable to the patient.
eight times per patient. Salvage cystectomy was required in 11 Continent orthotopic or cutaneous diversion will be consid-
of 24 cases, in 7 alone because of recurrent macrohematuria. ered if the patient is suitable and motivated. It may take
M ajor complications that might have been prevented with 3 to 12 months before continence and an acceptable quality of
early cystectomy were ileus in three cases and an enterovesical life are attained (4). The presence of (completely resectable)
618
Chap t e r 94: Palliative Urinary Dive rsion 619
A B C
D E F
FIGURE 94.1 Supravesical urinary diversion.

A–D: Cutaneous ureterostomy with (A) median
or (B) lateral stoma, (C) transureteroureteros-
tomy, and (D) pyeloureteral anastomosis. E and
F: Transverse colon conduit, with (F) anasto-
G mosis to the pyelon; (G) ileal conduit.
nodal disease does not preclude the placement of an ortho- it should not be used if diseased, if exposed to radiation, or if
topic bladder substitute (4). In general, conduits will often be the internal iliac arteries have been ligated with the rectum
preferred in palliative situations. Some patients for whom pal- still in place. This last condition might lead to rectal sloughing
liation is the goal may be very poor surgical candidates. because of compromised rectal blood supply (10). The stoma
Therefore, in these select cases, less elaborate techniques such will usually be placed in the lower left abdominal quadrant
as cutaneous ureterostomy or nephrostomy placement may (Fig. 94.1).
also be considered.
Transve rse Co lo n Co nd uit

Ile al Co nd uit
The transverse colon is not within the radiation portals com-
Assuming adequate surgical risk and life expectancy, an ileal monly used for pelvic malignancies, such as cervical cancer.
conduit is the first choice of many urologists in a palliative situ- The blood supply via the middle colic artery is usually ample
ation. O stomy care is relatively easy, and patients may return to (10). Indications for the use of transverse colon for conduit
normal activity soon after discharge (Fig. 94.1). An ileal con- construction may be marked radiation fibrosis of the ureters or
duit should not be used in patients with short bowel syndrome impaired ureteral mobilization because of frozen pelvis or peri-
or inflammatory small bowel disease and in those who have ureteral lymph nodes. The ureterointestinal anastomosis can be
had high-dose radiation to the ileum. The small intestine and accomplished with very short ureteral stumps. Also, anastomo-
ureters are usually within the radiation portals for treatment of sis with the renal pelvis is feasible (Fig. 94.1). The perioperative
pelvic malignancy and may evidence long-term sequelae. mortality rate has recently been reported at 3% (10).
Impaired healing of gut anastomosis and scarring with stricture
formation of the ureterointestinal anastomosis may occur.
Bilat e ral Cut ane o us Ure t e ro st o my
w it h Sing le St o ma
Sig mo id Co lo n Co nd uit
In patients for whom major gut surgery is not advisable, cuta-
The sigmoid colon is a viable alternative to ileum if the latter neous ureterostomy is an alternative to transintestinal diver-
cannot be used for conduit construction (see above). H owever, sion (Fig. 94.1); operative time is short, and renal function is
not a selection factor, while paralytic ileus rarely occurs. Several percutaneous techniques to obliterate the ureteral
Construction of a single stoma in the lateral or midline posi- lumen have been proposed: butyl-2-cyanoacrylate, detachable
tion is generally feasible and ensures easy care with minimal balloons, liquid polyacrylonitrile, butyl-2-cyanoacrylate and
patient discomfort. O ccasionally, though, excessive obesity, lipiodol with adjuvant balloon catheter occlusion, electro-
extensive paraureteral lymph node involvement, or frozen cautery, and nylon and silicone occlusion devices. Some
pelvis makes construction of a single stoma impossible. nephrostomy devices for transient closure of the ureteral
Stoma construction is of critical importance. Stomal steno- lumen have been reported, including modified nephroureteral
sis rates of 50% and more have been reported (10). Distal catheters and balloon occlusion devices. N one of these meth-
spatulation of the ureteral end and plastic augmentation with ods has gained wide acceptance.
a V-shaped skin flap as proposed by Rodeck should be consid-
ered (8). Stomal stenosis results mainly from ischemia of the
distal ureteral end with consequent sloughing and fibrosis. De funct io nalizat io n o f t he
Also, postoperative tension or hyperplastic epithelium at the Co nt ralat e ral Unit
ureterocutaneous anastomosis may play a role. Firm fixation
of the anastomosis to the skin and healing by first intention If only one kidney is diverted and urine continues to flow
are essential. The following different techniques have been downstream from the contralateral kidney, it may be neces-
proposed. Both ureters are guided to the skin and anasto- sary to defunctionalize the latter. Some palliative patients are
mosed with each other and the stomal skin (Fig. 94.1). This poor candidates for nephrectomy. In a previously obstructed
can be done by passing one ureter to the contralateral side hydronephrotic kidney with significant parenchymal reduc-
through the retroperitoneum and behind the descending colon tion, ligature and transection of the ureter will usually result
(8). Alternatively, in slender patients, the ureters may be mobi- in long-term success. Postinterventional paralytic ileus and
lized completely extraperitoneally, led around the peritoneal some pain may be expected during the first postoperative
sac, and conjoined in the midline. An infraumbilical stoma days.
can then be formed (12). H owever, in unobstructed kidneys, ligature of the ureter
should not be done because of significant pain and sponta-
neous ureteral recanalization. Usually renal arterial em-
Transure t e ral Cut ane o us Ure t e ro st o my bolization will be considered. Excellent results to stop urine
production from the kidney have been reported with trans-
O ne ureter is retroperitoneally led to the other side and anas- catheter ablation with a mixture of ethanol and contrast
tomosed to the contralateral ureter end-to-side (e.g., with 5-0 agent and a combination of sponge and coil plugging of the
M onocryl). This ureter will be guided through the abdominal proximal artery: O ut of 20 patients, urinary flow ceased
wall and anastomosed to the skin. after 2 days in 18 patients; 2 required a second session. The
authors propose epidural anesthesia, which may also be
used in the first 2 postoperative days for pain control.
Transure t e ro p ye lo cut ane o us Transient postinterventional paralytic ileus and fever may
Ure t e ro st o my be expected (1).
Alternatively, the collecting systems of both renal units have

been connected with a high ureteral or pyeloureteral anasto-
mosis (Fig. 94.1). O perative mortality was 1.75% ; severe late PALLIATIVE TREATMENT O F
complications occurred in 10.5% . The most frequent prob- URETERAL O BSTRUCTIO N
lems arose from the nephrostomy and from stenoses of the
ureteropelvic or ureteral anastomosis (9). Common causes of malignant compression of the ureterovesi-
cal junction and the prevesical ureter are bladder, prostate,
and cervical cancers. M alignant obstruction of the mid- or up-
Pe rcut ane o us Ne p hro st o my per ureter is usually caused by metastatic lymphatic spread as
from metastatic breast cancer, lymphatic disease, colon cancer,
Percutaneous nephrostomy is another alternative for and cancers of the female internal genitalia. H owever, even
supravesical diversion. The advantages are the relative ease years after radiation therapy, newly arising ureteral obstruc-
with which these can be placed under local anesthesia, but the tion may represent long-term sequelae of radiation and not
drawbacks are the need for continuous replacement due to en- tumor recurrence.
crustation as well as the propensity for these to become dis- Indications for treatment should be considered very
lodged. Bilateral nephrostomies are sometimes badly tolerated, carefully. Septic episodes, with accompanying persistent
and usually only the renal unit with better function should be pain, are rare in malignant ureteral obstruction if there has
diverted by nephrostomy. been no retrograde endoscopic manipulation. The insertion
To prevent further flow of urine downstream, additional oc- of a regular double-J stent or a nephrostomy will result in
clusion of the ureter may sometimes be necessary. Transection repeated consultations to change the catheters, sometimes
and ligation of the ureter with nonabsorbable material may be under general anesthesia. Any measure carries the risk of
performed. This may be accomplished by a small flank incision infection or dislocation. M any patients are in critical con-
or laparoscopically. If feasible, a unilateral cutaneous ureteros- dition, and quality of life should be the main treatment
tomy may be the better alternative in such cases. goal.
Chap t e r 94: Palliative Urinary Dive rsion 621
FIGURE 94.2 Endourologic techniques for treatment of malignant ureteric obstruction. A: Ureteral
stent. B: Two parallel ureteral stents. C: M etal stent. D: N ephrostomy tube. E: Extra-anatomic prosthetic
bypass.
In patients with unilateral ureteral obstruction and suf- reduces kinking and luminal compression, and the potential
ficient function of the contralateral kidney, one should gen- space between the stents likely preserves flow around as well
erally abstain from therapy; however, if nephrotoxic as through them (Fig. 94.2).
chemotherapy is planned or life expectancy exceeds 1 to 2
years, intervention may be indicated. In patients with bilat-
eral ureteral obstruction and impending renal failure, it is Me t allic Me sh St e nt s
usually sufficient to stent, divert, or bypass only one renal
unit (usually the one with better function). In some patients, M etallic mesh stents such as the Wallstent have been used with
however, it may be preferable to abstain from any treatment limited success. Epithelial hyperplasia and tumor ingrowth
at all. The use of the below-mentioned techniques assumes through the mesh have been reported to result in recurrent
normal bladder function. O therwise, supravesical diversion ureteral obstruction. These stents are virtually unremovable.
may be discussed. An alternative might be nickel-titanium shape-memory alloy
Retrograde stenting with replaceable double-J stents is stents that occupy only the obstructed ureteral segment. These
often considered the first-line option for relieving ureteral ob- are soft and malleable at 10°C and regain their shape when re-
struction (Fig. 94.2). Transurethral resection will sometimes heated to 55°C. The tendency to form encrustations is appar-
be necessary to find the ureteral orifice or intramural ureter ently low (3).
hidden in the tumor. In these situations prior antegrade
placement of a guide wire or antegrade placement of the Ext ra-anat o mic Pye lo ve sical
stent itself may be very useful. Specific drawbacks of double-J
stents are irritative bladder symptoms, stent obstruction, and Pro st he t ic Byp ass
encrustation—necessitating repeated changes (intervals range
In 1992 Desgrandschamps and colleagues introduced their
from 6 weeks to 6 months, but can be much shorter) and
technique of pyelovesical bypass with a composite prosthesis
stent migration.
(internal diameter, 18Fr; external diameter, 28.5Fr), and
Under conditions of extrinsic compression, hard polyurethane
Jabbour et al. (2) reported long-term results with 35 pros-
stents are recommended over soft silicone to ensure patency of the
thetic ureters in 27 patients, 22 with malignancies. M inor early
stent lumen. Specially developed “ tumor stents” are available.
and late complications were noted in 5 and 3 patients, respec-
tively. N o encrustations of the inner silicone lumen were noted,
Tw o Do ub le -J St e nt s although asymptomatic bacteriuria sometimes was. The 5 sur-
viving patients (4 with renal transplants, 1 with retroperi-
Extensive compression from the tumor may lead to malfunc- toneal fibrosis) were followed from 34 to 84 months (mean,
tion and obstruction of conventional double-J stents. Liu 47 months), and the authors found no encrustation, kinking,
and H rebinko (6) used two 4.7Fr double-J stents passed or obstruction (2). Alternatively, single- or multiple-piece
simultaneously over guide wires when drainage with a single stents with small diameters (7Fr to 11Fr) have been used.
ureteral stent had failed. The increased stiffness of two stents Recent data from this work group suggest that quality of life
A B C
FIGURE 94.3 Combined reconfigured colon segments for incontinent diversion of solitary kidney. A, B: A 6-cm
segment is excised from the ascending or descending colon. The segment is split in the middle and the rings are
opened antimesenterically. When reconfigured, the tube produced will be approximately 18 cm long, suitable for
incontinent urinary diversion. C: Pyelocolocutaneostomy in a solitary kidney.
in patients with unimpaired bladder function may be better

than with conventional nephrostomy tubes.
Transve rse Re t ub ularize d Co lo n Se g me nt s

In selected patients, transverse reconfigured colon segments
may be used successfully to reconstruct extensive ureteral de-
fects (Figs. 94.3 and 94.4). The successful use of a combina-
tion of two such segments has been described to divert solitary
kidneys in palliative situations (11). In patients with renal in-
sufficiency or a history of irradiation, this technique may be
superior to the use of ileum. An advantage of the colon is its
immediate proximity to the ureters bilaterally and its position
outside the radiation portals for treatment of pelvic malig-
nancy. N evertheless, unreconfigured colon has not been
widely recruited for ureteral replacement because of its wide
diameter: Its large volume when replacing long defects could
result in metabolic or septic complications. Surgical access is
via flank or pararectal incision, and intraperitoneal surgery is
minimal. The colonic segments are taken immediately proxi-
mal to the ureteral defect, necessitating little mobilization of
the mesenteric pedicle. M etabolic consequences have not been
described and should be absent or low, as only minimal FIGURE 94.4 Interposition of a reconfigured colon segment to repair
amounts of intestine need be isolated (11). an extensive ureteral defect.
References
1. De Baere T, Lagrange C, Kuoch V, et al. Transcatheter ethanol renal abla- 7. Lodde M , Palermo S, Comploj E, et al. Four years experience in bladder
tion in 20 patients with persistent urine leaks: an alternative to surgical preserving management for muscle invasive bladder cancer. Eur Urol
nephrectomy. J Urol 2000;164:1148–1152. 2005;47(6):773–778.
2. Jabbour M E, Desgrandchamps F, Angelescu E, et al. Percutaneous implan- 8. Lodde M , Pycha A, Palermo S, et al. Uretero-ureterocutaneostomy
tation of subcutaneous prosthetic ureters: long-term outcome. J Endourol (wrapped by omentum). BJU Int 2005;95(3):371–733.
2001;15:611–614. 9. M arx FJ, Laible V. [Ureterotransversopyelostomy with unilateral nephros-
3. Kulkarni R, Bellamy E. N ickel-titanium shape memory alloy M emokath tomy]. Urologe A 1985;24:334–339.
051 ureteral stent for managing long-term ureteral obstruction; 4-year ex- 10. Segreti EM , M orris M , Levenback C, et al. Transverse colon urinary diver-
perience. J Urol 2001;166:1750–1754. sion in gynecologic oncology. G ynecol O ncol 1996;63:66–70.
4. Lebret T, H erve JM , Yonneau L, et al. After cystectomy, is it justified to 11. Ubrig B, Waldner M , Roth S. Reconstruction of ureter with transverse re-
perform a bladder replacement for patients with lymph node positive blad- tubularized colon segments. J Urol 2001;166:973–976.
der cancer? Eur Urol 2002;42(4):344–349. 12. Ubrig B, Lazica M , Waldner M , et al. Extraperitoneal bilateral cutaneous
5. Liguori G, Trombetta C, Pomara G, et al. M ajor invasive surgery for uro- ureterostomy with midline stoma for palliation of pelvic cancer. Urology
logic cancer in octogenarians with comorbid medical conditions. Eur Urol 2004;63(5):973–975.
2007;51:1600–1605.
6. Liu JS, H rebinko RL. The use of 2 ipsilateral ureteral stents for relief of
ureteral obstruction from extrinsic compression. J Urol 1998;159:179–181.
SECTIO N VIII ■ PEDIATRIC
H. GIL RUSHTO N
CHAPTER 95 ■ NEURO BLASTO MA

W. RO BERT DEFO O R, JR., PRAMO D P. REDDY, AND CURTIS A. SHELDO N
N euroblastoma represents the most common extracranial ma- TA B LE 9 5 . 1

lignant solid neoplasm of infancy and childhood and the most
common intra-abdominal malignancy in the newborn. The EVAN S STAGIN G SYSTEM
biological, genetical, and morphological characteristics of this Stage of Tumor Description of Stage
neoplasm demonstrate heterogeneous behavior. These tumors
have a varied clinical course, with reports of spontaneous re- I Tumor confined to the organ of origin
gression and tumor maturation from malignant to a benign II Tumor extends beyond organ of origin
histological form. H owever, in many cases the disease is pro- but does not cross the midline; unilateral
gressive (1,2) and exhibits a wide spectrum of morphological lymph nodes may be involved
differentiation, ranging from primitive (neuroblastoma) to III Tumor extends across the midline;
well differentiated (ganglioneuroma), or between these two bilateral regional lymph nodes may be
extremes (ganglioneuroblastoma). involved
The clinical incidence is approximately 1 in 8,000 to IV Distant metastases (skeletal, other organs,
10,000 children. There are approximately 500 new cases diag- soft tissues, distant lymph nodes)
nosed each year in the United States; 90% occur in children IV-S Stage I or II with remote disease confined
7 years old. Cervical and mediastinal lesions tend to present to one or more of the following sites:
in younger patients ( 1 year of age) and tend to have a better liver, skin, or bone marrow, but without
prognosis. N euroblastoma is slightly more common in boys evidence of bone cortex involvement
than in girls, with a ratio of 1.2:1, and has been described in From Evans AE, D’Angio GJ, Randolph J. A proposed staging for
familial settings (2). Infants presenting with the following four children with neuroblastoma. Children’s Cancer Study Group A.
clinical conditions have a higher incidence of neuroblastoma Cancer. 1971;27:374–378, with permission.
than the general population: Beckwith–Wiedemann syndrome,
H irschsprung disease, fetal alcohol syndrome, and fetal
hydantoin syndrome. copy number of tumor. Serum LDH , ferritin, and N SE are also
obtained.
DIAGNO SIS St ag ing Syst e ms

The clinical presentation of neuroblastoma is varied and M ultiple staging systems have evolved in the management of
dependent upon the site of the primary tumor, the presence of neuroblastoma. The Evans–D’Angio staging system (Table
metastatic disease, the age of the patient, and the production 95.1) consists of a clinical assessment that describes the initial
of metabolically active substances. Vasoactive tumors can tumor distribution and incorporates whether the tumor crosses
present with hypertension. The catecholamine urinary metabo- the midline (3). The International N euroblastoma Staging
lites, vanillylmandelic acid (VM A) and homovanillic acid System (IN SS) incorporates many of the important criteria
(H VA), are elevated in 80% of patients with a neuroblas- from each of these three staging systems and includes initial
toma. An increased VM A/H VA ratio is associated with a bet- tumor distribution as well as its surgical resectability (Table
ter prognosis in localized disease. O ther elevated metabolic 95.2) (4). The most useful histologic classification is the system
products can include lactate dehydrogenase (LDH ) 1,500 described by Shimada (5). This system utilizes the mitosis
IU/mL, serum ferritin 142 ng/mL, and serum neuron-specific karyorrhexis index (M KI) of nuclear fragmentation. This system
enolase (N SE) 100 ng/mL; these are associated with a poor divides the tumors into age-related favorable and unfavorable
prognosis. histologic categories based on whether the tumor exhibits a
At least 50% of children with neuroblastoma will have stroma-rich or stroma-poor appearance (Table 95.3).
metastatic disease, including spread to the cortical bone, bone
marrow, liver, and skin, at the time of initial presentation. Initial
evaluation of a child with a suspected neuroblastoma includes
random urine for VM A and H VA, chest radiograph, ultra- INDICATIO NS FO R SURGERY
sound of the abdomen, computed tomography (CT) or mag-
netic resonance imaging (M RI) body scans, radioisotopic bone The management of patients presenting with neuroblastoma
scan, I131 -metaiodobenzylguanidine (M IBG) scan, bone mar- varies with the extent of disease at the time of diagnosis, the
row aspirate/biopsy from multiple sites, and N -m yc oncogene age of the patient, and the staging criteria used. If the patient
623
624 Se ct io n VIII: Pe d iatric
TA B LE 9 5 . 2
IN TERN ATION AL N EUROBLASTOMA STAGIN G SYSTEM
Stage of Tumor Description of Stage
1 Localized tumor confined to the area of origin. Complete gross excision, with or without microscopic residual
disease. Identifiable ipsilateral and contralateral lymph nodes that are microscopically negative.
2-A Unilateral tumor with incomplete gross resection. Identifiable ipsilateral and contralateral lymph nodes that are
microscopically negative.
2-B Unilateral tumor with complete or incomplete gross excision. Positive ipsilateral regional lymph nodes.
Identifiable contralateral lymph nodes that are microscopically negative.
3 Tumor infiltration across the midline with or without regional lymph node involvement. Unilateral tumor with
contralateral lymph node involvement or midline tumor with bilateral regional lymph node involvement.
4 Dissemination of tumor to distant lymph nodes, bone marrow, bone, liver, or other organs (except as defined
in Stage 4-S)
4-S Localized primary tumor as defined for Stage 1 or 2 (Stage 2-A or 2-B), with dissemination limited to the liver,
skin, or bone marrow
From Brodeur GM , Seeger RC, Barrett A, et al. International criteria for diagnosis, staging, and response to treatment in patients with neuroblastoma.
J Clin O ncol. 1988;6:1874–1881, with permission.
TA B LE 9 5 . 3
SHIMADA PATHOLOGIC CLASSIFICATION
Favorable Histology Unfavorable Histology
Stroma rich Well-differentiated, intermixed appearance N odular appearance

Stroma poor
Age 18 mo M itosis karyorrhexis index (M KI) 200/5,000 M KI 100/5,000
Age 18–60 mo M KI 100/5,000 M KI 100/5,000
Differentiating Undifferentiated
Age 5 yr N one All
Shimada H , Ambros IM , Dehner LP, et al. The International N euroblastoma Pathology Classification (the Shimada
system). Cancer. 1999;86:364–372, with permission.
has stage I or II disease (with favorable histology), then surgi- mature spontaneously, and the majority of persistent tumors
cal resection alone can be undertaken with reasonable success. have favorable biological activity, with a 95% 4-year survival.
A multimodal approach utilizing chemotherapy, radiation, In addition, there are significant surgical risks of ablative
and surgery is used for advanced disease (stages III and IV). surgery in small or preterm neonates. Consequently, some cen-
Surgical intervention (“ second-look” laparotomy) after ters have adopted a “ wait-and-see” strategy of management for
open biopsy is usually performed 13 to 18 weeks after those detected from prenatal screening. H owever, each case
chemotherapy has been administered. During this procedure, should be evaluated thoroughly and carefully, with any possi-
surgical resection and dissection may appear to be somewhat ble benefit balanced against the morbidity of the diagnosis (6).
easier, especially around vital structures and major blood ves-
sels, because chemotherapy usually makes the tumors smaller
and firmer. This rubbery consistency also decreases the risk of
rupture and spillage of the tumor that might otherwise be en- SURGICAL TECHNIQ UE
countered. Intraoperative radiation (IO RT) may be utilized
and is helpful in reducing the exposure to normal adjacent In cases of very large tumors where resection of adjacent
structures. In advanced-stage tumors radiation therapy is de- organs or intestine might be required, a mechanical bowel
livered to the tumor bed and regional lymph nodes. preparation is reasonable. The procedure is performed with
the patient in a supine position. The patient should be given
prophylactic antibiotics (broad-spectrum cephalosporin).
Ne o nat al O b se rvat io n Pro t o co l Depending on the location and size of the tumor, the surgeon
can choose between three different incisions: (a) transverse
For neonatally detected adrenal tumors that are thought to be transperitoneal–supraumbilical incision (for primary tumor of
localized neuroblastoma, an option for close observation the retroperitoneum), (b) bilateral subcostal chevron incision
without surgical intervention has been proposed. This is based (for large tumors), or (c) thoracoabdominal incision (for up-
on the experience that many of these lesions may regress or per abdominal and/or large tumors).
Chap t e r 95: Ne urob lastoma 625
The retroperitoneum is entered by incising the posterior technique. A pneumoperitoneum is created, with the pressure
peritoneum along the white line of Toldt. The colon is re- maintained at around 12 mm H g. Two 3- or 5-mm ports are
flected medially to expose the retroperitoneum. For left-sided then placed under laparoscopic vision. The retroperitoneum is
tumors the spleen and pancreas are displaced upward and me- then dissected using electrocautery and/or a H armonic Scalpel
dially. For tumors on the right side the various peritoneal (Ethicon Endo-Surgery, O hio).
attachments of the liver can be divided to improve exposure. O n the right side, the retroperitoneum may be entered by a
In children with locally metastasizing disease it is sometimes transverse incision in the posterior peritoneum to expose the
necessary to perform en bloc excision of adjacent organs (i.e., inferior vena cava and the region of the adrenal gland. When
ipsilateral kidney, spleen). N euroblastomas typically have a operating on a left-sided lesion, the colon should be mobi-
friable pseudocapsule; therefore, during dissection it is useful lized; this is achieved by incising the posterior peritoneum
to think of the surgery as aimed at dissecting the patient from along the line of Toldt from the splenic flexure to the pelvic
around the tumor to decrease the risk of tumor spillage. rim. The major vessels surrounding the tumor, such as the in-
Vascular control should be achieved early in the procedure. ferior vena cava and the renal vein and artery and the adrenal
These tumors often invade the tunica adventitia of large blood vessels, are mobilized by blunt dissection; this dissection
vessels; therefore, special care should be taken to identify and should begin medially and proceeds laterally. Vascular control
spare the blood supply to important visceral structures such as may be obtained at this time prior to proceeding with the
the branches of the celiac axis and superior mesenteric artery. biopsy or excision of the mass.
The venous drainage of these tumors is usually constant, with O nce the tumor surface has been adequately exposed, a
right-sided tumors draining directly into the inferior vena Tru-cut biopsy of the tumor can be obtained by passing the
cava. Left-sided tumors drain into the left renal vein and sub- biopsy needle through one of the 5-mm ports or directly
diaphragmatic venous tributaries. Regional lymph nodes through the abdominal wall and performing the biopsy under
should be sampled to complete the surgical staging. O nce the visualization. H emostasis is then obtained. It is recommended
tumor has been resected, the margins of the tumor bed should that an incisional biopsy be obtained when possible as this
be marked with titanium clips to guide radiation therapy. A minimizes the chances of sampling error and provides the sur-
liver biopsy is indicated if there is clinical or imaging suspicion gical pathologist with adequate quantities of tissue. The tissue
of disease within the liver; an effort should be made to biopsy specimen is placed in a laparoscopic bag and removed through
the involved area. the umbilical port. The defect may be cauterized, but to
In some instances it is not possible to perform primary re- achieve complete hemostasis, an absorbable hemostatic agent
section of the tumor; in these cases a wedge biopsy of the tu- may be applied to the surface of the tumor. The fascial defect
mor should be obtained for histopathological and genetical left by the ports is closed with an absorbable suture, and the
analysis. N euroblastoma tissue should be rushed to the lab for skin edges are approximated. Some authors advocate that the
processing in a fresh state. Following a good response to fascial defect in 5-mm and smaller ports does not require clo-
chemotherapy, the residual tumor may be successfully re- sure because the risk of visceral herniation is low (8). N o
moved at a “ second-look” procedure (7). drains are left at the end of the procedure. To avoid port site
recurrence, high-dose adjuvant chemotherapy is given as soon
as possible.
Lap aro sco p ic (Minimally Invasive )
Pro ce d ure s fo r Ne uro b last o ma
M inimally invasive surgery (M IS) procedures are accepted as a O UTCO MES
safe alternative to open surgery. Its use in children has been in-
creasing rapidly as evidenced by a growing body of literature. Re sult s
The theoretical benefits include decreased surgical stress, de-
creased postoperative morbidity, decreased use of narcotic M odern chemotherapy has conferred improved survivability
analgesics, reduced time to initiation of enteral nutrition, and upon many pediatric neoplasms (e.g., Wilms tumor); however,
improved cosmetic appearance. M ost importantly, the earlier in the case of neuroblastoma chemotherapy has had no such
recovery may reduce the time to initiation of adjuvant therapy. effect. Although a demonstrable initial tumor response is
Previously, M IS techniques were reserved for biopsy prior to achieved in 70% to 80% of patients, current chemothera-
planned multimodal therapy in diffuse disease; however, there peutic protocols have not effectively increased the cure rate
are several contemporary reports in the literature that have in patients with neuroblastoma. The main purpose of
described M IS, including the use of the surgical robot, as a chemotherapy in the management of children with stage II or
safe alternative to open surgery for excision of small localized higher-stage neuroblastoma is to reduce the size of the tumor
primary lesions. This has not gained widespread international (permitting surgical excision), to clear the bone marrow of tu-
acceptance; thus, the following discussion is limited to the mor cells, and possibly to produce histological maturation of
technique of laparoscopic biopsy. the tumor.
General anesthesia is induced and the patient undergoes Figure 95.1 shows a coronal view from an M RI scan of a
endotracheal intubation. An orogastric or nasogastric tube solitary tumor adjacent to the lower pole of the right kidney. The
and urethral catheter are placed. The patient is then posi- patient was treated with surgical excision alone and remained
tioned in a 45-degree lateral decubitus position. The use of the free from relapse. Figure 95.2 shows the microscopic pathol-
open H asson technique is strongly recommended for initial ogy from the same mass consisting of small round blue cells
umbilical trocar placement (5 to 12 mm) to lower the risk of typical of neuroblastoma. Patients such as this with Evans stage
visceral or vascular injury associated with the Veress needle I or II with favorable histology (low-risk) neuroblastoma do not
therapy protocols include delivery of hyperfractionated radio-

therapy (2,100 cGy at 150 cGy twice daily). The final setting
for external beam treatments is a total body irradiation given
as part of a preparative regimen for autologous bone marrow
transplantation. IO RT is being used to treat patients with
advanced-stage disease. Initial reports demonstrate a low
complication rate with IO RT and a 38% 3-year survival rate
in patients with stage IV disease.
The age of the patient and the stage of the disease at the
time of diagnosis were the two main independent variables de-
termining the prognosis of children with neuroblastoma. The
worst survival data were observed in patients older than
1 year, with stage IV disease, and with metastases to cortical
bone (12). O ver the years a number of factors have become
available to the clinician managing these patients to help de-
termine the prognosis of the individual patient. These factors
are presented in Table 95.4. Patients with neuroblastoma de-
tected by urinary screening for VM A and H VA in Japan have
a survival rate of 96% , suggesting that most of these tumors
spontaneously regress and do not present with clinical disease
(13). The intrinsic properties of the tumor itself appear to be
the greatest determinant of the eventual outcome of the
patient with neuroblastoma. Survival data from the Children’s
FIGURE 95.1 Coronal M RI scan of a 1-year-old girl found to have a
left pararenal mass on a screening ultrasound after a urinary tract
Cancer Group neuroblastoma protocols are presented in
infection. Table 95.5 (13).
Surg ical Co mp licat io ns

Among the potential complications of open surgery are vascu-
lar injuries that may occur during dissection of the tumor.
O thers complications include injury to adjacent intraperi-
toneal organs (e.g., splenic injury, pancreatic injuries), lym-
phatic leak, brachial plexus injury related to patient
positioning, and acute renal failure (secondary to spasm of the
renal artery). M IS complications include hypercapnia, hy-
pothermia, surgical emphysema, and electrosurgical complica-
tions. O thers are gas embolisms, tension pneumothorax,
complications of surgical access, Veress needle injury to blood
vessels or bowel structures, access failure, bleeding/vascular
injury, and visceral injuries. Port site neoplastic recurrences
have also been described.
FIGURE 95.2 M icroscopical view of lesion excised from patient in

Figure 95.1 showing small round blue cells consistent with neuro- CO NCLUSIO N
blastoma.
N euroblastoma is a common pediatric malignancy that re-
mains an enigma because of the high variability in its natural
require adjuvant chemotherapy if the tumor can be surgically history and behavior. Information on prenatally detected cases
excised. Patients with stage II to IV disease and poor prognostic and the infant screening programs have clearly demonstrated
biological factors (intermediate- to high-risk neuroblastoma) that some tumors spontaneously regress and may be managed
should be treated with multiagent chemotherapy, including with close observation. A better understanding of the factors
a combination of carboplatin, doxorubicin (Adriamycin), influencing tumor regression, tumor differentiation, and tumor–
cyclophosphamide, and etoposide (VP-16) (9). host immunorelations will improve our ability to identify and
Clinical experience has demonstrated that neuroblastoma aggressively treat patients at risk for a poor outcome (14).
is a radiosensitive tumor. Tumor shrinkage and symptomatic This knowledge may also allow a decrease in treatment-
pain relief are often observed after radiation treatment. In related morbidity in patients with low-risk tumors. O ngoing
patients with advanced neuroblastoma, lymph node metastases, clinical trials utilizing retinoic acid and gene therapy may
and/or incomplete surgical resection of the primary tumor, result in the development of additional tools in the clinical
chemoradiotherapy appears to improve long-term disease armamentarium to better treat neuroblastoma and further
control as compared to chemotherapy alone (10,11). Radiation improve the prognosis of these patients (15).
Chap t e r 95: Ne urob lastoma 627
TA B LE 9 5 . 4
FACTORS AFFECTIN G PROGN OSIS OF THE CHILD WITH N EUROBLASTOMA
Prognostic Factor Good Prognosis Poor Prognosis
Patient age 1 yr 1 yr
Tumor stage I, II, IV-S III, IV
Shimada histology Stroma rich Stroma poor
Site of tumor M ediastinum, pelvis, neck Adrenal, celiac axis
10 copies N -m yc No Yes
DN A flow cytometry H yperdiploid Diploid
Elevated trk-A Yes No
Elevated serum ferritin No Yes
N euron-specific enolase No Yes
Lactate dehydrogenase No Yes
Loss of heterozygosity
(LO H ) chromosome 1p No Yes
M ultidrug-resistant gene No Yes
M ultidrug-resistant
protein–gene No Yes
Somatostatin receptors Yes No
Vasoactive intestinal
peptide secretion Yes No
M H C class I antigen Yes No
Detection by screening Yes No
From Grosfeld JL. N euroblastoma. In: O ’N eill JA, Rowe M I, Grosfeld JL, et al., eds. Pediatric Surgery.
St. Louis, M O : M osby; 1988:405–419, with permission.
TA B LE 9 5 . 5
SURVIVAL DATA FROM CHILDREN’S CAN CER GROUP NEUROBLASTOMA PROTOCOLS
IN SS Tumor Stage All Ages Patients <1yr Patients >1yr
All stages 76% 32%

I 94–99%
II 89–96%
III 37%
IV 12% 50–75% 10%
IV-S 90%
IN SS, International N euroblastoma Staging System. From Grosfeld JL. Risk-based management: current concepts
of treating malignant solid tumors of childhood. J A m Coll Surg 1999;189:407–425, with permission.
References
1. Evans AE, Gerson J, Schnaufer L. Spontaneous regression of neuroblas- 9. N itschke R, Cangir A, Crist W, et al. Intensive chemotherapy for metasta-
toma. N atl Cancer Inst M onogr 1976;44:49–54. tic neuroblastoma: a Southwest O ncology Group study. M ed Pediatr
2. Grosfeld JL, Rescorla FJ, West KW, et al. N euroblastoma in the first year of O ncol 1980;8:281–288.
life: clinical and biologic factors influencing outcome. Sem in Pediatr Surg 10. H aase GM , LaQ uaglia M P. N euroblastoma. In: Z eigler M M , Azizkhan
1993;2:37–46. RG, Weber TR, eds. O perative Pediatric Surgery. 1st ed. N ew York:
3. Evans AE, D’Angio GJ, Randolph J. A proposed staging for children with neu- M cGraw-H ill Professional, 2003:1181–1191.
roblastoma. Children’s Cancer Study Group A. Cancer 1971;27:374–378. 11. H aase GM , O ’Leary M C, Ramsay N K, et al, et al. Aggressive surgery com-
4. Brodeur GM , Seeger RC, Barrett A, et al. International criteria for diagnosis, bined with intensive chemotherapy improves survival in poor-risk neuro-
staging, and response to treatment in patients with neuroblastoma. J Clin blastoma. J Pediatr Surg 1991;26:1119–1124.
O ncol 1988;6:1874–1881. 12. Grosfeld JL, Baehner RL. N euroblastoma: an analysis of 160 cases. W orld
5. Shimada H , Ambros IM , Dehner LP, et al. The International N euroblastoma J Surg 1980;4:29–37.
Pathology Classification (the Shimada system). Cancer 1999;86:364–372. 13. Grosfeld JL. Risk-based management: current concepts of treating malig-
6. Fritsch P, Kerbl R, Lackner H , et al. “ Wait and see” strategy in localized nant solid tumors of childhood. J A m Coll Surg 1999;189(4):407–425.
neuroblastoma in infants: an option not only for cases detected by mass 14. Grosfeld JL. N euroblastoma. In: O ’N eill JA, Rowe M I, Grosfeld JL, et al.,
screening. Pediatric Blood Cancer 2004;43:679–682. eds. Pediatric Surgery. 5th ed. St. Louis: M osby, 1998:405–419.
7. Kumar AP, Wrenn EL Jr, Fleming ID, et al. Preoperative therapy for unre- 15. Reynolds CP, Kane DJ, Einhorn PA, et al. Response of neuroblastoma to
sectable malignant tumors in children. J Pediatr Surg 1975;10:657–670. retinoic acid in vitro and in vivo. Prog Clin Biol R es 1991;366:203–211.
8. Bloom DA, Ehrlich RM . O mental evisceration through small laparoscopy
port sites. J Endourol 1993;7:31–33.
CHAPTER 96 ■ WILMS TUMO R
SARAH CO NLEY AND MICHAEL L. RITCHEY
Wilms tumor, or nephroblastoma, is the most common solid represent precursor lesions in children genetically predisposed
tumor of childhood. It represents approximately 6% of all to Wilms tumor. N Rs are categorized as either perilobar or
childhood cancers in the United States and is the most com- intralobar based on their anatomical location within the kid-
mon primary malignant renal tumor of childhood. The inci- ney. Perilobar N Rs are observed in kidneys harboring Wilms
dence of Wilms tumor is 1 in 10,000 children, with a new case tumors with WT2 locus deletions, whereas intralobar N Rs
rate of approximately 500 annually in the United States. The are more often observed in those with WT1-associated
incidence has remained stable for the past several decades and tumors (5). The presence of multiple N Rs in the nontumoral
is equal among boys and girls (1). The mean age at diagnosis portion of a Wilms tumor kidney has been shown to be a risk
for unilateral Wilms tumor is 36.5 months for boys and 42.5 factor for development of metachronous tumor in the con-
months for girls. The age of peak incidence for bilateral tu- tralateral kidney.
mors is lower for both sexes: 29.5 months for boys and 32.6
months for girls.
M ost cases of Wilms tumor are sporadic; however, there
are certain phenotypical syndromes associated with Wilms tu- DIAGNO SIS
mor (2). These syndromes are divided into overgrowth and
non-overgrowth categories. Examples of overgrowth syn- M ore than 90% of children with Wilms tumor present with
dromes include Beckwith–Wiedemann syndrome, Perlman an asymptomatic abdominal mass discovered incidentally by a
syndrome, Sotos syndrome, and Simpson–Golabi–Behmel family member or physician. The mass may be extremely large
syndrome. Examples of non-overgrowth syndromes include relative to the size of the child and is not necessarily confined
isolated aniridia, trisomy 18, WAGR syndrome (Wilms tumor, to one side. Approximately 20% of children with Wilms tu-
aniridia, genitourinary malformations, and mental retarda- mor have hematuria at diagnosis. Gross hematuria warrants
tion), Bloom syndrome, and Denys–Drash syndrome. Wilms further evaluation to rule out tumor extension into the collect-
tumor is also associated with isolated genitourinary anomalies ing system (6). O ther symptoms include fever, anorexia, and
such as hypospadias, cryptorchidism, and renal fusion. Less weight loss in 10% of patients. Rarely children may present
than 2% of Wilms tumor cases show familial patterns of with acute abdominal pain from tumor rupture into the peri-
inheritance. toneal cavity or bleeding within the tumor. A persistent vari-
The identification of the relationship between Wilms tu- cocele in the supine position or hepatomegaly may be
mor and WAGR syndrome led to the discovery of genes asso- reflective of inferior vena caval obstruction from tumor
ciated with Wilms tumor. The WT1 gene located on thrombus. Atrial thrombus may present as hypertension or
chromosome 11p13 encodes a transcriptional factor that congestive heart failure.
serves both tumor-suppressive and developmental regulatory The preoperative laboratory evaluation of a child with an
functions (2). N onmutated WT1 is critical in the early em- abdominal mass should include a complete blood count, liver
bryogenesis of the genitourinary system. WT1 mutations are enzymes, and serum electrolytes, including blood urea nitro-
present in up to 15% of patients with unilateral Wilms tumors gen, creatinine, and calcium. There is an 8% incidence of ac-
(3). Another genetical mutation associated with Wilms tumor quired von Willebrand disease in patients newly diagnosed
has been designated the WT2 gene, located on chromosome with Wilms tumor. Coagulation studies, including prothrom-
11p15. Loss of heterozygosity (LO H ) at this locus is associ- bin time and partial thromboplastin time, may be normal in
ated with Beckwith–Wiedemann syndrome. the presence of von Willebrand disease. This defect can be cor-
LO H at chromosome 16q and/or 1p occurs in up to 20% rected preoperatively with the administration of 1-desamino-
of Wilms tumors (4). These have been shown to be associated 8-D-arginine-vasopressin (DDAVP).
with an increased risk for tumor relapse and mortality. In The first radiographic study usually obtained in children
N ational Wilms Tumor Study (N WTS)-5, patients with stage I with an abdominal mass is an abdominal ultrasound, which
or II favorable-histology Wilms tumor (FH WT) and LO H of can differentiate between solid and cystic masses. Real-time
either 1p or 16q had an increased relative risk of relapse and ultrasonography of the renal vein and inferior vena cava (IVC)
death compared to patients lacking LO H at either locus. The can evaluate for the presence of tumor thrombus in children
risks of relapse and death for patients with stage III or IV with renal tumors. If this study is inconclusive, magnetic reso-
FH WT were increased only with LO H for both regions. nance (M R) imaging is an excellent modality to assess for ve-
N ephrogenic rests (N Rs) are foci of primitive metanephric nous tumor extension. All patients should undergo computed
tissue that persist into infancy and are found in 1% of infant tomography (CT) of the abdomen and pelvis with oral and in-
postmortem kidneys. The presence of N Rs in up to 44% travenous contrast or M R of the abdomen and pelvis with
of kidneys removed for Wilms tumor suggests that they gadolinium. These imaging modalities allow for improved
628
Chap t e r 96: Wilms Tumor 629
preoperative planning by evaluating for extrarenal spread of primary tumor, facilitating surgical excision. The SIO P trials
disease, the relationship of the tumor to adjacent visceral have demonstrated that the incidence of tumor rupture is
structures, and the presence of synchronous tumors in the lower after preoperative therapy (9). There is no survival
contralateral kidney. Preoperative chest CT is performed to advantage over a primary surgical approach.
rule out pulmonary metastases. The Children’s O ncology Group (CO G) recommends pre-
operative chemotherapy in children with bilateral tumors, tu-
mors inoperable at surgical exploration, or IVC extension
above the hepatic veins. All other patients are recommended
INDICATIO NS FO R SURGERY to undergo primary excision of the tumor. This allows precise
staging of patients with modulation of treatment for each
There have been tremendous advances in survival with adju- individual, thereby decreasing the intensity of treatment when
vant therapy, but surgery remains an integral part of the mul- possible while maintaining excellent overall survival.
timodal approach to treatment of Wilms tumor. Primary
radical nephrectomy is the procedure of choice for the major-
ity of patients with unilateral Wilms tumor. N ephron-sparing
surgery is preferred for children with bilateral tumors. It may SURGICAL TECHNIQ UE
be considered for some children with syndromes known to be
at high risk for development of Wilms tumor, particularly if The recommended surgical approach for Wilms tumor is
these patients are found to have small tumors on screening through a transperitoneal transabdominal incision. An ex-
studies (7). There are reports of laparoscopic nephrectomy in traperitoneal flank incision should be avoided because it does
children with unilateral nonmetastatic Wilms tumor who re- not allow for proper staging. A generous transverse abdomi-
ceived preoperative chemotherapy (8). H owever, the role of nal incision allows for inspection and exploration of the
laparoscopy prior to chemotherapy may be limited because abdominal cavity. The patient is placed in a supine position
of large tumor size and risk of intraoperative spillage. with mild flexion of the lumbar spine to facilitate the exposure
H istopathology and tumor stage have been demonstrated to of retroperitoneal structures. The incision is made approxi-
be the key determinants of prognosis in patients with Wilms mately two fingerbreadths above the umbilicus beginning in
tumor. Tumor grade is the most important prognostic factor. the midaxillary line on the side of the neoplasm. The extent to
Assignment of tumor stage (Table 96.1) is based on intraoper- which the incision is extended across the midline will vary
ative and pathological findings. with the size of the tumor and amount of exposure needed.
The International Society of Pediatric O ncology (SIO P) ad- The incision may be extended into a thoracoabdominal ap-
vocates preoperative chemotherapy for all patients with proach by continuing through the bed of the ninth or tenth
Wilms tumor regardless of the extent of disease. Preoperative rib, if necessary. The muscle layers are divided sequentially to
treatment can produce dramatic reduction in the size of the facilitate exposure. The peritoneal space should be opened
carefully. The tumor may compress the colon and/or small
bowel against the anterior abdominal wall, inadvertently re-
sulting in enterotomy. A thorough exploration of the abdomen
TA B LE 9 6 . 1
is performed. The peritoneal cavity is assessed for evidence of
STAGIN G SYSTEM OF THE CHILDREN ’S ON COLOGY preoperative tumor rupture and peritoneal implants. The liver
GROUP is carefully examined, as liver metastases may not be identified
on preoperative imaging studies. An assessment of tumor
Stage Characteristics extent is performed next, including palpation of the IVC and
I The tumor is limited to the kidney and completely assessment of regional lymphadenopathy, perinephric exten-
excised. The renal capsule is intact and the sion, and tumor mobility.
tumor was not ruptured prior to removal. There In the past, formal exploration of the contralateral kidney
is no residual tumor. The vessels of the renal was routinely performed in children with presumed unilateral
sinus are not involved. Wilms tumor to rule out synchronous bilateral tumors.
II The tumor extends beyond the kidney, but is Imaging has improved dramatically over time and very few
completely excised. There is regional extension small contralateral lesions will be missed on preoperative
of the tumor (i.e., penetration of the renal imaging. Long-term outcomes in these cases are favorable (10).
capsule, extensive invasion of the renal sinus). Contralateral renal exploration is no longer recommended if
Extrarenal vessels may contain tumor thrombus preoperative CT or M R demonstrates a normal kidney.
or be infiltrated by tumor.
Following exploration of the abdominal cavity, the colon is
III Residual nonhematogenous tumor confined to reflected medially by incising the white line of Toldt. The
the abdomen: lymph node involvement, tumor
colonic mesentery is mobilized, with care taken to preserve the
spillage either before or during surgery,
peritoneal implants, tumor beyond surgical colonic vessels that may be draped over the tumor. The colon
margin either grossly or microscopically, or can then be retracted medially to expose the renal vessels (Fig.
tumor not completely removed. 96.1). For right-sided tumors, the posterior peritoneum can be
IV H ematogenous metastases (lung, liver, bone, incised up to the base of the mesentery. This will allow reflec-
brain, etc.) or lymph node metastases outside tion of the entire colon and small bowel, which provides ex-
the abdominopelvic region are present. cellent exposure of the retroperitoneal vessels. Early ligation
V Bilateral renal involvement at diagnosis of the renal vessels before manipulation is ideal. The renal ves-
sels are identified and encircled individually with vessel loops.
FIGURE 96.1 Descending colon retracted me-

dially after incising of the line of Toldt and mo-
bilizing of the mesocolon off the anterior surface
of the tumor.
The artery can be identified with careful retraction of the thrombus is free floating, it is manually extracted at this point.
vein. The renal vein and IVC should be carefully palpated for In many cases, the thrombus is adherent to the wall of the
the presence of Wilms tumor thrombus, which occurs in 4% IVC. A Fogarty or Foley balloon catheter can be passed be-
and 0.7% of patients, respectively. Prior to ligation of the ves- yond the level of the hepatic veins, then inflated. The catheter
sels, the contralateral renal vessels and superior mesenteric is then pulled inferiorly, thus displacing the adherent throm-
artery are identified to avoid injury to these structures. Large bus into the cavotomy. The vena IVC is allowed to fill by re-
tumors can significantly distort vascular anatomy. The renal leasing the vessel loops on the distal cava and contralateral
vessels are then doubly ligated and divided. The renal artery renal vein. This will displace the air from within the IVC. The
should be ligated prior to the renal vein in order to avoid dis- cavotomy is then clamped with a Satinsky clamp and over-
tention of the vein, which can dislodge the ligature. Early liga- sewn with a continuous 5-0 Prolene suture (Fig. 96.3). In rare
tion of the artery also decreases the theoretical risk of tumor instances, tumor thrombus invades the wall of the IVC, pre-
dissemination. cluding thrombectomy, and this may necessitate partial resec-
An alternative for management of the renal vein is to place tion of the IVC.
a Satinsky clamp on the vena IVC just proximal to the inser- Patients with IVC extension above the level of the hepatic
tion of the renal vein. This maneuver can be valuable when the veins or atrial thrombus remain a difficult surgical challenge.
vein is short or if there is tumor extension beyond the renal Pretreatment with chemotherapy is usually done. If this fails
vein. The tumor thrombus is gently milked back prior to to shrink the thrombus or if a primary surgical approach is
placement of the Satinsky clamp. The renal vein is then chosen, the procedure may require cardiopulmonary bypass
divided and the venous stump is oversewn with continuous and benefit from a combined abdominothoracic approach
5-0 Prolene in two layers (Fig. 96.2). with a pediatric cardiothoracic surgeon. Suprahepatic or atrial
If tumor thrombus is present in the IVC, additional surgi- involvement is best approached through a median sternotomy.
cal exposure is warranted. Both proximal and distal vascular This can be performed in conjunction with a subcostal incision
control is necessary. For minimal thrombus extension below or a midline abdominal incision required for nephrectomy.
the level of the hepatic veins, the inferior edge of the liver can After the vessels are controlled, a dissection plane is estab-
be retracted to expose the infrahepatic vena cava. For a tumor lished outside of the fascia of Gerota by sharp and blunt dis-
that extends more cephalad, mobilization of the liver is resection. The perforating vessels can be quite large and should
quired. Division of the triangular and coronary ligaments of be ligated individually. Gentle manipulation of the tumor
the liver allows rotation and exposure of the retrohepatic vena should be emphasized. Wilms tumors are very soft and may
cava. Additional exposure can be gained by dividing the lesser easily rupture, leading to tumor spill and an increased risk of
hepatic veins. The contralateral renal vein and infrarenal IVC local recurrence (11).
are controlled with vessel loops. The vena IVC is then verti- The ureter is palpated to rule out intraureteral extension
cally incised just medial to the entrance of the renal vein. If the before it is divided as distally as possible (6). Formal lymph
FIGURE 96.2 M obilization of left-sided Wilms tumor by blunt dissection after ligation and division of
the (A) renal artery and (B) vein.
node dissection is not required, but all suspicious lymph nodes more renal units preserved. This is important because the risk
should be biopsied. Lymphatic tissue in the renal hilum and of renal failure in patients with bilateral disease approaches
adjacent precaval and preaortic areas is generally removed 15% at 15 years posttreatment (13).
with the specimen. Failure to sample lymph nodes will man- The proposed CO G protocol for patients with bilateral
date increased therapy due to an increased risk of local recur- Wilms tumor recommends 6 weeks of chemotherapy prior
rence secondary to incomplete staging (11). After extraction to surgery. Tumor response is evaluated with CT or M R after
of the intact tumor, the wound is copiously irrigated and he- 6 weeks.
mostasis is assessed. Drains are not routinely placed unless a Patients with tumors amenable to renal-sparing procedures
portion of the pancreas or liver has been resected. The dis- can proceed with surgery. If there has not been a good re-
placed colon is replaced in the tumor bed. sponse, biopsy of the tumor(s) is recommended to determine
the histology. Additional chemotherapy is then given, but all
patients should proceed to surgical resection within 12 weeks
Bilat e ral Tumo rs of starting therapy.
At the time of definitive surgery, partial nephrectomy or
Synchronous bilateral Wilms tumor occurs in 4% to 6% of wedge excision of the tumor is preferred, but only if it will not
patients with Wilms tumor (12). Children with bilateral compromise tumor resection and if negative margins can be
Wilms tumors should not undergo initial radical nephrec- obtained. The kidney with the lower tumor burden is ad-
tomy; rather, they should receive preoperative chemotherapy dressed first. If complete excision of tumor from this kidney
with the goal of tumor shrinkage and renal preservation. can be performed leaving a viable and functioning kidney,
Children treated with preoperative chemotherapy will have then surgery of the contralateral kidney with more extensive
FIGURE 96.3 Surgical technique to manage tumor extension through the renal vein. A: Tumor extension
into the vena cava (limited to the infrahepatic level). B: After exposure of the vessels, the infrarenal vena
cava and contralateral renal vein are controlled with vessel loops and the vena cava is incised vertically at
the intersection with the renal vein. C: A Fogarty catheter is passed superior to the tumor thrombus and
the balloon is inflated. D: The vena cava is flushed of air and a Satinsky clamp is placed to allow closure
of the cavotomy.
tumor involvement is done. Enucleation of the tumor may be tumor; therefore, renal-sparing surgery should be entertained
considered in lieu of a formal partial nephrectomy. This will in all patients.
usually be considered for large centrally located tumors where
removal of a margin of renal tissue would compromise the
vascular supply to the kidney. Even when very large bilateral PO STO PERATIVE CARE
masses remain after initial chemotherapy, a high percentage of
children can be successfully managed with renal-sparing All clinical trials for children with Wilms tumor strive to tai-
surgery (14). It is easy to underestimate the amount of renal lor treatment to individual risks for tumor recurrence and
parenchyma that can be salvaged due to compression by the reduce the overall morbidity of treatment. The latter will allow
TA B LE 9 6 . 2
RECOMMEN DED THERAPY ON CHILDREN ’S ON COLOGY GROUP PROTOCOLS
Stage/ Histology Radiotherapy Chemotherapy
Stage I FH WT 2 y, 550 g N one N one

Stage 1 FH WT, 2 y or 550g N one Regimen EE-4A
Stage II FH WT N one Regimen EE-4A
Stage I or II FH WT and LO H 1p, 16q N one Regimen DD-4A
Stage III FH WT, no LO H 1p, 16q Yes Regimen DD-4A
Stage I–III focal AH WT Yes Regimen DD-4A
Stage I diffuse AH WT Yes Regimen DD-4A
Stage III or IV FH WT and LO H 1p, 16q Yes Regimen M
Stage IV FH WT pulmonary metastases
Lesions resected at diagnosis Yes Regimen DD-4A
Lesions resolve after 6 weeks chemo N one Regimen DD-4A
Lesions persist after 6 weeks chemo Yes Regimen M
Stage IV FH WT nonpulmonary metastases Yes Regimen M
Stage II or III diffuse AH WT Yes Regimen UH -1
Stage IV diffuse AH WT Yes Regimen UH -1
(no measurable disease)
Stage IV focal AH WT Yes Regimen UH -1
Stage I CCSK N one Regimen I
Stage II or III CCSK Yes Regimen I
Stage IV CCSK Yes Regimen UH -1
Stage I–III M RT Yes Regimen UH -1
Stage IV M RT Yes Regimen UH -2
Stage IV AH WT (measurable disease) Yes Regimen UH -2
Regimen EE-4A: Pulse-intensive AM D plus VCR (18 weeks)

Regimen DD-4A: Pulse-intensive AM D, VCR, and DO X (24 weeks)
Regimen M : VCR, AM D, DO X, alternating with CYCLO and ETO P (24 weeks)
Regimen UH -1: CYCLO , carboplatin, ETO P alternating with VCR, DO X, CYCLO (30 weeks)
Regimen I: VCR, DO X, CYCLO alternating with CYCLO , ETO P (24 weeks)
Regimen UH -2: VCR, DO X, CYCLO alternating with CYCLO , carboplatin, ETO P and VCR, irinotecan (30 weeks)
FH WT, favorable-histology Wilms tumor; LO H , loss of heterozygosity; AH WT, anaplastic-histology Wilms tumor;
CCSK, clear cell sarcoma of the kidney; M RT, malignant rhabdoid tumor of the kidney; AM D, dactinomycin; VCR,
vincristine; DO X, doxorubicin; CYCLO , cyclophosphamide; ETO P, etoposide.
clinicians to reduce treatment-related side effects. Current treat- (AH WT) and stage I diffuse AH WT are treated with AM D,
ment recommendations of the CO G are listed in Table 96.2 VCR, DO X, and abdominal irradiation. Patients with stage II,
(3,15). All renal tumors are eligible for enrollment in CO G III or IV (no measurable disease) diffuse AH WT, stage IV focal
protocols, including renal cell carcinoma and congenital AH WT, stage IV clear cell sarcoma, and stage I to III malignant
mesoblastic nephroma. rhabdoid tumor will be treated with a new chemotherapy regi-
There are several study arms grouped by risk for recurrence men to try to improve overall survival.
(very low, low, standard, and high). The CO G will again exam-
ine the role of surgery-only treatment for patients with stage I
FH WT weighing 550 g and age 2 years. Children with stage
I or II FH WT and LO H of 1p and 16q will undergo treatment O UTCO MES
with vincristine (VCR), dactinomycin (AM D), and doxorubicin
(DO X) without radiotherapy. Patients with stage III FH WT dis- Co mp licat io ns
ease without LO H of 1p and 16q are treated with VCR, AM D,
and DO X and irradiation of the flank or abdomen. The CO G The most common intraoperative complication of nephrec-
will evaluate a response-based approach for management of tomy for Wilms tumor is bleeding. M ajor vascular injuries and
children with pulmonary metastases. Those with resolution of injury to other organs are less frequent. Following surgery the
the pulmonary lesions on chest CT after 6 weeks of chemotherapy most common complication is small bowel obstruction, which
will not be given whole-lung irradiation and will be treated occurs in about 5% of patients. The surgical complication rate
with VCR, AM D, and DO X. Patients who do not have resolu- of nephrectomy for Wilms tumor has declined over the past
tion of the pulmonary lesions by week 6 will receive more in- three decades.
tensive chemotherapy and pulmonary irradiation. Children Preoperative chemotherapy may influence surgical complica-
with stage I to III focal anaplastic histology Wilms tumor tion rates by producing tumor shrinkage. In a report from SIO P,
nephrectomy performed after 4 or 8 weeks of chemotherapy was

associated with an overall surgical complication rate of 5% (16). Re sult s
A prospective comparison of complications in patients enrolled
The overall prognosis for children with FH WT is excellent as
in the N WTS-5 and the SIO P-93-01 trials demonstrated that the
a result of multimodal therapy. Common sites of recurrence
overall complication rate for the SIO P patients was 6.4% com-
are the lungs, liver, and renal fossa. Tumor histology and clin-
pared to 9.8% in N WTS-5 patients (17). There was a much
ical stage are the most important predictors of outcome. There
lower incidence of intraoperative tumor spill in the SIO P patients
is an increased risk for local recurrence in the setting of unfa-
(2.2% ) than the N WST-5 ones (15.3% ).
vorable histology and intraoperative tumor rupture (11).
A mortality rate of 0.5% related to surgical complications
O mission of lymph node biopsy also correlates with recur-
was reported from N WTS-3. H owever, a higher intraoperative
rence and is attributed to understaging. Preventing local recur-
mortality rate of 1.5% has been reported from other centers.
rence is important as the survival after abdominal recurrence
The latter may reflect that intraoperative deaths may not be
is poor. Current trials continue to refine chemotherapeutic
reported to the cooperative groups since study enrollment
regimens to improve survival, in particular for higher-risk
occurs after surgery. Factors that have been associated with an
populations with unfavorable histology. The use of biological
increased risk for surgical complications are higher tumor
factors to further stratify patients for therapy may further
stage, tumor size 10 cm, incorrect preoperative diagnosis,
advance survival and minimize late effects of treatment.
thoracoabdominal incision, intracaval tumor extension, and
resection of other visceral organs.
References
1. Breslow N , O lshan A, Beckwith JB, et al. Ethnic variation in the incidence, 10. Ritchey M L, Shamberger RC, H amilton T, et al. Fate of bilateral renal le-
diagnosis, prognosis, and follow-up of children with Wilms’ tumor. J N atl sions missed on preoperative imaging: a report from the N ational Wilms
Cancer Inst 1994;86:49–51. Tumor Study Group. J Urol 2005;174:1519–1521.
2. Dome JS, Coppes JM . Recent advances in Wilms tumor genetics. Curr 11. Shamberger RC, Guthrie KA, Ritchey M L, et al. Surgery-related factors
O pin Pediatr 2002;14:5–11. and local recurrence of Wilms’ tumor in N ational Wilms’ Tumor Study 4.
3. Ehrlich PF. Wilms tumor: progress and considerations for the surgeon. Surg A nn Surg 1999;229:292–297.
O ncol 2007;16:157–171. 12. H orwitz JR, Ritchey M L, M oksness J, et al. Renal salvage procedures in
4. Grundy PE, Breslow N E, Li S, et al. Loss of heterozygosity for chromo- patients with synchronous bilateral Wilms’ tumors: a report from the
somes 1p and 16q is an adverse prognostic factor in favorable histology N ational Wilms’ Tumor Study Group. J Pediatr Surg 1996;31:1020–1025.
Wilms tumor: a report from the N ational Wilms Tumor Study Group. J 13. Breslow N E, Collins AJ, Ritchey M L, et al. End-stage renal disease in pa-
Clin O ncol 2005;23:7312–7321. tients with Wilms tumor: results from the N ational Wilms Tumor Study
5. Beckwith JB. N ephrogenic rests and the pathogenesis of Wilms tumor: Group and the United States Renal Data System. J Urol 2005;174:
developmental and clinical considerations. A m J M ed G enet 1998;79: 1972–1975.
268–273. 14. Davidoff AM , Giel DW, Jones DP, et al. The feasibility and outcome of
6. Ritchey M L, Daley S, Shamberger R, et al. Ureteral extension in childhood nephron-sparing surgery for children with bilateral Wilms tumor. Cancer
renal tumors: a report from the N ational Wilms Tumor Study Group 2008;112:2060–2070.
(N WTSG). J Pediatr Surg 2008;43:1625–1629. 15. Dome JS, Cotton CA, Perlman EJ, et al. Treatment of anaplastic histology
7. M cN eil DE, Langer JC, Choyke P, et al. Feasibility of partial nephrectomy Wilms’ tumor: results from the fifth N ational Wilms’ Tumor Study. J Clin
for Wilms’ tumor in children with Beckwith-Wiedemann syndrome who O ncol 2006;24:2352–2358.
have been screened with abdominal ultrasonography. J Pediatr Surg 16. Godzinski J, Tournade M F, deKraker J, et al. Rarity of surgical complica-
2002;37:57–60. tions after postchemotherapy nephrectomy for nephroblastoma. Experience
8. Duarte RJ, Denes FT, Cristofani LM , et al. Further experience with laparo- of the International Society of Paediatric Oncology—Trial and Study “SIOP-9.”
scopic nephrectomy for Wilms’ tumour after chemotherapy. BJU Intl Eur J Pediatr Surg 1998;8:83–86.
2006;98:155–159. 17. Ritchey M L, Godzinski J, Shamberger RC, et al. Surgical complications
9. Tournade M F, Com-N ougue C, Voute PA, et al. Results of the Sixth following nephrectomy for Wilms tumor: prospective study from the
International Society of Pediatric O ncology Wilms’ Tumor Trial and Study: N ational Wilms Tumor Study Group (N WTSG) and the International
a risk-adapted therapeutic approach in Wilms’ tumor. J Clin O ncol 1993; Society of Pediatric O ncology (SIO P). Unpublished manuscript.
11:1014–1023.
CHAPTER 97 ■ RENAL FUSIO N AND ECTO PIA

RO SS M. DECTER
Abnormalities of renal position and fusion predispose to infec- The ureteral bud branches from the wolffian duct and ex-
tion, hydronephrosis, stone disease, and, in some instances, tends toward the metanephric blastema during the fourth and
neoplasia. Although clinical problems associated with these fifth weeks of gestation. The ureteral bud induces the
anomalies present infrequently in urological practice, an un- metanephric blastema to form the functioning kidney. The ex-
derstanding of the deviations from standard urological tech- act mechanism of renal ascent is not known, but during nor-
niques required to address them is important. mal development the kidneys ascend and rotate. The renal
Chap t e r 97: Re nal Fusion and Ectop ia 635
FIGURE 97.1 Three common variants of blood

supply in horseshoe kidney. A: Single renal arteries
arising from the aorta. B: M ultiple aortic arteries.
C: M ultiple aortic and iliac arteries.
pelvis rotates from its initial anterior position 90 degrees to- than normal (Fig. 97.4). In crossed ectopia, the kidney crosses
ward the midline until it reaches its final medial position. the midline and is frequently fused to its contralateral mate.
M igration and rotation occur simultaneously between the The autopsy incidence of renal ectopia is about 1 in 1,000
fourth and eighth or ninth weeks of gestation. The blood sup- cases, and the condition often is totally asymptomatic (4).
ply to the kidney is derived from successively higher levels of Reviews of renal ectopia show that the left kidney is affected
the aorta and its branches during ascent. slightly more frequently than the right. Ectopic kidneys occur
The most common anomaly of renal position is malrota- bilaterally around 10% of the time, and the most common po-
tion: incomplete rotation of the kidney to its final position. sition of the ectopic kidney is in the pelvis. Pelvic ectopia was
The renal pelvis in a malrotated kidney in general lies anterior reported in about 55% of patients in one series of ectopic kid-
to the parenchyma, as opposed to its normal medial location. neys; crossed–fused ectopia occurred in 27% ; lumbar ectopia
Simple malrotation of a normally positioned kidney is often occurred in 12% ; non–crossed–fused ectopia occurred in 5%
an incidental finding. The pyelocaliceal systems of malrotated of patients; and a thoracic kidney was recorded only 1% of
kidneys are morphologically abnormal, but functionally they the time (4). Rarely, a solitary pelvic kidney occurs. This kid-
usually drain without impairment. M alrotation occurs occa- ney suffers the risk of injury during pelvic surgical procedures
sionally in orthotopically positioned kidneys, and it is com- and on occasion has been reported as an unusual cause of
monly observed in ectopic kidneys. giant hydronephrosis.
Close approximation of the two proliferating renal Ectopic kidneys are smaller than their orthotopically posi-
blastemas prior to significant ascent is a normal embryological tioned mates (5). The blood supply to the pelvic kidney, the
finding (1). If there is any disturbance of separation of the most common of the ectopic kidneys, is variable. The arterial
closely approximated renal blastemas, fusion anomalies of the supply may arise from the distal aorta or bifurcation, the ipsi-
kidneys may develop. lateral common iliac, or the hypogastric vessels. In general,
The most common fusion anomaly is the horseshoe kidney. the lower the kidney is in its pelvic location, the greater the
The horseshoe kidney in general ascends until the upper bor- likelihood that multiple arterial vessels will supply it (6).
der of the isthmus is at the level of the inferior mesenteric
artery. H orseshoe kidney occurs in 1 in 400 to 1 in 1,800
births (2). There is a male predominance for the condition (3).
The fusion in horseshoe kidney almost always occurs at the DIAGNO SIS
lower poles; cases of upper pole fusion are recorded rarely (3).
The isthmus of the horseshoe kidney lies just below the infe- Ho rse sho e Kid ne y
rior mesenteric artery at the L4 vertebral level. The blood sup-
ply to these kidneys is variable (Fig. 97.1). H istorically, 25% to 33% of patients with horseshoe kidneys
Crossed–fused ectopia is the second most common fusion who survived beyond the newborn period were asymptomatic
anomaly. This abnormality occurs when the developing kid- (3). The advent of prenatal ultrasound screening makes it likely
ney crosses from one side to the other during its ascent or that an even larger proportion of these kidneys are asympto-
when the ureteral bud from one side crosses to the contralat- matic. Patients with symptoms typically present with urinary
eral side and induces abnormal development of that tract infections (about 50% of the time), an abdominal mass,
metanephric blastema. Crossed ectopia with fusion may occur hematuria, or abdominal pain (approximately 10% each).
in a variety of forms (Fig. 97.2). Although crossed ectopia oc- The initial diagnostical evaluation in children is usually a
curs most frequently with fusion, the anomaly may occur renal ultrasound (RUS), and many patients subsequently have
without fusion (Fig. 97.3). intravenous pyelography (IVP) or computed axial tomogra-
An ectopic kidney lies outside of the normal position in the phy (CT). M any adults have an IVP as their initial study. The
renal fossa. The kidney, in simple ectopia, in general lies in the intravenous pyelographic features of the horseshoe kidney
ipsilateral retroperitoneal space at a position that is lower are typical. The renal axis is abnormal, being either vertically
FIGURE 97.2 Six types of crossed renal ectopia with fusion. A: Ectopic kidney superior. B: Sigmoid or
S-shaped kidney. C: Lump kidney. D: L-shaped kidney. E: Disk kidney. F: Ectopic kidney inferior.
(M odified from M cDonald JH , M cClellan DS. Crossed renal ectopia. A m J Surg 1957;93:995.)
orientated or tilted laterally. The renal pelves tend to be lo- position during the evaluation of other anomalies each account
cated anteriorly and the ureters course ventral to the isthmus. for the diagnosis in about 20% of cases. H ematuria, inconti-
The lower calices are oriented caudally or even medially as op- nence, renal insufficiency, and nephrolithiasis are less common
posed to laterally. Kidneys with fusion anomalies are subject presenting complaints. It is important to emphasize that the
to a high incidence of vesicoureteral reflux, variably reported majority of patients with ectopic kidneys are asymptomatic.
between 20% and 50% . Voiding cystourethrography (VCUG) The evaluation in children is usually by RUS, while older
is therefore mandated during the evaluation of children with a patients will in general have an IVP or CT scan. The ectopic
horseshoe kidney. kidney can be difficult to detect on the IVP because the pyelo-
The diagnosis of a ureteropelvic junction (UPJ) obstruction caliceal system often overlies the bony pelvis. Functional eval-
in a horseshoe kidney is straightforward when the patient’s uation of the ectopically positioned kidney is routinely
symptoms lead to a RUS, IVP, or CT that reveals significant performed with a renal scan. Ectopic kidneys have a high inci-
pyelocaliectasis. In other instances, with less severe dilation, dence of associated vesicoureteral reflux, so a VCUG should
and especially when there is coexistent stone disease, we find be a routine part of the evaluation of these patients.
the diuretic renal scan a valuable adjunct in assessing the
drainage of these systems and assessing whether the hy-
dronephrosis is functionally significant. INDICATIO NS FO R SURGERY
The indications for surgical intervention in the ectopic or
Ect o p ic Kid ne y horseshoe kidney are similar to those in a normally positioned
kidney. Pyeloplasty is required in patients with symptomatic
Patients with a symptomatic ectopic kidney frequently present UPJ obstruction or when the evaluation suggests that the ab-
with a urinary tract infection, or the ectopic kidney is discovered normality at the UPJ may affect ultimate renal function.
in the evaluation of abdominal pain. The workup of a palpa- Symptomatic stone disease needs to be addressed using open,
ble abdominal mass and the discovery of the abnormal renal endoscopic, or extracorporeal techniques. If the evaluation
FIGURE 97.3 Types of crossed renal ectopia. A:

Fused. B: N onfused. C: Solitary. D: Bilateral.
(M odified from M cDonald JH , M cClellan DS.
Crossed renal ectopia. A m J Surg 1957;93:995.)
of infections in a horseshoe kidney reveals vesicoureteral re-

flux, operative management, either subureteral injection of
Deflux or ureteral reimplantation, may be mandated if the
reflux is of high grade, if it persists, or if prophylaxis fails to
prevent infection.
ALTERNATIVE THERAPY
The alternative to surgical intervention for reflux is nonopera-
tive management, usually consisting of observation either with
or without antibiotic prophylaxis.
Surgery is the only viable option for patients with signifi-
cant UPJ obstruction, significant stones, and tumors.
Endopyelotomy has been utilized to treat UPJ obstruction
in horseshoe kidneys. The initial results of endopyelotomy
performed in adults by experienced surgeons are encouraging;
however, we currently prefer pyeloplasty as the initial proce-
dure for UPJ obstructions in children.
SURGICAL TECHNIQ UE
Pye lo p last y
Pyeloplasty is the most common open procedure performed
FIGURE 97.4 Location of lumbar and pelvic ectopically positioned on the horseshoe kidney. Division of the isthmus with
kidneys in relation to the normally positioned kidney. nephropexy had been considered to be an important part of
the procedure, but recent experience suggests that isthmus The fact that the ureter is dismembered and freely mobile
division or symphysiotomy is rarely necessary in the correc- allows the surgeon to position it so that the ureteral spatula-
tion of UPJ obstruction. Pyeloplasty may be performed either tion can extend into a relatively wide portion of the ureter and
open or laparoscopically. Laparoscopic procedures can be simultaneously the ureter can be oriented to avoid torsion or
accomplished with or without robotic assistance. Although redundancy that might kink the ureter distal to the repair. The
laparoscopic pyeloplasty is becoming more widely practiced, anastomosis in the dismembered pyeloplasty seems technically
we still favor open surgery in abnormally positioned kidneys. easier than the Foley Y–V because the ureter is not fixed at
The surgical exposure of the horseshoe kidney can be two points.
achieved through a midline transperitoneal, anteriorly posi- We begin the anastomosis at the heel, suturing the most de-
tioned flank extraperitoneal, or transverse transperitoneal ap- pendent portion of the V-shaped incision to the apex of the
proach. We prefer the transverse transperitoneal exposure as it ureteral spatulation. The initial portion of the anastomosis is
seems to provide the widest exposure with a cosmetically ac- performed using interrupted sutures, in general one at the
ceptable scar. We perform a retrograde ureteropyelogram at apex and two on either side of the apex. Each stitch must be
the time of pyeloplasty so we can position the incision accu- precisely positioned to avoid postoperative leakage and/or
rately. The incision generally extends from the anterior axil- compromise of the lumen. After the apex is anastomosed, the
lary line on the affected side to the midline several centimeters remainder of the pyeloplasty is performed using a running
below the umbilicus. It can be extended laterally in either locking 7-0 Vicryl suture up one side of the spatulated ureter
direction if necessary. For a right-sided UPJ obstruction, the and then up the other side. Prior to complete closure, the
posterior peritoneum may be incised medial to the inferior patency of the anastomosis is tested by passing a 5Fr and 8Fr
mesenteric, then inferior and laterally along the small bowel feeding tube through the repair. N o stent or diversion is in
mesentery around the cecum, and up along the line of Toldt. general employed in children. A Penrose drain is positioned
The small bowel and cecum can then be reflected upward out near the anastomosis and made to exit through a separate stab
of the operative field and packed in the upper abdomen. For a wound. The abdominal wall closure is performed using run-
left-sided UPJ obstruction, the sigmoid colon may be mobi- ning 3-0 or larger PDS. We close the skin with a subcuticular
lized if necessary to afford better exposure. Exposure is main- pull-out stitch of 3-0 Prolene. M ost children are discharged
tained with a ring retractor. the day after surgery. The skin suture is removed between
Repair of UPJ obstruction in the horseshoe kidney can be 6 and 8 days postoperatively and the drain is removed at that
performed by a Foley Y–V-plasty or a dismembered pyelo- time if drainage is minimal.
plasty. Although the Foley Y–V repair is nicely suited to the
typical high-insertion obstruction seen in horseshoe kidneys
(Fig. 97.5D), we prefer the dismembered technique because it Ure t e ro calico st o my
provides more flexibility. During the conduct of the pyelo-
plasty, care must be taken to avoid inadvertent division of A ureterocalicostomy is usually performed to salvage a failed
small vessels to the parenchyma and excessive dissection of the prior pyeloplasty, but it should be considered as the primary
ureter or pelvis. As much adventitial tissue is left on the ureter as procedure for UPJ obstruction when there is a small intrarenal
possible, and no vessels to the ureter are sacrificed unless their pelvis or in other instances with significant lower-pole caliec-
division is necessary to provide for adequate mobilization. tasis and thin overlying parenchyma (7) (Fig. 97.6). The ureter
After the proximal ureter and renal pelvis are adequately is carefully separated from the pelvis as described above, and
exposed using sharp dissection, two stay stitches of 5-0 if feasible a pyelotomy is performed. We find that a finger in-
chromic are positioned in the ureter just below the UPJ (Fig. serted into the open renal pelvis and positioned in the lower
97.5). The ureter is divided between these stitches and care- pole calyx aids in the dissection. The parenchyma over the di-
fully mobilized. A pelvic flap is then created by orienting a lated lower-pole calyx is incised with electrocautery; the cap-
wide-based inverted-V-shaped incision on the renal pelvis, sule is incised and the parenchyma resected to allow adequate
with the apex of the inverted V at the UPJ. The flap is de- exposure of the calyx. H emostasis is achieved using cautery
signed such that it will provide a dependent portion of pelvis and/or sutures of 4-0 chromic through the edge of the resected
for the anastomosis. It is important that the base of the V be parenchyma. The ureter is spatulated and the anastomosis
wide to avoid ischemia of the flap. The flap is opened with between the ureter and the opened calyx is performed as
tenotomy scissors and the tip is trimmed minimally to smooth described in the figure. We divert the urine by using a nephros-
the point of the V. The ureter is then positioned so the length tomy tube (a 10Fr or 12Fr M alecot catheter) and either a
and position of the spatulation can be judged. The spatulation ureteral stent (usually a 5Fr feeding tube) or a double-J stent.
is positioned on the posterior aspect of the ureter using Potts A ureterocalicostomy as it would appear in a horseshoe
scissors such that the ureter will not be twisted when it is laid kidney is shown in Figure 97.7.
on the dependent pelvic flap. It is critical that the flap and the
spatulated ureter are approximated in a tension-free fashion.
If the repair is performed under tension, an anastomotic stric- Surg e ry fo r Tumo rs
ture may result. It is also important that the upper ureter or
anastomosis are not compressed by any of the renal vessels, as Renal cell carcinoma and renal pelvic tumors are reported in
they may obstruct the repair (7). The anastomosis and dissec- horseshoe kidneys (12). Wilms tumor occurring in a horseshoe
tion are performed with the aid of 2.5 optical magnification. kidney represented 0.48% of tumors in the N ational Wilms
We perform the anastomosis using 7-0 Vicryl in younger chil- Tumor Study; this incidence is about twice that expected in the
dren and 6-0 Vicryl in adolescents. general population (8). When Wilms tumor involves a horseshoe
FIGURE 97.5 Pyeloplasty techniques. A–C: The

Foley Y–V technique. A: Broken lines indicate in-
verted-Y–shaped incision. Stay sutures of 5-0
chromic help define the margins of the incision.
B: A’ indicates the tip of the renal pelvic flap. A
indicates the inferior margin of the ureteral inci-
sion. C: A and A’ are sutured together with 7-0
Vicryl; as the remainder of the repair is closed, a
widely patent dependent anastomosis is created.
D–G: The dismembered technique. D: The ureter
is divided distal to the ureteropelvic junction
after stay stitches are positioned. The inverted V,
indicating the outline of the pelvic incision, is in-
dicated by a broken line. E: The ureter has been
spatulated after the narrowed segment is excised
and the pelvic flap developed. The initial stitch of
7-0 Vicryl is positioned to approximate the most
dependent portion of the pelvic flap to the heel of
the ureteral spatulation. F: Interrupted sutures
around the heel are completed. G: The running
locking sutures extending between the spatulated
ureter and pelvis are completed, creating a
widely patent anastomosis.
C D
FIGURE 97.6 Ureterocalicostomy for correction of ureteropelvic obstruction after a prior failed pyeloplasty. A: The scarred ureter is divided and
spatulated widely. Thin cortex over the dilated lower pole calyx has been excised and hemostasis achieved. B: The spatulated ureter is anastomosed
to the open lower-pole calyx. The sutures of 4-0 chromic catch the capsule, calyx, and ureter (the end of a double-J stent is visualized in the pelvis).
C: The anastomosis is completed with interrupted sutures. A nephrostomy tube (not visualized) should be used. The surgeon may irrigate through
the nephrostomy tube to ensure a watertight repair. D: Place one or two nephropexy sutures to obviate kinking of the repair. Replace the perirenal
fat and place a perinephric drain. (M odified from Steffens J, H umke U, H aben B, et al. O pen ureterocalycostomy. BJU Int 2008;101(3):397–407.)
A B
FIGURE 97.7 A: H orseshoe kidney with prior failed pyeloplasty; note the dilated intrarenal collecting
system. B: After ureterocalicostomy, dependent drainage has been achieved. (M odified from Kay R.
Ureterocalicostomy as a salvage procedure. Urol Tim es 2001;April:34.)
kidney, the involved portion of the kidney and isthmus are addressed to avoid excessive blood loss and necrosis of the re-
generally resected in the course of removal of the tumor. If the maining parenchyma, with the risk of secondary bleed and
tumor occurs in the isthmus, some authors have recommended urinary fistula. The area must be carefully dissected and arter-
bilateral lower-pole heminephrectomy. If the Wilms tumor is ies to the isthmus sequentially occluded with bulldog clamps
bilateral at presentation, management is the same as for bilat- to assess the line of demarcation. O nce this line is established,
eral Wilms tumors in orthotopically positioned kidneys. the capsule is divided sharply and the parenchyma divided.
Tumor surgery of the horseshoe kidney deserves special Bleeding from the cut parenchyma is controlled with 4-0
mention because excision of the involved kidney will necessi- chromic sutures. Any exposed calices are closed with running
tate division of the isthmus. If the isthmus is composed of a locking 4-0 or 5-0 chromic sutures, and the capsule and
band of fibrous tissue, it can be readily divided using cautery; parenchyma are closed with carefully positioned horizontal
however, if it is functioning parenchyma, it must be carefully mattress sutures of 2-0 chromic (Fig. 97.8).
FIGURE 97.8 Division of the isthmus of a horseshoe kidney with a right-sided renal tumor. The isthmus
blood supply is from the left iliac. A: After identification of the line of demarcation, an incision is made
around the capsule of the isthmus. B: The capsule is peeled back. C: The parenchyma of the isthmus is
transected in a wedge fashion to facilitate closure. D: Horizontal mattress sutures of absorbable 2-0 material
are used to close the parenchyma for hemostasis. E: The capsule is closed over the parenchyma with a
continuous absorbable suture.
St o ne Surg e ry in t he Ho rse sho e Kid ne y Surg ical O p t io ns fo r t he Ect o p ic Kid ne y

Pyelolithotomy had been utilized in past decades to clear cal- The ectopic kidney can be affected by any of the processes that
culi from horseshoe kidneys, but currently, percutaneous and occur in a normally positioned kidney. O verall, the evaluation
extracorporeal techniques are employed almost exclusively. and surgical management of these conditions will follow the
Extracorporeal shock-wave lithotripsy (ESWL) in the horse- lines of those discussed with horseshoe kidney. Reflux, if it
shoe kidney has not enjoyed the success rate that it provides in mandates operative treatment, is addressed by a standard
orthotopically positioned kidneys. M ost series note the re- ureteral reimplantation or, alternatively, subureteral injection
quirement for an increased number of shocks, an increased of a bulking agent.
need for retreatment, and a somewhat decreased stone clear- O n occasion, one has to address the problem of a failed
ance rate in horseshoe kidneys compared to stones in normally pyeloplasty in a patient who has an ectopic pelvic kidney.
positioned kidneys. O ne series recorded a 73% stone-free rate Ureterocalicostomy is one alternative in management of
in horseshoe kidneys using ESWL after multiple treatments this problem; another is the use of a pyelovesicostomy.
(9). O ne of the reasons for difficulties treating stones with Pyelovesicostomy has been performed in renal transplant re-
ESWL is that the anterior position of the stone makes it harder cipients after ureteral loss due to ischemia and/or rejection
to position the stone at the F2 focus; often, the surgeon will and has proven to be a viable salvage procedure.
have to employ the blast path to try to fragment the stone.
Some investigators have used prone positioning to overcome
this problem.
After appropriate CT planning, percutaneous access to the
O UTCO MES
horseshoe kidney is best achieved using an upper-pole poste-
rior calyx. Stones in any calyx can be managed though this Co mp licat io ns
access, although often a long nephroscope and flexible instru-
mentation are required (10,11). Reports comparing ESWL of Complications of pyeloplasty, such as prolonged urine leakage
stones in horseshoe kidneys to percutaneous nephrostolitho- and poor anastomotic drainage, occur somewhat more fre-
tomy conclude that the percutaneous technique provides supe- quently in horseshoe kidneys than in normal kidneys. The risk
rior stone clearance rates (10). of renal ischemia caused by damage to an aberrant vessel is in-
When calculus disease complicates obstruction of the UPJ creased in the horseshoe or ectopically positioned kidney.
in a horseshoe kidney, the stone is removed at the time of
pyeloplasty. In these instances, there may be considerably
more reaction around the pelvis and ureter, so the use of a Re sult s
nephrostomy tube and ureteral stent is prudent. An antegrade
study can be performed 10 to 12 days postoperatively prior to Pyeloplasty in the horseshoe kidney is in general a successful
nephrostomy tube removal to confirm drainage through the procedure. A higher rate of complications was experienced in
UPJ and integrity of the repair. the era when division of the isthmus was employed.
References
1. Friedland GW, DeVries P. Renal ectopia and fusion: embryologic basis. 7. Dewan PA, Clark S, Condron S, et al. Ureterocalycostomy in the manage-
Urology 1975;5:698–706. ment of pelvi–ureteric junction obstruction in the horseshoe kidney. BJU
2. Kolln CP, Boatman DL, Schmidt JD, et al. H orseshoe kidney: a review of Int 1999;94:366–368.
105 patients. J Urol 1972;107:203–204. 8. N eville H , Ritchey M L, Shamberger RC, et al. The occurrence of Wilms tu-
3. Pitts WR Jr, M uecke EC. H orseshoe kidneys: a 40-year experience. J Urol mor in horseshoe kidneys: a report from the N ational Wilms Tumor Study
1975;113:743–746. Group (N WTSG). J Pediatr Surg 2002;37:1134–1137.
4. Gleason PE, Kelalis PP, H usmann DA, et al. H ydronephrosis in renal 9. Locke DR, N ewman RC, Steinbock GS, et al. Extracorporeal shock-wave
ectopia: incidence, etiology and significance. J Urol 1994;151:1660– lithotripsy in horseshoe kidneys. Urology 1990;35:407–411.
1661. 10. Gupta M , Lee M W. Treatment of stones associated with complex or anom-
5. Dretler SP, O lsson C, Pfister RC. The anatomic, radiologic and clinical alous renal anatomy. Urol Clin N orth A m 2007;34:431–441.
characteristics of the pelvic kidney: an analysis of 86 cases. J Urol 11. Jones DJ, Wickham JEA, Kellett M J. Percutaneous nephrolithotomy for
1971;105:623–410. calculi in horseshoe kidneys. J Urol 1991;145:481–483.
6. Dretler SP, Pfister R, H endren WH . Extrarenal calyces in the ectopic kid- 12. Buntley D. M alignancy associated with horseshoe kidney. Urology 1976;
ney. J Urol 1970;103:406–410. VIII:146.
CHAPTER 98 ■ TRANSURETERO URETERO STO MY
H. GIL RUSHTO N
Ureteral surgery and various conditions, including trauma, reimplantation or in conjunction with cutaneous ureterostomy
stricture, neoplasm, or a previous failed surgical procedure, for urinary diversion (4–6). Because TUU requires only one
can render a ureter inadequate for successful ureteroureteros- ureter for reimplantation, this procedure was commonly em-
tomy or ureteroneocystostomy. Transureteroureterostomy ployed in the 1980s for urinary undiversion of conduits or in
(TUU), first described by H iggins (1) in the 1930s, has gained the construction of continent urinary reservoirs (3,7). In the
increased prominence in pediatric urology as a method to majority of these cases, TUU was used simultaneously with
compensate for a lacking or defective distal ureter. In some reimplantation of the recipient ureter, many of which required
cases, bridging the midureter to the contralateral ureter TUU tapering or tailoring, frequently with a psoas hitch and/or
may salvage a renal unit, especially in cases when an ipsilat- bladder augmentation. TUU has also been used as an adjunct
eral psoas hitch and/or Boari flap are insufficient to accom- to reimplant procedures complicated by an abnormal bladder,
plish this task. In other situations, TUU can be performed as a which precludes reimplantation of more than one ureter, or as
salvage procedure following previous failed ureteral surgery a salvage procedure for failed ureteral reimplantation surgery
(2,3). M ore recently, TUU has been employed in complex re- (3). M ore recently, indications for TUU have been broadened
constructive procedures that entail harvesting of the distal to allow for harvesting the distal donor ureter to construct a
donor ureter for alternative purposes, including augmentation continent ureteral conduit for clean intermittent catheteriza-
ureterocystoplasty or as a continent catheterizable conduit (2). tion or for unilateral ureterocystoplasty in cases where there is
sufficient ureteral dilatation (2).
Ureteral reconstruction with TUU may not be possible if
there is insufficient donor ureter (approximately one-half the
DIAGNO SIS original length) for a tension-free anastomosis. Any disease
process that has the potential to affect contralateral renal
In the majority of cases in pediatric urology, TUU is employed function or drainage is also a contraindication, such as
as part of a planned reconstruction. The preoperative workup retroperitoneal fibrosis, high-dose radiation therapy, calculus
requires thorough assessment of bilateral renal function and disease, recurrent pyelonephritis, and urothelial malignancy.
drainage, knowledge of the anatomy of both the donor and re- Although size disparity between ureters has been regarded as a
cipient ureters, and careful evaluation of bladder function. relative contraindication in the past, successful TUU has been
Differential renal function and drainage are the most objec- accomplished by use of a longer vertical ureterotomy in the
tively determined by preoperative M AG-3 renal scintigraphy. recipient ureter to accommodate a larger-caliber donor ureter
Sonography can aid in determining the presence and severity (3,5,7).
of hydronephrosis. Contrast imaging with intravenous, retro-
grade, or antegrade pyelography may be necessary in select
cases when detailed anatomic definition of the ureters is re-
quired. Contrast voiding cystography is the best modality to ALTERNATIVE THERAPY
assess for the presence of vesicoureteral reflux, which when
present provides a “ free” retrograde ureteropyelogram. In O ther procedures to be considered in lieu of TUU include
cases involving children with abnormal or neuropathic blad- ureteroneocystostomy with a psoas hitch or Boari flap,
der function, preoperative urodynamics is required to evaluate nephropexy to allow ureteroneocystostomy or ureteroureteros-
bladder capacity, compliance, and emptying. tomy, ileal substitution, and autotransplantation. O ther alter-
Less commonly in children than in adults, initial recogni- natives to TUU include mitigating or temporizing procedures
tion of a ureteral injury requiring a TUU occurs intraopera- such as cutaneous ureterostomy, pyelostomy, nephrostomy
tively during resection of a tumor or during exploration for drainage, and ureteral stenting. N ephrectomy should also be
trauma. Fortunately, in the majority of these cases one can considered in cases of marginal donor renal function.
usually anticipate a normal recipient ureter and bladder.
SURGICAL TECHNIQ UE
The patient is placed supine with such options as kidney rest
The primary goal of a TUU is to reestablish nonobstructive, elevation, retroflexion of the surgical bed, and Trendelenburg
nonrefluxing drainage of the ureter. H istorically, TUU in chil- positioning to enhance retroperitoneal exposure. A midline
dren has been performed either to salvage a failed ureteral vertical incision is usually made in the abdomen, extending
643
FIGURE 98.1 Transureteroureterostomy

(TUU) approached by two incisions in the
posterior peritoneum. A: Schematic dia-
gram of left-to-right TUU. B: The donor
ureter is approximated to the vertical
ureterotomy on the anteromedial aspect of
the recipient ureter. C and D: The anasto-
mosis is begun at the apex and is extended
to the posterior aspect of the TUU, using
either running or interrupted absorbable
sutures. E and F: The anterior aspect of
the anastomosis may be performed over a
catheter or feeding tube removed prior to
the last stitch. G: Completed TUU in situ.
from just above the umbilicus to the pubic symphysis. they pass over the iliac vessels, two options for opening the
H owever, in cases of distal TUU following a failed reimplanta- retroperitoneum have been described (8): (a) two 5-cm vertical
tion, a Pfannenstiel incision may be sufficient. A choice of incisions may be made over the ureters where they cross the
exposure approaches is then available. iliac vessels, creating a window on each side (Fig. 98.1), and
(b) wider retroperitoneal exposure can be achieved through
a single curved incision that opens the retroperitoneum
Transp e rit o ne al Ap p ro ach from over the left distal ureter, extending across the midline
along the small bowel mesentery and cecum, and up the
Wide transperitoneal exposure is indicated in cases that re- right side along the line of Toldt (Fig. 98.2). This technique
quire complex adjunct procedures such as tapered reimplanta- allows for more extensive mobilization of the bowel in an
tion of the recipient ureter or bladder augmentation, as well as upward direction.
when there is a long segment of diseased distal donor ureter. O nce the ureters are adequately exposed, the retroperi-
This approach would also be preferred when a high TUU is toneal tunnel is created by blunt dissection beneath the poste-
necessary for the distal donor ureter to be used as a continent rior peritoneum, anterior to the great vessels and superior to
catheterizable channel or for augmentation of the bladder. the inferior mesenteric artery (IM A). The angle between the
The bowel is packed and retracted superiorly to allow for aorta and IM A may kink or even obstruct the donor ureter.
further dissection. O nce the ureters have been visualized as The position of the IM A should therefore be noted and
Chap t e r 98: Transure te roure te rostomy 645
taken to avoid unnecessary disruption of the adventitia.

The ipsilateral gonadal vessel may be tied off with a 3-0 silk
suture to provide even greater mobilization with adventitial
preservation. If even greater donor ureteral length is necessary,
the donor kidney may be gently mobilized, moved inferiorly,
and pexed to the psoas muscle using interrupted 3-0 Vicryl or
3-0 polydioxanone sutures.
After dividing the donor ureter as distal as possible, a long
tagged 4-0 chromic or Vicryl suture is then placed on the most
distal aspect of the divided donor ureter to allow the ureter to
be brought through the retroperitoneal tunnel. A right-angle
clamp can then be passed from the recipient to the donor side
to grasp the stay suture on the donor ureter and pull the donor
ureter through the tunnel. Care must be taken to avoid twist-
ing or kinking of the ureter, and the ureter should reach easily
to the other side without tension.
With respect to the recipient ureter, mobilization should be
minimized. To enable touch-free manipulation of the recipient
ureter, stay sutures consisting of 4-0 or 5-0 chromic may be
placed in the recipient ureteral adventitia, superior and infe-
FIGURE 98.2 Approach for single curvilinear incision in the posterior to the intended area of anastomosis. A vertical ureterotomy
rior peritoneum to mobilize the bowels and mesentery and expose the at least 1.5 cm in length on the anteromedial wall of the recip-
retroperitoneum. ient ureter is then performed at the site of the anastomosis. The
donor ureter is then spatulated to accommodate the recipient
ureterotomy. H owever, spatulation may not be necessary if the
avoided in calculating the path of the donor ureter to the donor ureter is sufficiently dilated. The anastomosis is performed
contralateral retroperitoneum. Rarely, it may be necessary to using interrupted (Fig. 98.3) or running 4-0 or 5-0 absorbable
ligate the IM A to prevent donor ureteral compression.
Re t ro p e rit o ne al Ap p ro ach
This technique provides the benefit of preventing complica-
tions associated with intraperitoneal procedures. The author
prefers this approach for a more distal TUU, which requires
less mobilization of the donor ureter. O ther authors have also
described this method as a viable alternative to the transperi-
toneal approach (9). M ost commonly, this approach would be
used in salvage procedures for failed ureteral reimplantation.
After the transversalis fascia is incised, the extravesical
space is mobilized on each side of the bladder. The ureters are
identified crossing beneath the obliterated umbilical arteries.
After dividing these vessels with Vicryl or silk ties, the peri-
toneal sac is retracted superiorly to further expose the retro-
peritoneum. The peritoneal sac may also be reflected medially
to expose the area of interest.
O nce adequate exposure of the ureters has been achieved,
blunt finger dissection is then used to create an ample retro-
peritoneal tunnel. In cases of a low TUU using a retroperi-
toneal approach, the tunnel is created beneath the posterior
peritoneum just superior to the posterior wall of the bladder
and anterior to the sacral promontory.
TUU
Adjunct procedures required for the recipient ureter, such as
tapering and reimplantation, should be undertaken prior to FIGURE 98.3 Transureteroureterostomy (TUU) anastomosis per-
the anastomosis of the donor and recipient ureter. For a stan- formed with interrupted absorbable sutures. A and B: After aligning
the distal donor ureteral lumen and recipient ureterotomy, apical
dard TUU, mobilization of the donor should be sufficient to sutures are placed and tied. C: Subsequent intervening interrupted
create a tension-free anastomosis. Because preservation of sutures are placed halfway between previously placed sutures. D:
blood supply is essential for the success of TUU, great care is Completed anastomosis. E: Schematic diagram of completed TUU.
sutures, beginning with the superior and inferior apices, fol- through the retroperitoneal tunnel with an atraumatic grasper
lowed by the approximation of the more posterior wall of the or a stay suture. If the donor ureter was under tension, further
anastomosis. At this juncture, a ureteral catheter or infant proximal mobilization is performed. Care is taken to avoid
feeding tube may be helpful in some cases to facilitate the an- twisting or kinking of the donor ureter as it enters the retro-
terior wall anastomosis. This tube may be removed just prior peritoneal tunnel. A longitudinal ureterotomy at the medial
to the final anastomotic stitch (Fig. 98.1). aspect of the recipient ureter is performed to match the lumen
The use of an indwelling ureteral stent is mandatory only of the donor ureter using laparoscopic sharp KO H Ultramicro
when the recipient ureter distal to the anastomosis has been suture scissors. The indwelling stent is identified and left in place.
altered in some fashion, such as in reimplantation. A 5Fr or The anastomosis is carried out with running 5-0 absorbable
8Fr feeding tube or a double-J stent may be used. In addition, monofilament sutures. An abdominal drain is left in the prox-
nephrostomy drainage of the recipient ureter may be em- imity of the anastomosis and exteriorized through one of the
ployed if extensive mobilization or tapering of the recipient port sites. The Foley catheter is removed on postoperative
ureter and/or kidney is required to complete the reconstruc- day 2, and the drain is subsequently removed once the patient
tion (3). In all cases, it is vital to drain the retroperitoneal has voided and urine leakage is ruled out. The double-J stents
space using either a Penrose or closed-suction drain. Further- are removed 2 to 4 weeks postoperatively.
more, with the transperitoneal approach it is recommended to
close the posterior peritoneum to avoid drainage of urine into
the peritoneal cavity. Finally, a suprapubic catheter or urethral
catheter should be placed to keep the bladder decompressed, O UTCO MES
as an overly distended bladder in the early postoperative period
may stress the TUU anastomosis. Co mp licat io ns
Approximately 2 months postoperatively the patient
should undergo a renal sonogram and/or a diuretic renal scan Postoperative complications include urinoma, pyelonephritis,
to assess drainage and/or renal function. Depending on the re- prolonged anastomotic drainage, and stricture (11). The risk
sults, imaging may be repeated in 3 to 9 months until a trend of any of these complications is heightened by tenuous
of progression has been established. Renal function by creati- ureteral blood supply from excessive mobilization or from
nine measurements should also be followed, particularly if previous radiation (12). Patients with neuropathic or abnor-
these levels were elevated preoperatively. mal bladders may be more at risk for developing new vesi-
coureteral reflux or distal ureteral stenosis in cases that
involve reimplantation of the recipient ureter (13). Early anas-
Lap aro sco p ic Ap p ro ach tomotic obstruction leading to persistent drainage may be ini-
tially treated conservatively with placement of a double-J
Laparoscopic TUU has recently been described in children (10). ureteral stent or percutaneous nephrostomy.
The patient is initially placed in the lithotomy position under Late complications include small-bowel obstruction, but
general anesthesia for cystoscopy and retrograde pyelogram only in cases involving the transperitoneal approach. A TUU
with stent placement, wire placement, or both in the normal performed in the context of neoplasm may suffer from late
recipient ureter. The patient is then placed supine and re- ureteral obstruction. Subsequent stone disease can potentially
draped. After gaining periumbilical access to the peritoneal obstruct the common segment, rendering the patient anuric
cavity, working ports (3 to 5 mm) are placed under laparo- and mandating emergent percutaneous nephrostomy drainage.
scopic vision in the hypogastrium and in the right and left Rarely, compression of the donor ureter by the IM A can develop
flank. The position is adjusted according to patient size, at years after TUU if precautions to avoid the artery during
the level of the umbilical line and above for infants and donor ureter tunneling were not taken. H owever, despite
older children, respectively. The patient is placed in the potential problems and the possible need for reoperation,
Trendelenburg position with the donor ureter side elevated several series have shown that TUU anastomotic revision is
30 to 45 degrees and the surgeon standing on the opposite rarely, if ever, necessary. Also, donor renal loss due to chronic
side. infection or obstruction has proven infrequent, with rates
The donor ureter is identified at the pelvic brim. The peri- ranging from 0% to 6% (2,3,5). Recipient kidney loss is even
toneum is incised and the ureter is dissected distally as close less common, reportedly occurring only after extensive mobi-
to the bladder as possible, with special care not to damage lization required in complex reconstructions (3,7).
the vas deferens in male patients. The distal ureter is ligated
with an absorbable suture and divided in an oblique fashion.
Proximal mobilization of the donor ureter is performed, pre- Re sult s
serving the periureteral tissue and its vascularization. The
surgical table is then turned to elevate the side of the recipi- N umerous studies have shown excellent results after TUU.
ent ureter, and the surgeon changes position to the other side. Damage to the recipient kidney and ureter has rarely been
The recipient ureter is exposed at the same level while incis- observed, and successful preservation of both renal units
ing the peritoneum. A tunnel under the rectosigmoid mesen- occurs in 90% of cases. TUU performed in the correct set-
tery is created with blunt dissection, bridging the two ting, with meticulous attention to maintaining ureteral blood
peritoneal windows. supply and a tension-free anastomosis, is clearly an important
O nce enough space is developed to accommodate the donor component of the urologist’s repertoire of reconstructive
ureter free of external compression it is transposed, pulling it ureteral surgery.
Chap t e r 99: Pye lop lasty 647
References
1. H iggins CC. Transuretero-ureteral anastomosis. Report of a clinical case. 8. Casale A. Transureteroureterostomy. In: G lenn’s Urologic Surgery, 5th ed.
J Urol 1935;34:349. Philadelphia: Lippincott Williams & Wilkins, 1998.
2. M ure P, M ollard P, M ouriquand P. Transureteroureterostomy in childhood 9. Baert L, Claes H . A retroperitoneal approach for transureteroureteros-
and adolescence: long-term results in 69 cases. J Urol 2000;163:946–948. tomy: a neglected and forgotten procedure. A cta Urol Belg 1990;58(4):
3. Rushton H G, Parrot TS, Woodard JR. The expanded role of transureter- 51–58.
oureterostomy in pediatric urology. J Urol 1987;138:357–363. 10. Piaggio LA, Gonzalez R. Laparoscopic transureterouretostomy: a novel
4. H alpern GN , King LR, Belman AB. Transureteroureterostomy in children. approach. J Urol 2007;177:2311–2314.
J Urol 1973;109:504–509. 11. Sandoz IL, Paul DP, M acFarlane CA. Complications with transureter-
5. H odges CV, Barry JM , Fuchs EF, et al. Transureteroureterostomy: 25-year oureterostomy. J Urol 1977;117:39–42.
experience with 100 patients. J Urol 1980;123:834–838. 12. Ehrlich RM , Skinner DG. Complications of transureteroureterostomy.
6. Weiss RM , Beland GA, Lattimer JK. Transureteroureterostomy and cuta- J Urol 1975;113:467–473.
neous ureterostomy as a form of urinary diversion in children. Urol Int 13. Pesce C, Costa L, Campobossa P, et al. Successful use of transureter-
1968;23:103–112. oureterostomy in children: a clinical study. Eur J Pediatr Surg 2001;11:
7. H endren WH , H ensle TW. Transureteroureterostomy: experience with 395–398.
75 cases. J Urol 1980;123:826–833.
CHAPTER 99 ■ PYELO PLASTY

EVAN J. KASS AND KEVIN M. FEBER
Ureteropelvic junction (UPJ) obstruction is a common etiology

for hydronephrosis in the neonate and young child. UPJ ob- INDICATIO NS FO R SURGERY
struction has been classically divided into intrinsic, extrinsic,
and secondary causes. The most common etiology in an infant The indications for pyeloplasty at our institution encompass
is an intrinsic adynamic or atretic segment of ureter that in- the following: (i) severe hydronephrosis (Society for Fetal
hibits urine exiting from the renal pelvis (1). This restriction to Urology grade III or IV) postnatally and a diuretic renogram of
urine flow can lead to varying degrees of renal pelvic dilation the affected side with 40% differential kidney function and no
and renal damage. Less common causes of intrinsic obstruc- response to furosemide; (ii) worsening hydronephrosis on ser-
tion include valvular mucosal folds and persistent fetal ial ultrasound studies; (iii) symptomatic UPJ obstruction with
ureteral convolutions. Extrinsic obstruction is most often the intermittent flank pain; (iv) loss of relative renal function
result of periureteral fibrous bands or aberrant lower-pole ( 10% on serial scans of the affected kidney); or (v) a persis-
vessels. Rarely, severe vesicoureteral reflux with periureteral tent obstructive half-time on serial diuretic renograms in a
scarring can be a cause of secondary UPJ obstruction. child with severe hydronephrosis.
DIAGNO SIS ALTERNATIVE THERAPY

H istorically, most cases of UPJ obstruction were diagnosed in Any procedure for correction of UPJ obstruction must satisfy
older children who presented with symptoms of flank pain, four criteria first described by Foley in 1937: (i) formation
urinary tract infection, hematuria, and abdominal mass. The of a funnel at the UPJ, (ii) dependent drainage, (iii) water-
widespread utilization of prenatal ultrasound has allowed ear- tight anastomosis, and (iv) tension-free anastomosis (3). The
lier identification of UPJ pathology in newborns. Children Anderson–H ynes dismembered pyeloplasty is the most widely
with hydronephrosis persisting on a postnatal ultrasound used procedure today and is in general applicable regardless of
routinely should have a voiding cystourethrogram to exclude the etiology of obstruction. Access to the UPJ can be achieved
reflux as a possible etiology. When no reflux is present a from several incisions, including anterior extraperitoneal,
M AG-3 renogram with Lasix washout allows objective mea- flank, and dorsal lumbotomy. These approaches allow excel-
surement of renal function and drainage. Whitaker antegrade lent exposure to the renal pelvis with minimal morbidity to
perfusion studies are no longer routinely preformed. The nat- the child. Anterior transperitoneal incisions are rarely used
ural history of most children with antenatally detected hy- due to the increased morbidity associated with intraperitoneal
dronephrosis is usually benign. O perative intervention is in bowel manipulation and the possibility of secondary bowel
general reserved for patients demonstrating increasing hy- obstruction.
dronephrosis, worsening renal function, pain, urinary tract in- Ureterocalicostomy is another option for children with
fection, or other symptoms. The role of the Lasix washout massive hydronephrosis or those who have failed primary
half-time remains controversial (2). pyeloplasty. A Foley Y- or V-plasty is indicated when there is a
FIGURE 99.1 Dismembered pyeloplasty. A: The

renal pelvis is incised, redundant tissue excised,
and the ureter divided distal to the atretic segment.
B: The ureter is spatulated and brought to the
most dependent portion of the pelvis. C: The re-
maining pelvis is closed with running sutures.
UPJ obstruction secondary to a high insertion of the ureter, the tissues. The renal pelvis is incised circumferentially, de-
which is often found in patients with horseshoe kidney. compressing the obstructed collecting system (Fig. 99.1). The
The refinement of more minimally invasive technologies proximal ureter is mobilized using the stay suture distal to the
has allowed correction of UPJ obstruction with minimal oper- obstructing segment to facilitate handling, and the atretic por-
ative morbidity. Antegrade and retrograde endopyelotomy tion is excised. The renal pelvis is trimmed of redundant tis-
procedures have been successful in older children with UPJ sue, the ureter is spatulated for 2 cm, and a 5Fr feeding tube is
obstruction (4). This technique, however, is associated with placed in the ureter. The ureter is then anastomosed to the
decreased success rates and an increased risk of intraoperative most dependent portion of the renal pelvis using 7-0 inter-
and postoperative bleeding. rupted PDS sutures, and the feeding tube is removed. O ptical
Laparoscopic and robotic-assisted pyeloplasty procedures magnification with a 3.0 to 4.5 loupe facilitates precise suture
are evolving techniques to correct UPJ obstruction. In expert placement. Alternatively, 7-0 running sutures can be used, but
hands, success rates following laparoscopic repairs approach in infants we prefer interrupted sutures to decrease the purse-
results seen with open pyeloplasty (5). Decreased hospital stay string effect and subsequent narrowing of the anastomosis.
and analgesic requirements have been reported in children un- Care is taken to ensure there is no twisting or kinking of the
dergoing the transperitoneal or retroperitoneal approach with anastomosis. The remainder of the trimmed upper renal pelvis
or without robotic assistance (6,7). The drawbacks of the lais closed with a running 6-0 polydioxanone suture.
paroscopic and robotic techniques include increased operative If the UPJ obstruction is secondary to an accessory lower-
time, expensive surgical instruments that may not be available pole vessel, the divided ureter is brought anterior to the vessel
at all centers, and the need for proficiency in laparoscopic and anastomosed to the pelvis (Fig. 99.2). Pelvic tailoring is
surgery. Although laparoscopic and robotic-assisted pyelo- often required in this correction as well.
plasty procedures have been gaining popularity, open pyelo-
plasty with optical magnification continues to be the gold
standard, with established long-term results.
SURGICAL TECHNIQ UE
The patient is placed in the flank position and flexed with the
use of rolled towels and/or table flexion with elevation of the
kidney rest. We make a transverse incision starting just medial
to the angle of the 12th rib and carry it anteriorly. The subcu-
taneous tissues and musculofascial layers are opened with
electrocautery. The lumbodorsal fascia in then divided, the
peritoneum is mobilized medially, and the fascia of Gerota is
opened.
The lower pole and entire renal pelvis are sharply dissected A B
to identify the UPJ to determine the cause of the obstruction.
FIGURE 99.2 Dismembered pyeloplasty with accessory vessels.
Care is taken in dissection to preserve the blood supply in the A: Vessels causing ureteral compression and hydronephrosis.
periureteral tissues and ureter. Stay sutures are placed just B: Anastomosis performed anterior to crossing vessels. Pelvic tailoring
cephalad to the UPJ and in the ureter to minimize handling of as needed.
Chap t e r 100: Me g aure te r 649
The placement of intraoperative stents and/or nephros- 24 hours of surgery. A follow-up ultrasound is done at 3 to 4
tomy tubes remains controversial, and we do not use either weeks postoperatively. If a stent was placed at the time of
routinely. Whereas some of the early pyeloplasty descriptions pyeloplasty, it is removed in 4 to 6 weeks.
used both internal and external drainage, many authorities
now believe routine stenting is unnecessary. Stents are indi-
cated in children with poor renal function, those undergoing O UTCO MES
repeat pyeloplasty, those with a solitary kidney, and those re-
quiring extensive renal pelvic tailoring (4). Disadvantages of Co mp licat io ns
percutaneous nephrostomy tubes and ureteral stenting include
patient discomfort and need for drain removal either in the of- M ost children do very well postoperatively. Significant bleed-
fice or under a second anesthetic. A 0.25-in Penrose drain is ing, infection, or other morbidity is uncommon. Urinary leak-
placed in the perirenal space and brought out through a sepa- age from the anastomosis can occur and usually resolves
rate, more caudal incision. The musculofascial layers are spontaneously. When leakage persists or when hydronephrosis
closed using 3-0 Vicryl. The subcutaneous tissues are closed increases postoperatively, a ureteral stent can be placed in
using 4-0 plain sutures and the skin is reapproximated with either an antegrade or retrograde fashion.
5-0 M onocryl in a subcuticular fashion.
Postoperatively the patient is kept on intravenous antibi-
otics until the drain in removed, usually on postoperative day Re sult s
1 or 2. We routinely administer ketorolac 0.5 mg/kg intra-
venously for the first 48 hours. We have found that it provides We have found that dismembered pyeloplasty has been
excellent pain relief, with the majority of children requiring no shown to successfully relieve pelvic obstruction in 95% of
parenteral narcotic. Children are typically discharged within cases.
References
1. Park J. The pathophysiology of UPJ obstruction: current concepts. Urol 5. Tan H . Laparoscopic Anderson–H ynes dismembered pyeloplasty in chil-
Clin N orth A m 1998;25:161–170. dren using needlescopic instrumentation. Urol Clin N orth A m 2001;28:
2. Kass E. Pediatric hydronephrosis: my approach to management. D ialog 43–51.
Pediatr Urol 2002;25:1–2. 6. Bonnard A, Fouquet V, Carricaburu E, et al. Retroperitoneal laparoscopic
3. Foley F. N ew plastic operation for strictures at the ureteropelvic junction: versus open pyeloplasty in children. J Urol 2005;173:1710–1713.
report of 20 operations. J Urol 1937;38:643–372. 7. Lee R, Retik A, Borer J, et al. Pediatric robot assisted laparoscopic dismem-
4. Ward A. Ureteropelvic junction obstruction in children: unique considera- bered pyeloplasty: comparison with a cohort of open surgery. J Urol
tions for open intervention. Urol Clin N orth A m 1998;25:211–218. 2006;175:683–687.
CHAPTER 100 ■ MEGAURETER

J. CHRISTO PHER AUSTIN AND DO UGLAS A. CANNING
M egaureter, or wide ureter, is an unusual congenital anomaly of or hematuria. Today, most cases are detected in asymptomatic
the urinary tract. We define megaureter as a ureter that is 8 mm infants with hydroureteronephrosis in utero. This earlier pre-
or greater in diameter. M egaureter is classified into three cate- sentation has led to changes in the approach to management.
gories: (a) refluxing megaureter, (b) obstructed megaureter, and The pathophysiology of obstructive megaureters lies not
(c) nonobstructed, nonrefluxing megaureter. Urologists fur- within the dilated ureter but in the distal nondilated segment.
ther subdivide megaureters into primary and secondary types, This segment of ureter fails to effectively propagate the wave
with the secondary types resulting from an abnormality such of peristalsis as it descends down the ureter. This segment is
as posterior urethral valves, high-volume vesicoureteral reflux not usually narrowed compared with the normal ureter. When
or neuropathic bladder resulting in higher detrusor pressure, the bolus of urine is propagated to the aperistaltic segment,
or less commonly an acquired condition such as external com- only a portion of the urine passes into the bladder; the remain-
pression of the ureter from a mass lesion. Primary mega- der is reflected back up the ureter in a yo-yo fashion. This
ureters, in contrast, are isolated abnormalities of the ureter or causes the characteristic appearance of the ureter with
ureterovesical junction resulting in a wide ureteral lumen. fusiform dilation affecting the distal ureter more severely.
Prior to the widespread use of screening prenatal ultra- When the amount and force of the bolus are sufficiently large
sonography, most children with megaureters presented with that it dilates the entire ureter and reaches the renal pelvis, hy-
urinary tract infection, flank pain, urolithiasis, abdominal mass, dronephrosis may develop as well.
approaches to primary repair, given the infant’s small, thin-

DIAGNO SIS walled bladder and the technical difficulties of reimplanting a
hydronephrotic ureter into the infant bladder. O ptions in this
Differentiating an obstructed megaureter from a nonrefluxing, case include a staged reconstructive approach with temporary
nonobstructed megaureter can be difficult. These ureters demon- diversion to an end-cutaneous ureterostomy, construction
strate a spectrum of severity rather than separate conditions. of a refluxing ureteral reimplantation, or, rarely, diverting
The diagnostic workup depends on the presenting signs and pyelostomy should be given consideration instead of primary
symptoms and may vary from patient to patient. For the child surgical repair (1,2).
with prenatal hydronephrosis, the usual evaluation includes a We usually operate on children with megaureter who pre-
renal/bladder ultrasound, a voiding cystourethrogram (VCUG), sent with symptoms of intermittent flank pain or urinary tract
and a renal scintigram (renal scan). H ydroureteronephrosis is infection. Prior to surgery, we evaluate the child for voiding
identified with the renal ultrasound. The dilated ureter is usu- dysfunction. Rarely, children develop a secondary megaureter
ally visible in the pelvis and is often posterolateral to the blad- from high-pressure bladder storage that is transmitted to the
der. If the ureter is dilated beyond the level of the trigone, an ureter and renal pelvis. Ureteral dilation can be detected in
ectopic ureter may be present rather than a primary mega- association with neuropathic bladder dysfunction, posterior
ureter. The VCUG separates children with refluxing mega- urethral valves, or severe voiding dysfunction. Appropriate
ureters from those without reflux. The renal scan in the treatment of the posterior urethral valves or the bladder dys-
newborn should be performed with mercaptoacetyl triglycine function may result in improvement or resolution of ureteral
(M AG-3) with diuretic washout. The scan will estimate the dilation. Failure to recognize bladder dysfunction before plan-
relative function of each kidney and measure the effectiveness ning surgery leads to persistent obstruction or postoperative
of renal clearance of radiotracer from the collecting system. In vesicoureteral reflux.
the past, the t 1/2 (time required for half of the radiotracer to
clear from the renal pelvis) had been used as an indicator of
obstruction. H owever, in practice, the use of the t 1/2 alone to
estimate obstruction is not always reliable. Because the clear-
ALTERNATIVE THERAPY
ance is variable based on the patient’s prestudy hydration
Because most patients are asymptomatic and identified as part
level, age, renal function, and response to the diuretic, we pre-
of an in utero ultrasound, most children with primary mega-
fer to follow trends in the relative renal function, reserving
ureters do not require surgical correction. Ureteral dilation
surgery for those with increasing t 1/2 or decreasing relative re-
does not always equal obstruction. Dilation in some boys and
nal function.
girls may represent the residuum of in utero obstruction that
In children who are symptomatic, the presenting symptom
has resolved. The long-term experience at the Children’s
determines the workup. H ematuria, rarely noted in children
H ospital of Philadelphia has been that the majority of children
with megaureter, is normally evaluated initially with a
with megaureter maintain renal function and ureteral dilation
renal/bladder ultrasound. The finding of hydroureteronephro-
often improves with time. In a series of 27 children with mega-
sis should be followed by a renal scan or intravenous pyelo-
ureters treated conservatively with a mean follow-up of 6.8
gram. If there is suspicion of renal or ureteral stone, a
years, hydronephrosis completely resolved in 53% and was
noncontrast computed tomography scan should be per-
improved or stable in the rest. O nly 10% of patients required
formed. The renal scan may be required to provide a baseline
surgical correction, while 90% were followed with serial radi-
estimate of relative renal function.
ologic studies. A single patient from this cohort developed
If the anatomy is unclear, magnetic resonance (M R) imag-
progression of hydronephrosis and diminished function at age
ing or M R urography may be useful in distinguishing primary
14 (3). Likewise, in a series of 53 patients with 67 mega-
megaureters from ectopic ureters. If there is impaired function
ureters, only 17% required surgery for poor initial function or
of the affected kidney and the child is undergoing surgical cor-
progressive loss of function; in addition, the dilation com-
rection, cystoscopy should be performed at the beginning of
pletely resolved by ultrasound in 34% (4). These two series
the reconstructive procedure to evaluate the position of the
suggest that the majority of megaureters can be managed con-
ureteral orifice. The orifice is normally positioned in an ob-
servatively. Because of the rare risk of late decompensation,
structed megaureter. If an ectopic ureter is present, the trigone
children with persistent hydronephrosis require extended
on the affected side will be distorted and the ectopic orifice
follow-up.
will not be located at the trigone.
SURGICAL TECHNIQ UE
The surgical correction is similar for refluxing and obstructed
Relative indications to proceed with surgical repair include megaureters. O bstructed megaureters have a distal ureteral seg-
poor initial relative function ( 40% of differential renal func- ment of variable length with a normal or narrowed caliber that
tion by renal scan), progressive hydronephrosis, decreasing does not contract normally and should be excised. Refluxing
function ( 10% ) in serial renal scans, persistent severe hy- megaureters are dilated to the level of the ureterovesical junc-
droureteronephrosis, bilateral megaureters, or the develop- tion. Distal segment excision is not always required.
ment of symptoms such as pain or urinary tract infection The child is positioned supine on the operating room table.
localized to the side of the megaureter. In some cases, we con- In boys, the lower abdomen and genitalia are fully prepared
sider infants with a poorly functioning kidney for alternative and draped. Females are placed in a mild frog-legged position
FIGURE 100.1 M ajor arterial supply to the ureter. It is not necessary to sacrifice any medially based
blood supply for primary megaureter repair.
with gel bolsters under the knees to permit intraoperative mobilization should proceed extravesically. The ureter at this
access to the urethra if needed. The bladder may be left full point can be passed through the bladder wall, and the dissec-
during the initial surgical exposure. A Pfannenstiel incision is tion proceeds more proximally. When the dilated region of the
made in the abdominal skin crease. The rectus fascia is opened ureter is reached, dissection should continue until an adequate
along the course of the incision and the flaps of fascia are ele- length for reimplantation has been mobilized, again paying at-
vated off the muscle superiorly to just below the umbilicus tention to the previous outlined principles for preserving the
and inferiorly to the pubis. The rectus muscles are separated in blood supply. An ischemic distal ureter may lead to fibrosis
the midline. The space of Retzius is entered, exposing the and obstruction.
bladder. At this point the surgeon must decide whether to taper the
ureter. In general, if the lumen of the ureter is significantly
larger than 16Fr it should be tapered prior to reimplantation.
Int rave sical Ap p ro ach There are two techniques used to taper the size of the ureter:
(a) excisional tapering and (b) tapering by folding. We will re-
At this point, depending upon the surgeon’s preference, the view the three most commonly used procedures. The goal of
dissection of the ureter begins either intravesically or through tapering is to provide a distal ureter with a small enough di-
an extravesical exposure. It has been our preference to begin ameter that postoperative vesicoureteral reflux will be pre-
intravesically. The bladder is opened via a midline cystotomy. vented with a reasonable length of intramural tunnel. The
The bladder dome is packed with damp sponges and a tapering needs to extend for only a short distance beyond the
Dennis–Brown retractor is placed to provide exposure of the bladder wall rather than the whole length of the ureter. The di-
trigone. A 5Fr feeding tube is passed up the ureter and secured lation of the proximal ureter should improve postoperatively
at the orifice with a 4-0 suture. The urothelium surrounding with the relief of obstruction and/or reflux. The decision to
the orifice is divided using electrocautery. With the mucosa di- perform an excisional versus a folding technique depends on
vided circumferentially, the ureteral catheter is gently pulled to the preference of the surgeon and the size and thickness of the
expose the medial and inferior attachments of the trigonal ureter. Folding a very dilated, thick wall ureter will create a
musculature. These attachments are divided with electro- large amount of bulk, making the creation of the submucosal
cautery. At this point the dissection proceeds to carefully di- tunnel difficult. In general, the taper should not be aggressive.
vide the muscular attachments of the ureter through the plane In a bladder that functions well, reflux is less hazardous than
of Waldeyer’s sheath. This dissection will free the distal ureter, persistent obstruction.
which should have a normal or narrowed caliber. The surgeon Excisional tapering (Fig. 100.2) begins with carefully ex-
should recognize the blood supply of the ureter, as shown in amining the ureter. Without twisting the ureter, the surgeon
Figure 100.1. As the dissection proceeds more proximally, the observes the pattern of blood supply to the ureter. In most
blood supply of the ureter originates from medial branches of cases, the longitudinal ureteral vessels are predominately
the hypogastric (male) or cervical (female) arteries. These vessels along the medial aspect of the ureter. Usually, the excised seg-
should be preserved, as should the longitudinal blood supply, ment of ureter is taken from the opposite side along the lateral
by taking care to prevent dissection too close to the ureteral border. The distal nondilated ureteral (aperistaltic) segment is
wall. When the ureter is free from its detrusor attachments, the excised. A 16Fr catheter is passed up the ureter. With this
proximally. The ureter is then closed. The mucosa and the

muscularis of the ureter are closed with absorbable inter-
rupted or running fine suture. A second layer if desired may
incorporate the muscularis and adventitia with a series of in-
terrupted absorbable fine sutures. The ureter is then reim-
planted in a cross-trigonal fashion. If possible, the suture line
should be positioned facing the detrusor muscle to prevent
the development of a ureterovesical fistula and reflux. The
12Fr catheter is replaced with a 5Fr or 8F feeding tube or a
double-J stent. The advantage to leaving an open-ended
ureteral catheter is that a retrograde ureteral study can be
performed postoperatively to demonstrate ureteral drainage,
and the catheter can be removed in the office. The internal
stent is easy to care for and leaves the patient free of external
tubes; however, it requires a general anesthetic for removal.
All tapered reimplants should be stented, regardless of which
type of stent is used.
There are two techniques commonly employed for taper-
ing by ureteral folding: (a) Starr plication and (b) the
Kaliscinski technique. Both techniques are similar to exci-
sional tapering with regard to the length of ureter to be nar-
rowed and the choice of the segment of the wall based upon
the intrinsic blood supply. Starr plication (Fig. 100.3) reduces
the diameter of the ureter by infolding the ureteral wall with
interrupted Lembert sutures of 5-0 polyglyconate or poly-
dioxan. The tapering begins proximally and gradually re-
duces the caliber of the ureter until the diameter approaches
that of the 12Fr catheter. Care should be taken to ensure the
wedge of folded ureter stays in the same position of the
ureteral wall as you proceed distally and does not spiral from
FIGURE 100.2 A and B: The wedge of ureter to be excised is secured lateral to medial as the sutures are placed more distally. The
with Allis or H endren clamps. C: The outlined segment of ureteral
wall is excised sharply. D and E: The ureter is closed in two layers.
ureter is reimplanted with the plication sutures facing the de-
Distally, interrupted sutures are placed to allow for trimming of the trusor muscle as was described with excisional tapering. The
end of the ureter at the time of reimplantation. Kaliscinski technique (Fig. 100.4) begins with a running hor-
izontal mattress suture of 5-0 or 6-0 chromic that runs the
length of the segment to be tapered, creating a defunctional-
in place, the wedge to be excised is identified and outlined. ized wedge of ureter that is then wrapped around the ureter
Aggressive tailoring may result in obstruction. The process and secured posterior with interrupted absorbable sutures.
of excising and suturing the ureter will result in consider- The ureter is reimplanted with the imbricated segment
able contraction of the ureteral lumen. The tailored seg- against the muscularis. Again, ureteral stents are placed in
ment should gradually widen as the ureter is reconstructed both repairs as with excisional tapering.
FIGURE 100.3 A: Starr plication of the ureter suture to infold the

ureter. B: Cross section to show placement of Lembert-type sutures.
C: Cross section after ligation of sutures.
The ureter is freed from all detrusor attachments, keeping

the mucosal attachments intact. The edges of the detrusor in-
cision are then dissected free of the urothelium to form flaps
that can be closed over the ureter. If the urothelium is perfo-
rated during the dissection it can be repaired with 6-0 or 7-0
chromic. The most distal region is ligated and the ureter di-
vided proximal to the ligature. The aperistaltic segment of the
ureter is resected. The dilated ureter is then tapered as neces-
sary. An indwelling stent is placed if the ureter is tapered. The
bladder is partially emptied and the ureter is then directly
anastomosed to the urothelium at the distal apex of the detru-
sorotomy using 5-0 absorbable sutures. With this accom-
plished, the distal ureter is fixed to the detrusor with 5-0
polyglyconate horizontal mattress sutures at the apex. The de-
trusor is then closed over the ureter with 4-0 polydioxan su-
tures. The hiatus should be approximated, but not closed too
tight. A Foley catheter is left indwelling postoperatively and a
Penrose drain is placed during closure.
St ag e d Ap p ro ach
Although repair of megaureters has been performed safely in
newborns and young infants, there is a reasonable concern
about reimplanting a markedly dilated ureter into the thin
bladder wall of an infant (1,7). In some infants where severe
dilation and diminished relative function ( 35% ) exists, end-
cutaneous ureterostomy is a good alternative to reimplanta-
tion with tapering (7). The infant bladder often empties with
high pressure, and postponing the definitive reimplantation
while decompressing the obstructed ureter may reduce com-
plications. In this case an end-cutaneous ureterostomy (tech-
nique presented in Chapter 93) is performed and the distal
stump is resected. This provides reliable decompression of
the kidney and allows for improvement in the degree of
FIGURE 100.4 Kaliscinski technique of ureteral imbrication. A: ureteral dilation prior to reimplantation. In some cases the
Placement of cobbler’s stitch to exclude a major portion of the
ureteral lumen. B: Same in cross section. C: After ligation. D:
ureterectasis recovers enough to avoid the need for tapering.
Excluded portion of the ureter is folded over and wrapped around the In addition, if the initial function is poor and the kidney
intubated ureter. E: Final appearance in cross section. fails to recover following decompression, a nephrectomy
rather than reimplantation may be preferred. This temporary
measure will allow the reimplantation to be delayed until the
Ext rave sical Ap p ro ach infant is older. The takedown of the ureterostomy and
ureteral reimplantation is usually done when the child is 12
Several authors have reported good results with the extravesical to 18 months old and can be performed intravesically or
approach to megaureter repair (5,6). We avoid this technique extravesically.
in bilateral megaureter. In cases of bilateral megaureters, a
high rate of voiding dysfunction postoperatively has been re-
ported that may require intermittent catheterizations for a pe- PO STO PERATIVE CARE
riod following surgery. A Foley catheter is placed at the
beginning of the procedure. The catheter may be attached A Foley catheter is usually left in place for 24 to 48 hours. The
with a Y-connector for intraoperative filling and emptying. external stent is left in place for 10 to 14 days. Children are
The ability to regulate the bladder volume aids in the dissec- discharged from the hospital on prophylactic antibiotics.
tion. The incision and initial approach is identical as for the Contrast injection of external stents at low pressure by gravity
intravesical approach until the bladder is exposed. The dissec- infusion with antibiotic coverage is performed to document
tion then proceeds into the lateral extravesical space. The drainage. If there is not prompt drainage around the stent, it is
obliterated umbilical artery is divided to expose the ureter. left for another 10 to 14 days and the study is repeated.
The ureter is carefully dissected free and encircled with a ves- Internal stents are removed 4 to 6 weeks postoperatively.
sel loop. The ureter is dissected distally to the ureterovesical Patients are evaluated with a renal ultrasound 1 month after
junction. With the bladder full, a detrusorotomy is made in a surgery or stent removal. If hydronephrosis is not improved, a
line extending from the bladder neck cephalad and circum- renal scan should be obtained. A VCUG and renal scan should
scribing the detrusor adjacent to the ureter. The length of the be performed 3 months after surgery, and the ultrasound is re-
incision should be 3 to 4 cm. peated at 1 year.
stenting may be successful, but failures will require an open

O UTCO MES revision.
Co mp licat io ns
Re sult s
The most common complication related to surgery for mega-
ureters is new or persistent reflux. This complication is more M ost series report success rates 90% (1,7–9). In a series of
common when the surgery is performed for refluxing mega- infants treated with reimplantation, 20% had reflux postoper-
ureters than for obstructed megaureters. M anagement options atively; however, with time a few patients had spontaneous
include observation with prophylaxis, endoscopic injection, resolution of their reflux, lowering the rate to 12.5% (10).
and surgical revision. O bstruction is a rare complication, with Extravesical reimplants had rates of postoperative reflux simi-
reported rates of 0% to 4% (4,5,7). It should be initially eval- lar to intravesical rates (12% ). When performed bilaterally for
uated endoscopically as on occasion a synechia has been re- megaureters, two thirds of patients treated with extravesical
ported to narrow the orifice. Strictures can be assessed by reimplantation required intermittent catheterization for a pe-
retrograde pyelography. Initial management with dilation and riod of 1 to 4 months (5).
References
1. Vereecken RL, Proesmans W. A review of ninety-two obstructive mega- 7. Perdzynski W, Kalicinski Z H . Long-term results after megaureter folding in
ureters in children. Eur Urol 1999;36:342–347. children. J Pediatr Surg 1996;31:1211–1217.
2. Lee SD, Akbal C, Kaefer M . Refluxing ureteral reimplant as temporary 8. Rabinowitz R, Barkin M , Schillinger JF, et al. The influence of etiology on
treatment of obstructed megaureter in neonate and infant. J Urol 2005; the surgical management and prognosis of the massively dilated ureter in
173:1357–1360. children. J Urol 1978;119:808–813.
3. Shukla AR, Cooper JR, Patel RP, et al. Prenatally detected primary mega- 9. Fretz PC, Austin JC, H awtrey CH , et al. Long-term outcomes analysis
ureter: a role for extended followup. J Urol 2005;173:1353–1356. of Starr plication for primary obstructed megaureters. J Urol 2004;172:
4. Liu H Y, Dhillon H K, Young CK, et al. Clinical outcome and management 703–705.
of prenatally diagnosed primary megaureter. J Urol 1994;152:914–917. 10. Peters CA, M andell J, Lebowitz RL, et al. Congenital obstructed megau-
5. M cLorie GA, Jayanthi VR, Kinaham TJ, et al. A modified extravesical reters in early infancy: diagnosis and treatment. J Urol 1989;142:641–645.
technique for megaureter repair. Br J Urol 1994;74:715–719.
6. Perovic S. Surgical treatment of megaureters using detrusor tunneling ex-
travesical ureteroneocystostomy. J Urol 1994;152:622–625.
CHAPTER 101 ■ PRUNE BELLY (TRIAD)

SYNDRO ME
DAVID B. JO SEPH
Triad syndrome—the clinical association of a thin flaccid ab- Approximately three quarters of children with classic triad
dominal wall, undescended testes, and bladder hypertrophy syndrome will have other associated anomalies. Urethral ab-
with hydroureters—was originally described in 1895 by normalities, including atresia and megalourethra, have been
Parker (1). Shortly thereafter, O sler presented a similar con- reported but are not required as part of the triad. Urethral
stellation of findings in a child he described as having the ap- atresia is usually associated with a patent urachus. The most
pearance of “ a wrinkled prune” (2). From that point, “ prune common skeletal abnormality is a thoracic deformity result-
belly” has unfortunately become synonymous with this syn- ing in a protruded upper sternum, depressed lower sternum,
drome. This clinical manifestation is also known as the and splayed ribs. O ther less frequent skeletal deformities
Eagle–Barrett syndrome and the abdominal muscular defi- include talipes equinovarus, congenital hip dislocation, calca-
ciency syndrome. By classic description, the triad syndrome neus valgus, polydactyly, syndactyly, arthrogryposis, scolio-
occurs in boys. H owever, 5% of patients are girls presenting sis, and lordosis. Intestinal malformations are noted in
with similar physical findings, with the obvious exception of approximately one third of children and most often are due
the gonadal abnormality. The incidence of triad syndrome to defective fixation or malrotation of the midgut. Cardiac
occurs in 1 of every 30,000 to 50,000 live births. M ost cases atrial or ventricular septal defects, patent ductus, and teratol-
are sporadic, although a familial occurrence has been de- ogy of Fallot have been reported in approximately 15% of
scribed (3). children (3).
Chap t e r 101: Prune Be lly (Triad ) Synd rome 655
DIAGNO SIS
The diagnosis of triad syndrome can be established in utero
with fetal sonography. H owever, similar findings can be seen
in a fetus with posterior urethral valves or the megacystis–
megaureters syndrome. Close inspection for thinned or absent
abdominal wall musculature should hedge the differential diag-
nosis to that of the triad syndrome. In utero diagnosis allows
for a planned neonatal investigation. Triad syndrome is often
obvious at birth with the pathognomonic physical findings of
a loose, lax, wrinkled abdominal wall; flared chest; and unde-
scended testes.
Several classifications of the triad syndrome have been es-
tablished based on severity and initial clinical presentation.
There is no single classification system that incorporates the
total spectrum of this syndrome. For practical purposes, chil-
dren can be grouped into severe, moderate, or mild presenta-
tions. With a severe presentation, survival is often limited by
significant respiratory compromise due to pulmonary imma-
turity and dysplasia, as well as extensive renal dysplasia, re-
sulting in a Potter-like syndrome. Children described with
moderate involvement have combined renal and respiratory
insufficiency, mandating close observation and early interven-
tion to minimize the sequelae of pulmonary and renal com-
promise. The combination of increased bilateral renal FIGURE 101.1 A: Scaphoid megalourethra. Corpora spongiosum
echogenicity on sonography, chronic urinary tract infections (CS) is deficient throughout the ventral aspect of penile urethra.
Corpora cavernosum (CC) is normal. B: Fusiform megalourethra.
(UTIs), and a nadir serum creatine of 0.7 mg/dL are prog- Both corpora spongiosum and cavernosum are deficient. Glans (gl) is
nostic for renal failure (4). M onitoring of the urinary system is normal in both variants.
necessary to prevent progressive renal deterioration due to
stagnation of urinary flow, UTIs, and possible urinary tract
obstruction. Urinary tract reconstruction may play an impor-
tant role in limiting long-term morbidity. Children with mild persistent and difficult to clear. Therefore, it is of utmost
involvement do not suffer from respiratory or renal compro- importance that any invasive lower urinary tract imaging be
mise. While long-term follow-up is necessary, operative inter- performed in a sterile environment, with the child receiving
vention is often limited to orchiopexy and abdominal wall pre- and postprocedural antibiotics.
reconstruction. M egalourethra has been classified as scaphoid and
A team approach consisting of a pediatric urologist, fusiform (Fig. 101.1). The more common scaphoid defect is
neonatologist, nephrologist, pulmonologist, and cardiolo- confined to the penile portion of the corpus spongiosum,
gist is required to maximize the outcome. The initial car- resulting in a variable length of massively enlarged ventral,
diorespiratory status of the neonate must be established. anterior urethra similar in appearance to a saccular diverticu-
The baby should undergo a chest X-ray and, when indi- lum. The fusiform variety encompasses a defect of the corpus
cated, cardiac sonography. Urologic evaluation commences spongiosum and deficiency of one or both of the corpus caver-
with abdominal sonography and a baseline chemistry pro- nosum, resulting in circumferential ballooning of the urethra
file. Both the upper and lower urinary tract should be and generalized penile flaccidity. M egalourethra is usually an
assessed. Attention should be placed on the degree of isolated defect but can present with upper urinary tract
hydronephrosis, the volume of renal parenchyma, and its changes, including hydronephrosis, vesicoureteral reflux, and
echogenicity. O ften, there will be a disproportionate degree renal dysplasia. It has been reported to occur with the triad
of distal ureteral dilation and megacystis compared to dila- syndrome, which may represent a continuation of the abnor-
tion of the proximal ureter and kidney. O n occasion, a mal mesodermal theory of development related to the triad
marked transition of ureteral dilation is noted. If the infant syndrome.
is clinically stable with normal renal function and is voiding
per urethra or draining through a patent urachus, further di-
agnostic testing can be placed on hold. INDICATIO NS FO R SURGERY
Children with renal insufficiency require further imaging to
differentiate renal dysplasia and stagnant urine flow from true Each child presents with a unique constellation of problems
obstruction. The M AG-3 renal scan has limitations in the new- resulting in its own set of considerations and requires individ-
born period but still provides the most objective data. The ualized care (5). Therefore, no one treatment plan is appropri-
voiding cystourethrogram can assess vesicoureteral reflux and ate for all children. In general, operative management can be
the effectiveness of bladder emptying. The neonate with triad divided into three broad areas: reconstruction of the urinary
syndrome and hydroureteronephrosis is susceptible to bacteri- system, reconstruction of the abdominal wall, and transfer of
uria and can quickly become symptomatic. Bacteriuria is often the intra-abdominal testes to the scrotum.
abnormal tissue. While the appearance of the abdomen was

Urinary Tract Re co nst ruct io n improved, it was not ideal and resulted in a transverse incision
and loss of the umbilicus. M onfort described preservation of
Controversy surrounds the need for aggressive urinary tract
the umbilicus, and others have added various modifications
reconstruction. Early aggressive operative intervention for
(8–10). Based on this approach, abdominal wall reconstruc-
all children is countered by the fact that renal dysplasia may
tion now allows for an excellent cosmetic and functional out-
be inherent, thus preventing any intervention from improving
come (11). The benefit of abdominal wall reconstruction is
the functional status. In addition, imaging studies depicting
dependent on the degree of abdominal wall laxity. The timing
significant hydroureteronephrosis do not always correlate
for this procedure should be based on the need for other oper-
with obstruction or the potential for symptoms, and hy-
ative intervention. If it is obvious that the child will not re-
droureteronephrosis by itself does not mandate reconstruction.
quire upper urinary tract reconstruction, abdominal wall
Urinary tract reconstruction is beneficial in a child who has a
reconstruction can be undertaken at any time. If, however,
component of obstructive uropathy and has been shown to
there is the potential for upper urinary tract reconstruction,
have improved renal function with decompression of the uri-
abdominal wall reconstruction should be deferred until the
nary system. Reconstruction is also of benefit in the child who
time of that intervention.
has progressive hydroureteronephrosis associated with increas-
ing renal compromise and in the child who has recurrent symp-
tomatic UTIs due to stagnant urine flow.
Urinary diversion plays an initial temporary role in the O rchio p e xy
management of acute renal failure or sepsis. O ften, children
The timing for orchiopexy can be individualized based on the
with urethral atresia or obstruction will present with a patent
child’s need for urinary reconstructive surgery. If urinary re-
urachus, effectively emptying their lower tract. Infants with
constructive surgery is required, orchiopexy can be performed
associated posterior urethral abnormalities resulting in obstruc-
at the same time. If urinary reconstructive surgery is not re-
tion or poor bladder decompression, who are not candidates
quired, then the timing and approach are variable. Placement
for intermittent catheterization, benefit from a vesicostomy. A
of the testes within the scrotum is important for maintaining
vesicostomy, however, may not adequately drain the upper
hormone function, allowing for pubertal development and
urinary tract due to a relative obstruction of the ureter at the
sexuality, but unfortunately fertility is not improved (12).
level of the bladder or poor urinary transport secondary to a
Biopsies of testes have shown a Sertoli-cell-only feature pro-
highly compliant, adynamic ureter. Vesicostomy should be un-
hibiting future fertility.
dertaken only when bladder catheterization has been shown
to be effective. O therwise, temporary diversion of the upper
urinary tract will be required. N ephrostomy tube drainage is
helpful to stabilize an acute problem but its long-term effec- Ure t hral Re co nst ruct io n
tiveness is limited, resulting in a need for a more formal upper
urinary tract diversion. There is a theoretical advantage in Correction of the megalourethra is dependent on presenting
performing upper tract diversion as proximal as possible. This symptoms of urinary dribbling and/or urinary infections.
should maximally relieve stress to the kidney and limit stagna- M ost often operative correction is undertaken because of the
tion of urine in a dilated tortuous ureter. H owever, there is unusual appearance of the megalourethra. Urethral tapering is
often a disproportionate degree of distal versus proximal an appropriate treatment.
ureteral dilation that can prevent easy access of the proximal
ureter.
It is compelling to perform a reduction cystoplasty during ALTERNATIVE THERAPY
urinary reconstruction in a child with triad syndrome.
H owever, long-term follow-up has not shown an objective ad- Alternative therapy relates to conservative medical manage-
vantage (6,7). With time, the bladder will often regain its large ment and observation. The floppy abdominal wall and poor
size and lose its tone, resulting in inadequate emptying. For musculature can be supported with use of an elastic corset.
these reasons, it is not practical to proceed with reductive
cystoplasty as the primary indication for urinary reconstruc-
tion. If a large, poorly contracting bladder results in inade- SURGICAL TECHNIQ UE
quate urinary emptying, intermittent catheterization would be
a more appropriate form of initial management. H owever,
when undertaking formal upper tract reconstruction and
Ve sico st o my
ureteral tailoring, reductive cystoplasty is practical and may
A vesicostomy is placed between the symphysis and umbilicus.
provide limited improved bladder emptying.
A 2- to 3-cm incision is made down to the rectus fascia. A tri-
angular segment of fascia is removed, which will help limit
Re co nst ruct io n o f t he Ab d o minal Wall problems of stenosis. The rectus is separated, the space of
Retzius is entered, and the dome of the bladder is identified
Several techniques have been devised to maximize the cos- along with the urachus and umbilical ligaments. The bladder
metic benefits of abdominal wall reconstruction in children is opened in this region to decrease the risk of prolapse. The
with triad syndrome. There is evidence indicating that the bladder wall is secured to the rectus fascia with 4-0
muscular defect is more pronounced centrally and caudally. polyglactin sutures and the bladder epithelium is approxi-
Initial reconstructive efforts were based on removal of this mated to the skin with 4-0 chromic gut.
approach, but in most children it is helpful to enter the peri-

Dist al Cut ane o us Ure t e ro st o my toneum and reflect either the descending or ascending colon
along the white line of Toldt. The dilated ureter is often ex-
When there is minimal proximal dilation, a low distal cuta-
ceedingly redundant and tortuous. Straightening of the ureter
neous ureterostomy provides adequate decompression with re-
without devascularization is required. The functional capabil-
lief of stagnated urine flow and stabilization of renal function.
ity of the ureter for peristalsis and transmission of urine into
The ureter can be approached from a small (2.5-cm) incision
the bladder parallels the degree of hydroureter. Therefore,
placed in a lower inguinal location. The muscles are split to en-
ureteral tapering may enhance urinary flow into the bladder.
ter the retroperitoneum. The ureter may have the appearance
M ultiple techniques exist for ureteral tailoring, including
of bowel due to its large size. When in doubt, a 21-gauge nee-
ureteral imbrication and formal ureteral excision as with any
dle should be passed, aspirating contents to confirm urine.
megaureter (Fig. 101.2). Ureteral imbrication is appropriate
O nce confirmed, the ureter is opened at the level of the obliter-
for marginally dilated ureters. But, when massive ureteral dila-
ated umbilical artery. The size of the ureter usually prevents
tion is present, which is usually the reason for reconstruction,
postoperative stenosis, allowing for either an end or loop
formal excision is preferred, eliminating the bulky tissue that
ureterostomy. An advantage of distal diversion is noted at the
results from the large imbricated ureter.
time of definitive urinary reconstruction: the proximal urinary
The ureter is tapered loosely over either a 10Fr or 12Fr
system will have remained uncompromised, allowing for easier
catheter, depending on the child’s age and size. The excised
mobilization and greater flexibility when tailoring the ureter.
ureteral segment may need to take an unconventional course
to preserve adequate blood supply to the tailored ureter. If a
large, redundant renal pelvis is present in association with a
Ure t e ral Re co nst ruct io n
dilated proximal ureter, a reduction pyeloplasty should be per-
When definitive primary urinary reconstruction is necessary, formed in line with the ureteral excision. Preservation of the
the initial approach to the ureter can be extravesical. The proximal ureteral blood supply is mandatory.
ureter is isolated at the level of the bladder and proximal dis- After excision, the ureter and renal pelvis are closed in a
section ensues. If there is an obvious transitional phase noted two-layer technique using absorbable sutures. The first run-
on imaging between the dilated distal ureter and the normal ning suture line is 5-0 or 6-0 chromic gut, polydioxanone, or
proximal ureter, the dissection should be continued proximal polyglactic acid, directly apposing the mucosa and muscularis
to the transition point. During dissection, the adventitial tis- of the ureter. The second layer reapproximates the adventitial
sue surrounding the ureter is preserved to prevent devascular- tissue using the same suture material. Both running layers are
ization. All of the distal ureter is excised when there is discontinued a few centimeters from the distal end of the
adequate length for the proximal ureter to be reimplanted in ureter. The very distal portion of the ureter is closed with in-
the bladder in a standard fashion or with the assistance of a terrupted sutures. This allows for excision of the distal ureter
psoas hitch. without interruption of the running suture line. Enough
If total proximal and distal ureteral tailoring is necessary ureteral length should be preserved to allow for a tunneled an-
due to massive dilation, full mobilization of the ureter will be tirefluxing ureteroneocystostomy in all cases. A ureteral stent
required. This can be accomplished via a retroperitoneal will remain for 5 to 10 days postoperatively.
FIGURE 101.2. A: The tortuous dilated ureter is

carefully straightened without compromising
blood supply. The redundant portion is excised and
the remaining distal segment tapered if necessary.
B: Ureteral folding over a 10Fr or 12Fr ureteral
catheter. C: Formal ureteral tapering with excision
and closure. N ote: The continuous running closure
stops 1 to 2 cm from the end of the segment, fol-
lowed by interrupted suture placement, allowing
for excision of the distal end of the ureter without
compromising the running closure.
FIGURE 101.3 Reduction cystoplasty. A: The dome of the bladder, including any urachal
remnant, is removed. B: A 2- to 3-cm mucosal strip is then removed from one portion of the
bladder. C and D: The bladder is closed with overlapping suture lines.
second parallel incision is made lateral to these arteries. The

Re d uct io n Cyst o p last y central fascial bridge with the umbilical island is now sup-
ported by both sets of epigastric arteries. The two lateral inci-
Reductive cystoplasty should include the urachus and the ma-
sions provide excellent exposure for orchiopexy and major
jority of the dome of the bladder (Fig. 101.3). A 2- to 3-cm
urinary tract reconstruction when required.
strip of mucosa is removed from one side of the bladder wall,
At the time of abdominal closure, the lateral fascia wall is
allowing for a reinforced overlapping suture line. The bladder
secured to the central fascial strip with a running 2-0 or 3-0
is closed in three independent layers using a running suture of
polyglactin suture. The lateral fascia can be scored with the
3-0 chromic gut, polydioxanone, or polyglactic acid. A supra-
cautery along the intended suture line to enhance adherence.
pubic tube is inserted for postoperative monitoring regarding
The edge of the lateral fascia is then overlapped and secured in
the effectiveness of bladder emptying.
the midline with figure-of-eight suture placement using 2-0 or
3-0 polyglactin sutures. This pants-over-vest closure provides
additional ventral support. Two flat 7Fr suction drains are
Ab d o minal Wall Re co nst ruct io n
placed between the fascia and the subcutaneous space. The
The M onfort approach begins with a midline incision from skin flaps are then tailored, removing the excess, allowing for
the tip of the xiphoid process carried inferiorly, circumscribing a midline and periumbilical closure. The skin flap is closed in
the umbilicus, leaving an adequate umbilical island of tissue, multiple layers, securing the subcutaneous tissue with 4-0
and ending at the symphysis pubis (Fig. 101.4). A full-thickness plain gut sutures. The epithelial edge is reapproximated with a
skin flap is created bilaterally, elevating the subcutaneous fat running subcuticular suture of 4-0 or 5-0 polyglactin. The
from the underlying fascia. The dissection is continued later- drains remain in place for 2 or 3 days for decompression of
ally to the anterior axillary line. O ften, there will be variability the dead space. An alternative laparoscopic-assisted approach
and asymmetry of muscular development. Care must be taken may allow for improved abdominal wall plication and simul-
not to enter the peritoneum while mobilizing the skin flaps, in taneous orchiopexy (13).
particular in areas where the fascia is relatively thin. An in-
cision is then made lateral to the superior epigastric artery
through the fascia, entering the peritoneum. The incision is O rchio p e xy
continued lateral and parallel to the course of the superior and
inferior epigastric arteries from the costal margin to the The testicle is usually found closely associated with a dilated
symphysis pubis. The fascia is then elevated and the contralat- distal ureter and should be released from the ureter in order to
eral superior and inferior epigastric arteries are identified. A determine whether it can be delivered into the scrotum without
FIGURE 101.4 A: An incision is begun at the xiphoid, circumscribing the umbilicus, and carried down to
the pubis. B: Skin flaps are then elevated, dissecting between the subcutaneous fat and the fascial layer. The
lateral extension is the anterior auxiliary line. C and D: The umbilicus is supported by the central fascial
bridge. Incisions will be made into the peritoneum lateral to the epigastric vessels. The central fascial bridge
is easily manipulated to allow for excellent intra-abdominal exposure. E: At the time of closure, a line is
scored on the peritoneal surface of the fascia. F: The central fascial strip is then secured laterally to the
scored fascia line with a running suture of 2-0 or 3-0 polyglactin. G: The lateral fascia is then secured in the
midline above and below the umbilicus with 2-0 or 3-0 polyglactin. Centrally, the fascia is secured directly
to the umbilicus. This allows for an overlapping reinforced fascial wall closure. Subcutaneous tissue is
closed with 3-0 or 4-0 plain gut and the skin with a running subcuticular 4-0 or 5-0 polyglactin suture.
sacrifice of the gonadal artery. If orchiopexy is undertaken peritoneal flap. A tunnel is then made into the scrotum and an
early, particularly within the first 6 months of life, there is of- incision placed inferiorly in the scrotum to create a dartos
ten adequate vascular length to deliver the testicle directly into pouch. A clamp is passed from the scrotum to the inguinal
the scrotum without transection of the gonadal artery (5). After canal. The testicle is grasped, pulled down through the tunnel,
the testicle is separated from the ureter, an incision is made and delivered to the scrotum. Care must be taken not to twist
in the peritoneum lateral to the gonadal artery and directed to or place the peritoneal pedicle on tension. If desired, the testicle
the internal ring. A second incision medial to the gonadal vessels can be secured to the dartos tissue with a 5-0 polydioxanone
is made in the peritoneum and continued caudally along the suture. When the orchiopexy is approached as an independent
course of the vessels and vas deferens. It is important not to procedure it can be undertaken laparoscopically.
disrupt the vascular supply of the peritoneal pedicle running
on both sides of the vas deferens. If it becomes apparent that the
testes will not reach into the scrotum after mobilization, the Ure t hral Re co nst ruct io n
gonadal artery is sacrificed to obtain adequate length for the tes-
ticle to be delivered in the scrotum, as described by Fowler and Urethral reconfiguration is most effective by formal excisional
Stephens (14). The blood supply to the testes is maintained by tapering, as described by N esbitt (Fig. 101.5). An incision is
the vasal artery and small anastomotic channels within the made in line with the previous circumcision or beneath the
FIGURE 101.5 N esbitt reduction urethroplasty for megalourethra. A:

The urethra is opened vertically in the midline, followed by excision of
the lateral redundant tissue (B). C: Reconstruction is carried out over a
12Fr catheter using two layers of running suture. D: The penile skin is
reapproximated to the coronal margin circumferentially.
coronal sulcus if the patient is uncircumcised. The penile shaft excised and then reapproximated to the coronal ring. A ure-
skin is then mobilized to the base of the penis. The anterior thral stent or catheter can be positioned for 7 days, depending
urethral wall is usually thin and poorly supported, and care on the length of the defect. The penis is dressed as above.
needs to be taken to prevent inadvertent entrance into the ure-
thra. The urethra is split in the midline ventrally. The redun-
dant portion of the urethra is excised and the urethra is O UTCO MES
reapproximated over a 10Fr or 12Fr catheter, depending on
the child’s age. The urethra is closed in two layers using 6-0 or Co mp licat io ns
7-0 polydioxanone or polyglactic acid sutures. The glanular
urethra is usually patent and the reconstruction is limited to Ureteral devascularization resulting in ischemia and subse-
the penile shaft. Because of poor development of the spongio- quent obstruction can occur if attention has not been paid to
sum it may be difficult to achieve additional tissue for a sec- the ureteral blood supply. The risk of bowel obstruction is pre-
ond layer of coverage. The penile shaft skin is then secured to sent as in any intra-abdominal procedure. Testicular ischemia
the coronal tissue with 6-0 chromic sutures. A urethral stent and atrophy due to a single-stage Fowler–Stephens procedure
or catheter is placed for 7 days. The penis is dressed with the has been reported to occur in 30% of children. This can be de-
personal technique used for a hypospadias repair. creased with a staged approach (12). M ore importantly, isch-
A variant of megalourethra is the “ megameatus with an in- emia may be prevented with early orchiopexy, eliminating the
tact prepuce” (M IP). This is corrected using standard hypospa- need for sacrificing the gonadal vessels.
dias techniques (Fig. 101.6). The glans is infiltrated with a The cosmetic appearance following urethral tapering is
mixture of 1:200,000 epinephrine for hemostasis. Parallel inci- good and limited only by any residual corpora cavernosa defi-
sions are made lateral to the urethral plate and extended into ciency. Postvoid dribbling can be abolished and the risk of uri-
the glans, creating two glanular wings. The incisions are con- nary infections due to stagnant urine can be diminished. The
tinued along the shaft of the penis and connected beneath the most common complication is that of a urethral fistula due to
urethral meatus. The urethra is then tubularized over an 8Fr, limited spongiosum tissue for a multiple-layer closure. The cir-
10Fr, or 12Fr catheter using 6-0 or 7-0 polyglactic or polygly- cumferential degloving of the penis with subsequent reapprox-
colic acid sutures. The glans is closed in the midline, reapproximation of the penile shaft skin to the corona will limit fistula
imating the deep tissue with 6-0 Vicryl and the epithelium with formation. The greatest risk for a fistula is located at the level
6-0 chromic. The penile shaft skin is brought up and the excess of the ventral coronal sulcus.
FIGURE 101.6 A: Pyramid pro-

cedure for repair of the megamea-
tus with intact prepuce variant of
hypospadias. B and C: Stay su-
tures are placed and the urethra is
mobilized sharply. D and E: The
urethra is tubularized in a two-
layer technique. F: Subcutaneous
glandular tissue is reapproxi-
mated and the skin closed.
reduction. For those reasons, long-term follow-up of the uri-

Re sult s nary tract is required. Patients should be prepared for the po-
tential need for intermittent catheterization. Because of
The results of urologic reconstruction can be very gratifying in
normal sensation, children are often unwilling to cooperate
the initial postoperative period, in particular the cosmetic ap-
with urethral catheterization. Placement of an appendicovesi-
pearance of the abdomen and improvement in upper urinary
costomy should be considered if catheterization appears to be
tract drainage. Voiding function may become more effective
a realistic possibility at the time of urinary reconstruction. An
due to the benefits of abdominal wall reconstruction and
appendicovesicostomy provides excellent access to the bladder
reduction cystoplasty (11). H owever, with time there can be
in a normally sensate child.
an increase in both bladder size and ureteral dilation. This is
often due to ineffective voiding and is independent of bladder
References
1. Parker RW. Absence of abdominal muscles in an infant. L ancet 8. Bukowski TM , Smith CA. M onfort abdominoplasty with neoumbilical
1895;23:1252. modification. J Urol 2000;164:1711–1713.
2. O ster W. Congenital absence of the abdominal muscles with distended and 9. Ehrlich RM , Lesavoy M A, Fine RN . Total abdominal wall reconstruction
hypertrophied urinary bladder. Bull Johns H opk ins H osp 1901;12: in the prune-belly syndrome. J Urol 1986;136:282–285.
331–335. 10. M ontfort G, Guys JM , Boccoardo A, et al. A novel technique for recon-
3. Strand WR. Initial management of complex pediatric disorders: prunebelly struction of the abdominal wall in the prune belly syndrome. J Urol 1991;
syndrome, posterior urethral valves. Urol Clin N orth A m 2004;31: 146:639–640.
399–415. 11. Smith CA, Smith EA, Parrott TS, et al. Voiding function in patients with
4. N oh PH , Cooper CS, Winkler AC, et al. Prognostic factors for long-term the prune-belly syndrome after M onfort abdominoplasty. J Urol 1998;
renal function in boys with the prune-belly syndrome. J Urol 1999;162: 159:1675–1679.
1399–1401. 12. Patil KK, Duffy PG, Woodhouse RJ, et al. Long-term outcome of Fowler-
5. Woodard JR. Prune-belly syndrome: a personal learning experience. BJU Stephens orchiopexy in boys with prune-belly syndrome. J Urol 2004;171:
Int 2003;92:10–11. 1666–1669.
6. Bukowski TM , Perlmutter AD. Reduction cystoplasty in the prune-belly 13. Franco I. Laparoscopic-assisted modification of the Firlit abdominal wall
syndrome: a long-term follow-up. J Urol 1994;152:2113–2116. plication. J Urol 2005;174:280–283.
7. Kinahan TJ, Churchill BM , M cLorie GA, et al. The efficiency of bladder 14. Fowler R, Stephens FD. The role of testicular vascular anatomy in the sal-
emptying in the prune-belly syndrome. J Urol 1992;148:600–603. vage of high undescended testis. A ust N Z J Surg 1959;29:92–106.
CHAPTER 102 ■ CHILDHO O D
RHABDO MYO SARCO MA
HSI-YANG WU AND HO WARD M. SNYDER III
The management of rhabdomyosarcoma (RM S) remains the TA B LE 1 0 2 . 1

most controversial topic in pediatric urological oncology. While
all agree that a combination of surgery, chemotherapy, and ra- PREOPERATIVE STAGIN G
diotherapy is best, the optimal timing and extent of the three
treatment modalities remain unclear. It is useful to remember T1: Confined to organ of origin, a: 5 cm, b: 5 cm
three key points: (i) chemotherapy cures microscopical disease, T2: Extension or fixed to surrounding tissue, a: 5 cm,
(ii) residual mass does not equal disease, and (iii) radiotherapy b: 5 cm
renders pathology very difficult to read. N 0: Regional nodes clinically negative
Twenty percent of RM S cases involve the bladder, prostate, N 1: Regional nodes clinically positive
vagina, or paratesticular area. The incidence of RM S peaks be- N x: Unknown
tween ages 2 to 4 and ages 15 to 19. The tumor is nonencapsu- M 0: N o distant metastasis
lated, grows rapidly, and spreads to regional lymph nodes as M 1: M etastasis present
well as hematogenously. The Intergroup Rhabdomyosarcoma Stage I: Vaginal and paratesticular RM S, any T, any N , M 0
Study (IRS) Group initiated studies in the United States in 1972 Stage II: Bladder/prostate RM S, T1a or T2a, N 0 or N x, M 0
to achieve better survival with less morbidity. The Children’s
Stage III: Bladder/prostate RM S, (T1a or T2a) and N 1, M 0,
O ncology Group (CO G) has taken over responsibilities for O R (T1b or T2b), any N , M 0
these trials, and is currently investigating new chemotherapeu-
Stage IV: Any tumor with M 1
tic options such as irinotecan (1). Patient survival, which was
only 40% to 73% prior to chemotherapy, has improved to
86% in IRS IV with VAC (vincristine, dactinomycin, and cy- TA B LE 1 0 2 . 2
clophosphamide) (2). During the same time, the surgical ap- POSTOPERATIVE GROUPIN G
proach has changed from initial exenterative surgery to
organ-preserving surgery following chemotherapy. The func- Group 1: Localized disease, completely excised, no
tional bladder salvage rate has risen from 25% to approxi- microscopical residual
mately 60% with this change in management. A: Confined to site of origin, completely resected
RM S consists of small, blue, round cells, arising from undif- B: Infiltrating beyond site of origin, completely resected
ferentiated mesoderm, with a microscopical appearance of spin- Group 2: Total gross resection
dle cells resembling fetal skeletal muscle. Embryonal pathology A: Gross resection with microscopical local residual
accounts for 90% of genitourinary RM S cases. Embryonal B: Regional disease with involved lymph nodes,
pathology is more favorable than alveolar pathology, which completely resected with no microscopic residual
tends to occur in extremities. Sarcoma botyroides (“ bunch of C: M icroscopical local and/or nodal residual
grapes” ) is a polypoid form of embryonal pathology.
Group 3: Incomplete resection or biopsy with gross residual
Group 4: Distant metastases
DIAGNO SIS
The IRS studies included both preoperative staging and post-
Bladder and prostate primaries present with urinary reten- operative grouping (2) (Tables 102.1 and 102.2). The IRS I–III
tion and gross hematuria and tend to be located at the studies grouped patients based on completeness of resection,
trigone and bladder neck. O ften, determining the organ introducing biases (shifting patients from group 1 to group 3)
from which the tumor arose can be difficult. Vaginal pri- that are not seen with the use of the tumor–node–metastasis
maries present with vaginal bleeding or an introital mass (TN M ) system in IRS IV and V.
and tend to occur on the anterior vaginal wall.
Paratesticular primaries present with a painless scrotal
mass. The preoperative evaluation can be carried out with INDICATIO NS FO R SURGERY
ultrasound, computed tomography (CT), or magnetic reso-
nance imaging (M RI) (T2 weighting). The retroperitoneum During the initial procedure, adequate tissue for a definitive
is best evaluated with CT or M RI. M etastatic workup is diagnosis should be obtained and, if possible, one should re-
completed with a chest X-ray, liver function tests, bone move the tumor without removing the affected organ (with
scan, and bone marrow biopsy. the exception of paratesticular RM S, where the testis is
662
Chap t e r 102: Child hood Rhab d omyosarcoma 663
removed with the tumor inguinally). If excision is not possi- amenable to partial cystectomy with a 2- to 3-cm margin,
ble, primary chemotherapy should be given. In follow-up stag- then the bladder does not need to be entirely removed. RM S
ing, a biopsy is needed during the “ second-look” operation is a nonencapsulated, infiltrative tumor, so adequate margins
because residual mass does not always represent tumor: the are necessary.
cancer can involute more rapidly than the supporting stroma. If the tumor extends down the urethra, then the symphysis
Definitive surgery aims to do a good radical but pelvic- should be split to gain better access. After completing distal
organ–sparing operation if possible. If microscopical residual dissection of the urethra, the symphysis is closed with long-
disease is found, it is treated with brachytherapy or external- term absorbable sutures. With this improved exposure, it is
beam radiotherapy. Exenteration is reserved for patients who also possible to perform a nerve-sparing dissection (see
fail this protocol of chemotherapy, conservative surgery, and Chapter 33), although follow-up potency data are not yet
radiotherapy. In Europe, the approach is to give primary available. The placement of brachytherapy catheters for after-
chemotherapy without initial local control (radiotherapy or loading (to treat microscopical positive margins if needed)
surgery) and offer local therapy based on the initial chemo- should be considered.
therapy response (3). Following cystectomy, we have often placed Dexon mesh
across the abdomen to hold the intestines out of the pelvis at
the level of the sacral promontory. This is done by attaching
ALTERNATIVE THERAPY it to the sacral promontory and wrapping it around the sig-
moid. This serves to prevent adhesion of the bowel to the
The use of surgery or radiotherapy as definitive local control raw surface of the pelvis until it has re-epithelialized, and if
remains a difficult choice. In favor of radiotherapy, it has been postoperative radiation is necessary for microscopical residual
remarkably successful in decreasing the need for radical disease it limits the exposure of the bowel to the radiation
surgery to achieve a cure. H owever, the difficulty with radio- field. Currently, pelvic exenteration is reserved for patients
therapy and bladder RM S is that because the tumors tend to who have failed both chemotherapy and radiotherapy
be located at the bladder neck, even the lowest dose (41 Gy) and who have tumors that invade both the bladder and the
that the radiation oncologists are willing to deliver may signif- rectum.
icantly risk urinary continence. Current attempts at limiting The final surgical decision is whether to proceed with con-
radiation toxicity to adjacent organs involve both conformal tinent urinary reconstruction at the same time. We have taken
radiotherapy and brachytherapy. The long-term risk of radia- the approach that it is not necessary to perform the recon-
tion vasculitis, which is inevitably progressive, as well as pos- struction at the same time unless the patient is both motivated
sible bony pelvis deformity in these children is another issue to and able to perform clean intermittent catheterization to drain
consider. Therefore, one must sometimes weigh whether pre- a urinary reservoir. For younger patients who are not ready to
serving a bladder without an outlet is better than removing the manage a urinary reservoir, we have either brought up the re-
bladder entirely (4). The final issue is that postradiation arti- maining bladder plate with ureterovesical junctions intact as a
fact makes subsequent biopsy very difficult to interpret, so it vesicostomy or performed low end-cutaneous ureterostomies,
would make sense to delay radiation until the patient is free of with the ureters placed side by side as a single stoma on the
gross disease. abdomen.
SURGICAL TECHNIQ UE Pro st at e

For bladder and prostate RM S, we will summarize the surgi-
The approach is similar to that for localized prostatic adeno-
cal options available after the initial biopsy has shown RM S,
carcinoma (see Chapter 33). Again, no follow-up on nerve-
the patient has received chemotherapy, and the choice has
sparing procedures is yet available. Splitting the symphysis is
been made to use surgery to achieve local control. For vaginal
useful as it is essential to remove the urethra to the midbulbar
and paratesticular RM S, we will review the overall surgical
level, and the placement of brachytherapy catheters for after-
approach starting with the initial resection.
loading (to treat microscopical positive margins if needed)
should be considered.
Blad d e r
The approach to partial or total cystectomy is similar to that Vag ina
for muscle-invasive transitional cell carcinoma (see Chapters
23 and 24). We will highlight the technical points that are The patient is placed in the lithotomy position and the pelvis
unique to the management of bladder RM S. and vagina are prepared. For the initial resection, vaginoscopy
The initial step after opening the abdomen is to examine is helpful in defining the limits of the tumor. Stay sutures and
the retroperitoneum. While we do not perform a full retro- a small weighted vaginal speculum are helpful for exposure, as
peritoneal lymphadenectomy because there is no therapeutic is a headlight for vision. Sharp excision of the tumor is carried
benefit, any suspicious lymph nodes along the vessels be- out, staying away from the external sphincter, urethra, and
tween the obturator fossa and the renal veins are removed. bladder neck. The vaginal mucosa is closed with interrupted
The next step is to properly stage the tumor by obtaining absorbable sutures. H ysterectomy is rarely carried out because
multiple frozen-section biopsies of the bladder around the uterine tumors are rare and tend to present in older girls ( 10
area of the tumor. If these are negative and the tumor is years old).
In a larger international series, 48% of patients underwent

Parat e st is biopsy alone, 30% had partial cystectomy, and 21% had com-
plete cystectomy. O f male patients, only 24% underwent
The testis and adnexa are removed via inguinal orchiectomy
prostatectomy. Bladder function was normal in 69% of pa-
(see Chapter 62). Frozen section of the proximal cord should
tients treated with biopsy alone and 73% of patients who un-
reveal no tumor. The key step is to avoid making a scrotal
derwent partial cystectomy. N either of these series utilized
incision for a solid paratesticular mass because, while
urodynamic studies to fully evaluate bladder function. Renal
chemotherapy often cures residual disease, some cases have
function was abnormal in 40% of patients, and bowel func-
required hemiscrotectomy due to tumor infiltration.
tion was abnormal in 13% (8).
Retroperitoneal lymph node dissection is carried out for all
boys with stage I disease older than age 10, regardless of the Vag ina
findings on abdominal CT. The technique is identical to that
Surgery and chemotherapy cure most cases of vaginal RM S. In
used for retroperitoneal involvement by testicular tumors (see
the overall IRS I–IV experience, 42% of patients were treated
Chapter 63). Again, sympathetic nerve-sparing techniques can
with surgery and chemotherapy, 19% required additional ra-
be used to maintain ejaculation, but no follow-up data are
diotherapy, 21% were treated with biopsy and chemotherapy
currently available. For boys under age 10, the retroperi-
alone, and 12% were managed with biopsy, chemotherapy,
toneum is imaged by CT or M RI, and if there is no gross
and radiotherapy (9). In IRS IV, only 19% of patients required
disease then retroperitoneal lymph node dissection is not per-
wide excision of the tumor. Primary treatment with VAC
formed. Chemotherapy has been shown to adequately clear
chemotherapy is usually successful, and a biopsy 8 to 12 weeks
microscopical disease (30% to 40% incidence).
after chemotherapy is recommended. Pelvic lymph node dissec-
tion is not necessary. Radiotherapy should be used only for
persistent disease or relapse (10). Rhabdomyoblasts on biopsy
Po st o p e rat ive De cisio ns are evidence of chemotherapy response, and therefore further
chemotherapy, instead of resection, is the proper treatment (5).
Review of the pathology may reveal persistent rhabdomy-
oblasts in a patient who has received as much chemotherapy Parat e st is
as can safely be given. Currently, there is debate concerning Paratesticular RM S has two peak incidences: in the 3- to
the malignant potential of these cells, which represent ma- 4-month-old boy and in the teenager. Scrotal ultrasound will
tured rhabdomyoblasts (5). N ormally, resection of the in- confirm the paratesticular primary, which should then be re-
volved organ is carried out. If this would require destruction sected along with the testis in a radical inguinal orchiectomy.
of a functional bladder, observation with frequent radiological Serum -human chorionic gonadotropin and -fetoprotein lev-
follow-up may be an option to consider. els should be obtained to confirm that the mass is not a testicu-
lar primary. Thirty percent to 40% of patients will have
metastases to the retroperitoneum. The biological activity of the
O UTCO MES tumor is different between the neonate and the teenager (90%
vs. 63% failure-free survival at 3 years). In previous studies, all
Re sult s patients underwent retroperitoneal lymph node dissection
(RPLN D) (2). H owever, O live et al. (11) showed in 1984 that of
19 patients with clinical stage I disease, 17 were cured with ad-
Blad d e r and Pro st at e juvant chemotherapy alone. This showed that chemotherapy
Bladder and prostate RM S has a 2.5:1 male predominance. can clear microscopical retroperitoneal disease, making RPLN D
IRS III included intensified chemotherapy (dactinomycin, unnecessary. In IRS IV, RPLN D was not recommended, leading
etoposide) and 6 weeks of radiotherapy, increasing the func- to a significant understaging of disease and a decrease in failure-
tional bladder salvage rate from 25% to 60% . The initial free survival rates because patients with negative CT scans did
procedure consists of percutaneous, endoscopic, or transrec- not receive radiation. Thirty percent of those patients who were
tal biopsy of the mass, followed by chemotherapy. In IRS IV, clinically stage I and over at 10 years of age required retreat-
VAC was shown to be as effective as two other three-drug ment. Because the outcome for stage I disease in those under
regimens (VIE/VAE: ifosfamide, etoposide) (2). O n a “ second- 10 years of age was so good in IRS IV, those patients who are
look” procedure, half of patients were managed with biopsy, 10 years old and have stage I disease and negative ab-
30% had partial cystectomy, 13% had cystoprostatectomy, dominopelvic CT are treated with VA (vincristine, dactino-
and the remainder had either cystectomy or prostatectomy mycin) only in IRS V, whereas all patients with stage I disease
alone (6). For persistent disease, group 2 was treated with 41 Gy who are 10 years or older undergo RPLN D regardless of CT
and group 3 was treated with 50 Gy. At 24 weeks, a third op- findings. Group 2 tumors (positive lymph nodes on pathology)
erative evaluation was performed with consideration for ex- are treated with radiotherapy and VAC. The 3-year failure-free
enteration. Patients with embryonal pathology had an 83% survival rate was 81% for group 1 tumors overall, but those pa-
3-year failure-free survival, compared to 40% in those with tients 10 years old had only a 63% survival rate (2).
alveolar pathology. All patients with group 4 (metastatic)
prostate disease died. Renal function, as assessed by serum
blood urea nitrogen and creatinine, was normal in 95% , al- Co mp licat io ns
though 29% of patients had abnormal renal scans (7).
Bladder function (as assessed by questionnaire) was normal The majority of patients have acute toxicity from the chemo-
in only 40% of patients (6). therapy: 90% developed myelosuppression, 55% developed
Chap t e r 103: Ve sicoure te ral Re flux 665
significant infections, and renal toxicity was seen in 2% (2). chance of 3-year survival, compared to 41% in group 1 or 2
M ost relapses occur within 3 years of initial diagnosis (12). patients (localized disease or total gross resection) (2).
Late recurrences can occur in patients who are treated with Twenty-nine percent required sex hormone replacement and
chemotherapy alone. O f 883 patients, 10 developed a sec- 11% were shorter than expected (4). If radiotherapy has been
ondary cancer. Patients with pre-existing renal abnormalities used, there is an increased risk of a secondary neoplasm, often
were at a higher risk of death (5% vs. 1% ). Relapse in group another sarcoma, in the radiation field.
3 patients (incomplete resection) was associated with a 22%
References
1. Ferrer FA, Isakoff M , Koyle M A. Bladder/prostate rhabdomyosarcoma: 7. Paidas CN . Results of rhabdomyosarcoma of the bladder and prostate: is
past, present, and future. J Urol 2006;176:1283–1291. bladder preservation successful? Presented at the Section on Surgery,
2. Crist WM , Anderson JR, M eza JL, et al. Intergroup Rhabdomyosarcoma American Academy of Pediatrics meeting, Chicago, 2000.
Study—IV: results for patients with nonmetastatic disease. J Clin O ncol 8. Raney B, Anderson J, Jenney M , et al. Late effects in 164 patients with
2001;19:3091–3102. rhabdomyosarcoma of the bladder/prostate region: a report from the
3. Flamant F, Rodary C, Rey A, et al. Treatment of non-metastatic rhab- International Workshop. J Urol 2006;176:2190–2195.
domyosarcoma in childhood and adolescence. Results of the second study 9. Arndt CAS, Donaldson SS, Anderson JR, et al. What constitutes optimal
of the International Society of Paediatric O ncology: M M T84. Eur J Cancer therapy for patients with rhabdomyosarcoma of the female genital tract?
1998;34:1050–1062. Cancer 2001;91:2454–2468.
4. Raney B, H eyn R, H ays DM , et al. Sequelae of treatment in 109 patients 10. Andrassy RJ. M odern approach to rhabdomyosarcoma of the vagina and
followed 5 to 15 years after diagnosis of sarcoma of the bladder and uterus. Presented at the Section on Surgery, American Academy of
prostate. Cancer 1993;71:2387–2394. Pediatrics meeting, Chicago, 2000.
5. Arndt CAS, H ammond S, Rodeberg D, et al. Significance of persistent ma- 11. O live D, Flamant F, Z ucker JM , et al. Paraaortic lymphadenectomy is not
ture rhabdomyoblasts in bladder/prostate rhabdomyosarcoma. Results necessary in the treatment of localized paratesticular rhabdomyosarcoma.
from IRS IV. J Pediatr H em atol O ncol 2006;28:563–567. Cancer 1984;54:1283–1287.
6. Arndt C, Rodeberg D, Breitfeld PP, et al. Does bladder preservation (as a 12. Pappo AS, Anderson JR, Crist WM , et al. Survival after relapse in chil-
surgical principle) lead to retaining bladder function in bladder/prostate dren and adolescents with rhabdomyosarcoma: a report from the
rhabdomyosarcoma? Results from Intergroup Rhabdomyosarcoma Study Intergroup Rhabdomyosarcoma Study Group. J Clin O ncol 1999;17:
IV. J Urol 2004;171:2396–2403. 3487–3493.
CHAPTER 103 ■ VESICO URETERAL REFLUX

MARK R. ZAO NTZ
Considering that vesicoureteral reflux (VUR) was first recog- general prevents new renal scarring. Reflux in the presence of
nized during the time of Galen (150 A.D .), not much progress sterile urine in general does not cause renal damage, although
was noted until the beginning of the 20th century. Young (1) and reflux in the presence of UTI can lead to renal scarring.
later Sampson (2) noted that those patients with both normal Boys in general present with higher reflux grades than girls
ureterovesical junction and ureteral path through the bladder of the same age, but boys also have a higher spontaneous res-
did not have VUR. It was not until the 1950s that the strong olution rate than girls. Studies showing that circumcised boys
relationship between VUR and pyelonephritis was recognized with low grades of reflux rarely get UTIs or related morbidity
by H utch (3). H is work demonstrated the pathologic anatomy have led to a nonoperative algorithm in this group of patients.
that underlies VUR and led to successful surgical correction Reflux is commonly linked with voiding dysfunction in
of this entity. H is pioneering work was also instrumental in children. Recent evidence using urodynamics and biofeedback
making the voiding cystourethrogram (VCUG) part of the techniques has shown high spontaneous cure rates for refluxing
evaluation in patients with urinary tract infection (UTI) as children with concomitant voiding dysfunction. Conversely,
well as hydronephrosis. children with significant voiding dysfunction have higher fail-
Until the 1980s, the treatment for reflux was largely surgi- ure rates from conventional surgery than those with normal
cal, with cure rates approaching 98% . H owever, multicenter bladder function.
studies have shown that lower grades of reflux had high spon- Sampson (2) in the early 1900s proposed a flap-valve
taneous resolution rates and these patients could be followed mechanism for the ureterovesical junction that was corrobo-
at least initially with medical management using prophylactic rated by Gruber (4), who found that those ureters with shorter
antibiotics and yearly reassessment. H igher grades of reflux intravesical segments were more prone to have reflux and
are associated with a higher incidence of renal scarring and therefore have a defective flap-valve mechanism. Stephens and
lower rates of spontaneous resolution. Lenaghan (5) added that the deficiency of the intravesical
Surgical correction of reflux may not prevent progression of ureter’s longitudinal muscle with or without a deficiency in
reflux nephropathy when present, although corrected reflux in ureteral tunnel length was also responsible for the reflux
phenomenon. From a surgical perspective we have learned H owever, a second febrile UTI would still warrant a VCUG.
that a 5:1 ratio of ureteral tunnel length to ureteral lumen di- O nce reflux is diagnosed, it is graded according to the
ameter is necessary to prevent reflux. International Study Classification (Fig. 103.1) (6). This system
While most cases of reflux are congenital in nature and is based on the radiographic appearance of the ureter and col-
considered primary reflux, increased intravesical pressure due lecting system during a VCUG. Follow-up studies are in general
to anatomic bladder outlet obstruction or functional causes done using nuclear cystography at yearly intervals to assess
such as neuropathic bladder/voiding dysfunction may lead to the resolution or progression of reflux.
what is termed secondary reflux. Ultrasound appears to be relatively accurate in determining
the presence or absence of renal scars in low-grade reflux pa-
tients. H owever, in those with higher-grade reflux a “ normal”
DIAGNO SIS renal ultrasound may miss significant renal scarring. The
DM SA scan is to date the best available study to assess focal
Today, thanks in great part to common antenatal screening, pyelonephritis and renal scarring.
reflux is often diagnosed prior to the development of a urinary Cystoscopy has little value in predicting the presence or ces-
infection and, as a result, pyelonephritis may be avoided by sation of reflux based on ureteral orifice configuration or loca-
promptly beginning prophylaxis just after delivery. Presenting tion. Factors such as tunnel length or the presence of incomplete
symptoms in neonates may include malaise, fever, vomiting, versus complete duplication anomalies will guide the surgeon to
diarrhea, or failure to thrive. Toddlers and young children choose an appropriate technique, open or endoscopic.
may have more typical symptoms, such as fever, frequency, ur-
gency, dysuria, foul-smelling urine, incontinence, or abdomi-
nal and/or back discomfort. INDICATIO NS FO R SURGERY
It is critical that a urine culture be obtained in all cases of
suspected UTI. A urinalysis alone is unacceptable as it only Indications for surgical correction of VUR include an older
alludes to the presence of UTI and at best is only 80% accu- patient, higher grade of reflux, presence of renal damage, non-
rate in diagnosis. Radiographic evaluation is indicated after compliance with prophylaxis, and the family’s concerns with
the first UTI in boys of any age and in all preadolescent girls. respect to repeated invasive testing and long-term prophy-
Further, any girl with a febrile infection or recurrent UTIs laxis. Findings from the International Reflux Study lend sup-
should be studied regardless of her age. Workup for UTI port toward surgical intervention in grade III and IV refluxers,
should include an ultrasound of the kidneys and bladder as with the majority of these patients failing to resolve their
well as a VCUG. In cases where screening is needed for reflux (7). O ther studies have supported these findings, with
siblings or children of known refluxers, a renal ultrasound rates of resolution of reflux ranging from 10% to 33% in
and nuclear cystogram (N VCUG) for girls and a fluoroscopic patients with grade IV reflux (8,9). Surgery is in general rec-
VCUG for boys is recommended. Recently, there has been ommended for grade V reflux because of the low likelihood of
discussion of alternative initial evaluation of the first febrile spontaneous resolution.
UTI by performing a 99m T c-labeled dimercaptosuccinic acid Girls should not be allowed to go into puberty with reflux
(DM SA) scan to see if the kidney has been engaged in the in- due to the increased risk and morbidity of pyelonephritis
fection. If the scan is negative, then a VCUG can be obviated. during pregnancy. Recurrent breakthrough urinary infection
FIGURE 103.1 International classification of vesicoureteral reflux. Grade I, into the nondilated ureter;
grade II, into the pelvis and calices without dilation; grade III, mild to moderate dilation of the ureter,
renal pelvis, and calices with minimal blunting of the fornices; grade IV, moderate ureteral tortuosity
and dilation of the pelvis and calices; grade V, gross dilation of the ureter, pelvis, and calices and loss of
papillary impressions and ureteral tortuosity.
while on adequate antibiotic prophylaxis is the sine qua non intravesical techniques (13). The benefits of this procedure are
for surgical intervention because otherwise these children are several: (a) The surgery is performed outside of the bladder
at high risk for renal damage. mucosa and as such avoids gross hematuria and irritable post-
operative voiding problems such as urgency symptoms and
bladder spasms, (b) catheter drainage of the bladder is brief,
ALTERNATIVE THERAPY (c) wound drains are avoided, and (d) ureteral stents are elim-
inated. A further advantage of this technique is that hospital
There are several factors that must be taken into consideration stay is brief, averaging 1.5 days in my hands, thus decreasing
for appropriate management: reflux grade, presence/degree of overall hospital costs.
renal scarring, patient age, presence or absence of bladder out- Prior to the incision, after the patient is prepared and
let obstruction, compliance of the patient/family on prophylac- draped, the bladder is catheterized and the bladder filled to
tic antibiotics, ability to remain infection-free while on about one third to one half of its estimated capacity with ster-
prophylaxis, and presence/absence of associated voiding dys- ile saline. This allows for easier dissection when separating the
function. Reflux may spontaneously resolve, and the peak time detrusor muscle from the mucosa. The bladder may be further
for resolution is between 5 and 7 years of age. The lower the filled or emptied depending on the surgeon’s preference during
grade of reflux, the higher is the likelihood for spontaneous res- the procedure. The surgical procedure for detrusorrhaphy be-
olution. Unilateral reflux is statistically more likely to resolve gins similarly to the intravesical approach with a Pfannenstiel
than bilateral reflux. M edical management consists of antibi- incision. A Dennis–Browne retractor is then placed over moist-
otic prophylaxis, usually a sulfa-based compound or nitrofu- ened gauze pads and the bladder is carefully mobilized and
rantoin at bedtime. In addition to antibiotics, bladder training rotated anteromedially, exposing the appropriate perivesical
in cases of dysfunctional voiding is instituted. This is designed to space. Care should be taken to avoid entering the peritoneum
improve bladder emptying at regular intervals, obviate bladder- during this maneuver. Placing an appropriate-sized Deaver
sphincter dyssynergia, and have minimal postvoid residual. retractor to help keep the rotated bladder in place will greatly
This may require a variety of teaching aids and the use of phar- facilitate locating the obliterated hypogastric vessel. This vessel
macotherapy such as anticholinergics and/or alpha antagonists. is tied off with 3-0 polyglycolic acid suture and the most lateral
In addition, urodynamics and biofeedback may be used in tie is clamped to help expose the ureter, which lies just beneath
selected cases. Equally important is to improve bowel function/ this vessel. In cases of bilateral detrusorrhaphy, the obliterated
evacuation in the presence of constipation. hypogastric vessel need not be tied off but simply recognized
for ease of finding the underlying ureter. This minimal dissec-
tion technique, as well as limiting the dissection of the extra-
SURGICAL TECHNIQ UE vesical submucosal tunnel, may help prevent significant nerve
denervation and avoid postoperative urinary retention. The
O nce the decision is made for surgical intervention, there are a ureter is carefully mobilized and encircled with a vessel loop
myriad of operative procedures available depending on one’s (Fig. 103.2). The ureter is freed up to its entry point into the
preference and comfort level. The existing techniques are di- bladder. During this maneuver the Deaver retractors may
vided into endoscopic, extravesical, intravesical, a combination need to be reset such that the ureter is in the middle of the op-
of intravesical and extravesical approaches, and laparoscopic erative field throughout the procedure. A tennis racket inci-
correction. sion is made around the ureteral detrusor hiatus and
deepened until the ureter is only attached to its connection
with the mucosa. The incision is then extended such that a 3-
End o sco p ic Surg e ry to 5-cm trough is created. All vessels encountered during this
dissection are tied off with 4-0 or 3-0 polyglycolic acid su-
Teflon was the first bulking agent used for endoscopic correc- ture. Dissection carefully proceeds down to the mucosa and
tion of reflux. Although the results were encouraging, later great care is exercised to avoid making a rent in the bladder
studies showed that there was migration of the Teflon parti-
cles to the lung, lymph nodes, and brain as well as the finding
of granuloma formation; this resulted in the search for more
biocompatible bulking agents (10). These have included both
autologous agents (fat, blood, human collagen, bladder muscle
cells, and ChondroGEL) and nonautologous agents (silicone,
BioGlass, polyvinyl alcohol, and dextronomer microspheres).
Deflux (dextronomer microspheres) is at present approved by
the U.S. Food and Drug Administration for use as a bulking
agent. Endoscopic surgery technique for reflux will be discussed
in another chapter.
Ext rave sical Ap p ro ach

Lich (11) and Gregoir (12) in the 1960s separately developed FIGURE 103.2 A: After ureteral mobilization, detrusor is incised
the extravesical approach to correct reflux. Further modifica- (dotted lines) at level of ureteral hiatus. B: Sagittal section demon-
tions of this approach have yielded success equal to that of the strates ureteral hiatus.
FIGURE 103.3 Ureter contiguous with detrusor mucosa (arrow -

heads).
(Fig. 103.3). If this occurs, immediately close the defect with

the 6-0 chromic catgut. Place stay sutures of 3-0 polyglycolic
acid on the detrusor edges to facilitate dissection of the mu-
cosa off the detrusor muscle. The mucosal dissection should
be generous enough to allow the ureter to easily sit in the
newly created trough and permit the detrusor muscle to be
closed over the ureter without tension. Prior to this step, fur-
ther dissection is performed toward the bladder neck beyond
the distalmost detrusor incision to allow placement of the ad-
vancement sutures. O nce completed, the ureteral orifice is ad-
vanced on the trigone toward the bladder neck with a pair of
“ vest-type” sutures of 4-0 chromic catgut (Fig. 103.4). The
first limb of the sutures is through the detrusor (outside/in). FIGURE 103.4 A: Bladder mucosa is elevated off bladder wall muscle
The sutures enter the detrusor at the distal limit of the trigo- and vest-type sutures are placed. B: Sagittal section shows suture pass-
ing between undermined mucosa and detrusor. C: Alignment of vest su-
nal musculature and exit in the plane between the mucosa tures after placement. D: Sagittal section demonstrates appropriate
and detrusor. The second limb of the suture is through the positioning of sutures. E: Tying vest sutures advances and anchors
ureteral muscle, and the final limb of the suture is back ureter onto trigone. F: Sagittal section of ureteromeatal advancement.
through the detrusor (inside/out). Tying the pair of vest su-
tures advances and anchors the ureteral orifice distally and
creates a new longer submucosal tunnel. The remaining de-
trusor defect is closed over the ureter in two layers; the first is
a running layer and the second is an interrupted Lembert su-
ture, both using 4-0 polyglycolic acid suture. Care must be
exercised to avoid making the ureteral hiatus too snug. The
exit point for the ureter should be able to admit a hemostat
between the detrusor and the ureter easily (Fig. 103.5). N o
perivesical drains or ureteral stents are used, and the Foley
catheter is removed the following morning.
Complete and incomplete ureteral duplication may also be
approached extravesically. Cystoscopy at the time of surgery
is recommended to visualize the ureteral orifice location with
respect to location and proximity to each other as well as dis-
tance to the bladder neck. This information will aid in deter-
mining if detrusorrhaphy is feasible or if another technique is
more appropriate.
Finally, as we continue to push the envelope into minimally
invasive procedures, the extravesical technique can also be
approached in selected patients via a small transverse inguinal
incision to achieve access to the ureter. In these cases, I find
it advantageous to first cystoscope the patient and pass a tem- FIGURE 103.5 Closure of detrusor flaps over ureter allows for long
porary ureteral stent up the refluxing ureter to aid in initial submucosal tunnel and completes detrusorrhaphy.
identification. The procedure is otherwise essentially the same provides a precise incision. Carefully, using long tenotomy scis-
as already described, although some institutions are obviating sors, vascular forceps, Kittner dissector, a right-angle clamp,
the advancement portion of the procedure, making this tech- and judicious use of the cautery unit, the muscular attachments
nique that much simpler. to the ureter are taken down. As the dissection proceeds proxi-
mally, I have employed the use of a number 3 Freer elevator
along the posterior surface of the ureter, which further aids in
Int rave sical Ap p ro ach mobilization. It is critically important to stay outside of the ad-
ventitia of the ureter to avoid devascularization during its dis-
O ne of the earlier and still highly popular and successful tech- section. As the peritoneum is encountered, it is generously
niques to correct reflux is the Politano–Leadbetter approach swept back off the ureter to avoid injuring the bowel during the
(14). This procedure is performed entirely intravesically and relocation of the ureter. A hernia retractor or a very thin Deaver
avoids mobilization of the bladder as seen in the extravesical helps to better expose the peritoneum and extravesical attach-
approach. O nce the bladder is exposed via the technique de- ments to the ureter. Take care in the male patient to avoid injury
scribed for the extravesical approach, it is opened in the midline to the vas deferens.
between 3-0 chromic catgut stay sutures. The bladder is packed After completion of ureteral mobilization, the surgeon may
with moist 4 8-inch gauze pads to allow superior retraction choose one of several procedures to complete the ureteral
of the bladder and easier exposure of the ureteral orifices. This reimplantation. The Politano–Leadbetter repair employs a
is further facilitated with the placement of a Dennis–Browne re- suprahiatal approach (Figs. 103.7 and 103.8). A submucosal
tractor with the curved blades actually within the bladder over tunnel is created from the old hiatus superiorly, long enough
moist sponges. The ureteral orifice is identified and intubated to achieve a 5:1 ratio of submucosal tunnel to ureteral diameter.
with a 5Fr feeding tube and secured with 4-0 or 5-0 silk sutures I like to use 135-degree blunt-tip M etzenbaum scissors to fa-
to allow tenting of the ureter by pulling on the feeding tube. As cilitate this maneuver and avoid tearing the bladder mucosa.
with all intravesical repairs the ureter is mobilized in similar O nce the desired tunnel length is achieved, the new hiatus is
fashion (Fig. 103.6). An incision is made to score the mucosa developed by making a small incision directly on top of a
around the orifice. This can be done with a scalpel, tenotomy right-angle clamp. Using a stay suture or the feeding tube,
scissor, or, as I prefer, the cutting current of the Bovie, which the mobilized ureter is passed from the old hiatus to the new
FIGURE 103.6 Intravesical mobilization of ureter.

A: Low transverse incision. B: A 3.5Fr or 5.0Fr polyeth-
ylene tube and traction suture. C: Incision around meatus
with mucosal cuff using long-handled knife. D: Cutting
and blunt dissection of muscle of superficial trigone.
E: Extravesical mobilization with right-angle clamp and
Kittner dissector.
FIGURE 103.7 Politano–Leadbetter repair.

A: M obilization of intravesical ureter.
B: Dissection of peritoneum with Kittner dis-
sector. C: Development of submucosal tun-
nel. D: Creation of the new hiatus.
FIGURE 103.8 Politano–Leadbetter repair and details of

ureteral reimplant. A: The ureter is brought through the
new hiatus, and the old hiatus is closed with interrupted
absorbable suture. B: The ureter is brought through the
new tunnel (C), spatulated if necessary (D), and sewn in
place with interrupted absorbable suture (E).
hiatus, care being taken to avoid twisting, kinking, or angulat-

ing the ureter as well as avoiding the peritoneum. The old hia-
tus is repaired with 4-0 chromic catgut. The ureter is then
brought through the new tunnel. The old meatus is then
trimmed up and spatulated if necessary. The distal and poste-
rior lip of the ureter is anchored first with a deep suture of 4-0
or 5-0 chromic catgut to the mucosa and muscular layers
of the bladder. The remaining anastomosis is performed with
the same suture for a mucosal-to-mucosal approximation.
Leaving a ureteral stent is at the surgeon’s preference. In gen-
eral, I assess how the urine output appears from the reim-
planted ureteral orifice. If there is copious drainage, I do not
leave a stent. If I am uncomfortable with urine drainage or
there is significant edema at the orifice, a stent is left and
brought out through a separate stab wound in the bladder and
secured there with a chromic catgut suture. Then, a separate
stab wound is made to bring the stent out through the skin
and secured there with 4-0 nylon. Likewise, if I have to taper
the ureter a stent is left in place for 4 to 7 days postoperatively.
I close all bladders in three layers using running 4-0 chromic
catgut for the mucosa, muscularis, and seromuscular layers.
This has allowed me to avoid leaving any perivesical drains
when the ureters are not stented. A Foley catheter remains in
the bladder for 1 or 2 postoperative days.
The Glenn–Anderson procedure (Fig. 103.9) (15), in com-
FIGURE 103.9 Glenn–Anderson repair. (From Walker RW.
Vesicoureteral reflux. In: Gillenwater JY, Grahhack JR, H owards SS, parison to the Politano–Leadbetter, is an infrahiatal repair and
et al., eds. A dult and Pediatric Urology, vol 2. St. Louis: M osby–Year develops a submucosal tunnel toward the bladder neck (Fig.
Book, 1996, with permission.) 103.10). It is in particular advantageous when there is good
distance between the native ureteral orifice and the bladder
neck such that an appropriate tunnel length can be obtained.
Adequate mobilization of the ureter is paramount to achieve
satisfactory success rates. If the tunnel length appears too
FIGURE 103.10 Glenn–Anderson re-

pair: details of ureteral reimplantation.
A: Tunnel made toward bladder neck.
The ureter is brought through the
tunnel (B) and sewn in place (C). An
alternative, similar to the M athison
technique, allows enlargement of
hiatus (D) and results in longer repair
(E and F).
short on initial inspection, moving the hiatus more superiorly obstruction. If bilateral reimplant is necessary, it is important
will allow for satisfactory tunnel creation. Advantages of the to create separate tunnel paths for each ureter. Always remem-
Glenn–Anderson technique are that the entire procedure is ber to close the hiatus with absorbable 4-0 chromic catgut.
done under direct vision and it creates a relatively straight tun- Leave enough room for a hemostat or right-angle clamp to be
nel with an easily catheterized ureter. interposed between the ureter and the approximated detrusor
The transtrigonal approach (Cohen) (16) is similar to the muscle to avoid obstruction at the hiatus. A potential disad-
Glenn–Anderson procedure with the exception that the ureter vantage of the Cohen technique is the difficulty of ureteral ac-
is transposed across the trigone (Fig. 103.11). This is in partic- cess postoperatively. These patients may need percutaneous
ular useful in small-capacity and neurogenic bladders where access for any future procedures.
an appropriately long tunnel is critical to success. The ureteral
course created is an extension of the natural direction of the
ureter; thus, it carries a low risk of ureteral kinking and Ure t e ral Dup licat io n
Determining whether the ureteral duplication is complete or
incomplete guides operative considerations. In the absence of
a ureterocele, an intravesical complete duplication can be ap-
proached extravesically as well as intravesically. The key to in-
travesical surgery is to mobilize the duplicated ureters as one
unit because their blood supply at the bladder level is inter-
twined within a common sheath (Fig. 103.12). This will avoid
unnecessary devascularization. The technique chosen for
reimplant can be any of the intravesical repairs mentioned. In
cases of a complete duplication, an ipsilateral ureteroureteros-
tomy is an attractive alternative. In situations where there is
an associated ectopic ureter with a salvageable renal moiety,
separate ureteral tunnels should be created.
O ne tip that I have found useful to aid in freeing up the
ureter and also with submucosal dissection for all of the in-
travesical techniques is the use of 1% lidocaine (Xylocaine)
with a 1:100,000 epinephrine solution. This is injected peri-
ureterally at the orifice and along the proposed subepithelial
tunnel using a 26-gauge needle. This minimizes bleeding and
provides ease of dissection in a readily defined plane.
Int ra–Ext rave sical Ap p ro ach

The Paquin technique (Fig. 103.13) (17) is a commonly used
repair and has the advantage over the Politano–Leadbetter
approach of doing the complete procedure under direct vi-
sion, thus avoiding the potential risk of peritoneal injury. The
approach to the ureter is extravesical, similar to that de-
scribed in detrusorrhaphy. When the ureter is mobilized to
the level of the detrusor hiatus, a right-angle clamp is used to
clamp the ureter and then the distal stump is oversewn after
the ureter has been divided using polyglycolic acid suture.
Alternatively, the bladder may be opened in the midline and
the ureteral orifice circumscribed and mobilized from within
the bladder. The ureter should be intubated with a 5Fr or 8Fr
feeding tube and secured with a suture prior to mobilization.
The ureter is then passed extravesically, taking care to avoid
the peritoneum, which should be swept off the posterior lat-
eral bladder wall. If ureteral tailoring is warranted, it is per-
formed at this point of the procedure. If a longer tunnel is
needed and ureteral length is suspect, consider a psoas hitch
at this time as well (Fig. 103.14). Using two fingers inside the
bladder, bring the bladder up to the psoas muscle tendon,
FIGURE 103.11 Cohen technique of ureteral reimplantation. Cross- where it should sit under no tension. Place interrupted figure-
trigonal tunnel, with the stippled area (A) sewn in place with inter- of-eight sutures of heavy chromic or polyglycolic acid from
rupted sutures (B). C: Bilateral reimplants easily accomplished. (From
Walker RW. Vesicoureteral reflux. In: Gillenwater JY, Grayhack JT,
the tendon of the psoas to the bladder wall just lateral to
H owards SS, et al., eds. A dult and Pediatric Urology, vol 2. St. Louis: where the new ureteral hiatus will be situated. Avoid the gen-
M osby–Year Book, 1996, with permission.) itofemoral nerve running along the psoas muscle during this
FIGURE 103.12 Reimplantation of duplex

ureters.
FIGURE 103.13 Paquin repair.

FIGURE 103.14 Bladder mobilized and sutured to psoas over iliac vessels by psoas hitch. A: Blunt
dissection and exposure of psoas tendon and iliac vessels. B: Psoas hitch with interrupted absorbable
sutures. C: Completed reimplant. Long submucosal tunnel to prevent reflux is shown. (From Ehrlich
RM , M elman A, Skinner DG. The use of the vesicopsoas hitch in urologic surgery. J Urol 1978;119:324,
with permission.)
maneuver. Likewise, the vas deferens in boys and the fallop- The operating room table is rotated away from the refluxing
ian tubes in girls must be protected. side to shift the peritoneal contents and bladder away from
A submucosal tunnel is created as described for the the operative location. The peritoneum is incised over the iliac
Politano–Leadbetter repair. The ureter is brought through the vessels, where the obliterated hypogastric artery is recognized.
new hiatus, under the subepithelial tunnel, and secured in its The ureter is identified (Fig. 103.15), grasped with a Babcock-
new location. Care is taken to avoid twisting or kinking the type instrument, and tented up to allow dissection and mobi-
ureter as it is brought back intravesically. As with all of the in- lization of the ureter for 3 or 4 cm proximal to its detrusor
travesical techniques, after the final ureteral anastomosis is insertion. This will allow placement of the ureter within a
complete, a 5Fr feeding tube should easily pass up through the trough that is to be created. N ext, using electrocautery the
reimplanted ureter to the kidney. muscle layer of the bladder is incised for approximately 3 cm
proximal to the ureterovesical junction. Spreading carefully
with scissors will expose the mucosa. Dissection continues for
Lap aro sco p ic Re p air the length of the tunnel until the mucosa bulges throughout
the incision. The ureter is placed in the trough and the detru-
The modern era of laparoscopy has brought forth many new sor edges are approximated and the ureter is advanced with a
and innovative techniques. These new procedures have been fixation suture at the distalmost part of the trough. The re-
designed to decrease morbidity and hospital costs as well as maining detrusor defect is closed over the ureter with either
speed patient recovery. Among these is the laparoscopic ex- absorbable polydioxanone suture or staples. A Foley catheter
travesical ureteral reimplant. Designed to emulate the is left overnight.
Lich–Gregoir repair, this repair is at present utilized in few At present, laparoscopic correction of reflux takes longer
centers specializing in laparoscopic technique. This particular than traditional repairs and the incisions made are actually
repair requires two surgeons and can be performed intraperi- more unsightly than the single lower-abdominal incision done
toneally or retroperitoneally. The technique for intraperi- for open surgery. The instruments used are more costly. As a
toneal access has been well described. In the pediatric whole, the laparoscopic repair is not yet as cost-effective as
population, access to the peritoneum should be performed either open surgery or endoscopic correction.
using an open technique. I do this using the 10-mm H assan
trocar to avoid intraperitoneal injury. O nce the pneumoperi-
toneum is created, three other trocars are placed. A second PO STO PERATIVE CARE
10-mm trocar (instruments) is placed 1 to 5 cm above the in-
fraumbilical site (camera) on the opposite side of the refluxing The patient stays on prophylactic antibiotics until reflux has
ureter in the midclavicular line. Two 5-mm trocars are placed in been shown to be resolved. An ultrasound of the kidneys
the left and right midclavicular lines at the level of the anterior and bladder is usually done 4 to 6 weeks after surgery to as-
superior iliac spine for dissecting instruments and retraction. sess for occult hydronephrosis and hydroureter. Assuming
FIGURE 103.15 Laparoscopic reimplant. A: Ureteral mobilization. The obliterated umbilical artery is identified
and traced distally until the ureter is seen. The ureter is grasped gently and the periureteral tissue dissected bluntly
toward the ureterovesical junction. B–D: Creation of bladder wall trough. Bladder wall is incised with electro-
cautery 3 cm proximal to the ureterovesical junction. M uscle fibers are gently cut and spread. Dissection is complete
when mucosal tissue bulges outward. E: After placing the ureter in the trough-grasping instruments, the superior
aspect of the bladder wall is wrapped around the ureter and a suture placed proximally, immobilizing the ureter in
the trough (left). Remaining sutures are placed throughout the length of the tunnel (right). F: Completed repair.
(From Atala A, Keating M . Vesicoureteral reflux. In: Walsh PC, Retik AB, Wein A, et al., eds. Cam pbell’s Urology,
vol 2. Philadelphia: WB Saunders, 1997, with permission.)
the ultrasound is normal, a follow-up VCUG or nuclear cys- valves, the success rates diminish somewhat. Previously unrec-
togram is performed 3 months later to assess the surgical re- ognized bladder and bowel dysfunction is the most common
sult. If reflux is no longer present, I routinely repeat a renal cause of postoperative problems and needs to be vigorously
ultrasound 1 year later to make sure that anatomically all is addressed. The most common complication is persisting reflux
well. Should known renal scarring be present, then yearly on the operative side or contralateral reflux of a previously
urinalysis, blood pressure measurements, and periodic ultra- nonrefluxing ureter. In most cases observation is the treatment
sounds are recommended. of choice as the vast majority of these patients will have spon-
taneous resolution of reflux within 1 year. Always look for
voiding or bowel dysfunction in any case of persistent reflux.
O UTCO MES If the recurrent reflux is high grade, then most likely there was
a technical failure such as not creating a long enough tunnel or
Co mp licat io ns insufficient ureteral mobilization. These cases frequently re-
quire reoperation. Always treat any voiding problems first.
Fortunately, the success rates for open surgery to correct re- Ureteral obstruction is fortunately a rare complication of
flux approach 98% for nondilated ureters and those with nor- reflux surgery and frequently is transient in nature, resulting
mal bladder function. In cases with dilated ureters, significant from postoperative bladder spasms, edema, or blood clots.
voiding dysfunction, neuropathic bladder, and anatomic con- H ence, it is not unusual to see some mild renal or ureteral
ditions such as prune belly syndrome and posterior urethral dilatation in the first few weeks after surgery on sonography.
Should problems persist, ureteral stenting or percutaneous obstruction or reflux, then observation is all that is needed. In
nephrostomy will help temporize the situation until resolution the presence of ureteral pathology or poor drainage of the di-
occurs spontaneously or surgical reimplantation is performed. verticula, surgical correction is necessary.
H igher-grade obstructions usually present with a variety of
symptoms such as flank pain, fever, nausea, vomiting, and
ileus. These are due to angulation, obstruction at the hiatus, CO NCLUSIO NS
extravasation (of a tapered ureter), or ureteral ischemia with
resultant stricturing. Urinary diversion or stenting is para- Surgical management of VUR is highly successful if performed
mount in these situations and redo reimplantation required. If for the right indications and if one adheres to the proper
the remaining ureter is too short to reimplant in the standard principles of good surgical technique. There are a myriad of
fashion, consider a psoas hitch or a transureteral ureterostomy. corrective techniques available, each with their respective ad-
Bladder diverticula are usually the result of a defect in the vantages and disadvantages. It is up to the individual surgeon
closure of the muscular hiatus at the original procedure. If the to decide what works best in his or her hands after analyzing
diverticula is wide-mouthed and drains well in the absence of the available information on the respective patient.
References
1. Young H H , Wesson M B. The anatomy and surgery of the trigone. A rch 9. Skoog SJ, Belman AB, M ajd M . A nonsurgical approach to the manage-
Surg 1921;3:1. ment of primary vesicoureteral reflux. J Urol 1987;138:941.
2. Sampson JA. Ascending renal infection with special reference to the reflux 10. Aaronson IA, Rames RA, Greene WB, et al. Endoscopic treatment of re-
of urine from the bladder into the ureters. Johns H opk ins H osp Bull flux: migration of Teflon to the lungs and brain. Eur Urol 1993;23:394.
1903;14:334. 11. Lich R Jr, H owerton LW, Davis LA. Recurrent urosepsis in children. J Urol
3. H utch JA. Vesicoureteral reflux in the paraplegic: cause and correction. 1961; 86:554.
J Urol 1952;68:457. 12. Gregoir W, Van Regemorter GV. Le reflux vesico-ureteral congenital. Urol
4. Gruber CM . A comparative study of the intravesical ureters (ureterovesical Int 1964;18:122.
valves) in man and in experimental animals. J Urol 1929;21:567. 13. Z aontz M R, M aizels M , Sugar EC, et al. Detrusorrhaphy: extravesical
5. Stephens FD, Lenaghan D. The anatomical basis and dynamics of vesi- ureteral advancement to correct vesicoureteral reflux in children. J Urol
coureteral reflux. J Urol 1962;87:669. 1987;138:947–949.
6. International Reflux Study Committee. M edical versus surgical treatment 14. Politano VA, Leadbetter WF. An operative technique for the correction of
of primary vesicoureteral reflux. Pediatrics 1981;67:392–400. vesicoureteral reflux. J Urol 1958;79:932–941.
7. Weiss R, Duckett J, Spitzer A, on behalf of the International Reflux Study 15. Glen JF, Anderson EE. Technical considerations in distal tunnel ureteral
in Children. Results of a randomized clinical trial of medical vs. surgical reimplantation. J Urol 1978;119:194.
management of infants and children with grades III and IV primary vesi- 16. Cohen SJ. The Cohen reimplantation technique. Birth D efects 1977;
coureteral reflux (United States). J Urol 1992;148:1667. 13:391.
8. Duckett JW. Vesicoureteral reflux: a conservative analysis. A m J Kidney 17. Paquin AJ. Ureterovesical anastomosis. The description and evaluation of a
D is 1983;3:139–144. technique. J Urol 1959;82:573.
CHAPTER 104 ■ ENDO SCO PIC TREATMENT

O F VESICO URETERAL REFLUX
WO LFGANG H. CERWINKA AND ANDREW J. KIRSCH
Approximately 1% of children are diagnosed with vesi- injection for VUR was introduced as an investigational method
coureteral reflux (VUR), a condition that promotes and the first clinical experience was published in 1984 (1,2).
pyelonephritis and may lead to renal scarring and hyperten- O ver the last 20 years, injection techniques, injectable agents,
sion. VUR is one of several treatable risk factors, such as dys- and consequently treatment success rates have significantly im-
functional elimination, in the development of urinary tract proved (3). The success rate of outpatient endoscopic treat-
infection (UTI). The goal of VUR treatment is to prevent ment of VUR approaches that of open ureteral reimplantation
pyelonephritis and to preserve renal function. Antibiotic pro- and offers considerable advantages to patients and parents
phylaxis is initiated in most children irrespective of VUR such as lower morbidity (e.g., pain, scar), fewer complications,
grade. Surgical management, indicated in cases of break- and reduced cost. Consequently, an apparent trend from reim-
through UTIs and/or persistence of VUR, comprises ureteral plantations toward injection treatments has been observed
reimplantation and endoscopic injection. In 1981 endoscopic over the last several years.
Chap t e r 104: End oscop ic Tre atme nt of Ve sicoure te ral Re flux 677
of some infants and young children secondary to sedation.

DIAGNO SIS Although technically feasible, it seems unlikely that M RVCU
will gain widespread acceptance.
VUR is diagnosed by nuclear cystography or voiding cys-
tourethrography (VCUG) and graded from I to V. This grading
system bears clinical significance not only for spontaneous res- INDICATIO NS FO R SURGERY
olution, but also for treatment method and outcome. VCUGs
performed with a single cycle of filling and voiding show false Endoscopic treatment using Deflux is U.S. Food and Drug
negatives in approximately 20% ; for improved sensitivity, Administration (FDA) approved for VUR grades II to IV in sin-
cyclic VCUGs consisting of three voiding cycles are recom- gle or duplex ureters and for cases of initial endoscopic treat-
mended. VCUG as a means to detect VUR is indicated in vari- ment failure; however, it has been applied to all VUR scenarios.
ous clinical scenarios. The current guidelines recommend While open ureteral reimplantation may be a good treatment
VCUGs for children of both sexes and all ages after the first option after failed injection therapy, endoscopic treatment has
febrile UTI or subsequent UTIs if the previous VCUGs did not been successfully employed after failed ureteral reimplantation
demonstrate VUR. Approximately 40% of children with (Table 104.1). Current evidence does not suggest that antire-
febrile UTIs are subsequently diagnosed with VUR. Children flux surgery of any means reduces the incidence of renal scar-
who experience recurrent febrile UTIs without evidence of ring or end-stage renal disease. Valuable goals of VUR
VUR by VCUG may suffer from occult VUR. It is conceivable treatment are to prevent UTIs, particularly pyelonephritis, to
that despite negative conventional VCUG, occult VUR is clini- avoid long-term antibiotic prophylaxis, and to reduce the need
cally significant. O ne method to diagnose occult VUR is the for distressing VCUGs and radiation exposure. Proponents of
positional instillation of contrast cystography (PICC). The tip the endoscopic approach will argue that decreasing the inci-
of the cystoscope is positioned at the ureteral orifice and con- dence of UTIs is the main goal of therapy. Recurrence, while
trast instilled at full flow with a pressure of 80 cm of water. A possible, may occur in the absence of symptoms and be viewed
patient is designated PICC-positive if contrast is seen in the as subclinical, similar to an individual with VUR diagnosed af-
ureter, without the need to grade occult VUR. An alternative ter a sibling screen or for fetal hydronephrosis. Proponents of
approach for the diagnosis of occult VUR is hydrodistention of the open surgical approach will argue that ureteral reimplanta-
the distal ureter, thus avoiding the use of contrast and ionizing tion provides a permanent cure of VUR and is worth the in-
radiation. The degree of hydrodistention was shown to corre- creased morbidity to achieve this goal. In terms of reducing the
late with the presence of occult reflux. VCUGs are recom- risk of UTI, endoscopic treatment may achieve this goal as well
mended in patients with multicystic dysplastic kidneys because as or better than open surgery, and there are no long-term data
of the condition’s association with contralateral VUR in 15% on the radiographic results of open surgery (4,5).
to 20% . Antenatal hydronephrosis, even when it resolves post- The indications for ureteral reimplantation and endoscopic
natally, will be associated with VUR in 20% . Screening siblings treatment are with few exceptions identical and include persis-
or parents implies a 30% to 65% chance of VUR. VUR may be tent VUR after a period of observation, new renal scarring,
incidentally discovered by a VCUG obtained for reasons other breakthrough UTIs, and poor compliance with antibiotic pro-
than febrile UTIs, such as posterior urethral valves, patent ura- phylaxis. When surgical options are discussed with parents, a
chus, or suspected bladder rupture. The obligation to diagnose significant preference for endoscopic treatment becomes ap-
VUR in asymptomatic patients (no history of febrile UTIs, pre- parent (6,7). While endoscopic injection has focused on the
natally diagnosed hydronephrosis, sibling screening) has been treatment of primary VUR, it was largely avoided for cases
questioned because the natural history of asymptomatic VUR of complex VUR (i.e., VUR associated with functional or
may be benign and treatment not necessary. anatomic abnormalities such as neurogenic bladder or mega-
The “ top-down approach” in the management of UTI at- ureters). In general, endoscopic treatment is emerging as the
tempts to distinguish clinically significant from insignificant treatment modality of choice for VUR, whereas ureteral reim-
VUR by evaluating kidneys for pyelonephritis and/or scarring plantation remains reserved for cases of failed injection ther-
with DM SA scans performed within weeks of the onset of apy, significant anatomic abnormalities (e.g., large paraureteral
acute pyelonephritis. A positive DM SA scan is an indication diverticula, ectopic ureters, megaureters), and surgeon’s or
for VCUG and consequently 50% of “ unnecessary” VCUGs parents’ preference.
can be avoided. H owever, many patients suffering from the sig-
nificant morbidity of recurrent febrile UTIs without detectable
renal injury are missed. At this time, this approach is rarely ALTERNATIVE THERAPY
used and should be considered investigational until long-term
data become available. M ost patients diagnosed with VUR are started on antibiotic
While VCUGs and nuclear cystographies both apply ioniz- prophylaxis irrespective of grade. Antibiotic prophylaxis may
ing radiation to a field that includes the gonads, in cases of be continued for several years until VUR resolution or signifi-
prolonged nonoperative management of VUR, nuclear cystog- cant grade reduction or if it is deemed clinically insignificant.
raphy is often preferred because it utilizes a lower radiation The presumed benefits of antibiotic prophylaxis, prevention of
dose. M agnetic resonance voiding cystourethrography pyelonephritis, and avoidance of surgery have been challenged
(M RVCU) became a potential alternative to conventional by recent studies demonstrating increased bacterial resistance
VCUG with the advent of near real-time magnetic resonance and failure to protect against UTIs. O bservation off antibiotics
fluoroscopy. In comparative studies, M RVCU demonstrated was consequently proposed as an alternative management
inferior sensitivity (76% ) and specificity (90% ) to conven- option. H owever, at the current time, observation protocols in
tional VCUG and has limitations, such as incomplete voiding young patients who are at risk for renal injury ( 4 years of age)
TA B LE 1 0 4 . 1
SUCCESS RATES OF EN DOSCOPIC TREATMEN T FOR PRIMARY AN D COMPLEX VESICOURETERAL REFLUX
Volume Follow-Up
Reference Indication Bulking Agent (mL) Ureters (months) Success (%)
Elder JS et al., 2006 Various Various 0.2–1.7 8,101 Variable 85

Capozza N et al., 2004 Various Various 0.2–2.2 1,694 12–204 77
Kirsch AJ et al., 2004 Various Dx/H A 0.5–1.5 119 3–12 92
Kirsch AJ et al., 2006 Various Dx/H A 0.8–2.0 139 3–18 93
Van Capelle JW Primary PDM S 0.2–2.0 311 3–110 75
et al., 2004
Kajbafzadeh AM Primary Ca hydroxylapatite 0.4–0.6 364 6 69
et al., 2006
Yu RN et al., 2006 Primary Dx/H A 1.0 162 2–26 93
Puri P et al., 2006 Various Dx/H A 0.2–1.5 1101 3–46 96
Lorenzo AJ et al., 2006 Various PDM S 351 72 72
Pinto KJ et al., 2006 Primary Dx/H A 86 3 84
Perez-Brayfield M N eurogenic Dx/H A 0.4–2.0 9 3 78
et al., 2004 bladder
Läckgren G et al., 2007 Voiding Dx/H A 74 12 83
dysfunction
Elmore JM et al., 2006 Failed initial Dx/H A 1.0–1.5 53 3 89
injection
Perez-Brayfield M Failed Dx/H A 0.4–2.0 19 3 88
et al., 2004 reimplantation
Kitchens D Failed Dx/H A 0.7–3.8 20 19 83
et al., 2006 reimplantation
Campbell JB Renal Dx/H A 11 55
et al., 2006 transplantation
M olitierno JA Duplicated Dx/H A 0.8–2.8 63 1.3 85
et al., 2007 ureter
Cerwinka WH Paraureteral Dx/H A 0.8–1.8 20 6.6 81
et al., 2007 diverticulum
Chertin B et al., 2007 Ureterocele Various 44 1–21 91
M eta-analysis by Elder JS et al., 2006, summarizes results until 2003. M ore recent series are listed here. Success after one or several treatments in some
studies.
Dx/H A, dextranomer/hyaluronic acid; PDM S, polydimethylsiloxane.
or who have shown a propensity for recurrent pyelonephritis

should be considered investigational. SURGICAL TECHNIQ UE
Treatment of concomitant dysfunctional elimination (i.e.,
constipation and/or voiding dysfunction) reduces the risk of N umerous injectable bulking materials have been utilized
UTIs in patients with VUR. Surgical intervention comprises and abandoned over time in search of a nonimmunogenic,
open ureteral reimplantation (extravesical and intravesical), la- noncarcinogenic, biocompatible, and biodegradable agent.
paroscopic ureteral reimplantation, and endoscopic treatment. Teflon, the first bulking material used for the treatment of
Ureteral reimplantation has a success rate of 95% to 99% for VUR, was abandoned in pediatric urology in the United
grade I to IV and 80% for grade V VUR. Persistent or recur- States because of the material’s propensity to migrate to
rent VUR after surgical treatment may be treated in an identi- distant organs and to form granulomas; however, carcino-
cal fashion or with an alternative method (i.e., reimplantation genesis of Teflon has not been reported. Silicone also demon-
or endoscopic injection). A second injection was shown to be strates distant migration and granuloma formation. Its
highly successful in patients after initial endoscopic treatment carcinogenic potential has been controversial but is most
failure (90% ); however, a third injection in general yields low likely unsubstantiated. Glutaraldehyde cross-linked bovine
success (34% to 50% ) and is not recommended. O lder patients collagen demonstrates a lower degree of absorption as com-
with persistent VUR and no other risk factors (e.g., worsening pared to native collagen and can cause allergic reactions even
VUR grade, renal scarring, dysfunctional elimination) often rein patients with a negative skin test. Several new bulking
main asymptomatic and may be taken off antibiotic prophy- agents are currently under investigation, such as inorganic
laxis (8). H owever, parents should be warned of the risks of materials and autologous tissue. The latter is nonimmunogenic;
pyelonephritis and its associated morbidity that may be seen however, cell harvest and/or cell culture are time-consuming
during sexual activity and pregnancy. and expensive.
Chap t e r 104: End oscop ic Tre atme nt of Ve sicoure te ral Re flux 679
Dextranomer/hyaluronic acid copolymer (Deflux) is easy to

inject and is biodegradable with stable implant volume, and its
relatively large particle size prevents distant migration. It has
been used as an injectable material in pediatric urology since
1995 and is currently the first-choice injectable agent due to its
safety and efficacy (9). Deflux implants in animal tissue were
shown to undergo time-dependent histopathological changes.
The initial phase was dominated by an ingrowth of granulation
tissue, a foreign body giant cell reaction, and the formation of
a surrounding capsule. In the later phase, cellular elements be-
came largely replaced by a collagen-rich matrix, whereas the
capsule remained unchanged. These findings were confirmed
in patients who had failed endoscopic injection and proceeded
to ureteral reimplantation. Besides biological properties, cost
of bulking agents, and surgeon’s experience, the choice may ul-
timately depend on approval by administrative agencies, such
as the European M edicines Agency or the FDA.
The endoscopic method currently achieving the highest suc-
cess rates is the double hydrodistention implantation technique
FIGURE 104.2 N eedle placement algorithm for the endoscopic treat-
(H IT) (Fig. 104.1). The patient is placed in the low dorsal ment of vesicoureteral reflux. The double hydrodistention implanta-
lithotomy position and antibiotic prophylaxis is given. tion technique uses sites 1 and 2; site 3 (subureteric injection of
Cystoscopy is performed with a pediatric cystoscope equipped Teflon) is rarely used.
with an offset lens. An offset lens permits direct passage of
the needle in line with the ureter without bending the needle.
The bladder is filled to less than half capacity to permit visual-
ization of the ureter and avoid tension within the submucosal the mid-ureteral tunnel at the 6 o’clock position. Sufficient
layer of the ureter secondary to overdistention. H ydro- bulking agent is injected to produce a bulge, which initially
distention (H D) is performed with the tip of the cystoscope coapts the detrusor tunnel, while a second implant within the
placed at the ureteral orifice (UO ) and a pressured stream is most distal intramural tunnel leads to coaptation of the UO
achieved by placing the irrigation bag approximately 1 meter (approximately 1 to 1.5 mL). Rarely, if the two intraureteric
above the bladder on full flow. H D of the distal ureter serves submucosal injections (double H IT method) fail to coapt the
two purposes: it allows visualization of the intraureteral injec- ureter, a classic STIN G (supraureteric injection of Teflon) is
tion site and assessment of treatment progress (i.e., ureteral needed to achieve coaptation. The latter two injection sites are
coaptation). The needle is passed into the UO and inserted at used more commonly in complex or redo cases (Fig. 104.2).
H D is performed after each injection to monitor treatment
progress; when H D ceases to dilate the UO , appropriate coap-
tation has been achieved.
In general, all procedures are performed on an outpatient
basis and all patients receive preoperative antibiotic prophy-
laxis, which is continued until resolution of VUR has been con-
firmed. Radiographic success is defined as grade 0 VUR on a
postoperative VCUG, 1 to 6 months after a single treatment.
Patients are then followed clinically on an annual basis to de-
termine clinical success and recurrence.
O UTCO MES
O utcome of endoscopic treatment for VUR has been evaluated
in several large series (Table 104.1). M ost studies included
both primary and complicated cases of VUR. Interpretation of
and comparison among these studies are confounded by differ-
ent inclusion criteria (e.g., with or without complex VUR,
grade I, grade V), varying lengths of follow-up, definitions of
success, and single versus multiple injections. N evertheless,
most current series report cure rates of 85% . Age, gender,
and bilaterality of VUR have not been shown to predict treat-
ment outcome. While the STIN G technique yields lower suc-
cess rates with higher grades of VUR, the H IT method achieves
FIGURE 104.1 Endoscopic treatment of vesicoureteral reflux (double
H IT technique). A: Proximal intraureteric injection. B: Coapted similar outcomes across all VUR grades up to grade V.
intramural ureter. C: Distal intraureteric injection. D: Coapted ureteral Endoscopic treatment of complicated VUR has been evaluated
orifice. in smaller series and success rates vary significantly depending
(implant migration), disruption (mucosal breach), or dissolu-

tion (decrease in implant volume). Success may be improved
with the H IT method when performed by an experienced sur-
geon familiar with the subtleties of the technique. N ew tech-
nologies will continue to improve the success of endoscopic
injection. For example, a prototype of a new retractable injec-
tion needle guide (Injekt, Cook Urological, Spencer, IN ) has
been developed to reproduce the double H IT method and re-
duce the learning curve (Fig. 104.3). N ew biologic injectable
agents are also under study.
FIGURE 104.3 Retractable injection needle guide (Injekt, Cook

Urological, Spencer, IN ). A: Flexible wire is placed into the ureter and
the needle is advanced submucosally. B: Depth gauge allows needle
advancement in 1-mm increments.
CO MPLICATIO NS
In comparison to ureteral reimplantation, endoscopic VUR
treatment offers major advantages to patients and parents. The
procedure generally lasts 15 minutes and is performed on
on the associated pathologies (Table 104.1). In general, cure an outpatient basis. While cure rates are approaching those
rates for complex cases of VUR are lower than for primary of open ureteral reimplantation, significant complications are
VUR. Treatment of VUR associated with neurogenic bladder rare. Endoscopic treatment entails greater patient convenience,
or voiding dysfunction was shown to yield acceptable out- lower morbidity (e.g., pain, abdominal scar), and reduced cost
comes. Endoscopic injection has been successfully employed in (11). Consequently, a significant parental preference for endo-
patients who failed either ureteral reimplantation or initial scopic treatment is evident (6,7). A recent study demonstrated
injection. Injection after failed reimplantation or second injec- that both patients and parents viewed injection therapy as the
tion will be curative in most instances, whereas a third injec- least bothersome aspect of VUR treatment, followed by antibi-
tion has been shown to be far less successful (10). Refluxing otic prophylaxis and VCUG (5).
ureters of transplanted kidneys in symptomatic patients may The most common complications following endoscopic
be treated endoscopically. Although this approach is curative treatment of VUR are new contralateral VUR (2.3% to
in only half the cases, it represents an attractive alternative to 17.3% ) and treatment failure. Less than 4% of children com-
open surgery in the setting of immune compromise and reduced plain of flank pain or emesis several hours after the procedure
wound-healing properties. VUR associated with anatomical and all respond to analgesics. Gross hematuria, urinary reten-
abnormalities (e.g., duplex ureters, paraureteral diverticula, tion, or febrile UTIs have not been observed. The most signifi-
and ureteroceles), previously thought to be contraindications cant potential complication of endoscopic treatment for VUR
for endoscopic treatment, was recently shown to be amenable includes a 0.6% risk of ureteral obstruction (12). Factors that
to injection treatment. may increase the risk of obstruction include bladder dysfunc-
There are many factors that may affect the success of the tion and markedly dilated ureters. Patients with recurrent VUR
procedure. Preoperative (i.e., patient selection), intraoperative often remain asymptomatic, and those without risk factors
(i.e., injection technique, injected volume), and postoperative for pyelonephritis such as young age, voiding dysfunction,
variables have been shown to correlate with treatment outcome. or significant history of UTIs may be taken off antibiotic
Postoperatively, failures may result from Deflux displacement prophylaxis (8).
References
1. M atouschek E. Die Behandlung des vesikorenalen Refluxes durch 8. Cooper CS, Chung BI, Kirsch AJ, et al. The outcome of stopping prophylac-
transurethrale Einspritzung von Teflonpaste. D er Urologe A usgabe A 1981; tic antibiotics in older children with vesicoureteral reflux. J Urol 2000;
20:263–264. 163:269–272.
2. O ’Donnell B, Puri P. Treatment of vesicoureteric reflux by endoscopic injec- 9. Stenberg A, Läckgren G. A new bioimplant for the endoscopic treatment of
tion of Teflon. Br M ed J (Clin R es) 1984;289:7–9. vesicoureteral reflux: experimental and short-term clinical results. J Urol
3. Kirsch AJ, Perez-Brayfield M , Smith EA, et al. The modified STIN G proce- 1995;154:800–803.
dure to correct vesicoureteral reflux: improved results with submucosal im- 10. Elder JS, Diaz M , Caldamone AA, et al. Endoscopic therapy for vesi-
plantation within the intramural ureter. J Urol 2004;171:2413–2416. coureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract in-
4. Jodal U, Smellie JM , Lax H , et al. Ten-year results of randomized treatment fection. J Urol 2006;175:716–722.
of children with severe vesicoureteral reflux. Final report of the 11. Kobelt G, Canning DA, H ensle TW, et al. The cost-effectiveness of endo-
International Reflux Study in Children. Pediatr N ephrol 2006;21:785–792. scopic injection of dextranomer/hyaluronic acid copolymer for vesi-
5. Stenberg A, Läckgren G. Treatment of vesicoureteral reflux in children us- coureteral reflux. J Urol 2003;169:1480–1484.
ing stabilized non-animal hyaluronic acid/dextranomer gel (N ASH A/DX): a 12. Vandersteen DR, Routh JC, Kirsch AJ, et al. Postoperative ureteral obstruc-
long-term observational study. J Pediatr Urol 2007;3:80–85. tion after subureteral injection of dextranomer/hyaluronic acid copolymer.
6. O gan K, Pohl H G, Carlson D, et al. Parental preferences in the management J Urol 2006;176:1593–1595.
of vesicoureteral reflux. J Urol 2001;166:240–243.
7. Capozza N , Lais A, M atarazzo E, et al. Treatment of vesico-ureteric reflux:
a new algorithm based on parental preference. BJU Int 2003;92:285–288.
CHAPTER 105 ■ URETERO CELES
RICHARD N. YU, CHESTER J. KO H, AND DAVID A. DIAMO ND
Ureteroceles are congenital cystic dilations of the intravesical associated with a ureterocele may lead to lateral deviation of the
submucosal ureter. They are more commonly found in female upper pole away from the spine.
children and are almost exclusively diagnosed in whites.
Approximately 10% of these children have bilateral uretero-
celes. Ureteroceles may be “ orthotopic” and contained entirely INDICATIO NS FO R SURGERY
within the bladder, or “ ectopic” and partially situated at the
bladder neck or urethra. An orthotopic ureterocele is typically The goals of surgical treatment should be the preservation of
associated with a single collecting system, while an ectopic renal function, elimination of obstruction and reflux, preven-
ureterocele is usually associated with the upper-pole moiety of tion or elimination of infection, and maintenance of urinary
a kidney with complete ureteral duplication. continence (3) while minimizing surgical morbidity. The main
factors to consider in developing an individual treatment plan
should be patient age, patient’s clinical presentation, uretero-
cele size and anatomy, presence of reflux and UTI, and func-
DIAGNO SIS tion of the involved renal segments.
Increasingly, ureteroceles are diagnosed by prenatal ultra-

sonography, which can demonstrate both the intravesical
cystic dilation as well as the corresponding hydronephrosis. ALTERNATIVE THERAPY
These patients should undergo a comprehensive postnatal
urological evaluation and be placed on prophylactic antibi- The anatomy and clinical presentations of children with ureter-
otics, which may help to prevent future urinary tract infec- oceles vary widely. Therefore, each child should have an indi-
tions (UTIs) (1). H owever, for many children the diagnosis of vidualized treatment plan as no single method of surgical
ureterocele is made only after a UTI or urosepsis. Ureteroceles repair is appropriate for all cases. Table 105.1 lists some thera-
can also present as a palpable abdominal mass, usually repre- peutic options for patients with ureteroceles.
senting a hydronephrotic kidney, or as a vaginal mass, which
represents prolapse of an ectopic ureterocele. Large ureteroce-
les may even lead to obstruction of the bladder neck or of the SURGICAL TECHNIQ UE
contralateral ureteral orifice, which may result in bilateral
hydronephrosis. Techniques that preserve functional upper-pole moieties are
In general, ultrasonography is the first radiological study listed below. H owever, in many instances the upper pole has
obtained in diagnosing ureteroceles. In addition to the intrav- little to no contribution to the overall renal function and
esical cystic dilation, ureteroceles are usually seen with duplex upper-pole ablative techniques, also described below, may be
collecting systems, with the ureterocele being associated with indicated.
hydronephrosis of the upper-pole moiety.
A voiding cystourethrogram (VCUG) is essential in the
evaluation of the patient with a ureterocele because of the high TA B LE 1 0 5 . 1
incidence of concomitant ipsilateral and contralateral vesi- URETEROCELE THERAPEUTIC OPTION S
coureteral reflux. In addition to the reflux, VCUG can demon-
strate the size and location of the ureterocele. Upper-pole preservation
Currently, the dimercaptosuccinic acid (DM SA) renal scan Endoscopic incision of the ureterocele
provides the most precise estimates of the differential renal Complete lower-tract reconstruction (excision of
function between each kidney, as well as of the associated up- ureterocele with ureteral reimplantation)
per pole’s contribution to the overall renal function. DM SA Ureteroureterostomy/ureteropyelostomy
scans may even detect lower-moiety abnormalities that may
not have been demonstrated by ultrasonography (2). Upper-pole ablation
Intravenous urography (IVU) is less commonly used in the Upper-tract approach (upper-pole nephrectomy and
modern evaluation of ureteroceles. H owever, in cases of unusual partial ureterectomy)
urinary tract anatomy IVU may be helpful in the delineation of Complete reconstruction
previously undefined anatomy. Severe hydroureteronephrosis
681
A, B C, D
FIGURE 105.1 Endoscopic incision. A: Endoscopic incision of the ureterocele using the pediatric resecto-
scope and the right-angle hook electrode with the cutting current to create a small transverse incision prox-
imal to the bladder neck. B: The right-angle hook electrode in position for the initial decompression. C: The
ureterocele after the initial decompression. D: The right-angle hook electrode in position for enlarging the
incision. E: After drainage, the ureterocele collapses and acts as a flap valve to prevent reflux; the lower-
E pole ureter lies over the collapsed ureterocele.
Co mp le t e Lo w e r-Tract Re co nst ruct io n (Excisio n o f

Up p e r-Po le Pre se rvat io n
Ure t e ro ce le w it h Ure t e ral Re imp lant at io n)
End o sco p ic Incisio n o f t he Ure t e ro ce le For excision of the ureterocele and common sheath reimplan-
tation of upper- and lower-pole ureters, a Pfannenstiel incision
The goal of endoscopic incision of ureteroceles is to decom-
is made and the bladder is opened (Fig. 105.2). The lower-pole
press the ureterocele in a minimally invasive manner while
and contralateral ureters are intubated with 5Fr feeding tubes,
minimizing the risk of postincision vesicoureteral reflux and
and multiple circumferential stay sutures are placed. A circum-
the need for further urinary tract reconstruction (4). This tech-
ferential incision is made around the perimeter of the uretero-
nique can be used in infants if infant-sized endoscopic equip-
cele with electrocautery and the wall of the ureterocele and its
ment is available and should be used to drain obstructive
urinary systems in any ureterocele patient with urosepsis. Blyth
et al. recommended the use of a 3Fr Bugbee wire electrode (us-
ing the cutting current) to incise the roof of the ureterocele
through its full thickness near its base and proximal to the
bladder neck (5). A new unobstructed intravesical ureteral ori-
fice will be created, and the roof of the collapsed ureterocele
can act as a flap-valve mechanism to prevent reflux. While the
Bugbee electrode has been a widely utilized instrument for
ureterocele puncture, it has limitations, primarily that follow-
ing initial decompression enlargement of the puncture site is
difficult. Therefore, we prefer to use the pediatric resectoscope
and the right-angle hook electrode with the cutting current,
which allows one to make a clean transverse incision and en-
large it by placing the hook into the original incision and with-
drawing under vision (Fig. 105.1). M agnification with the use
of video projection helps improve the accuracy of the incision.
M aking the incision as distal and as close to the bladder neck
as possible should reduce the risk of postoperative reflux into FIGURE 105.2 Complete lower-tract reconstruction. A: After the
the corresponding ureter. The adequacy of the incision can be bladder is opened, multiple circumferential stay sutures are placed
confirmed by the presence of a jet of urine from the ureterocele around the ureterocele to assist with the excision. B: All ureters should
be intubated with 5Fr feeding tubes for identification of the ureters
or by visualization of the urothelium inside the ureterocele. The during the dissection. C: After excising the ureterocele, the posterior
major advantage of the endoscopic incision is that it can be done bladder wall is repaired with running 3-0 absorbable sutures and the
on an outpatient basis, without the need for hospitalization. ureters are reimplanted into a generous tunnel.
Chap t e r 105: Ure te roce le s 683
associated upper-pole ureter are dissected away from the

thinned posterior muscular wall of the bladder, incorporating
the lower-pole ureter in the dissection. All attempts should be
made to avoid injury to the sphincteric mechanisms at the
bladder neck during the distal dissection of the ureterocele.
The upper- and lower-pole ureters are dissected as a common
sheath to avoid injury to the blood supply of both ureters.
After excising the distal ureterocele, the dilated upper-pole
ureter often requires tapering. The thin posterior bladder wall
is repaired by imbrication of adjacent muscle with running 3-0
absorbable sutures to provide sufficient muscle backing for the
reimplanted ureters. An unoperated portion of the bladder
floor is selected and the ureters are reimplanted as a common
sheath into a generous ureteral tunnel.
Ure t e ro ure t e ro st o my/ Ure t e ro p ye lo st o my

In upper urinary tract anastomotic techniques, the dissection
of the upper tracts should be kept to a minimum, and mobi-
lization should be directed toward the upper-pole ureter, so that
distortion of the adjacent lower-pole ureter can be avoided.
Because the upper-pole ureter is usually larger than the lower-
pole ureter, generous spatulation of the ureters during ureter-
oureterostomy may be necessary for an optimal end-to-side
anastomosis. Furthermore, a feeding tube should be passed dis-
tally into the ureterocele to decompress it.
FIGURE 105.3 Upper-pole partial nephrectomy and partial ureterec-

tomy. A: This procedure is commonly used for a duplex system with a
Up p e r-Po le Ab lat io n nonfunctioning upper pole and minimal or absent ipsilateral reflux. B:
The upper-pole ureter is transected early after a stay suture has been
Up p e r-Tract Ap p ro ach (Up p e r-Po le Ne p hre ct o my placed proximally. Upward traction on the proximal portion of the
transected ureter assists in the manipulation of the upper pole during
and Part ial Ure t e re ct o my) the partial nephrectomy. C: After removal of the upper pole, the
In many cases, the upper pole associated with the ureterocele wedge-shaped kidney defect is repaired with 3-0 chromic sutures in a
has minimal or no contribution to the overall renal function. vertical mattress fashion. D: This approach should result in the decom-
pression of the ureterocele, with the return of the trigone to a more
The upper-tract approach (upper-pole nephrectomy and partial normal configuration.
ureterectomy) should lead to the relief of obstruction, preven-
tion of recurrent infection, and resolution of the reflux that is
present in about half of these patients. This approach should
result in the decompression of the ureterocele, hopefully with Co mp le t e Re co nst ruct io n
resolution of the ipsilateral lower-pole reflux, because the
trigone will be returned to a more normal configuration. This In certain instances, a complete reconstruction may be indi-
usually eliminates the need for lower-tract reconstruction with cated where both an upper-tract repair and a lower-tract recon-
a potentially difficult bladder neck and urethral dissection (3). struction are performed via separate incisions in a single stage.
For the upper-pole heminephrectomy, we suggest the use These situations include the presence of high-grade reflux into
of the flank or laparoscopic approach, which offers superior the ipsilateral lower-pole ureter or the presence of lower-pole
access to the upper-pole vessels. With either approach, care reflux associated with a large, everting ureterocele and a non-
should be taken to avoid excessive traction upon the kidney to functioning upper pole. Depending on the amount of upper-
avoid damage to the viable lower pole. In many cases, the up- tract function, either an upper-pole nephrectomy with partial
per pole resembles a dysplastic nubbin, and early division of ureterectomy or a ureteropyelostomy (as described above) is
the upper-pole ureter with upward traction on the proximal performed for the upper-tract repair. Lower-tract reconstruc-
portion of the transected ureter usually helps in the definition tion is also performed, which involves excision of the uretero-
and manipulation of the upper pole (Fig. 105.3). After the up- cele with reimplantation of the ureters as a common sheath, as
per-pole vessels are sequentially ligated, demarcation of the up- previously described.
per-pole parenchyma should become apparent. We recommend
the use of a no. 15 blade or electrocautery around the upper-pole
parenchyma, which usually results in a wedge-shaped defect. O UTCO MES
During the dissection of the upper-pole parenchyma, the plane
of dissection should remain as close as possible to the upper- Co mp licat io ns
pole ureter to avoid injury to the vascular supply of the lower-
pole ureter. After the upper-pole nephrectomy, the wedge- Excision of the ureterocele with ureteral reimplantation achieves
shaped defect is closed with interrupted 3-0 chromic sutures in the goal of upper-tract drainage. H owever, the disadvantage of
a vertical mattress fashion to achieve effective hemostasis. this approach is the morbidity associated with bladder surgery,
including hematuria, bladder spasm, and catheter drainage. with a high rate of secondary surgery and a significant inci-
Extensive distal dissection also carries the risk of bladder dence of postoperative reflux after endoscopic incision.
neck and sphincteric injury, which may jeopardize urinary Therefore, patients with ectopic ureteroceles may be best
continence (6). served by more definitive reconstruction, even those 1 year of
age (8).
The upper-tract approach, which includes upper-pole
Re sult s nephrectomy and partial ureterectomy, is usually reserved for
the patient with an upper pole that provides little or no contri-
Endoscopic incision of the ureterocele may be the only surgical bution to the overall renal function and mild or absent ipsilat-
procedure required for many patients. For infants, endoscopic eral reflux. This approach has the advantage of avoiding the
incision may be used as a temporizing measure that achieves lower-tract complications noted previously.
early decompression. Secondary surgery, if necessary, can be For patients who are at significant risk for requiring a second
performed electively when the child is older. If the ureterocele procedure with some of the approaches detailed previously,
is orthotopic, one can expect high rates of decompression and such as those patients with large, ectopic ureteroceles or high-
low rates of de novo reflux and the need for secondary proce- grade ipsilateral reflux, complete upper- and lower-tract recon-
dures (7). O n the other hand, ectopic ureteroceles are associated struction in a single stage has the advantage of expediency (9).
References
1. Upadhyay J, Bolduc S, Braga L, et al. Impact of prenatal diagnosis on the mor- 6. Coplen DE, Duckett JW. The modern approach to ureteroceles. J Urol
bidity associated with ureterocele management. J Urol 2002;167:2560–2565. 1995;153:166–171.
2. Connolly LP, Connolly SA, Drubach LA, et al. Ectopic ureteroceles in in- 7. H agg M J, M ourachov PV, Snyder H M , et al. The modern endoscopic
fants with prenatal hydronephrosis: use of renal cortical scintigraphy. Clin approach to ureterocele. J Urol 2000;163:940–943.
N ucl M ed 2002;27:169–175. 8. H usmann D, Strand B, Ewalt D, et al. M anagement of ectopic ureterocele
3. Schlussel RN , Retik AB. Ectopic ureter, ureterocele, and other anomalies of associated with renal duplication: a comparison of partial nephrectomy and
the ureter. In: Walsh PC, ed. Cam pbell’s Urology, 8th ed. Philadelphia: WB endoscopic decompression. J Urol 1999;162:1406–1409.
Saunders, 2002:2022–2034. 9. Scherz H C, Kaplan GW, Packer M G, et al. Ectopic ureteroceles: surgical
4. De Filippo RE, Bauer SB. N ew surgical techniques in pediatric urology. Curr management with preservation of continence—review of 60 cases. J Urol
O pin Urol 2001;11:591–596. 1989;142:538–543.
5. Blyth B, Passerini-Glazel G, Camuffo C, et al. Endoscopic incision of uretero-
celes: intravesical versus ectopic. J Urol 1993;149:556–560.
CHAPTER 106 ■ URACHAL ANO MALIES AND

RELATED UMBILICAL DISO RDERS
LESLIE T. MCQ UISTO N AND ANTHO NY A. CALDAMO NE
During bladder development, the urogenital sinus is initially The urachus normally closes or involutes at approximately
contiguous with the allantois. When the lumen of the allantoic 32 weeks’ gestation, and urachal anomalies in general repre-
duct becomes obliterated, the urachus remains, connecting the sent an abnormality in this process. These anomalies are char-
bladder to the umbilicus (Fig. 106.1A,B). It continues to elon- acterized as patent urachus, urachal cyst, urachal sinus, and
gate as the fetus grows. The urachus is a muscular tube, with a urachal diverticulum (Fig. 106.2) (1). O f these anomalies,
length ranging from 3 to 10 cm and a diameter of approxi- urachal cysts (45% ) and sinuses (37% ) are the most commonly
mately 8 to 10 mm, that extends from the dome of the bladder identified (2).
to the umbilicus. It has three distinct tissue layers: (a) an
epithelial-lined lumen with cuboidal or transitional epithelium,
(b) an intermediate connective tissue layer, and (c) an outer
smooth muscle layer. In the adults, the urachus lies between two DIAGNO SIS
layers of umbilicovesical fascia along with the umbilical liga-
ments and the remnants of the obliterated umbilical arteries. In general, the diagnosis of urachal anomalies requires clinical
This fascial investment tends to contain the spread of urachal suspicion and a thorough physical examination. Further evalu-
disease between the peritoneum and transversalis fascia (Fig. ation in patients with periumbilical drainage should include a
106.1C). sinogram, and those with a periumbilical mass should undergo
Chap t e r 106: Urachal Anomalie s and Re late d Umb ilical Disord e rs 685
FIGURE 106.1 A: At 9 weeks of gestational age showing the allantois

extending into the body stalk. B: At 3 months’ gestation, the urachus
connects to the dome of the bladder. C: The urachus persisting as the
median umbilical ligament in the adult.
ultrasonographic imaging. A voiding cystourethrogram may be confirmed with a sonogram, although a voiding cys-
required in only selected patients (2,3). tourethrogram may be more useful because it may rule out
Complete failure of the urachal lumen to close results in bladder outlet obstruction concurrently. Alternatively, meth-
an open connection between the bladder and the umbilicus. ylene blue or indigo carmine may be instilled in either the
Patients present with umbilical leakage of urine and often a bladder or the umbilical opening and detected in the umbili-
protruding tissue mass (Fig. 106.3). The leakage may be cus or bladder, respectively. The differential diagnosis for
more obvious during times of increased intra-abdominal patent urachus includes patent omphalomesenteric duct,
pressure such as crying, coughing, or straining. The fluid may urachal sinus, omphalitis, granulation of a healing umbilical
be analyzed for urea and creatinine to confirm its urinary stump, and infected umbilical vessel.
quality. Two factors thought to contribute to a persistent Segmental or incomplete closure of the urachal lumen may
patent urachus are bladder outlet obstruction and failure of result in the formation of a urachal cyst (Fig. 106.4). The cyst
the bladder to descend into the pelvis (4,5). With regard to usually forms in the proximal or lower third of the urachal
bladder outlet obstruction, distal urinary obstruction is remnant near the bladder (7). Usually, the cyst is lined with
thought not to be the only causative factor because normally transitional epithelium and filled with serous fluid, but muci-
the urachus closes developmentally before the urethra be- nous contents have been described. In general, urachal cysts
comes tubularized (6). In addition, only 14% of patients with are small and asymptomatic. Symptoms such as pain, redness
patent urachus demonstrate bladder outlet obstruction clini- with localized swelling, and tenderness below the umbilicus
cally, and it is uncommon for a patent urachus to be associ- may occur with infection and may be accompanied by chills,
ated with posterior urethral valves. The diagnosis may be fever, irritative voiding symptoms, hematuria, and pyuria.
FIGURE 106.2 The four types of abnormalities involving the urachus. A: Complete patency to the umbili-
cus. B: A blind-ending urachal sinus open at the umbilicus but not complete to the bladder. C: A urachal
cyst without communication to either the umbilicus or the bladder. D: Simple diverticulum from the dome
of the bladder.
FIGURE 106.4 Abdominal ultrasound that demonstrates an infected

FIGURE 106.3 Patent urachus. urachal cyst.
Chap t e r 106: Urachal Anomalie s and Re late d Umb ilical Disord e rs 687
Alternatively, symptoms may arise as the result of mass effect therapy with possible drainage followed by delayed excision
due to a large urachal cyst. These patients present with a may be required. Similarly, in the case of the urachal sinus
sensation of abdominal fullness or pain, a mass, or irritative initial treatment should focus on the eradication of any infec-
voiding symptoms due to compression of the bladder. tion before excision is undertaken.
Diagnosis is most easily confirmed by ultrasound or computed Treatment of urachal malignancy follows the principles of
tomography (CT). treatment for any malignancy of the bladder and is discussed
Incomplete closure of the urachus may also result in a elsewhere in this book.
urachal sinus. This may be the result of a urachal cyst that ex-
tended either to the bladder or to the skin for drainage. Some
urachal sinuses may alternate and at first drain at the umbilicus
and then later into the bladder. Presenting symptoms may in- SURGICAL TECHNIQ UE
clude periumbilical redness and tenderness with intermittent
drainage, umbilical irritation or granulation tissue, or symp- For the patent urachus, urachal cyst, alternating urachal sinus,
toms of urinary tract infection. Clinical suspicion of a urachal or urachal diverticulum requiring correction, the patient is
sinus may be confirmed by a sinogram or ultrasound. A cys- placed in a supine position. If possible, a small catheter, guide
togram may show an irregular area at the dome of the bladder. wire, or probe is placed through the patent urachus (Fig.
Cystoscopy may demonstrate an inflamed area at the dome 106.5). If nothing will pass, the tract may be stained with
that may extrude purulent drainage. methylene blue for later identification. A Foley catheter should
A urachal diverticulum results from failure of closure of the be placed in the bladder and the bladder distended with sterile
urachus adjacent to the bladder, leaving a wide-mouth divertic- saline to bring the anterior bladder wall up to the abdominal
ulum at the dome of the bladder. The urachal diverticulum may wall and, in doing so, push the peritoneum cephalad.
or may not be associated with bladder outlet obstruction, as The urachus may be approached via a vertical midline inci-
has been often reported in patients with prune belly syndrome. sion or a transverse infraumbilical incision one-half to two-
In general, aside from treatment for any coexisting bladder thirds the distance from the symphysis pubis to the umbilicus.
outlet obstruction, the urachal diverticulum requires no spe- Although the transverse infraumbilical incision will result in
cific management as it usually drains well. excellent exposure, alternatively a vertical midline incision
O mphalomesenteric disorders may be confused with along the course of the urachus may be more direct and can
urachal anomalies. The omphalomesenteric duct is a fetal allow for extension to the umbilicus in a cosmetic fashion,
structure that connects the yolk sac and the gut. Incomplete should this be required because of difficulty in procuring the
closure of this tubular structure may lead to a patent om- umbilical end of the urachus or for any additional necessary
phalomesenteric duct, an omphalomesenteric sinus, or an om- procedures. The rectus fascia is opened and the dome of the
phalomesenteric cyst. A patent duct may be characterized by bladder is identified. The urachus is identified and isolated.
the drainage of intestinal fluid or fecal material. A sinogram O nce the proximal portion of the urachus is delineated, it is re-
should demonstrate a connection to the gastrointestinal tract. sected along with a small cuff of bladder to prevent a residual
Malignant lesions of the urachus are rare; however, the cancer diverticulum. The bladder is then closed in two layers.
risk does increase with advancing adult age (8). The most com- Dissection then proceeds toward the umbilicus. The operation
mon sign of urachal cancer is hematuria. Patients may also pre- is facilitated by identifying the proper plane of dissection be-
sent with a suprapubic mass, abdominal pain, irritative voiding tween the peritoneum posterior to the urachus and the poste-
symptoms, or mucus in the urine. The diagnosis may be made rior rectus fascia, which is anterior to the urachus. In this
by identification of a filling defect at the dome of the bladder same plane will lie the obliterated umbilical arteries, which
with calcifications on intravenous urogram or cystogram, CT, may be ligated proximally on the bladder wall or distally at the
and cystoscopy with transurethral biopsy. Adenocarcinoma is umbilicus.
the most common malignancy; however, sarcoma and transi- Infected urachal remnant structures, such as urachal cyst or
tional cell carcinoma have been reported (9). sinus, may present a more challenging dissection. In fact, it is
sometimes advisable to drain a large infected urachal cyst ini-
tially percutaneously and allow a period for antibiotic therapy
to reduce the local inflammation. Smaller infected urachal
INDICATIO NS FO R SURGERY cysts or sinuses, however, can be managed safely as a single
procedure. With these infected remnants, it may be impossible
Surgical management is central to the treatment of urachal to dissect the urachus away from contiguous structures. For in-
anomalies with the exception of infants under 6 months of age, stance, a larger portion of the bladder may need to be removed
in whom the anomalies may resolve spontaneously, and the with the infected urachal cyst. Similarly, one may find it impos-
wide-mouth diverticulum, which in general requires no treat- sible to separate the infected cyst or sinus from the underlying
ment (10). In the patient with a persistently patent urachus be- peritoneum. O ne should be extremely careful in identifying
yond 6 months of age, surgical excision is recommended adherent loops of bowel that may have been involved in the
because of the risk of recurrent infections, stone formation, inflammatory process and could easily be injured.
and persistent umbilical drainage, excoriation, and pain. O nce the urachus is completely dissected distally it is ex-
Urachal cysts that are symptomatic due to size or infection cised or ligated at its obliterated point. The goal is to remove
also merit surgical treatment. Incidentally discovered small, all urachal tissue and leave the umbilicus intact. If an umbilical
asymptomatic urachal cysts may be excised at the time of dis- hernia is present, it may be corrected concurrently. A catheter
covery or watched for the development of symptoms or pro- may be left in the bladder and a drain in the prevesical space
gressive enlargement. With infected cysts, initial antibiotic postoperatively at the surgeon’s discretion.
FIGURE 106.5 A and B: Typical transverse infraumbilical approach to the urachus. The catheter through
the urachus can aid in identification of a patency. C and D: The fascia is divided transversely and the rec-
tus muscle is parted in the midline, remaining preperitoneal. E: The urachus or urachal remnant can be
separated from the peritoneum and identified in its proximal and distal extent. F and G: The urachus is re-
sected with a cuff of bladder and the bladder closed in a watertight fashion. The urachus is removed com-
pletely out to the umbilicus if necessary.
For the urachal sinus draining at the umbilicus, dissection has been reported in both children and adults with excellent
is begun by circumscribing the sinus, again with the goal of visualization and access to the urachal remnant (Fig. 106.6)
preserving as much of the umbilicus as possible. The obliter- (11,12). Port placement may vary by surgeon preference; how-
ated umbilical arteries are ligated as they are encountered. The ever, in general, the first port is placed using open H asson tech-
tract is dissected to its termination and excised, and the area is nique in the midline halfway between the umbilicus and the
drained because the sinus tract is usually infected. xiphoid process, and two additional ports are placed under
An alternative to open surgical treatment is laparoscopic direct vision on each anterior axillary line just above the um-
treatment. Laparoscopic treatment, including robotic treatment, bilicus, creating an angle of approximately 45 degrees between
Chap t e r 107: Ve sical Ne ck Re construction 689
the working ports. The procedure then follows the principles

as outlined previously for open surgery.
O UTCO MES
Co mp licat io ns
Postoperative complications include persistent urinary
drainage, which can be managed by prolonged bladder
catheter drainage, and infection, which is generally superficial
and responds well to antibiotic therapy. With laparoscopic
procedures, the reported complications are most often port-
related, and therefore, open H asson technique for initial port
placement is recommended.
FIGURE 106.6 Typical view of the bladder and urachus during

laparoscopy with a 30-degree telescope, showing the urachus, bladder,
and medial umbilical ligaments.
References
1. Bauer SB, Retik AB. Urachal anomalies and related umbilical disorders. 8. Ashley RA, Inman BA, Routh JC, et al. Urachal anomalies: a longitudinal
Urol Clin N orth A m 1978;5:195. study of urachal remnants in children and adults. J Urol 2007;178(4 pt 2):
2. Yiee JH , Garcia N , Baker LA, et al. A diagnostic algorithm for urachal 1615–1618.
anomalies. J Pediatr Urol 2007;3(6):500–504. 9. Sheldon CA, Clayman RA, Gonzalez R, et al. M alignant urachal lesions.
3. Galati V, Donovan B, Ramji F, et al. M anagement of urachal remnants early J Urol 1984;131:1–8.
in childhood. J Urol 2008;180(4 supp):1824–1826. 10. Cilento BG, Bauer SB, Retik AB, et al. Urachal anomalies: defining the best
4. H inman F. Surgical disorders of the bladder and umbilicus of urachal origin. diagnostic modality. Urology 1998;52:120–122.
Surg G ynecol O bstet 1961;113:605–614. 11. Khurana S, Borzi PA. Laparoscopic management of complicated urachal
5. N ix JT, M enville JG, Albert M , et al. Congenital patent urachus. J Urol disease in children. J Urol 2002;168:1526–1528.
1958;79:264. 12. Yamzon J, Kokorowski P, DeFilippo RE, et al. Pediatric robot-assited exci-
6. Schreck WR, Campbell WA III. The relation of bladder outlet obstruction to sion of urachal cyt and bladder cuff. J Endourol 2008; 22(10):2385–2388.
urinary–umbilical fistula. J Urol 1972;108:641–643.
7. Persutte WH , Lenke RR, Kropp K, et al. Antenatal diagnosis of fetal patent
urachus. J Ultrasound M ed 1988;7:399–403.
CHAPTER 107 ■ VESICAL NECK

RECO NSTRUCTIO N
JO HN C. PO PE IV AND JO HN H. MAKARI
Prior to toilet training, the functions of the lower urinary tract with bladder exstrophy, bilateral single ectopic ureters, persis-
include storage of urine at low pressure and good emptying. tent cloaca, and rarely an extensive ureterocele. In the second,
The result is protection of the upper tract and avoidance of uri- more common, group involving neurogenic dysfunction, the
nary tract infection. Adequate outflow resistance is not neces- outlet is normally developed from an anatomic standpoint, but
sary during that time, but is eventually critical to achieve abnormal neurologic control results in inadequate function.
urinary continence, another ultimate function of the lower
tract. Congenital anomalies resulting in inadequate outflow re-
sistance, and thus failure to achieve urinary continence, can in DIAGNO SIS
general be divided into two groups based on pathophysiology.
In the first group there is an anatomic or developmental abnor- When urinary continence is not achieved in children, the criti-
mality where the bladder outlet is malformed and incapable of cal evaluation is video urodynamic study of the bladder and
providing adequate resistance. This group would include patients outlet. Parameters that need to be evaluated include sphincteric
function, outflow resistance, detrusor function, and bladder with reconstructive surgery, including a willingness to perform
compliance. intermittent catheterization if necessary, is critical.
M onitoring of external urinary sphincter activity is helpful
during studies of storage and emptying. Perineal surface elec-
trodes are most widely used to evaluate the activity; however, ALTERNATIVE THERAPY
in children with neurogenic dysfunction who tolerate place-
ment, a concentric needle electrode or dual electrodes placed In few areas of reconstructive urology are there as many
through a 25-gauge needle increase accuracy. choices to consider as for bladder neck repair and as little con-
The functional length and pressure of the external sphincter sensus as to which repair is appropriate for a given patient or
are important and can be measured with urethral pressure pro- setting. O ne reason for the variety of choices is the wide range
filometry. This measurement is technically challenging in a of patients and problems for which the procedures are used. In
small child and there are no adequate standard nomograms for some cases, the procedure to increase outflow resistance may
urethral pressure profilometry to use in pediatric patients. logically be chosen based on particular patient considerations,
Continuous monitoring of the urethral pressure during filling but the experience and confidence of the surgeon with a given
in the area of maximum resistance may demonstrate an etiol- technique also may play a significant role in the choice.
ogy of incontinence. Some surgeons also use leak point pres- Conceptually, techniques to increase outflow resistance may
sure to evaluate outflow resistance during passive filling and be considered as one of two general types. The first set of re-
performance of Valsalva maneuvers. Simultaneous fluoro- pairs is used to improve the function of the native outlet, while
scopic observation is advantageous. the second set is designed to repair the anatomy and function-
Detrusor function should be evaluated by the cystometro- ally alter the outlet. Several procedures that may provide bene-
gram, synergistic relaxation of the external sphincter on fit and are occasionally used include urethral suspensions,
electromyography, urinary flow rate, and measurement of injection of bulking agents, artificial sphincters, and oblitera-
postvoid residual urine. Bladder compliance should also be tion of the bladder neck.
evaluated with the detrusor pressure measured as the bladder O ne of the first bladder neck repairs to function in such a
is filled with warm saline or contrast (37°C) at a rate equal to manner was the urethral suspension described by M arshall,
or 10% of estimated or known bladder capacity. Such fill- M archetti, and Krantz and since modified by numerous sur-
ing minimizes irritation of the bladder, which may artifactu- geons. While these procedures have been successful in treating
ally increase bladder pressure. O ther artifacts that affect the stress urinary incontinence among neurologically normal
measurement of compliance such as urinary infections or female patients, they have had minimal effect and are rarely
low urethral resistance should be eliminated to obtain the indicated for pediatric patients with congenital anatomic anom-
best results. alies of the outlet or neurogenic dysfunction.
Before reconstructive surgery on the bladder is considered, Recently, transurethral injection of bulking agents has been
the status of the patient’s upper urinary tract should also be tried to improve the function of the existing outlet. Initially,
evaluated. Standard evaluation includes renal ultrasonography the use of polytetrafluoroethylene and later, the use of bovine
and serum electrolytes, including creatinine. If hydronephrosis collagen were reported. M ore recently, the availability of dex-
is present, renography should be obtained to rule out obstruc- tranomer/hyaluronic acid copolymer has renewed interest in
tion. Vesicoureteral reflux should be sought on voiding cys- injection therapy for increasing bladder outlet resistance and for
tourethrography, often at the time of video urodynamic correction of sphincteric incontinence. Injection therapy is rel-
evaluation. Any upper-tract obstruction or reflux should be atively simple and avoids any incision, but has met with limited
corrected at the time of lower urinary tract reconstruction. results for significant outlet anomalies (1). Further, the durabil-
Unfortunately, no test ensures that a patient will be able ity of this approach is a concern, as declining rates of dryness
to void spontaneously and empty well after outlet reconstruction and/or improvement are observed even years after treatment
with or without bladder augmentation. All patients must be pre- (2). Injection therapy may, however, be useful after primary re-
pared to perform clean intermittent catheterization before con- pairs in patients who have some persistent incontinence (2,3).
sidering reconstruction. The native urethra should, therefore, be The most definitive procedure to improve the function of
examined for the ease and discomfort of catheterization. the outlet as it exists is placement of an artificial urinary
sphincter. This group of procedures would seem appropriate
for patients with a normal or near-normal outlet from an
INDICATIO NS FO R SURGERY anatomic standpoint and to have little role for patients with
significant anatomic anomalies such as bladder exstrophy or
If urinary continence is not achieved at an appropriate age in bilateral single ectopic ureters.
patients with congenital anomalies, and the patient has failed The ultimate procedure to increase outlet resistance is divi-
behavioral regimens such as timed voiding, had urodynamics, sion of the bladder neck. Effective closure requires extensive
and failed all medical regimens and other conservative thera- mobilization of the bladder and bladder neck away from the
pies (e.g., intermittent catheterizations), then surgical interven- urethra with interposition of omentum between. It must be
tion should be considered. It is critical to ensure that the accompanied by construction of a continent abdominal wall
bladder is a compliant storage reservoir prior to any recon- stoma for bladder catheterization and effectively moves the re-
structive procedure on the lower urinary tract. Increasing out- construction into the realm of continent urinary diversion.
flow resistance in the presence of inadequate bladder capacity Division of the bladder neck has in general been reserved for
would put the patient at significant risk for upper-tract deteri- complex patients who have failed multiple prior procedures
oration and febrile urinary tract infection. Determining the to effectively increase outflow resistance; however, it may be
commitment of the patient and family to achieve a good result performed in select patients as primary definitive management.
Extremely high success rates have been reported for both pri- O nce the proper plane is developed and the appropriate
mary or secondary management when the previous principles length of graft determined, a rectus abdominis fascial strip
are followed (4). 1 cm in width and appropriate in length is harvested. The fascia
may be taken in either a vertical or horizontal fashion depend-
ing on the initial incision. Fascia from other sites has been uti-
SURGICAL TECHNIQ UE lized but requires a second incision. Autologous cadaveric
tissue or biodegradable scaffolds may also be used.
Fascial Sling fo r Blad d e r Ne ck Susp e nsio n All of the grafts are in general brought though the rectus
muscle and anterior rectus fascia on either side and approxi-
In adults, fascial slings may be performed transvaginally, and a mated to the anterior rectus fascia using permanent sutures
small patch of fascia is secured with suspension sutures. In (Fig. 107.1C). If long enough, the two limbs of the sling may
pediatric patients with congenital anomalies, fascial slings have also be approximated to each other superficial to the fascia.
in general been placed from above, often at the time of bladder In patients with stress incontinence, the sling is placed
augmentation. Before placement, the pelvic floor is cleared of tightly enough to maintain the proximal urethra and bladder
overlying fatty tissue and a 2-cm incision made through the en- neck in the appropriate anatomic position. Too snug of
dopelvic fascia on either side of the bladder neck and proximal placement in such a setting may impede spontaneous void-
urethra (Fig. 107.1A). This area may be identified by palpation ing. When used for patients with neurogenic dysfunction
of a transurethral catheter and balloon seated at the bladder who will not rely on spontaneous voiding, the sling may be
neck. Using blunt dissection, a plane is developed between the pulled up more tightly to improve compression of the blad-
bladder neck and vagina in girls or rectum in boys (Fig. 107.1B). der neck and proximal urethra. If intermittent catheteriza-
This plane may at times be more easily developed from the tion will be performed postoperatively through the native
cul-de-sac by dissecting behind the bladder and ureters from urethra, intraoperative catheterization should be repeated
above. With a difficult dissection it may be useful to open the frequently to make sure the fascial sling is not placed so
bladder, in particular if bladder augmentation is planned. tightly as to impede catheterization.
Fascial
sling
FIGURE 107.1 Pubovaginal sling. A: The endopelvic fascia is cleared

of fatty tissue and a 2-cm incision made on either side of the urethra. A
Foley catheter through the urethra may be palpated for identification
of the urethra and bladder neck. B: The plane between the posterior
urethra and anterior vagina is carefully developed using a right-angle
clamp. C: A fascial strip 1 cm wide is passed through the anterior rec-
tus fascia and rectus muscle lateral to the midline incision. It is secured
on the left to the anterior fascia. The sling is then passed behind the
bladder and will be brought through the right rectus muscle and fascia
C to be secured at the proper tension.
dilute epinephrine in those two areas may aid in excision and

Yo ung –De e s–Le ad b e t t e r Blad d e r decrease bleeding. The midline strip of mucosa and the subse-
Ne ck Re p air quent neourethra are typically made 4 to 6 cm long, depending
on how much proximal urethra is exposed and reconstructed.
O ften done after bladder exstrophy closure, the procedure is The midline strip is tubularized over an 8Fr catheter using ab-
typically performed through a lower midline incision. For sorbable sutures to approximate the edges. This tubularization
patients with epispadias who do not require augmentation, may be done with interrupted or running absorbable sutures but
the reconstruction may be done through a Pfannenstiel incision. should be tension free (Fig. 107.2B). Small purchases of the ad-
The anterior bladder is opened. This incision is carried as far jacent superficial muscle of the trigone may be included with the
distally into the proximal urethra as possible. Splitting of the in- mucosa for strength. The closure is easier to begin distally and
tersymphyseal band with subsequent closure may allow closure finished cephalad. The lateral flaps of trigone muscle are then
and tapering of the proximal urethra. Virtually all exstrophy pa- wrapped over the neourethra in an overlapping fashion. To do
tients require antireflux surgery, and typically the ureteral hia- so without tension, the muscle must be incised transversely at
tus is initially quite low in the bladder. The ureters are mobilized the cephalad margin of the mucosal excision. O ne flap of muscle
and reimplanted into the bladder 3 to 4 cm more cephalad in is wrapped over the neourethra and approximated to the under-
location. Typically, the ureters are reimplanted with a cross- side of the other muscle flap using interrupted, absorbable mat-
trigonal technique, although the tunnels may even be angled tress sutures. The second flap of muscle is then wrapped over the
upward in a cephalad direction from the new hiatus. A 12- to first and approximated to the outside of the muscle, again with
15-mm-wide strip of mucosa is preserved in the posterior mid- absorbable sutures (Fig. 107.2C). A soft urethral catheter is left
line of the urethra and bladder trigone for reconstruction of in place during healing but should be secured so as to avoid ten-
the neourethra. Parallel incisions through mucosa are made on sion on the neourethra. Ureteral stents or catheters are often left
either side of this strip and the triangles of trigone mucosa on in place because of potential edema. The bladder is closed in
either side are excised (Fig. 107.2A). Submucosal infiltration of two layers.
FIGURE 107.2 Young–Dees bladder neck

repair. A: The trigone mucosa is incised to
leave a posterior, central strip of mucosa
15 mm wide. The triangles of mucosa on
either side are excised. The ureters have
previously been reimplanted in a more
cephalad position. B: The central mucosa
strip is tubularized using a running ab-
sorbable suture. C: The lateral trigone
muscle flaps are closed in an overlapping
fashion around the neourethra. D: After
completion of the bladder and urethral clo-
sure, several pairs of suspension sutures se-
cure the urethra and bladder to the
underside of the intersymphyseal band and
lower abdominal wall.
FIGURE 107.3 Leadbetter modification of Young–Dees–Leadbetter bladder neck repair. A: Full-thickness

parallel incisions are made through the trigone mucosa and muscle, leaving a central strip 15 mm wide. B:
The mucosa of the neourethra is tubularized using a running absorbable suture. The muscle is then closed.
The lateral flaps of trigone are left in continuity with the bladder.
If bladder augmentation is required, the bladder should be between the orifices is adequate for urethral tunneling, ureteral
closed to itself for a short distance from the urethra prior to reimplantation may not be necessary. The ureteral stents are
applying the bowel segment. A clear demarcation between often left in place for 4 to 5 days due to edema. Posterior inci-
the neourethra and bladder can often be seen after closure. sion of the mucosa at the bladder neck is performed using cut-
Care should be taken that there is effective closure of the ure- ting current with the electrosurgical cautery to completely
thra and bladder at this junction. The bladder may tend to separate the neourethra from the bladder at the mucosal level.
kink over the urethra at that level, and the neourethra and Further dissection through the posterior muscle in the midline
new bladder neck should be suspended to the undersurface is performed to allow smooth tubularization of the neourethra.
of the intersymphyseal band and lower abdominal wall using Posterolateral musculoadventitial tissue at the 5 and 7 o’clock
several pairs of sutures as described for the M arshall– positions is left intact so that the bladder remains anchored in
M archetti–Krantz procedure (Fig. 107.2D). a caudal position. This eventually ensures that the tubularized
Alternatively, Leadbetter described full-thickness, parallel neourethra reaches well into the bladder lumen to achieve an
incisions through the trigone mucosa and muscle on either side effective flap valve.
of the central strip. These incisions, again made 12 to 15 mm The anterior bladder flap in continuity with the urethra is
apart, are started distally at the old bladder neck and contin- tubularized by approximating the mucosa and then the muscle
ued in a cephalad direction for 4 to 5 cm (Fig. 107.3A). The with continuous absorbable sutures (Fig. 107.4B). This closure
central strip of mucosa is tubularized with interrupted or run- is again begun distally and continued in a proximal or cepha-
ning absorbable sutures. The muscle of the central strip is lad direction.
closed as a second layer. If the incision through the muscle is A submucosal tunnel is developed from the posterior blad-
made slightly wider than on the mucosa, the muscle may be der neck to a position several centimeters above the in-
approximated in an overlapping manner but to a lesser degree terureteric ridge (Fig. 107.4C). The more cephalad portion of
than that described by Young and Dees. The lateral triangles of this tunnel is easily developed from above and the more distal
full-thickness trigone are left in continuity with the bladder or caudal portion is typically developed from the bladder neck
and included in that closure (Fig. 107.3B). (Fig. 107.4D). This tunnel must be made wide enough that the
neourethra can be brought through in a nice smooth course.
Care must be taken that there is no kink whatsoever at the en-
Kro p p Ure t hral Le ng t he ning Pro ce d ure trance of the neourethra into the bladder at the area of the old
bladder neck. Any kinking at that level will result in difficult
The bladder is exposed through a lower midline incision and catheterization.
the bladder neck is identified by palpation of a catheter placed Alternatively, the mucosa in the posterior midline may be
through the urethra. A rectangular, full-thickness strip of ante- incised for the entire length for the proposed tunnel. The mu-
rior bladder is marked and incised. This strip is based at the cosa on either side is then mobilized to create a wide trough
bladder neck and should be left in continuity with the urethra into which to place the urethra. The mucosa from either side is
(5). The incised strip measures 6 cm in length and 2 cm in then approximated to the adventitia of the neourethra and will
width (Fig. 107.4A). Stay sutures placed at the cephalad cor- eventually grow to cover it completely. The tubularized
ners of the strip aid in mobilization. The bladder cephalad to neourethra should not be redundant in length relative to the
the strip is opened in the midline. After anterior incision, the submucosal tunnel to minimize the risk of difficult catheteriza-
catheter is pulled over the pubis to expose the posterior blad- tion. If necessary, excess length may be excised. The proximal
der neck. This allows identification of the ureteral orifices, end of the neourethra is approximated to the bladder mucosa
which are catheterized. If reflux is not present and the space at its orifice with interrupted absorbable suture (Fig. 107.4E).
FIGURE 107.4 Kropp procedure for urethral lengthening. A: A 6 2-cm flap of anterior bladder is
mobilized in continuity with the urethra. B: The flap is tubularized. C: The posterior mucosa is incised
transversely at the bladder neck and a tunnel created for the neourethra from the old bladder neck to a
position above the interureteric ridge. D: The neourethra is brought through the tunnel, taking care that it
does not kink. N ote that the posterolateral musculoadventitial tissue is intact and keeps the bladder
anchored distally. E: The proximal end of the neourethra is trimmed flush with its orifice in the bladder.
The end is approximated to the vesical mucosa circumferentially. F: The bladder is carefully closed distally
by approximating the bladder muscle and mucosa to the adventitia of the neourethra. The neourethra
extends well into the lumen of the bladder to create an effective flap valve. Bladder augmentation is
performed when necessary.
Distally, the lateral and anterior bladder is securely approxi- left in place for 4 to 6 weeks during healing, often with a
mated to the adventitia and muscle of the urethra (Fig. suprapubic cystotomy tube as well. After a static cystogram
107.4F). This closure should be performed as distally as possi- demonstrates no leakage and good healing, self-catheterization
ble on the urethra to avoid foreshortening of the tunnel within may begin.
the bladder. Ease of catheterization through the neourethra
should be tested at each step of reconstruction and any prob-
lems addressed when noted. If augmentation of the bladder is Pip p i Salle Ure t hral Le ng t he ning
necessary, the incision is extended and the peritoneal cavity Pro ce d ure
entered. A short segment of distal bladder should be closed to
itself up from the urethra prior to placing the segment for aug- In an effort to achieve the effective flap valve created with the
mentation. A soft urethral catheter is left in place per urethra Kropp procedure while decreasing the risk for problems with
during healing. The catheter should be secured so as to avoid any catheterization, Salle et al. (6) described a modification for ure-
pressure on the reconstructed urethra. The catheter is usually thral lengthening. The anterior bladder wall flap is used as an
FIGURE 107.5 Pippi Salle procedure for urethral lengthening. A: A full-thickness, anterior bladder flap
5 1 cm is marked and incised. Parallel incisions through the trigone mucosa posteriorly leave a central
strip of similar length and width. B: The lateral trigone mucosa is mobilized to cover the neourethra. The
mucosa of the anterior flap is approximated to the edge of the central mucosal strip using a running
absorbable suture. C: The muscle of the anterior flap is approximated to the superficial trigone muscle on
either side of the mucosal closure. D: The lateral mucosa is closed over the neourethra. E: The distal bladder
is closed to itself and carefully to the urethra. F: Bladder augmentation is performed when necessary.
onlay and eventually contributes half of the circumference of (Fig. 107.5C). The trigone muscle on either side of the poste-
the neourethra. Therefore, a full-thickness anterior bladder rior mucosal strip may be incised superficially to provide an
flap 5 1 cm is mobilized in continuity with the bladder neck edge to which to sew the muscle of the anterior flap. Closure of
(Fig. 107.5A). O ne millimeter of mucosa on either side is the lateral mucosa of the trigone over the reconstructed
excised to avoid overlapping suture lines. Two parallel inci- neourethra creates a flap valve and a neourethra with an intact
sions through the mucosa of the trigone are made so as to leave posterior wall (Fig. 107.5D,E). Distally, the muscle and mu-
a central strip of mucosa 8 to 10 mm in width and 5 cm in cosa of the bladder neck are approximated to the lateral and
length. The lateral trigone mucosa on either side is mobilized anterior adventitia and muscle of the neourethra as distally as
to eventually close over the neourethra. The mucosa of the possible. Proximally, the neourethra should extend well into
anterior flap is approximated to the midline strip of trigone the lumen of the bladder to create an effective flap-valve mech-
mucosa using a running absorbable suture started distally anism for continence. The neourethra and ureters are often
(Fig. 107.5B). The muscle of the anterior flap is approximated stented temporarily in a manner similar to that described for
to the superficial muscle on either side of the central mucosa the Kropp procedure (Fig. 107.5F).
concerns about the potential problem with catheterization,

O UTCO MES some surgeons prefer routine construction of a continent
catheterizable stoma (13). A significant incidence of new reflux
In the pediatric population, fascial slings have been used most has been apparent in some series using the Kropp technique
extensively in patients with neurogenic sphincter incompe- (13). Using the modification by Salle et al., less trouble with
tence. Long-term success with slings in that population has catheterization in male patients has been noted, although
varied greatly, from 40% to 100% . Success rates have varied continence rates have not been quite as high (14,15).
so much that it is not clear that any particular modification of Urethrovesical fistula and partial necrosis of the intravesical
the sling configuration results in any difference in terms of con- neourethra have on occasion resulted in incontinence after the
tinence. Fascial slings have been used more extensively and repair, and widening the base of the anterior flap at the level of
with better results in girls with neurogenic dysfunction, in the bladder neck may decrease those problems.
whom the continence rate may reach 75% (7). The primary fac-
tor predictive of success has been concomitant enterocystoplasty
to ensure a compliant bladder. Placement does not in general Co mp licat io ns
interfere with the ability to perform intermittent catheteriza-
tion, which is usually necessary in the patient population. Relatively common clinical problems after bladder neck recon-
The Young–Dees–Leadbetter bladder neck repair has been struction include urinary tract infection and bladder stones.
used most commonly in the classic staged reconstruction for Both may occur in exstrophy patients after Young–Dees–
bladder exstrophy. Continence with spontaneous voiding has Leadbetter bladder neck repair due to poor emptying (9), but
been achieved in up to 80% of patients with exstrophy and they are even more common among patients with neurogenic
may be even higher for patients with epispadias (8). O ther dysfunction requiring intermittent catheterization, in particu-
authors have reported a lower continence rate, and even lar if bladder augmentation has been performed. The urethral
among patients considered dry, clinical and urodynamic prob- sling and the artificial urinary sphincter possess unique compli-
lems related to poor emptying may exist (9). When used for pa- cations that are related to their periurethral placement or me-
tients with neurogenic dysfunction and denervated sphincter chanical and synthetic characteristics. Urethral erosion, although
muscle, the procedure initially resulted in continence in ap- the rate is low with fascial slings and 5% to 15% with artificial
proximately 25% of patients, but the rate can be improved to urethral sphincters, is most commonly related to infection.
almost 70% if combined with bladder augmentation (10,11). Erosion is a leading cause for permanent failure of the artificial
Due to the high percentage of additional procedures required, urinary sphincter. Additionally, mechanical problems or tissue
the repair has in general fallen out of favor for patients with atrophy at the cuff lead to artificial urinary sphincter revision
neurogenic dysfunction. Reliable catheterization through the rates of approximately one in four in modern series (16).
urethra after a Young–Dees–Leadbetter repair may be difficult. It is important to perform routine surveillance for hy-
The urethral lengthening procedures have primarily been dronephrosis of the upper urinary tract with ultrasonography
used in boys with neurogenic bladder dysfunction. Using the after any form of bladder neck repair. This is particularly true
technique described by Kropp, continence has been achieved among patients with neurogenic dysfunction if they have not
in 75% to 90% of such patients (5,12). Difficulty with undergone bladder augmentation. Even if the bladder appeared
catheterization has been reported in 40% of male patients in adequate prior to outlet reconstruction, up to one quarter of pa-
some series, although that incidence may be lowered when tients may develop bladder hostility after an increase in outlet
the posterior urethra is not totally transected (12). Because of resistance, which may silently threaten the kidneys (17).
References
1. Perez LM , Smith EA, Parrott TS, et al. Submucosal bladder neck injection 9. Yerkes EB, Adams M C, Rink RC, et al. H ow well do patients with exstro-
of bovine dermal collagen for stress urinary incontinence in the pediatric phy actually void? J Urol 2000;164:1044–1047.
population. J Urol 1996;156:633–636. 10. Donnahoo KK, Rink RC, Cain M P, et al. The Young-Dees-Leadbetter blad-
2. Lottmann H B, M argaryan M , Lortat-Jacob S, et al. Long-term effects of der neck repair for neurogenic incontinence. J Urol 1999;161:1946–1949.
dextranomer endoscopic injections for the treatment of urinary inconti- 11. Leadbetter GW Jr. Surgical reconstruction for complete urinary inconti-
nence: an update of a prospective study of 61 patients. J Urol 2006;176: nence: a 10- to 22-year followup. J Urol 1985;133:205–206.
1762–1766. 12. Belman AB, Kaplan GW. Experience with the Kropp anti-incontinence pro-
3. Cole EE, Adams M C, Brock JW 3rd, et al. O utcome of continence proce- cedure. J Urol 1989;141:1160–1162.
dures in the pediatric patient: a single institutional experience. J Urol 13. Snodgrass W. A simplified Kropp procedure for incontinence. J Urol 1997;
2003;170:560–563. 158:1049–1052.
4. Jayanthi VR, Churchill BM , M cLorie GA, et al. Concomitant bladder neck 14. Rink RC, Adams M C, Keating M A. The flip-flap technique to lengthen the
closure and M itrofanoff diversion for the management of intractable uri- urethra (Salle procedure) for treatment of neurogenic urinary incontinence.
nary incontinence. J Urol 1995;154:886–888. J Urol 1994;152:799–802.
5. Kropp KA, Angwafo FF. Urethral lengthening and reimplantation for neu- 15. Salle JL, M cLorie GA, Bagli DJ, et al. M odifications of and extended indica-
rogenic incontinence in children. J Urol 1986;135:533–536. tions for the Pippi Salle procedure. World J Urol 1998;16:279–284.
6. Salle JL, M cLorie GA, Bagli DJ, et al. Urethral lengthening with anterior 16. Kryger JV, Gonzalez R, Barthold JS. Surgical management of urinary incon-
bladder wall flap (Pippi Salle procedure): modifications and extended indi- tinence in children with neurogenic sphincteric incompetence. J Urol 2000;
cations of the technique. J Urol 1997;158:585–590. 163:256–263.
7. Perez LM , Smith EA, Broecker BH , et al. O utcome of sling cys- 17. Bauer SB, Reda EF, Colodny AH , et al. Detrusor instability: a delayed
tourethropexy in the pediatric population: a critical review. J Urol 1996; complication in association with the artificial sphincter. J Urol 1986;135:
156:642–646. 1212–1215.
8. Gearhart JP, M atthews R. Exstrophy–epispadias complex. In: Wein AJ,
Kavoussi LR, Novick AC, et al., eds. Cam pbell-Walsh Urology, 9th ed.,
vol. 4. Philadelphia: Saunders Elsevier, 2007:3497–3553.
CHAPTER 108 ■ SURGERY FO R PO STERIO R
URETHRAL VALVES
RO SALIA MISSERI AND KENNETH I. GLASSBERG
A posterior urethral valve (PUV) is the most common cause of

congenital bladder outlet obstruction in boys. It is associated
with a dilated posterior urethra, poor urinary stream, and in-
complete bladder emptying. Bilateral hydroureteronephrosis
of varying degrees is almost always present and frequently ac-
companied by vesicoureteral reflux and/or bladder diverticula.
DIAGNO SIS
With the widespread use of antenatal ultrasound, PUVs are
often diagnosed prenatally. The condition is suspected in utero
when a male fetus is found to have bilateral hydroureteronephro-
sis and a thick-walled bladder that does not empty completely
on sonography. In addition, there may be a keyhole deformity
noted on sonography. This is noted when a dilated bladder and
posterior urethra is seen. In severely affected fetuses, oligohy-
dramnios, pulmonary hypoplasia, and Potter syndrome may FIGURE 108.1 Voiding cystourethrogram of newborn with posterior
occur. Newborns may present with abdominal masses represent- urethral valves. N ote the dilated posterior urethra and bladder
diverticulum.
ing a distended bladder or hydronephrotic kidney, dry diapers,
nonspecific gastrointestinal symptoms, respiratory distress, or
urinary ascites. Younger boys usually present with urinary tract hydronephrosis, some report better long-term outcomes when
infection, respiratory distress, abdominal distention, sepsis, or these infants are temporarily diverted, while most feel that pri-
azotemia, while older boys may present with dysfunctional void- mary valve ablation is the treatment of choice (1). For those
ing symptomatology, incontinence, poor urinary stream, urinary who believe temporary diversion is best, many methods of vesi-
tract infections, or hematuria. cal and supravesical diversion of the obstructed bladder exist.
If a PUV is suspected in an infant, prophylactic antibiotics
should be initiated and the bladder should be drained with a
5Fr or 8Fr feeding tube securely taped in place with a clear ALTERNATIVE THERAPY
transparent dressing. Positioning is best confirmed with an ab-
dominal radiograph as the tube may coil in the dilated poste- There is no effective alternative to surgical therapy.
rior urethra. The feeding tube is left in place until a voiding
cystourethrogram (VCUG) is obtained to make the diagnosis.
In patients with severe hydroureteronephrosis and/or azotemia, SURGICAL TECHNIQ UE
the catheter should be left in place until the azotemia resolves/
stabilizes and hydroureteronephrosis improves. Transure t hral Valve Ab lat io n
The VCUG of a boy with a PUV will reveal a posterior
urethra that appears dilated, often taking on a “ shield shape” Valve ablation is most commonly accomplished trans-
or squared-off appearance. The bladder neck is often clearly urethrally. The size of the infant’s fossa navicularis usually
demarcated and may appear as a thick collar, and the urethra limits the size of cystoscope that may be used. Typically, a
distal to the obstruction will appear less full than normal 7.5Fr or 8.5Fr scope is used in infants, while a larger scope
(Fig. 108.1). may be used in older children. The cystoscope should be well
lubricated and advanced under direct vision. Gentle dilation
of the distal urethra may be required to advance the cys-
INDICATIO NS FO R SURGERY tourethroscope. With the bladder full and applying gentle
suprapubic pressure, the valve leaflets are more easily seen
Today, most valve ablation is accomplished transurethrally. coming off the verumontanum and extending distally to fuse
Some controversy still exists as to what to do once the bladder anteriorly (Fig. 108.3). The goal of valve ablation is to disrupt
has been drained with a catheter (Fig. 108.2). For severe the leaflet, hence destroying the obstruction.
697
FIGURE 108.2 Proposed management of posterior urethral

valves.
(2) preferred incising at the 12 o’clock position, while

Gonzales (3) advocated cutting at the 4, 8, and 12 o’clock
positions. H owever, most prefer incising at the 4 to 5 o’clock
and 7 to 8 o’clock positions using a hook-shaped cold knife or
with the cutting current set at 20 to 25 W pure cut.
Lasers such as the neodymium:YAG have also been em-
ployed for PUV ablation. Additional methods of PUV ablation
have also been described for use in patients with small-caliber
urethras. With the advent of smaller scopes, perineal urethros-
tomy is now rarely necessary for valve ablation. Z aontz and
Firlit (4) have described percutaneous antegrade ablation of
PUV as well as antegrade incision of PUV in infants with
small-caliber urethras.
O nce the valves are endoscopically ablated the bladder
should be cystoscoped to evaluate for diverticula, trabecula-
tions, and the appearance of the ureteral orifices. A full stream
should be noted at the end of the procedure while applying
gentle pressure to the suprapubic area. A small urethral
catheter is left in place for 1 to 2 days following the procedure
or until an elevated creatinine nadirs. A VCUG may be per-
FIGURE 108.3 Cystoscopic appearance of type 1 posterior urethral formed after the catheter is removed to assess the success of the
valve.
procedure. Timing of the VCUG is determined by the surgeon
based on his or her confidence in the adequacy of ablation. A
VCUG and urodynamics or preferably videourodynamics
A PUV may be ablated or incised in several ways. It may be should be delayed no 6 to 8 weeks after ablation. If there is
ablated using a 3Fr Bugbee electrode through a cystoscope. suspicion of inadequate ablation or continued obstruction,
Alternatively, the wire insert of a 3Fr ureteral catheter with the “ second-look” cystoscopy with ablation of residual leaflets
distal end connected to electrocautery may be used. O nce in should be considered. If the child is found to have diminished
position the wire is advanced and pushed into the valve at the compliance or detrusor hyperactivity, anticholinergic therapy
5 and 7 o’clock positions while employing a cutting current of should be considered. Anticholinergic therapy may also be in-
20 to 25 W. (N ote that power settings may vary from machine stituted immediately after valve ablation or prior to closure or
to machine.) When using cautery care must be taken to ensure reversal of vesical or supravesical diversion.
that thermal energy is targeted at the valves alone. This may
be particularly useful if the infant resectoscope is too large for
the child’s urethra. Ve sico st o my
Using a small pediatric resectoscope, the valves are incised
with a right-angle hook, loop electrode, or hook-shaped cold- While most patients with PUV are treated with primary valve
knife. When using a loop electrode, a narrow, more oblong ablation, a vesicostomy may be useful in neonates whose ure-
loop is preferable to a wider, more circular loop. Some debate thra will not accommodate a cystoscope or in those whose
exists as to the best location for valve incision. Williams et al. creatinine rises despite adequate valve resection.
Chap t e r 108: Surg e ry for Poste rior Ure thral Valve s 699
With the patient in the supine position the lower abdominal The vesicostomy may be created in one of two ways. In the
skin is prepared and draped in the typical fashion. The proce- first method, a stay suture is placed proximal to the urachus.
dure is more easily performed with a full bladder. A 2-cm trans- The urachus is then transected and excised. In the second
verse incision is then made midway between the pubic method, the portion of the bladder cephalad to the urachal
symphysis and umbilicus. The rectus fascia is exposed and a 2 remnant is used as the site for the vesicostomy. The bladder is
2-cm cruciate incision is made. Alternately, a triangle or circle of incised and the fascial edges are sewn to the outer bladder wall
rectus fascia measuring 2 cm may be excised. O ne must remem- using 3-0 or 4-0 polyglactin sutures approximately 0.5 to 1 cm
ber that the size of the fascial opening ultimately determines the from the opening created in the bladder. The vesicostomy
caliber of the stoma. The rectus muscles are then retracted later- should be calibrated to 24Fr or large enough to allow passage
ally, exposing the bladder. A 3-0 suture is placed near the dome of the surgeon’s fifth digit. If the fascial defect is too large, in-
of the bladder and used for traction. Using the traction suture terrupted 3-0 polyglactin sutures may be used to narrow the
the bladder is mobilized superiorly. The peritoneum is gently opening. The edges of the detrusor are then sewn to the skin
swept off the superior aspect of the bladder. Additional cephalad using 4-0 polyglactin sutures in an interrupted fashion. If the
sutures may be placed in a stepwise fashion to help bring the skin incision is wider than the stoma created, the skin is
dome into the surgical field. Care is taken to avoid the peritoneal approximated with a suture of choice (Fig. 108.4).
contents. With gentle traction one should be able to visualize the The decision to close a vesicostomy should be made only
urachus or obliterated hypogastric artery. once bladder dynamics have been assessed and a plan for
FIGURE 108.4 Blocksom vesicostomy. A: A 2-cm transverse incision is made midway between the pubic symphysis and
umbilicus. B: A 2 2-cm cruciate fascial incision is made. C: Using the traction suture the bladder is mobilized superiorly.
The peritoneum is gently swept off the superior aspect of the bladder. D: The urachus is incised and the bladder is further
mobilized. E: The urachus is excised. F and G: The outer bladder wall is sewn to the edges of the incised rectus fascia.
H: The edges of the detrusor are sewn to the skin. (Modified from Belman AB, King LR. Vesicostomy: useful means of
reversible urinary diversion in selected infant. Urology 1973;1:208–213.)
permanent therapy has been devised. Ultimately, the timing

of closure is dictated by the surgeon’s philosophy. Some be-
lieve an empty bladder becomes a contracted bladder, while
others close vesicostomies just prior to the expected time of
potty training.
Initially, an adequate-size balloon catheter is placed into
the stoma of the vesicostomy. With the balloon inflated, an
elliptical skin incision is made around the stoma. The subcuta-
neous and perivesical tissues are dissected circumferentially
around the vesicostomy. N ext, 3-0 chromic stay sutures are
placed through the bladder wall approximately 1 cm cephalad
FIGURE 108.6 Fascial incision through lumbodorsal fascia lateral to
and 1 cm caudad to the stoma. The skin and protruding por- the sacrospinalis and quadratus lumborum, avoiding the division of
tion of the bladder are excised. The previously placed catheter muscles.
is removed and a urethral catheter is placed for bladder
drainage. The bladder defect is then closed in two layers: a
running 4-0 chromic suture is used to reapproximate the blad- injuring the subcostal neurovascular bundle. The lumbodorsal
der mucosa, followed by interrupted or running 3-0 polyglactin fascia is exposed by elevating the skin and subcutaneous tis-
or chromic sutures as a second layer. The remainder of the sues for about 3 cm on either side of the incision so that a ver-
wound is closed in a standard fashion. tical fascial incision may be comfortably made. The posterior
layer of the lumbodorsal fascia is incised vertically 2 cm lat-
eral to the midline. The sacrospinalis muscle is then retracted
Sup rave sical Dive rsio n medially. This exposes the middle layer of the lumbodorsal
fascia, which is incised at the lateral border of the quadratus
Cut ane o us Pye lo st o my lumborum. Retracting the quadratus lumborum medially, the
The decision to proceed with a supravesical diversion remains anterior layer of the lumbodorsal fascia is exposed (Fig.
controversial, and it is rarely used. To safely perform a cuta- 108.6). This layer and the transversalis fascia are then incised
neous pyelostomy, the renal pelvis should be sufficiently dilated between the subcostal and iliohypogastric nerves. The per-
to avoid tension on the renal pelvis as it is pulled toward the ab- inephric fat should then be in view. The kidney should be
dominal wall. A dilated renal pelvis also ensures that dissection located in the superomedial part of the wound.
can be carried out away from the ureteropelvic junction (UPJ). O nce the fascia of Gerota is entered, the dilated renal pelvis
The renal pelvis may be approached in several ways, in- is identified and rotated anteromedially. The surgeon must as-
cluding a dorsal lumbotomy or a subcostal extraperitoneal ap- sess if the pelvis can comfortably reach the skin. If not, a very
proach. A surgeon may use the approach he or she is most proximal portion of the ureter may be brought out to serve the
comfortable with. Despite the limited exposure that a dorsal same purpose. Care should be taken to avoid dissection near
lumbotomy incision affords, it is excellent for visualization of the UPJ so as to avoid the possibility of a future UPJ obstruc-
the renal pelvis and upper ureter. The procedure avoids a muscle- tion. Two 3-0 chromic traction sutures are placed on the poste-
splitting incision and may produce less postoperative pain. rior aspect of the renal pelvis away from the UPJ. Using a
After the patient is intubated, he should be placed in the scalpel a 3-cm incision is made. The full thickness of the renal
prone position on the operating room table. Cushions should pelvis is sutured to the posterior corner of the skin incision us-
then be placed under the chest and just superior to the anterior ing multiple interrupted 4-0 polyglactin sutures (Fig. 108.7).
superior iliac spines. The landmarks include the 12th rib supe- The pyelostomy should be calibrated to approximately 20Fr to
riorly, the iliac crest inferiorly, and the lateral border of the avoid future stenosis or prolapse. O nce the planned procedure
sacrospinalis medially. A vertical incision with or without a
slight curve at its distal end is made approximately one-third
to one-half the distance between the 12th rib and the iliac
crest. Alternatively, an oblique incision may be made along
the Langer lines (Fig. 108.5). Care should be taken to avoid
FIGURE 108.5 Positioning for dorsal lumbotomy and possible skin

incisions. The solid line represents our incision of choice; the brok en
line represents a suitable alternative. FIGURE 108.7 Cutaneous pyelostomy (sutures at the skin level).
Chap t e r 108: Surg e ry for Poste rior Ure thral Valve s 701
has been performed, the posterior layer of the lumbodorsal fas-

cia is reapproximated with 3-0 polyglactin sutures and the skin
is then closed with either a subcuticular suture or skin staples.
Hig h Cut ane o us Lo o p Ure t e ro st o my

This method is typically employed when the renal pelvis is not
large enough for a cutaneous pyelostomy to be performed. The
initial steps for a high cutaneous ureterostomy are similar to that
for a cutaneous pyelostomy. The ureter is brought to skin level.
Two 4-0 polyglactin sutures are placed in the upper ureter ap-
proximately 5 mm from each other. Using a scalpel a 2-cm verti-
cal ureterotomy is created. The abdominal musculature is closed
on either side and behind the loop of ureter. Care is taken to
avoid strangulating the ureter. The incised ureteral margins are
sewn to the skin using interrupted 4-0 polyglactin sutures. The
final product is a double-barreled ureteral stoma (Fig. 108.8).
Loop ureterostomies maintain continuity of part of the
ureter, therefore decreasing the likelihood of disruption of
ureteral blood supply and possibly making closure of the FIGURE 108.9 Pelvioureterostomy-en-Y (Sober ureterostomy).
ureterostomy simpler.
the procedure of choice in critically ill patients as it is more
Pe lvio ure t e ro st o my-e n-Y (So b e r Lo o p extensive and time consuming than other forms of diver-
Ure t e ro st o my) sion, and it is best used in patients with redundant tortuous
The Sober Y ureterostomy allows some urine to drain into ureters. The ureter is mobilized from the level of the kidney
the bladder, thus avoiding a completely defunctionalized to the level of the true pelvis. The ureter is divided at a point
bladder that may eventually become contracted (5). It is not where the lower ureteral segment comfortably reaches the
renal pelvis. The upper ureter that remains in continuity
with the renal pelvis is brought out to the flank caudad to
the flank incision. The proximal end of the lower portion of
the transected ureter is anastomosed to the renal pelvis. This
is done in an end-to-side fashion after creating a pelviotomy
at a point that will not cause ureteral kinking. The anasto-
mosis is performed using a 6-0 or 7-0 polyglactin suture in a
running fashion (Fig. 108.9). The flank incision is closed in
the standard fashion. A small Penrose drain may be tem-
porarily placed. Initially, most urine will drain via the
ureterostomy. O ver time, increasing amounts of urine will
drain into the bladder.
End Cut ane o us Ure t e ro st o my

To successfully perform a cutaneous ureterostomy, the ureter
must be sufficiently thick-walled and dilated. Preservation of
the ureteral blood supply is essential. The ureter should be ap-
proached extraperitoneally via either a low abdominal inci-
sion or a Gibson incision. The ureter should be carefully
dissected from the level of the sacral promontory to the blad-
der with care to avoid stripping the ureter’s adventitia. O nce
dissected, a thick vessel loop or Penrose drain should be
placed around the ureter. O ne should estimate whether the lig-
ated ureter will comfortably reach the anterior abdominal
wall at the right or left lower quadrant. O nce satisfied with
this, the ureter is clamped and cut. The distal segment is lig-
ated using a 3-0 polyglactin suture. A 3-0 polyglactin stay su-
ture is placed on the cut end with care to avoid the ureter’s
medial blood supply (Fig. 108.10).
The cutaneous stoma is then created. Stomas should be
placed in the right or left lower quadrant for ease of stomal fit
in the event an appliance will be used. O nce the site of the
stoma has been determined, a V-shaped incision is made and
taken down through the subcutaneous tissues and rectus
FIGURE 108.8 Loop cutaneous ureterostomy (sutures at the skin sheath. Using the previously placed stay suture, the ureter is
level). gently brought through the incision. If the ureter seems
Clo sure o f Sup rave sical Dive rsio ns

To close a cutaneous pyelostomy, an elliptical skin incision is
made around the stoma. The portion of pelvis that has been
exteriorized is trimmed so that healthy renal pelvic edges may
be approximated. Using a 6-0 polyglactin suture in a running
fashion the renal pelvis is closed in a transverse fashion. The
UPJ should be inspected to ensure that no kinking has
occurred secondary to pyelostomy closure.
To close a loop ureterostomy, an elliptical skin incision is
made in the skin surrounding the stoma. The proximal and dis-
tal ureteral segments are adequately mobilized. The fibrotic ex-
posed portions of the ureter are excised, while trying to
maintain the continuity of the ureter’s back wall and blood
supply. The remaining ureteral margins are then spatulated and
closed in a transverse fashion using a 6-0 polyglactin suture
(Fig. 108.11). Again, one must ensure that no angulation or
narrowing of the ureter has occurred. A temporary indwelling
ureteral stent may be placed to bridge the anastomosis.
A Sober ureterostomy may be reversed by excising the
stoma at the skin level along with the limb of ureter used to
create the cutaneous ureterostomy. The dissection is taken
down to the level of the renal pelvis. The defect in the renal
pelvis is closed using a 6-0 polyglactin suture in a running
watertight fashion.
FIGURE 108.10 End ureterostomy (sutures at skin level). (From
Indiana University School of M edicine, O ffice of Visual M edia, with
permission).
O UTCO MES
stretched, additional mobilization may be necessary. The
ureter is then spatulated medially to avoid its blood supply. Co mp licat io ns
The apex of the spatulated ureter is then sewn to the apex of
the skin incision using a 4-0 polyglactin suture. The ureter is Cutaneous vesicostomies may be complicated by early or late
then sewn to the other angles of the skin incision and addi- prolapse of the dome or posterior bladder wall in up to 17%
tional sutures are placed circumferentially. of patients. To prevent prolapse the most cephalad portion of
Bilateral end ureterostomies may be brought to the midline the bladder or the urachus should be used as the site for the
or either lower quadrant. The medial wall of each ureter is in- vesicostomy. By employing this portion of the bladder, the
cised approximately 3 cm. The apexes of the incised ureters peritonealized part of the dome becomes immobilized, de-
are sewn to each other using a two-armed 5-0 polyglactin creasing the risk of prolapse. The stomal opening itself should
suture. The incised walls of the ureters are then sewn to each be no larger than 2 cm. The final stoma should calibrate to
other in a running fashion. 24Fr. Excessive mucosal eversion should not be mistaken for
FIGURE 108.11 Takedown of loop cutaneous

ureterostomy.
Chap t e r 109: Hyp osp ad ias 703
prolapse. Despite its appearance, no intervention is necessary

for excessive eversion. Re sult s
If the vesicostomy does not appear to be draining well and
Despite the ease of performing a vesical diversion and its
there is evidence of large amounts of residual bladder urine or
effectiveness in relieving bladder outlet obstruction, contro-
large amounts of urine are voided by urethra, the suspicion of
versy exists regarding both its necessity and ultimate effects on
stomal stenosis should be raised. Stomal stenosis rates of 3% to
bladder function (1,3).
12% have been reported (6). The stenosis may be secondary to a
small fascial opening or excessive tension on the vesicocuta-
neous anastomosis. Continuous drainage of urine into a diaper
commonly may lead to peristomal dermatitis. Prolonged, severe ANTERIO R URETHRAL VALVES
dermatitis may ultimately lead to stomal stenosis. This can be
prevented by air drying the skin or applying topical ointments Anterior urethral valves occur 10 times less frequently than
used for diaper rash. Fungal superinfections may occur and are posterior urethral valves and may be located anywhere along
treated with antifungal creams and powders. the anterior urethra. In most cases, an anterior urethral valve
Some infants, particularly those with persistent vesi- is actually a congenital urethral diverticulum with the lip of
coureteral reflux, may have recurrent urinary tract infections the diverticulum preventing antegrade flow of urine. The
despite patent vesicostomy and small bladder residuals. These bulging diverticulum may further obstruct the urethra by com-
children may benefit from intermittent catheterization through pressing the lumen. These children present with symptoms
their vesicostomies. similar to those with a PUV, including varying degrees of
The most common complication associated with pyelostomy hydroureteronephrosis; however, many also present with pe-
is chronic skin irritation and dermatitis. As in other forms of nile ballooning. As with PUV, the diagnosis is also made on
diversion, chronic bacteriuria is also common. Less common VCUG. A renal ultrasound should be performed to complete
complications of pyelostomy include stomal stenosis and pro- the evaluation. Cystourethroscopy may miss the valve due to
lapse of the renal pelvis. Chronic bacteriuria has been found in the retrograde flow of fluid during the procedure.
approximately two thirds of patients with ureterostomies and The obstruction is relieved endoscopically. The distal lip is
is the most common complication in this group. Stomal incised using a hook or right-angle wire electrode. If unsuc-
stenosis occurs in 11% to 70% of patients undergoing end cessful, the diverticulum may be excised and the urethra re-
cutaneous ureterostomies (7). The incidence of stenosis and configured. Staged urethroplasty may be the best treatment
obstruction is related to the caliber of the ureter used as well as option when faced with a large urethral diverticulum.
the type of stoma created. Chronic skin irritation may also M anagement of the hydroureteronephrosis would be similar
result in scarring and stenosis. to that in a patient with a PUV.
References
1. Glassberg KI. The valve bladder syndrome: 20 years later. J Urol 5. Sober I. Pelvioureterostomy-en-Y. J Urol 1972;107:473–475.
2001;166:1406–1414. 6. Skoog SJ. Pediatric vesical diversion. In: Graham SD, Glenn JF, eds.
2. Williams DI, Whitaker RA, Barratt TM , et al. Urethral valves. Br J Urol G lenn’s Urologic Surgery. 5th ed. Philadelphia: Lippincott Williams &
1973;45:200–205. Wilkins, 1998:871–878.
3. Gonzales ET Jr. Posterior urethral valves and other anomalies. In: Walsh 7. Burstein JD, Firlit CF. Complications of cutaneous ureterostomy and other
PC, Retik AB, Vaughan ED Jr, et al, eds. Cam pbell’s Urology. 7th ed. cutaneous diversion. Urol Clin N orth A m 1983;10:433–443.
Philadelphia: WB Saunders, 1998:2069–2091.
4. Z aontz M R, Firlit CF. Percutaneous antegrade ablation of posterior ure-
thral valves in infants with small caliber urethras: an alternative to urinary
diversion. J Urol 1986;136:247–248.
CHAPTER 109 ■ HYPO SPADIAS

LAURENCE S. BASKIN
H ypospadias is defined by three major anatomic defects: (i) stream. There are five basic steps for a successful hypospadias
the abnormal location of the urethral meatus, (ii) penile curva- outcome: (i) orthoplasty (straightening), (ii) urethroplasty, (iii)
ture, and (iii) abnormalities of the foreskin. The objective in meatoplasty and glanuloplasty, (iv) scrotoplasty, and (v) skin
treating patients with hypospadias is to reconstruct a straight coverage. These various elements of surgical technique can be
penis for normal coitus and place the new urethral meatus on applied either sequentially or in various combinations to
the terminal aspect of the glans to allow a forward-directed achieve a surgical success (1).
Skin and Scro t al Ab no rmalit ie s

The skin of the penis is radically changed as a result of the dis-
turbance in the formation of the urethra. Distal to the meatus,
there is often a paucity of ventral skin, which may contribute
to penile curvature. The frenulum is always absent in hy-
Glandular
pospadias. Vestiges of a frenulum are sometimes found insert-
ing on either side of the open navicular fossa.
The skin proximal to the urethral meatus may be extremely
thin, so much so that a catheter or probe passed proximally is
readily apparent through a tissue-paper thickness of skin.
Midshaft When it is present, it abrogates the use of perimeatal skin flaps
in repairs.
The urethral plate extending from the hypospadiac meatus
to the glanular groove may be well developed. Even with a
meatus quite proximal on the shaft, this normal urethral plate
is quite elastic and typically nontethering. Artificial erection
demonstrates no ventral curvature in these situations. A nor-
mal urethral plate may be incorporated into the surgical re-
pair. H owever, if the urethral plate is underdeveloped, it will
act as a tethering fibrous band that bends the penis ventrally
during artificial erection. When this fibrous chordee tissue is
Scrotal divided, the penis will frequently straighten.
N ormally, the genital tubercle should develop in a cranial
position above the two genital swellings. The penis may be
caught between the two scrotal halves and become engulfed
with fusion of the penoscrotal area. The boundary between
the penis and the scrotum may be formed by two oblique
raphes that extend from the very proximal meatus to the dor-
Perineal sal side of the penis.
Pe nile Curvat ure

FIGURE 109.1 Location of the hypospadias meatus. Glandular, mid-
shaft, scrotal, and perineal.
The curvature of the penis is caused by deficiency of the normal
structures, most commonly on the ventral side of the penis. It
has been labeled chordee; however, this term implies a strand of
connective tissue stretched like a cord between the meatus and
glans, which is rarely found in practice. Penile curvature can be
DIAGNO SIS from skin deficiency, a dartos fascial deficiency, a true fibrous
chordee with tethering of the ventral shaft, or deficiency of the
Me at al Ab no rmalit ie s corpora cavernosa on the concave side of the penis (2).
There are occasional reports of other penile anomalies that
H ypospadias is characterized by an abnormality in location represent variations of the embryologic defect causing hy-
and configuration of the urethral meatus (Fig. 109.1). The pospadias. They can be characterized as a defect in the course
urethral meatus may be ventrally placed just below a blind of the urethra, such as congenital urethral fistula, and a group
dimple at the normal meatal opening on the glans or so far characterized by curvature of the penis without hypospadias,
back in the perineum that it appears as a “ vaginal” hypospa- or so-called chordee without hypospadias.
dias. M ost patients present with the urethral meatus some-
where between these extremes. The meatus is encountered in a
variety of configurations in form, diameter, elasticity, and SURGICAL TECHNIQ UE
rigidity. It can be fissured in both transverse and longitudinal
directions or can be covered with delicate skin. In the case of Hyp o sp ad ias Training
the megameatus intact prepuce, the distal urethra is enlarged,
tapering to a normal caliber in the penile shaft. O ften, there is Success is directly related to the experience of the surgeon. For
an orifice of a periurethral duct located distal to the meatus a successful result in hypospadias repair, the penile tissues
that courses dorsal to the urethral channel for a short dis- must be handled with great care. Experience in mobilizing and
tance. It is blind ending and does not communicate in any way rotating skin flaps is needed, as are the minutiae involved in
with the urinary stream. The periurethral duct corresponds plastic surgical techniques. It is not enough to review pictures
with the sinus of Guérin or the lacunae of M orgagni. Unless and follow descriptions; training in the techniques is essential.
these ducts are inadvertently closed, leading to a blind-ending Knowledge of a few methods is not enough, because the one
epithelial pouch, they are of no clinical consequence. used must be the best for the individual situation of the child.
A pediatric urology fellowship is the appropriate place to be- vasoconstrictor will reduce the bleeding during the dissection,
come competent in hypospadias surgery. but if the operation is prolonged beyond 90 minutes, rebound
vasodilation can be expected. Remember that halothane anes-
thesia sensitizes the heart to catecholamines, thus promoting
Pre o p e rat ive Evaluat io n arrhythmias. Avoid electrocoagulation as much as possible; if
it is necessary, use a bipolar cautery or touch a monopolar
Because hypospadias is an isolated anomaly, the entire geni-
cautery to only the forceps unit set at a low current. O nce the
tourinary tract does not require evaluation. The absence of
skin flaps are applied, bleeding improves, and a pressure dress-
one gonad, perineal hypospadias, severe chordee, or a bifid
ing will usually ensure hemostasis. O n rare occasion the use of
scrotum suggests a disorder of sex development and requires
a tourniquet that is typically used for artificial erections can
genotypic evaluation. If both gonads are not palpable, con-
facilitate hemostasis.
sider the possibility of congenital adrenal hyperplasia in a phe-
notypic female. Art ificial Ere ct io n
To induce a saline-induced erection, place a sterile rubber
Ag e fo r O p e rat io n band around the base of the penis and snug it with a hemostat.
Introduce a 25-gauge butterfly needle into the corpus caver-
Select a time between 6 and 9 months for surgery. At this age nosum. Gently distend the penis with injectable normal saline
the infants are also easiest to manage, are not walking and resolution; avoid overdistention. M aintain the erection during
main in diapers. Babies appear to have fewer bladder spasms evaluation of the chordee. After the chordee has been cor-
and require smaller doses of pain medication. They do not rected, create a second erection to check penile alignment.
seem to remember the surgery as teenagers and adults.
Lo cal Urinary Dive rsio n in Child re n
Parenteral testosterone may be administered to increase the
size of the penis and especially the size and vascularity of the Diversion of urine away from the suture lines has always been
prepuce should it be needed for proximal and perineal hy- a problem in children because any indwelling tube, particu-
pospadias repair. Give 25 to 50 mg intramuscularly, repeated larly one terminating in a balloon, induces bladder spasms
once or twice at 3-week intervals, before the operation. that force urine around it into the repair. This disrupts the
suture line and leads to formation of fistulas. Besides, the lumen
of a balloon catheter is small compared to that of a straight
O ut p at ie nt Re p air catheter, especially a plastic one.
M any techniques have been tried to minimize these prob-
An uncomplicated hypospadias operation can be done with- lems with diversion. The simplest method for infants, one that
out hospital admission. Parents and children should visit the combines stenting with drainage, is to insert a fine silicone
surgeon sometime before the date of surgery for history taking tube, such as 6Fr peritoneal shunt tubing or neurosurgical
and examination, as well as for instructions in feeding and tubing with its wand-like end, into the bladder through the
preoperative care. The surgeon and nurse should give consid- urethra and fasten the end to the glans in one or two places
erable support to the parents because of their need to know with nonabsorbable sutures.
what to expect. At this visit surgeons can explain the proce- Alternately, place a 6Fr Kendall catheter of soft Silastic,
dure, hand out suitable booklets describing details, and obtain with a Luer-loc at the end, to prevent internal migration and
informed consent. They can also review the postoperative to allow irrigation. Whatever intubation system is used in
catheter care and medications. infants, collect the urine in a double diaper. For older boys use
a urethral balloon catheter; tape it to the abdomen so that it
Ne rve Blo ck cannot disturb the ventral glans repair. Drainage should be
continued for 4 to 7 days for distal and penile shaft repairs
A caudal nerve block placed by the anesthesia team is an ex- and 7 to 10 days for more severe hypospadias repairs.
cellent form of postoperative pain control. A good alternative
is a penile nerve block. To place a penile nerve block in an in-
Dre ssing s
fant, use 3 to 4 mL of 0.5% long-lasting bupivacaine mixed
with 1% of quick-acting lidocaine. Inject it at the base of each Apply a dressing to immobilize the area, to reduce edema, and
crus just below the notch of the symphysis, or vertically in the to prevent the formation of a hematoma. Use transparent and
midline deep to the notch of the symphysis, with a 1-1/2-inch permeable absorbent plastic film (Tegaderm or O pSite) ap-
25-gauge needle. When placed at the beginning of an opera- plied over Telfa or tincture of benzoin. Let the catheter drain
tion it will reduce the amount of general anesthesia required into an outer diaper. The dressing may be removed in 2 to 3
and will provide anesthesia that will last well into the postop- days after a few warm baths at home. O nce the dressing has
erative period. been removed use petroleum jelly on the diaper to keep the re-
paired penis from sticking, typically for 4 to 5 days.
Surg ical Hint s
Se t up fo r O p e rat io n
He mo st asis
For hemostasis use 1% lidocaine with 1:100,000 epinephrine Inst rume nt s
and inject it through a 27-gauge needle within the glans and the Select instruments designed for delicate handling of tissues. A
area of abortive spongiosum. Wait 7 minutes for it to act. This reasonable list would include loupe magnification, genitourinary
urine from either a coronal or a slightly subcoronal meatus

Algorithm for Hypospadias Repair
(3). O nce the patient is asleep, the urethra itself must have a
normal ventral wall, without any thin or atretic urethral spon-
Preservation of Urethral Plate giosum. The urethra also must be mobile so it can be ad-
Skin and Dartos Dissection vanced into the glans (Fig. 109.3).
Glans Ap p ro ximat io n Pro ce d ure

Distal Proximal
The glans approximation procedure (GAP) is applicable in a
small subset of patients with anterior hypospadias who have a
wide and deep glandular groove (4). These patients do not have
Assess Curvature a bridge of glandular tissue that typically deflects the urinary
Glans Configuration (Finger test)
Meatal Quality and stream, as seen in patients who would be more appropriately
Dorsal Plication if necessary treated with the M AGPI procedure. In the GAP procedure, the
Location Rarely Resect Plate
Urethral Plate Width wide-mouth urethra is tubularized primarily over a stent (Fig.
(dermal graft) 109.4). Ventral glanular tilt, meatal retraction, and splaying of
the urinary stream can result from the inappropriate use of the
M AGPI technique in these circumstances.
Assess Curvature
Dorsal Plication if necessary Tub ularize d Incise d Plat e Ure t hro p last y
(Sno d g rass)
H istorically, if the urethral groove was not wide enough for
tubularization in situ, such as in the GAP or Thiersch–Duplay
MAGPI Onlay procedure, then an alternative approach such as the M athieu
GAP/ Pyramid Two Stage (foreskin amount) or, for more severe hypospadias, a vascularized pedicle flap
Tubularization Bracka two stage buccal graft was performed. Recently the concept of the incision in the ure-
Snodgrass Modification thral plate with subsequent tubularization and secondary
healing has been introduced by Snodgrass (5) (Fig. 109.5).
FIGURE 109.2 Algorithm for hypospadias repair. Short-term results have been excellent, and this procedure is
enjoying extensive popularity. O ne appealing aspect is the slit-
like meatus that is created with the dorsal midline incision.
fine and microsurgery sets, microsurgical knife (Weck), M ore recently, this technique has been applied to more poste-
toothed and nontoothed forceps (Adson), fine Allis clamps, rior forms of hypospadias. Theoretically, there is concern
fine clamps, two pairs of Bishop–H armon forceps or 0.5 plat- about the possibility of meatal stenosis from scarring as occurs
form forceps, sharp small tenotomy scissors, iris scissors, mi- in patients with urethral stricture disease, where direct-vision
crotip Castroviejo scissors, microtip Castroviejo needle internal urethrotomy often leads to recurrent stricture. H owever,
holders, plastic needle holders and ring retractor (Scott/Lone reports of meatal stenosis have been rare. In hypospadias, the
Star), and hooks. Also have available bougies á boule, 5Fr and native virgin tissue with excellent blood supply and large vas-
8Fr infant feeding tubes, rubber bands, a marking pen, a 25- cular sinuses seems to respond to primary incision and sec-
gauge butterfly needle and syringe, and a hand-held Bovie, or ondary healing without scar. The tubularized incised plate
an ophthalmic electrocautery. H ave fine sutures of appropri- (TIP) urethroplasty is conducive to preservation of the fore-
ate sizes and types at hand but unopened—for example, 5-0 skin (6). To preserve the foreskin the incision is made only on
Prolene on a C-1 tapered needle for glans traction, 7-0 PDS the ventrum; therefore, patients with significant penile curva-
and Vicryl for urethroplasty, and 6-0 PDS for the skin. ture are not candidates for this procedure. A three-layer clo-
sure of the prepuce prevents foreskin fistulas. The fact that the
foreskin cannot be used as a de-epithelialized flap theoretically
increases the chance for urethra fistula.
Se le ct io n o f t he O p e rat ive Te chniq ue
Figure 109.2 presents an algorithm for the reconstruction of
hypospadias. A tried-and-true approach is to start each repair Tre at me nt o f Po st e rio r Hyp o sp ad ias
by preserving the urethral plate, dissecting the skin to the pe-
nile scrotal junction, and assessing for the presence of penile The Ure t hral Plat e
curvature. If curvature is not present or is mild to moderate Duckett has popularized the concept of preservation of the
and amenable to dorsal plications, then a one-stage approach urethral plate, which is now standard practice for anterior as
is typically successful. The specific repair is now dependent on well as more severe posterior hypospadias surgery (7,8). The
the meatal configuration and the surgeon’s preference (1). urethral plate serves as the dorsal urethral wall, and the ven-
tral urethra is created by a vascular onlay flap of tissue from
Me at al Ad vance me nt and Glanulo p last y the inner prepuce. Extensive experience has shown that the
The hypospadiac penis that is amenable to meatal advance- urethral plate is rarely the cause of penile curvature. The con-
ment and glanuloplasty (M AGPI technique) is characterized cept of preserving the urethral plate yet undermining the plate
by a dorsal web of tissue within the glans that deflects the and exposing the corporal bodies with the idea that chordee
FIGURE 109.3 M eatal advancement

with glanduloplasty (M AGPI) proce-
dure. N ote the proximal location of the
initial circumcising incision in relation
to the urethral meatus (A). The dorsal
meatotomy is as shown (B and C). The
glans is then detached from the lateral
margin of the corpus spongiosum and
the side of the corpora cavernosa (D).
The edge of the glans on either side that
will be approximated ventrally is identi-
fied (E). The triangle of skin between
these two points and the urethral mea-
tus is excised completely (F). Dissection
must stay right on the skin because the
urethra here is usually thin and easily
entered. Excising this skin allows expo-
sure of the glans tissue which can now
be reapproximated into a conical shape
to complete reconstruction with the
meatus in a terminal position (G and H).
tissue could be released has not held true. In fact, careful

anatomic studies have shown an extensive network of blood
vessels supplying the urethral plate in the hypospadiac penis,
and lifting of the urethral plate defeats the purpose of preser-
vation by violating this intricate blood supply (9). At present,
in the majority of cases of posterior hypospadias, including
perineal hypospadias, the urethral plate can be preserved and
a vascularized flap used in an onlay fashion. In the rare case
when the urethral plate needs to be resected, a two-stage tech-
nique can be employed (see below).
O nlay Island Flap

The blood supply to the hypospadias preputial tissue is reli-
able and easily delineated. The abundance of cutaneous tissue
on the dorsum of the penis is vascularized in a longitudinal
fashion. For posterior hypospadias, all cases are approached
by initially leaving the urethral plate intact. This includes patients
with and without penile curvature. This technique can be ap-
plied to penile shaft as well as scrotal and perineal hypospadias.
The intact dorsal plate essentially avoids complications of
proximal stricture, and the excellent blood supply has de-
creased the fistula rate to approximately 5% to 10% for all
cases of onlay island flap hypospadias repair (Fig. 109.6) (7).
Long-term results with the onlay island flap have been very
durable. For very severe hypospadias, the prepuce can be de-
signed in a horseshoe style to bridge extensive gaps.
Tw o -St ag e Hyp o sp ad ias Re p air

FIGURE 109.4 Glans approximation procedure (GAP) hypospadias An alternative approach for severe hypospadias is to transfer
technique. A: Initial incision. B: Exposure of the glans mesenchyme by the dorsal prepuce to the ventrum after correction of penile
de-epithelialization of tissue, which is critical for a two-layer glans curvature (Fig. 109.7). In severe cases the urethral plate may
closure, allowing for good support of the urethroplasty. C: need to be resected to correct chordee. Dermal grafting may
Tubularization of the neourethra, followed by glans closure. D: The
completed repair. (Reproduced with permission from Grossfeld J,
be required, and performing a urethroplasty on top of the
O ’N eill J, Coran A, Fonkalsrud, E. Pediatric Surgery, 6th ed. Elsevier, healing graft is not suggested. Byars flaps can be rotated
2006.) from the dorsum, setting up ventral coverage for subsequent
FIGURE 109.5 Tubularized, incised plate (TIP) urethroplasty. A: H orizontal line indicates circumscrib-
ing incision to deglove penis. Vertical lines show junction of urethral plate and ventral glans. B: Parallel
incisions separate urethral plate from glans. C: M idline incision of urethral plate from meatus to granu-
lar tip. D: Incision has widened and deepened the urethral plate. E: Plate tubularized over 6Fr stent.
Dorsal subcutaneous tissues are rotated ventrally to cover the repair. F: M idline closure of glans wing,
mucosa collar, and ventral shaft skin.
urethroplasty (10). The second stage is performed at least 6 the first stage. In the second stage excess buccal tissue is
months after the first stage. To facilitate the urethroplasty trimmed off the glans, setting up a two-layer glans closure.
within the glans, during the first stage dorsal skin is tucked The buccal mucosa is rolled into the new urethra and subcuta-
within the glans wings. Subcutaneous secondary coverage of neous tissue is used for secondary coverage.
the reconstructed urethra is performed to prevent fistula.
Bracka Buccal Tw o -St ag e Re p air Pe nile Curvat ure (Cho rd e e )

For patients with prior surgery or with severe hypospadias,
Bracka has described a buccal free graft two-stage repair (11). Correction of penile curvature has also evolved along with the
In the first stage the penis is straightened and the scarred ure- concept of preservation of the urethral plate. Based on
thra is discarded (Fig. 109.8). Buccal mucosa is harvested anatomic studies of the human fetal penis, a simpler approach
from either the check or lip and grafted to the prepared bed placing dorsal midline plication sutures in the nerve-free zone
(12). Extensive quilting of the graft is performed to prevent at 12:00 is now advocated (9). The midline dorsal plication
hematoma from lifting off the buccal mucosa. During the first avoids the need for mobilization of the neurovascular bundle
stage, glans wings are mobilized in preparation for the cre- (Fig. 109.9). The midline plication can be applied to mild and
ation of a slit-like meatus during the second stage. The sec- moderate to severe degrees of curvature. If more than two rows
ond-stage urethroplasty is undertaken at least 6 months after of plication sutures or greater than four permanent sutures are
A B C
FIGURE 109.6 O nlay island flap A: Penile hypospadias. B: Preservation of the urethral plate and rectan-
gular outline of the onlay flap. C: O nlay of preputial island flap onto urethral plate.
FIGURE 109.7 Two-stage repair. Stage 1: The unfolded foreskin is brought out to the tip of the incised and mobilized
glanular wings (B). Delicate sutures reapproximate the skin in the midline and fix the skin to the corpora cavernosa (C).
Stage 2: A sufficient strip of skin is outlined (A). Dissection of the shaft skin is lateral and away from the neourethra. Two
layers of inverting sutures are used to close the neourethra (B). If the prepuce has been positioned sufficiently distal at the
first stage, a normally positioned meatus with good ventral glandular support can be achieved (C). Any excess shaft skin is
excised, but the dartos layer is preserved (de-epithelialization) to drape across the neourethral suture line (D).
FIGURE 109.8 Schematic two-stage Bracka

buccal hypospadias repair. First stage: A:
Patient with a midshaft hypospadias and a
paucity of available skin after multiple previ-
ous hypospadias repairs. B: Resection of scar
tissue. C: M obilization of glans wings D:
Buccal free graft quilted into the resected
scar. Second stage after 6 months of healing.
E: Exposure of glans mesenchyme and trim-
ming of buccal graft for subsequent urethro-
plasty. F: Urethroplasty. G: Secondary
de-epithelialized pedicle coverage of the ure-
throplasty. H: Two-layer glansplasty and
completed repair. (Reproduced with permis-
sion from Grossfeld J, O ’N eill J, Coran A,
Fonkalsrud E. Pediatric Surgery, 6th ed.
Elsevier, 2006.)
may result in constipation and lead to straining and urine

leakage.
Bleeding is an infrequent problem. A compressive sand-
wich dressing will resolve the problem in all but the rare pa-
tient. In selected cases, give a broad-spectrum antibiotic such
as trimethoprim (Septra) or a cephalosporin, and continue it
for a few days after the tubing has been removed. Should post-
operative erections in older boys become a problem, use amyl
nitrate ampules or diazepam sedation to reduce them.
See the patient 6 weeks and 1 year after the repair. Re-evaluate
after potty training and at puberty to confirm patient satisfac-
tion and the absence of fistula, stenosis, diverticulum, recur-
rent chordee, and cosmetic issues.
O UTCO MES
Results today, cosmetically and functionally, are better than
those in the past. The use of a one-stage hypospadias repair at
an early age with a low complication rate encourages our cur-
FIGURE 109.9 M idline dorsal plication technique. In this technique,
plication sutures are placed in the tunica albuginea in the 12 o’clock rent positive outlook for this condition. Curvature correction
position, which is free of both nerves and vascular structures. This with the aid of an artificial erection is extremely important for
technique involves a minimum amount of manipulation to the penis. ensuring satisfactory sexual function. With the placement of
It is not necessary to incise into the corporeal body or extensively mo- the urinary meatus at the tip of the glans, the infertility poten-
bilize the fascia of Buck. A maximum of two rows of parallel plica-
tions at the 12 o’clock position can be placed for correction. tial has been improved unless the patient has other coexisting
testicular problems. Evidence shows that the neourethra
grows with the child, and subsequent repairs are seldom
necessary, then an alternative approach such as complete re- necessary.
section of the urethral plate and possible dermal grafting Early hypospadias repair with minimal hospitalization
should be considered. During artificial erection, if the chordee helps to avoid separation anxiety and castration fears. We can
cannot be corrected with your “ finger,” the midline dorsal pli- now counsel parents confidently that there is an excellent out-
cation is not advised. look for a good cosmetic, functional, and emotional result in
boys with all degrees of hypospadias.
Po st o p e rat ive Pro b le ms

Co mp licat io ns
Bladder spasms not only cause the child to move about in re-
sponse to pain, but also force urine through the repair. Give Complications occur after 10% to 30% of hypospadias opera-
analgesics and antispasmodics, such as oxybutynin (Ditropan). tions. These include meatal retraction, urethrocutaneous fistula
Recommend a suitable diet, because the antispasmodic regimen formation, meatal stenosis, urethral stricture, development of a
Chap t e r 110: Comp le te Primary Re p air for Exstrop hy 711
diverticulum (sometimes with hair, followed by stones), and preference. Preservation of the urethral plate creates the best
persistent chordee. O f these, strictures, fistulas, and urethral possible chance to recreate normal urethral anatomy by incor-
diverticula account for most of the late problems. These compli- porating the abortive spongiosum into the repair. M idline dor-
cations should be managed at least 6 months from the time of sal plication is safe and effective for the correction of penile
the initial surgery. curvature in the majority of patients (placing more than two
rows of sutures is a sign that another technique, such as der-
mal grafting, is indicated). In the small percentage of patients
PRACTICAL CO NCLUSIO NS who require resection of the urethral plate, a two-stage
approach is generally warranted. Vascularized pedicle onlay
H ypospadias should be repaired within the first year of life, flaps are successful in primary and redo hypospadias surgery.
preferably at 4 to 6 months of age. Pain control and catheters De-epithelialized vascular flaps should be used as a second
seem better tolerated and the baby’s lack of mobility simplifies layer for all urethroplasties. Patients with a paucity of skin
postoperative care. are best managed with the Bracka two-stage buccal repair.
A terminal slit-like meatus should be the goal, with or Coronal fistulas require a redo glansplasty.
without preservation of the foreskin, depending on parental Surgical volume correlates with successful outcomes.
References
1. Baskin LS, Ebbers M B. H ypospadias: anatomy, etiology, and technique. 8. Duckett JW. The current hype in hypospadiology. Br J Urol 1995; 76(Suppl 3):
J Pediatr Surg 2006;41(3):463–472. 1–7.
2. Baskin L, Duckett J, Lue T. Penile curvature. Urology 1996; 48(3): 347–356. 9. Baskin LS, Erol A, Li YW, et al. Anatomical studies of hypospadias. J Urol
3. Duckett J. M AGPI (meatal advancement and glanuloplasty): a procedure 1998;160(3, Pt 2):1108–1015.
for subcoronal hypospadias. Urol Clin N orth A m 1981;8:513–520. 10. Retik AB, Bauer SB, M andell J, et al. M anagement of severe hypospadias
4. Z aontz M R. The GAP (glans approximation procedure) for glanular/ with a two-stage repair. J Urol 1994;152(2, Pt 2):749–751.
coronal hypospadias. J Urol 1989;141(2):359–361. 11. Bracka A. H ypospadias repair: the two-stage alternative. Br J Urol 1995;
5. Snodgrass W. Tubularized, incised plate urethroplasty for distal hypospa- 76(Suppl 3):31–41.
dias. J Urol 1994;151(2):464–465. 12. Baskin LS, Duckett JW. Buccal mucosa grafts in hypospadias surgery.
6. Snodgrass WT, Koyle M A, Baskin LS, et al. Foreskin preservation in penile Br J Urol 1995;76(Suppl 3):23–30.
surgery. J Urol 2006;176(2):711–714.
7. Baskin LS, Duckett JW, Ueoka K, et al. Changing concepts of hypospadias
curvature lead to more onlay island flap procedures. J Urol 1994; 151(1):
191–196.
CHAPTER 110 ■ CO MPLETE PRIMARY

REPAIR FO R EXSTRO PHY
RICHARD W. GRADY
Bladder exstrophy is a congenital anomaly that has character-

istic external physical manifestations; the diagnosis of exstro- DIAGNO SIS
phy is usually made immediately after birth, although it can
be detected antenatally. The anterior portion of the bladder In some situations, the diagnosis may be made antenatally,
and/or urethra and abdominal wall structures are deficient, although many affected fetuses are not suspected to have
and the pubic symphysis is widely separated from the midline exstrophy before birth (1). In Gearhart’s review of 29 antena-
in the exstrophy anomalies (Fig. 110.1); the bladder and tal studies of 17 children born with exstrophy (2), only 3 were
urethra are herniated ventrally. The exstrophic defects are identified before delivery despite the presence of findings to
typically found in isolation; other organ systems are only suggest the diagnosis. Ultrasonography can reliably detect
infrequently affected. H owever, children with exstrophy typi- exstrophy before the twentieth week of gestation (2,3). The
cally have an anteriorly located anus. Female genital anatomy absence of the bladder is a hallmark of exstrophy.
is altered, with a more vertically oriented vaginal opening Ultrasonographic findings of exstrophy also include a semi-
after closure and a wider and shorter vagina than normal. The solid mass protruding from the abdominal wall, an absent
anterior component of the penis is also foreshortened in males bladder, a lower abdominal protrusion, an anteriorly dis-
compared to the general population. placed scrotum with a small phallus in male fetuses, normal
and secondary infection. In contrast, when these patients re-

ceive effective surgical and medical treatment, they can lead
productive, healthy lives with minimal morbidity from their
underlying urologic abnormality.
SURGICAL TECHNIQ UE
Primary goals for exstrophy reconstruction include preservation
of kidney function, urinary continence, low-pressure urinary
storage, volitional voiding, and functional and cosmetically
acceptable external genitalia. Secondary goals for reconstruction
include minimization of urinary tract infections, adequate pelvic
floor support, minimization of the risk for malignancy associ-
ated with the urinary tract, minimization of the risk for urinary
calculi, and adequate abdominal wall fascia.
Surgical reconstruction of exstrophy and epispadias repre-
sents one of the most significant challenges for physicians who
specialize in the urologic care of children. O ver the last 15
years, a novel surgical reconstructive approach has been devel-
oped for the exstrophy-epispadias complex. In the late 1980s
FIGURE 110.1 Initial dissection, inferior view. D ashed lines indicate
lines of dissection. N ote that the lines of dissection proceed around M itchell (6) devised an anatomic approach that integrated
the umbilicus and superior to it. The line of dissection also extends epispadias and exstrophy repair. This operation evolved out of
subcoronally around the ventral aspect of the penis. See Fig. 110.2 for a technique developed for the treatment of epispadias: the
another view of the initial lines of dissection. complete penile disassembly technique. By employing this
technique, the surgeon permits the tissue deformation in
exstrophy to return more closely to an anatomically normal
kidneys in association with a low-set umbilical cord, and an position. We have used this approach exclusively for the surgi-
abnormal iliac crest widening. cal treatment of newborns with exstrophy since 1990. This
Subtle findings such as low umbilical cord insertion and operation or its principles are also useful in some reoperative
the location of the genitalia will only be seen if the fetus is ex- repairs or delayed repairs for exstrophy.
amined in a sagittal alignment with the spine (4). Because
exstrophy affects the external genitalia, the diagnosis is easier
to make in males than in females. Iliac crest widening can Pre o p e rat ive Care
also be seen during the routine prenatal evaluation of the
lumbosacral spine that is performed to evaluate for After delivery, to reduce trauma to the bladder plate, the um-
myelomeningocele. The iliac angle will be about 110 degrees bilical cord should be ligated with silk suture rather than a
rather than the 90 degrees that is normally seen (4). Since plastic or metal clamp. A hydrated gel dressing may be used to
urine production is normal for these fetuses, amniotic fluid protect the exposed bladder from superficial trauma. This
levels should be normal. type of dressing is easy to use, keeps the bladder plate from be-
Prenatal diagnosis allows optimal perinatal management of coming desiccated, and stays in place to allow handling of the
these infants. The infants can be delivered near a pediatric infant with minimal risk of trauma to the bladder. Plastic
center equipped to treat babies with this unusual anomaly. O f wrap is an acceptable alternative. Dressings should be re-
equal importance, antenatal diagnosis also allows the parents placed daily, and the bladder should be irrigated with normal
the opportunity to discuss early management of the patient. saline with each diaper change. A humidified air incubator
The early counseling should include the expertise of a pedi- may also minimize bladder trauma.
atric urologist experienced in the treatment of bladder exstro- We routinely use intravenous antibiotic therapy in the pre-
phy. Patients with exstrophy can have a satisfactory long-term and postoperative period to decrease the risk for infection fol-
outcome and life expectancy with appropriate management. lowing reconstruction. We also perform preoperative ultra-
sonography to assess the kidneys and to establish a baseline
examination for later ultrasonographic studies. Preoperative
spinal sonographic examination should be considered if sacral
INDICATIO NS FO R SURGERY dimpling or other signs of spina bifida occulta are noted on
physical examination.
Exstrophy anomalies are nonlethal; children with exstrophy
can survive untreated into adulthood (5). H owever, significant
morbidity exists with these conditions if they are left untreated, O p e rat ive Co nsid e rat io ns
including total urinary incontinence, bladder and kidney
infections, skin breakdown, and tumor formation in the blad- Ideally, the primary exstrophy closure is performed in the
der plate. The surrounding skin around the exposed newborn period. We routinely use general inhalation anesthe-
exstrophic bladder is often inflamed secondary to urine con- sia. H owever, nitrous oxide should be avoided during primary
tact dermatitis, loss of skin integrity from constant wetness, closure as it may cause bowel distention, which decreases
surgical exposure during the operation and increases the risk planes in this location. We use tungsten fine-tip electrocautery
of wound dehiscence. Some advocate the use of nasogastric (Colorado tip) during this dissection to reduce blood loss. The
tube drainage to decrease abdominal distention in the postop- umbilical vessels may be ligated if necessary. We also incise the
erative period, but we do not routinely use it postoperatively. periumbilical skin circumferentially at this time. The umbili-
We do routinely place an epidural catheter to reduce the in- cus will be moved superiorly to a more anatomically normal
haled anesthetic requirement during the operation. Tunneling location and will be later used as the location to bring out the
the catheter may reduce the risk for infection if it is left in for suprapubic catheter (Figs. 110.3 and 110.4).
prolonged periods after surgery.
For patients older than 3 days or newborns with a wide pubic Pe nile / Ure t hral Disse ct io n
diastasis, we perform anterior iliac osteotomies. Osteotomies Traction sutures placed into each hemiglans of the penis aid in
assist closure and enhance anterior pelvic floor support, which dissection at this point in the operation (Fig. 110.2). The su-
may improve later urinary continence. tures will rotate to a parallel vertical orientation (Fig. 110.5)
Factors that appear to be important in the operative period because the corporal bodies will naturally rotate medially
include use of osteotomies in selected cases and for newborn after they are separated from the urethral wedge (urethral
closures 48 hours after birth to decrease the tension on the plate plus underlying corpora spongiosa). We begin the penile
repair, ureteral stenting and bladder drainage catheters placed dissection along the ventral aspect of the penis as a circumcis-
intraoperatively for use in the postoperative period to divert ing incision (see line of dissection in Fig. 110.1). This step pre-
urine, avoidance of abdominal distention, and use of intraop- cedes dissection of the urethral wedge from the corporal
erative antibiotics. bodies because it is easier to identify the plane of dissection
above the Buck fascia ventrally (Fig. 110.6). The Buck fascia is
deficient or absent around the corpus spongiosum; as the dis-
Co mp le t e Primary Re p air fo r Exst ro p hy section progresses medially to separate the urethra from the
Surg ical Te chniq ue : Bo ys corpora cavernosa, the plane shifts subtly from above the
Buck fascia to just above the tunica albuginea. It is important
After standard preparation of the surgical field, we place to recognize this. Failure to adjust the plane of dissection will
transversely oriented traction sutures into each of the carry the dissection into the corpus spongiosum; this will result
hemiglans of the penis. We then mark the lines of dissection in excessive, difficult-to-control bleeding during the deep ventral
(Figs. 110.1 and 110.2). Care is taken in marking these lines dissection of the urethral wedge from the corporal bodies.
to exclude dysplastic tissue at the edges of the exstrophic blad- Applying methylene blue or brilliant green to the urethra
der and bladder neck. This is particularly important at the can help identify the plane between urothelium and squamous
bladder neck, where dysplastic tissue left in the continuity epithelium. We routinely inject surrounding tissues with
may impair later bladder neck function. Following this, we 0.25% lidocaine and 1:200,00 U per mL epinephrine to im-
place 3.5Fr umbilical artery catheters into both ureters and prove hemostasis. This may assist the dissection. Shallow inci-
suture them in place with 5.0 chromic sutures. Bladder polyps sions are made laterally along the dorsal aspect of the urethra
are removed prior to beginning the dissection, since these will to begin the dissection (Fig. 110.7). Sharp dissection is re-
act as space-occupying lesions after the bladder is recon- quired to develop the plane between the urethral wedge and
structed (Fig. 110.2). Initial dissection begins superiorly and the corporal bodies. Careful dissection will preserve urethral
proceeds inferiorly to separate the bladder from the adjacent width and length. This is particularly important because the
skin and fascia, since it is usually easiest to identify tissue urethra is often too short to reach the glans penis once the
bladder has been moved into the pelvis.
Careful lateral dissection of the penile shaft skin and dartos
fascia from the corporal bodies will avoid damaging the later-
ally located neurovascular bundles on the corpora of the epis-
padic penis. The lateral dissection on the penis should be
superficial to the Buck fascia because of the lateral location of
the neurovascular bundles in the epispadic penis.
Co mp le t e Pe nile Disasse mb ly and De e p Disse ct io n

O nce a plane is established between the penis and the urethral
wedge (Fig. 110.8), the penis may be disassembled into three
components: (a) the right and (b) left corporal bodies with
their respective hemiglans and (c) the urethral wedge (urothe-
lium with underlying corpora spongiosa). This is done primar-
ily to provide exposure to the intersymphyseal band and to
allow adequate proximal dissection. We have found that the
easiest plane of dissection to completely isolate the corporal
bodies is proximal and ventral (Fig. 110.9). The plane of dis-
section should be carried out at the level of the tunica albug-
inea on the corpora. After a plane is established between the
urethral wedge and the corporal bodies, this dissection is car-
FIGURE 110.2 View of lines of dissection from above. The urethral ried distally to separate the three components from each other
dissection is carried along the lateral aspect of the urethral plate. (Fig. 110.10). Complete separation of the corporal bodies
FIGURE 110.3 The exposure for deep dissection is

optimal after complete separation of the corporal
bodies. It is crucial to adequately divide the inter-
symphyseal band (inset) to allow the bladder and
urethra to move posteriorly.
FIGURE 110.4 To adequately cover the penis dorsally,

Z -plasty incisions may be necessary. We also employ tack-
ing sutures dorsally (inset).
later be tubularized and placed ventral to the corporal bodies.

Paraexstrophy skin flaps should not be used with this tech-
nique because this maneuver will place the blood supply to the
distal urethra at risk. Because the bladder and urethra are
moved posteriorly in the pelvis as a unit (with a common
proximal blood supply), division of the urethral wedge is
counterintuitive to the intent of the repair. In some cases, a
male patient will be left with a hypospadias that will require
later surgical reconstruction. The urethra and corporal bodies
do not always have to be separated; occasionally the urethra is
long enough and the bladder mobile enough to preserve the
connection between them while still effectively carrying out
the deep pelvic dissection that is integral to this repair.
After separating the components distally, the urethral dis-
section is carried proximally to the bladder neck. Exposure to
the pelvic diaphragm is optimized by complete separation of
the urethra and corporal bodies (Fig. 110.10). This creates the
surgical exposure to perform the deep incision of the inter-
symphyseal band required to move the bladder and urethra
posteriorly. When dissecting the urethral wedge from the cor-
poral bodies medially, the dissection plane is on the tunica al-
buginea of the corpora cavernosa (Fig. 110.9). This medial
dissection should be carried down through the intersymphy-
seal band (the condensation of anterior pelvic fascia and liga-
ments) (Fig. 110.3 inset).
Deep incision of the intersymphyseal band posterior and
lateral to each side of the urethral wedge is absolutely neces-
sary to allow the bladder and bladder neck to achieve a poste-
FIGURE 110.5 The urethra and bladder are reapproximated in a rior position in the pelvis. This dissection should be carried
two-layer closure. until the pelvic floor musculature becomes visible. Failure to
adequately dissect the bladder and urethral wedge from these
surrounding structures will prevent posterior movement of the
increases exposure to the pelvic diaphragm for deep dissec- bladder in the pelvis and create anterior tension along the ure-
tion. The corporal bodies may be completely separated from thral plate.
each other because they exist on a separate blood supply (Figs.
110.9 and 110.10). It is important to keep the underlying cor-
pora spongiosa with the urethra; the blood supply to the ure- Primary Clo sure
thra is based on this corporal tissue, which should appear O nce the intersymphyseal band is adequately incised and
wedge-shaped after its dissection from the adjacent corpora the bladder and urethral wedge are adequately dissected
cavernosa. The urethral/corpora spongiosa component will from the surrounding tissues, the bladder and urethra can be
FIGURE 110.6 Ventral dissection is initiated most eas-

ily below the glans with a circumcising incision. The
dissection may be carried proximally.
FIGURE 110.7 The urethra is dissected from

the corporal bodies. This plane of dissection
is developed from both a ventral and lateral
perspective using sharp dissection.
reapproximated. This portion of the repair is straightforward closure with monofilament and braided absorbable suture
and anatomic. To provide urinary drainage, we place a supra- (Fig. 110.5). Because of the previous deep dissection, we can
pubic tube and bring it out through the umbilicus. We then position the tubularized urethra ventral to the corpora in a
perform a primary closure of the bladder using a three-layer tension-free fashion. If the urethra cannot be positioned ven-
closure with monofilament absorbable suture (i.e., M onocryl trally without creating tension, it is likely that a deeper incision
and Vicryl). The urethra is tubularized using a two-layer running is required into the intersymphyseal band and pelvic fascia.
FIGURE 110.8 Disassembly of the corporal bodies from the

urethra and corpora spongiosa (the urethral wedge) can
often be most easily begun at the position depicted here. The
dissection is carried distally to completely separate the glans
penis.
We reapproximate the pubic symphysis using two no. 1

polydioxanone interrupted sutures placed in a figure-of-eight
fashion. Knots are left anteriorly to prevent suture erosion
into the bladder neck (Fig. 110.11). The rectus fascia is reap-
proximated using an interrupted or running 2-0 polydiox-
anone suture (PDS). We also place interrupted 6-0 PDSs along
the dorsal aspect of the corporal bodies to reapproximate
them (Fig. 110.12). We provide penile skin coverage by using
either a primary dorsal closure or reversed Byars flaps if
needed. The skin covering the abdominal wall is reapproxi-
mated using a two-layer closure of absorbable monofilament
suture.
The corporal bodies will rotate medially with closure (Fig.
110.11). This rotation will assist in correcting the dorsal de-
flection and can be readily appreciated by observing the new
vertical lie of the previously horizontally placed glans traction
sutures. O ccasionally, significant discrepancies in the dorsal
and ventral lengths of the corpora will require dermal graft in-
sertion to correct chordee.
If there is adequate urethral length, the urethra may be
brought up to each hemiglans ventrally to create an ortho-
topic meatus (Fig. 110.12). We reconfigure the glans using in-
terrupted mattress PDSs followed by horizontal mattress
sutures of 7-0 monofilament suture to reapproximate the
glans epithelium. The neourethra is matured with 7-0 braided
polyglactin suture similar to our standard hypospadias repair.
When needed, we also perform glans tissue reduction to create
a conical-appearing glans and to eliminate the furrow between
FIGURE 110.9 Perineal view of complete disassembly. N otice depth the glans halves. Tacking sutures are placed ventrally and dor-
of dissection. sally to prevent penile shaft skin from riding over the corporal
bodies and “ burying” the penis (Figs. 110.4 and 110.13).
In our hands, the urethra lacks enough length to reach
the glans in about half the cases. In this situation we mature
the urethra along the ventral aspect of the penis to create a
hypospadias. This can be corrected at a later date as a second-
stage procedure (7). We often leave redundant shaft skin ven-
trally in these patients to assist in later penile reconstructive
procedures.
FIGURE 110.10 The urethra and corporal bodies

are separated distally to allow deep dissection of
the pelvic floor musculature.
FIGURE 110.11 After the bladder and urethra are recon-

structed, these structures will move posteriorly. The urethra
will assume a more normal anatomic position. The pubic
symphysis is reapproximated with two figure-of-eight
sutures.
FIGURE 110.12 The corporal bodies will rotate medially

so that the neurovascular bodies are located medially. The
suprapubic tube can be brought out through the umbilicus.
The umbilicus is moved superiorly to a more normal
anatomic location.
FIGURE 110.13 The ventral shaft skin is secured

to the base of the penis to prevent the penile shaft
skin from riding over the body of the penis. The
ureteral catheters are brought out through the
urethra.
The Primary Re p air Te chniq ue : Girls lateral dissection, the intersymphyseal band will be encoun-
tered and should be deeply incised to allow the urethra and
The principles of this single-stage technique are similar in boys bladder neck to move posteriorly. The posterior limit of the
and girls. After preoperative antibiotics are given, the patient dissection is reached when the pelvic floor musculature is ex-
is prepared and draped in a sterile field. We mark the planned posed and the bladder, bladder neck, and urethra can move
lines of incision (Fig. 110.14) with the bladder neck, urethra, into the pelvis without tension.
and vagina mobilized as a unit. We perform this dissection Following adequate dissection, the vagina, urethra, and
with a tungsten-tip electrocautery (Colorado tip) to minimize bladder neck are moved posteriorly using a Y-V plasty if the
tissue damage while achieving hemostasis. The appropriate vagina is anteriorly located (Fig. 110.16). The urethra is then
plane of dissection is found anteriorly along the medial aspect tubularized using a two-layer closure of absorbable suture.
of the glans clitoris and proceeds posteriorly along the lateral Prior to the urethral closure, we routinely place a suprapubic
aspect of the vaginal vault (Fig. 110.15). The vagina is mobi- tube to provide postoperative urine drainage. The pubic sym-
lized with the urethra and bladder neck. Dissection along the physis is reapproximated using two figure-of-eight no. 1
vaginal wall extends quite laterally. Placement of a hemostat PDSs (Fig. 110.17). O steotomies may be necessary when a
in the vaginal vault will help with retraction to identify the wide pubic diastasis prevents a low-tension reapproximation
plane of dissection. The urethra and bladder neck should not of the pubic symphysis or if the patient is older than 48 to
be dissected from the anterior vaginal wall, as this will com- 72 hours old. We use anterior iliac osteotomies in these situa-
promise the blood supply to the urethra. During the posterior tions. The rectus fascia can then be closed in the midline. We
Incision
Bladder Plate
Labia
Clitoral Body
Urethral Plate
Vagina
Anus
FIGURE 110.14 A: Schematic diagram of lines of incision for com-

plete primary repair of a female infant with bladder exstrophy.
This concept has been applied to the repair of female epispadias in
the adjacent photograph (B), demonstrating lines of incision for an
infant girl with epispadias. N ote the posterior extent of dissection to
allow movement of the vagina, bladder neck, and urethra as a unit
B posteriorly.
Plane of Cross Section Correction of Exstrophy Cross Section
Incision through
Perineal Membrane
Uterus
Bladder
Symphysis
Urethra
Clitoris
Vagina
Superior Transverse
Perineal Muscle
Anus
Perineal Membrane
Anus Vagina Labia
FIGURE 110.15 The plane of dissection lies adjacent to the urethra and vaginal vault (dashed lines in
upper right cross-sectional view ).
FIGURE 110.17 The pubic symphysis is reapproximated (arrow ).

With adequate dissection, the pubic symphysis can be reapproximated
FIGURE 110.16 The intersymphyseal band is incised laterally (w hite with minimal compressive effects on the urethra and bladder.
arrow s) to allow the urethra, bladder, and vaginal vault to move pos-
teriorly as a unit.
mature the neourethra with 5-0 Vicryl sutures and reapproxi-

mate the bifid clitoris by denuding the parts medially so that Ad junct ive Asp e ct o f Re p air
they fuse together after suturing with 7-0 M axon suture
(Fig. 110.18). The labia majora should be advanced posteri- Inguinal hernias are commonly associated with exstrophy in
orly to the perineum at this time as well. A Z -plasty skin clo- both male and female patients. The majority of these hernias
sure aids in skin closure. A simplified monsplasty technique occur indirectly. They arise as a consequence of enlarged inter-
described by Pippi-Salle et al. (8) provides a satisfactory aes- nal and external inguinal rings combined with compromised
thetic result to the introital area and can be applied at the fascial support and lack of obliquity of the inguinal canal. In a
time of the primary repair. review of patients from the Toronto Sick Children’s H ospital,
lightweight splint can be used in newborns when the child is out

of traction to maintain hip adduction. We have stopped using
Buck traction because spica casts are easier for the families to
care for at home. External fixation devices have also been used
with success (10). Fixator pins for these devices should be
cleaned several times a day to reduce the chance for infection.
Internal fixation may be necessary in older patients.
Because of the high incidence of vesicoureteral reflux, we
prescribe low-dose suppressive antibiotic therapy for all new-
borns after bladder closure. This is continued until the vesi-
coureteral reflux is corrected or resolves spontaneously. Some
surgeons perform neoureterocystotomies at the time of initial
closure. The success of this approach has not been reported.
Postoperative factors that appear to directly impact the
success of initial closure include postoperative immobilization,
FIGURE 110.18 Final reconstruction demonstrates apposition of the use of postoperative antibiotics, ureteral stenting catheters,
labia and clitoral bodies. Denuding the epithelium on the clitoris me- adequate postoperative pain management, avoidance of ab-
dially improves the cosmetic results postoperatively. dominal distention, adequate nutritional support, and secure
fixation of urinary drainage catheters.
56% of classic male exstrophy patients and 15% of classic

female exstrophy patients developed inguinal hernias over a O UTCO MES
10-year period (9). The authors recommended that these her-
nias be repaired at the time of primary bladder closure to pre- Co mp licat io ns
vent incarcerated hernias, which could affect up to 50% of
these patients in the first 2 years of life. Reinforcement of the Complications can occur with this form of exstrophy closure.
transversalis and internal oblique fascia during hernia repair The most commonly reported complication is urethrocuta-
decreases the incidence of later direct inguinal hernias. neous fistula formation (at the penopubic angle dorsally) in
Umbilical hernias, as a contiguous defect with the bladder males. These fistulas will often close spontaneously. They may
plate, also uniformly occur with exstrophy and are repaired at initially be managed conservatively by providing urinary di-
the time of the primary repair. version via catheter drainage. If the fistula does not close after
conservative management, the bladder and urethra should be
examined cystoscopically for the possibility of obstruction at
PO STO PERATIVE CARE the bladder neck or urethra.
O ther complications have been reported following a pri-
The patient must be immobilized to decrease lateral stresses mary reconstructive technique. These include atrophy of the
on the closure after the primary reconstructive procedure for corpora cavernosa and urethra. These complications can oc-
exstrophy. A number of options exist for this purpose. We cur if the blood supply to the corporal bodies or urethral
prefer to use a spica cast for 3 weeks to prevent external hip wedge is damaged during dissection or during closure (11).
rotation and to optimize pubic apposition, which can facilitate Similar complications have been described following the ini-
early discharge and home care (Fig. 110.19). Modified Buck tial stage of a staged reconstruction (12). In experienced
traction has been used by many groups with success. A posterior hands, such complications are unusual and underscore the im-
portance of involving surgeons experienced in the surgical
management of these patients in their care.
If a child develops chronic bladder and kidney infections
following exstrophy closure, he or she should be evaluated for
possible outlet obstruction. We routinely maintain our pa-
tients on suppressive antibiotic therapy because of the high
incidence of vesicoureteral reflux in this population.
Re sult s
Since 1989 we have performed this operation for 36 children
with the exstrophy-epispadias complex in a prospective fash-
ion. This series represents a treatment group who underwent
the CPRE technique to construct classic bladder exstrophy
(n 31) or proximal or female epispadias (n 5). Twenty-
three of these children underwent this operation in the first
48 hours of life. M ean follow-up for the original group of
FIGURE 110.19 Use of a spica cast postoperatively to immobilize the patients that we reported in 1999 is 85 months. M ean follow-
pelvis and prevent hip abduction. up for the entire series is 68 months.
Daytime continence with volitional voiding was achieved Borer et al. (15) at Boston Children’s H ospital have per-
in 77% of boys and girls 4 years old or older. Primary urinary formed detailed urodynamic studies for 23 children with
continence was achieved by 18% of boys and 36% of girls exstrophy who have been closed using the complete primary
without the need for bladder neck reconstruction. Compli- repair technique. In a comparison with patients closed using a
cations occurred in 13% of the children in the entire series; staged approach, these children demonstrated universal blad-
81% of the children demonstrated mild or no hydronephrosis der stability, bladder capacities within the expected range, and
following this operative technique (13). normal sphincter electromyogram (EM G) activity, suggesting
H ammouda (14) reported a series of 33 cases. They no neuromuscular compromise of the pelvic floor. Further,
achieved continence in 72% of the patients with minimal magnetic resonance imaging studies in this group suggest that
complications, mirroring the results at our institution. urinary control is improved as pelvic floor anatomy becomes
H ammouda (14) has also used the complete penile disassem- more normal in appearance (16).
bly technique for 42 patients with excellent functional results.
References
1. Skari H , et al. Consequences of prenatal ultrasound diagnosis: a prelimi- 9. H usmann DA, M cLorie GA, Churchill BM , et al. Inguinal pathology and
nary report on neonates with congenital malformations. Acta O bstet G ynecol its association with classical bladder exstrophy. J Pediatr Surg 1990;25(3):
Scand 1998;77(6):635–642. 332–334.
2. Gearhart JP, et al. Criteria for the prenatal diagnosis of classic bladder 10. Sponseller PD, et al. Anterior innominate osteotomy in repair of bladder
exstrophy. O bstet G ynecol 1995;85(6):961–964. exstrophy. J Bone Joint Surg A m 2001;83-A(2):184–193.
3. M irk P, Calisti A, Fileni A. Prenatal sonographic diagnosis of bladder ex- 11. Gearhart JP. Complete repair of bladder exstrophy in the newborn: compli-
trophy. J Ultrasound M ed 1986;5(5):291–293. cations and management. J Urol 2001;165(6, Pt 2):2431–2433.
4. Sanders R. Prenatal diagnosis of bladder and cloacal exstrophy and related 12. Gearhart J. Complete repair of bladder exstrophy in the newborn: compli-
conditions. In: Gearhart M J, ed. T he ex strophy-epispadias com plex : research cations and management. BJU Int 2000;85[Suppl 4]:74 (abstract 150).
concepts and clinical applications. N ew York: Kluwer Academic/Plenum 13. Shnorhavorian M , M itchell M , Redel M , et al. Long-term followup of
Publishers, 1999:5–8. complete primary repair of exstrophy: the Seattle experience. J Urol 2008;
5. O ’Kane H O , M egaw JM . Carcinoma in the exstrophic bladder. Br J Surg 180(4 Suppl):1615–1619; discussion 1619–1620.
1968;55(8):631–635. 14. H ammouda H M . Results of complete penile disassembly for epispadias
6. Grady RW, M itchell M E. Complete primary repair of exstrophy. J Urol repair in 42 patients. J Urol 2003;170(5):1963–1965; discussion 1965.
1999;162(4):1415–1420. 15. Borer JG, et al. Bladder growth and development after complete primary
7. El-Sherbiny M T, H afez AT. Complete repair of bladder exstrophy in boys: repair of bladder exstrophy in the newborn with comparison to staged
can hypospadias be avoided? Eur Urol 2005 47(5):691–694. approach. J Urol 2005;174(4, Pt2):1553–1557; discussion 1557–1558.
8. Cook AJ, Farhat WA, Cartwright LM , et al. Simplified mons plasty: a new 16. Gargollo PC, et al. Magnetic resonance imaging of pelvic musculoskeletal
technique to improve cosmesis in females with the exstrophy-epispadias and genitourinary anatomy in patients before and after complete primary re-
complex. J Urol 2005;173(6):2117–2120. pair of bladder exstrophy. J Urol 2005;174(4, Pt 2):1559–1566; discussion
1566.
CHAPTER 111 ■ BLADDER EXSTRO PHY

AND EPISPADIAS
THO MAS E. NO VAK AND JO HN P. GEARHART
Bladder exstrophy is a rare, severe congenital defect that assumptions were correct, his surgical efforts were not suc-
affects the lower urinary tract, genitalia, abdominal wall, and cessful (2). Early failures lead to an abandonment of interest
pelvis. The reported incidence ranges from 1:10,000 to in primary closure with a shift toward urinary diversion. In
1:50,000 live births, with boys being affected five to six times 1942, H ugh H ampton Young performed the first successful
more frequently than girls (1). Bladder exstrophy is usually an primary closure of a female exstrophy patient (3). Although
isolated defect, and in its classic form, associated chromoso- similar reports about continent, primary closures were pub-
mal abnormalities or defects of the central nervous system, lished in the same era, the numbers were small and most sur-
heart, and digestive tract are extremely uncommon. geons were not able to reproduce these favorable results. Both
Until the middle of the 19th century, bladder exstrophy Jeffs (4) and Cendron (5) published their description about
was treated primarily nonsurgically. Early forms of repair successful staged anatomic reconstruction in the mid-1970s,
focused on abdominal wall closure using skin flaps for partial and their pioneering work set the standard for the modern
reconstruction, leaving a fistula to attach a urinal for dryness. staged repair of exstrophy (M SRE). Grady and M itchell (6)
Trendelenburg recognized that pubic reapproximation would subsequently developed the complete primary repair of exstro-
not only prevent prolapse of the reconstructed bladder but phy (CPRE), in which the primary closure is combined with a
also be crucial to achieve continence. Although his theoretical complete penile disassembly and epispadias repair.
Chap t e r 111: Blad d e r Exstrop hy and Ep isp ad ias 723
While older techniques have evolved and alternative ap-

proaches have been developed, the primary objectives of mod- INDICATIO NS FO R SURGERY
ern exstrophy management remain consistent:
H istorically, some children with bladder exstrophy have sur-
1. Secure closure of the abdominal wall, pelvis, bladder, and vived without surgical reconstruction. As mentioned previously,
urethra the earliest attempts at treatment focused on providing a suit-
2. Reconstruction of a functional and cosmetically acceptable drainage apparatus that would help to manage chronic
able penis in the male and external genitalia in the female wetness and odor. Because of the rarity of the condition, it is
3. Urinary continence, preferably via urethral voiding, with unlikely that a prospective study will ever compare observation
preservation of renal function to reconstruction. The importance of treating this condition,
The complex embryology and genetics of exstrophy are however, can be inferred from several studies that have investi-
not well understood. A number of theories have been pro- gated the profound negative impact of urinary incontinence and
posed, which include premature rupture of the cloacal mem- sexual dysfunction on quality of life and social and psychologi-
brane, arrested mesenchymal ingrowth, and failure of cranial cal well-being (9,10). Furthermore, it is known that chronic ex-
yolk sac progression during development (1). In its classic posure of the exposed bladder mucosa to the environment
form, bladder exstrophy describes the condition in which an results in painful ulceration and metaplastic and ultimately neo-
exteriorized bladder template develops in association with a plastic changes (11). It seems reasonable to conclude that all
diastasis of the pubic symphysis. This pubic separation results children with exstrophy deserve surgical treatment and that
in characteristic genital and pelvic abnormalities. The pubic every attempt should be made to deliver this to even underpriv-
diastasis is found in association with foreshortened, externally ileged populations whose medical capabilities are deficient.
rotated anterior pubic rami and a wide pelvic inlet. The per-
ineum is short and broad and there is anterior displacement of
the anus. The appearance of the genitalia varies by gender. In ALTERNATIVE THERAPY
boys, the urethra lies in an epispadiac position, splayed open
on the dorsal surface of the corporal bodies. The pubic diasta- Urinary Dive rsio n
sis results in corporal shortening and severe dorsal chordee.
The testes are usually descended, but inguinal hernias are ex- A number of different urinary diversion techniques have been
tremely common (especially in boys). In girls, the pubic dias- used historically with success in the management of exstrophy/
tasis results in an absence of a mons pubis, with a bifid epispadias (12). Although incontinent conduits are rarely
clitoris and lateral displacement of the labia. Girls usually pre- indicated in contemporary pediatric practice, reconstructive
sent with a bifid clitoris and a short vagina that often has a urologists should be comfortable with their construction.
stenotic orifice. In isolated epispadias, which can be viewed as Ureterosigmoidostomy was the first successful continent diver-
the least severe form of exstrophy, the bladder is closed and sion performed in an exstrophy patient, and continence rates
covered by a normal abdominal wall, but the pubic separa- without the need for intermittent catheterization are very good
tion and genital abnormalities persist. Degrees of epispadias (13). The role of ureterosigmoidostomy has decreased with the
vary in a manner analogous to hypospadias from the very application of anatomic reconstructions, but it is still used in
proximal “ complete” epispadias in which the urethra is open some centers today. The M ainz II pouch is a modification of
through the bladder neck, to minor distal variants. A number the ureterosigmoidostomy that reconfigures the sigmoid into a
of other exstrophy variants have been described (7). theoretically lower-pressure reservoir, thereby promoting con-
tinence and renal preservation (12). Long-term concerns over
the potential for malignancy at the ureterocolonic anastomosis
DIAGNO SIS and renal deterioration are cause for ongoing postoperative
surveillance. Urinary diversion remains an important salvage
The definitive diagnosis of bladder exstrophy is made by approach in children who fail anatomic reconstruction.
recognition of the characteristic physical examination findings
at the time of birth. Diagnosis by prenatal ultrasound is becom-
ing more common with advances in sonographic techniques. Anat o mic Re co nst ruct io n
Ultrasound findings include an absence of bladder filling,
an anterior abdominal mass, a low-set umbilicus, abnormal The modern staged repair of exstrophy will be described in de-
widening of the iliac crests, and an anteriorly displaced scro- tail as performed at Johns H opkins. Alternate anatomic recon-
tum with a small phallus in male fetuses (8). The differential structions have been proposed and are used in some centers.
diagnoses include cloacal exstrophy, omphalocele, and gas- Grady and Mitchell developed the one-stage closure in the new-
troschisis. Children with a prenatal diagnosis of exstrophy born period, which combined primary closure of the bladder,
should be delivered at term via cesarean section. The principal urethra, abdomen, and pelvis with epispadias repair using the
implication of prenatal diagnosis of exstrophy is that most complete penile disassembly technique. Proponents of CPRE
parents will seek early counseling regarding the nature of the believe that this approach will promote bladder growth and
disease and will temporarily relocate, if necessary, to a center better continence outcomes by initiation of bladder cycling
with experience in exstrophy management. Some parents ulti- early on (6). Schrott (14) describes bladder closure, ureteral
mately decide to terminate their pregnancies. The regionaliza- reimplantation, epispadias repair, and bladder neck reconstruc-
tion of complex surgical care such as that required for tion in the newborn period, applying the same technique to
exstrophy patients is the subject of current debate and out- even older children without osteotomies. Primary newborn
comes research. exstrophy closure followed by subsequent combined bladder
neck reconstruction and epispadias repair has been described by brought together in the midline by medial rotation of the
Baka-Jakubiak (15). The combination of bladder closure with greater trochanters. However, if the pubic bones are 4 cm
modified Cantwell–Ransley epispadias repair has been reported apart or unable to be reapproximated without tension, os-
in a series of delayed and secondary exstrophy closures (16). teotomies are mandated to ensure a secure closure.
SURGICAL TECHNIQ UE O st e o t o my
Pre o p e rat ive Co nsid e rat io ns The bilateral anterior innominate and vertical iliac osteotomy
has been used in our institution because it has numerous ad-
A type and screen with baseline complete blood count and vantages over the posterior approach. The patient is placed in
coagulation studies should be obtained. A plain film of the a supine position, preparing and draping the lower body
pelvis allows for precise measurement of the pubic diastasis. A below the costal margins and placing soft absorbent gauze
baseline renal/bladder ultrasound is recommended to establish over the exposed bladder. The pelvis is exposed from the infe-
the presence of both units and for purposes of later com- rior wings inferiorly and the pectineal tubercle and posteriorly
parison. The use of cross-sectional imaging (computerized to the sacroiliac joints. The periosteum and sciatic notch are
tomography/magnetic resonance imaging) is investigational. carefully elevated and a Gigli saw is used to create a transverse
The umbilical cord should be ligated with a heavy silk suture. If innominate osteotomy exiting anteriorly at a point halfway
a plastic cord clamp was used initially, this should be changed between the anterosuperior and the anteroinferior spines
in order to prevent it from irritating the bladder mucosa. (Fig. 111.1). This osteotomy is created at a slightly more cra-
Likewise, the bladder template should be kept moist with peri- nial level than that described for a Salter osteotomy to allow
odic saline irrigation and covered with either a hydrated gel or placement of external fixator pins in the distal segments. Also,
Saran-type dressing. Petroleum-based gauze dressings are dis- the posterior ileum may be incised from the anterior approach
couraged as they may dry and denude the mucosa when rein an effort to correct the deformity more completely. This is
moved. Latex precautions are recommended as many of these important because anatomic studies have shown that the pos-
children will develop latex sensitivity or allergy later in life. terior portion of the pelvis is also externally rotated in patients
with exstrophy, and as patients age they lose the elasticity of
their sacroiliac ligaments. An osteotome is used to create a
Timing and St ag ing closing wedge osteotomy vertically and just lateral to the
sacroiliac joint. The posterior iliac cortex is kept intact and
Modern staged closure has defined strict criteria for the selection used as a hinge (Fig. 111.2). Two fixator pins are placed in
of patients suitable for this approach. The technique includes the inferior osteotomized segment and two pins are placed in the
early bladder, posterior urethral, and abdominal wall closure, wing of the ilium superiorly. Radiographs are obtained to con-
usually with pelvic osteotomy in the newborn period, subse- firm pin placement, soft tissues are closed, and the urologic
quently followed by an early epispadias repair at 6 months of procedure is performed. At the conclusion of the exstrophy
age after intramuscular testosterone stimulation. Around age 4 closure, external fixators are applied between the pins to hold
to 5 years a competent bladder neck is reconstructed along with the pelvis in a correct position.
bilateral ureteral reimplantation, when adequate bladder capac- Radiographs are taken 7 to 10 days postoperatively. If the
ity is reached and the child demonstrates the maturity necessary diastasis has not been completely reduced, the right and left
to participate in a postoperative voiding program (17). sides can be gradually approximated using the fixator bars
Successful initial bladder and posterior urethral closure is over several days. Light longitudinal Buck skin traction is used
the most important factor for achieving eventual urinary conti- to keep the legs still. The patient remains supine in traction for
nence and sufficient bladder capacity. The primary objective in approximately 4 weeks to prevent dislodgement of tubes and
initial, functional closure is to convert the bladder exstrophy destabilization of the pelvis. The external fixator is kept on for
into a complete epispadias with incontinence with balanced approximately 6 weeks, until adequate callus is seen at the site
posterior outlet resistance that preserves renal function but of osteotomy. The pins are removed under light sedation at the
stimulates bladder growth. The size and the functional capac- bedside. Postoperatively, newborns undergoing closure with-
ity of the detrusor muscle are ultimately the most important out osteotomy are immobilized in modified Bryant traction
determinants of success (18). In the presence of a small, fibrotic for 4 weeks with the hips in 90 degrees of flexion.
bladder template without elasticity or contractility, the opera- Staged pelvic closure in the setting of an extreme ( 8 cm)
tion should be deferred until adequate template growth has pubic diastasis has been described with good results in a series
taken place. If sufficient size is not reached 4 to 6 months after of children with both classic and cloacal exstrophy. In this ap-
birth, alternative options should be considered. Inguinal hernia proach, osteotomies are performed in conjunction with inter-
repairs should be considered early if the closure is delayed in fragmentary pin placement during the initial procedure. The
order to guard against incarceration during this time interval. pelvis is then gradually reduced under sedation at the bedside
The role of pelvic osteotomy performed at time of initial clo- over the next several weeks, and ultimately the pubis is secured
sure ensures a tension-free approximation of the bladder, poste- with an interpubic stainless steel plate that is placed at the time
rior urethra, and abdominal wall, placement of the urethra of bladder and urethral closure (19).
deep within the pelvic ring, enhancing bladder outlet resistance, The use of spica casting and mummy wrapping for immo-
and finally aligning the large pelvic floor muscles to support the bilization following exstrophy closure has been described. In
bladder neck. Usually, osteotomies are not needed in the patient our experience, these techniques are associated with higher
72 hours old with malleable pubic bones that are easily rates of complications and inferior surgical outcomes and are
Post. periosteum
& cortex remain
intact
Wedges
removed
FIGURE 111.1 Combined transverse

anterior innominate and anterior vertical
iliac osteotomies with pin placement and
preservation of the posterior periosteum
and cortex. (Drawings by Timothy Phelps
after Leon Schlossberg. ©2002 Brady
Urological Institute, with permission.)
not recommended (20). O kubadejo (21) reviewed the orthope- If the decision is made to transect the urethral groove, then
dic complications of exstrophy management in 624 patients from it is cut distal to the verumontanum with continuity main-
Johns H opkins: 26 complications were noted (4% ), of which tained between the thin, mucosa-like non–hair-bearing skin
four were identified as being specifically caused by traction. adjacent to the posterior urethra and bladder neck and the
skin and mucosa of the penile glans. Flaps in the area of thin
skin are subsequently moved distally and rotated to recon-
Blad d e r, Po st e rio r Ure t hral, and struct the urethral groove, resurfacing the penis dorsally.
Ab d o minal Wall Clo sure The corporal bodies are not brought together because later
Cantwell–Ransley epispadias repair requires the urethral plate
The various steps in primary bladder closure are illustrated in to be brought underneath the corporal bodies. If the urethral
Figure 111.2. A strip of mucosa 2 cm wide, extending from the plate is left in continuity, it must be mobilized up to the level
distal trigone to below the verumontanum in the boy and to the of the prostate to create as much urethral and penile length as
vaginal orifice in the girl, is outlined for prostatic and posterior possible. Apparent penile lengthening is achieved by exposing
urethral reconstruction (Fig. 111.2A). With the advent of the the corpora cavernosa bilaterally and freeing the corpora from
modified Cantwell–Ransley epispadias repair, the urethral plate their attachments to the suspensory ligaments. After the uro-
should not be incised unless the length of the urethral groove genital diaphragm is completely incised bilaterally, freeing the
from the verumontanum to the glans is so short that it interferes bladder neck and urethra well from the pubis, the mucosa and
with eventual penile length and produces dorsal angulation. In muscle of the bladder and the posterior urethra well onto the
this situation, the urethral groove is lengthened. Figures 111.2B penis are closed in the anterior midline (Fig. 111.2G). The re-
to 111.2D show marking of the incision from just above the sulting orifice should be easily passed by a 12Fr sound, creat-
umbilicus down around the junction of the bladder and the ing enough resistance to aid in bladder adaptation and prevent
para-exstrophy skin to the level of the urethral plate. The ap- prolapse but not too much to cause outlet resistance alter-
propriate plane is entered just above the umbilicus and a plane ing the upper tracts. A second layer is closed if possible
is established between the rectus fascia and the bladder (Fig. (Fig. 111.2H ). Bladder drainage is achieved using a suprapu-
111.2E,F). The umbilical vessels are doubly ligated and incised bic nonlatex M alecot catheter for 4 weeks. The urethra is not
and allowed to fall into the pelvis. The peritoneum is taken off stented to prevent necrosis. Ureteral stents are left in place for
the dome of the bladder, to be deeply placed into the pelvis at 10 to 14 days, until swelling goes down.
the time of closure. The plane is continued caudally down By applying gentle pressure over the greater trochanters
between the bladder and rectus fascia until the urogenital di- bilaterally, the pubic bones are approximated in the midline. A
aphragm fibers are encountered bilaterally. With electrocautery, horizontal mattress suture of no. 2 nylon is placed between
these urogenital diaphragm fibers between the bladder neck, the the fibrous cartilages of the pubic rami and tied anteriorly to
posterior urethra, and the pubic bone are taken sharply down the pubic closure to avoid the neourethra (Fig. 111.2I,J). A
to the levator hiatus in their entirety (Fig. 111.2F). A double- second stitch is placed caudal to the insertion of the rectus fas-
pronged skin hook can be inserted into the pelvic bone and cia if possible for added support. Should the sutures work
pulled laterally to accentuate the urogenital diaphragm fibers. If loose or cut through the tissues during subsequent healing, the
this maneuver is not performed adequately, the vesicourethral anterior placement of the knot of the horizontal mattress
unit will be brought anteriorly with pelvic closure in an unsatis- suture ensures that it will not erode through into the urethra.
factory position for later reconstruction. A V-shaped flap of abdominal skin at a point corresponding to
UMB G H
A
B
Ureteral Skin incision
orifices and closure Umbilicus
Urethral
plate
1st layer
Ureteral closure 2nd layer
Hemi- orifices closure
clitoris Mucosal
VAG line of
closure
Ejaculatory
duct
Closure of
C D rectus fascia
Development
of retropubic
space
Bladder
attachments
incised
Urachus
Bladder J
Ejaculatory suspensory Approximation
duct ligaments Ejaculatory of sym
cut duct Catheter pubis
removed
Reminant
of
Suspensory
Ligament
E F
Sub-periosteal
detachment Umbilical
of crus tissue
incised
FIGURE 111.2 Steps in primary closure of the posterior urethra, blad-

der, and abdominal wall in the newborn patient. A–D: The incision line
around the umbilicus and bladder down to the urethral plate. C and D:
Rectus m.
Development of the retropubic space from below the area of the umbili-
cal insertion to facilitate separation of the bladder from the rectus
Outward
Urogenital sheath and muscle. E and F: M edial extension of the rectus muscle at-
reflection
diaphragm taching behind the prostate to the upper border of the urogenital di-
of pubic
(crus) aphragm, which together with the anterior corpus is freed from the
bone
incised pubis by deep incision. G and H: Ureteral stent placement and layered
closure of the bladder wall. I and J: A horizontal mattress suture is tied
on the external surface of the pubic symphysis and exit of the ureteral
Sym.
and suprapubic tube at the site of the neoumbilical opening. (Drawings
by Timothy Phelps after Leon Schlossberg. ©2002 Brady Urological
Institute, with permission.)
the normal position of the umbilicus is tacked down to the ab- maximal curvature, leaving a diamond-shaped defect (Fig.
dominal fascia, and the drainage tubes exit this neoumbilicus. 111.3E). The corpora are then closed over the neourethra
Postoperatively, before suprapubic tube removal the blad- with two running sutures of 5-0 polydioxanone (PDS), with
der outlet is calibrated to ensure free passage of urine. the adjacent areas of the diamond sutured to each other (Fig.
Repeated ultrasound examinations are obtained before dis- 111.3F). The now ventrally placed urethra is secured in place
charge and every 3 months to check for upper-tract dilatation with further 5-0 polyglycolic acid sutures between the cor-
and residual urine. Continuous, prophylactic antibiotic ther- pora, especially at the coronal level (Fig. 111.3G–I). The
apy is advised to prevent upper-tract infection from ureteral glans wings are subcuticularly closed with 5-0 and the glans
reflux. Yearly gravity cystograms under anesthesia are per- epithelium with 6-0 polyglycolic acid. Finally, the ventral
formed to receive quality information about reflux and, more skin is brought up and sutured to the ventral edge of the
importantly, bladder capacity. For successful continent proce- corona, while the flaps provide coverage of the dorsum. The
dures a minimal bladder capacity of 100 cc is needed (18). An skin as well as the Z -plasty at the base of the penis is re-
increase in bladder capacity is seen after epispadias repair, approximated with interrupted 5-0 or 6-0 polyglycolic acid
which is why the bladder neck procedure is performed after sutures (Fig. 111.3J,K). The silicon stent is secured and left
the urethral reconstruction. for 10 to 12 days.
In girls the mons and external genitalia are reconstructed at
the time of initial exstrophy closure. The bifid clitoris is
Ep isp ad ias Re p air denuded medially and brought together in the midline, along
with labia minora reconstruction, creating a fourchette.
Four key concerns have to be addressed: (a) a functional and Postoperatively it is critical to control pain and bladder
cosmetically pleasing penis, (b) correction of dorsal chordee, spasms to prevent urine extravasation and fistula formation.
(c) urethral reconstruction, and (d) penile skin closure and This is best achieved by preoperative placement of a caudal
glandular reconstruction. In patients undergoing delayed re- epidural catheter and the administration of anticholinergic
pair or reclosure, a combined epispadias/exstrophy closure us- medication. At the time of discharge, the postoperative plastic
ing the modified Cantwell–Ransley repair is possible. occlusive dressing is left intact and the patient is supplied with
The modified Cantwell–Ransley repair is begun by placing oral broad-spectrum antibiotics, pain medications, and anti-
a nylon suture through the ventral glans for traction. A meatal spasmodics.
advancement and glanuloplasty incorporated (M AGPI)
incision is made in the urethral plate distally and closed with
6-0 polyglycolic sutures in a transverse fashion to flatten the Co nt ine nce and Ant ire flux Pro ce d ure
distal urethral plate and advance the urethra to the tip of the
phallus (Fig. 111.3A). The reconstructed neourethra will be The bladder is opened through a transverse incision at the
in excellent glandular position once the wings are closed. bladder neck with a vertical incision (Fig. 111.4A). Figure
N ext, incisions are made over two parallel lines marked pre- 111.4 depicts a Cohen transtrigonal ureteral reimplantation
viously over the dorsum of the penis that outline an 18-mm- or a cephalotrigonal reimplantation for either moving the
wide strip of urethral mucosa extending from the prostatic ureter across the bladder above the trigone or, if the ureters
urethral meatus to the tip of the glans (Fig. 111.3A). are too low, moving them on the upper aspect of the trigone
Triangular mucosal areas of the dorsal gland are excised adja- (Fig. 111.4B). The modified Young–Dees–Leadbetter proce-
cent to the urethral strip, and thick glandular flaps are con- dure is begun by selecting a posterior strip of mucosa 15
structed bilaterally. Lateral skin flaps are mobilized and to 18 mm wide and 30 mm long that extends from the
undermined. midtrigone to the prostate or posterior urethra (Fig. 111.4C).
A Z -incision of the suprapubic area permits exposure The bladder muscle lateral to the mucosal strip is denuded of
and division of the suspensory ligament and old scar tissue mucosa and sponges, soaked in 1:200,000 epinephrine, and
from the initial exstrophy closure. The ventral skin is taken applied to control bleeding for better visualization. Tailoring
down to the level of the scrotum (Fig. 111.3B). Care is taken of the muscle triangles is aided by multiple small incisions on
to preserve the mesentery to the urethral plate, which arises the free edge bilaterally that allow the area of reconstruction
proximally and extends upward between the corpora as a to assume a more cephalic position (Fig. 111.4D). A trans-
blood supply to the urethral plate. The corpora are dissected verse, full-thickness muscular incision is not performed as de-
ventrally on the surface of the Buck fascia. The plane is fol- scribed in the original Young–Dees–Leadbetter procedure
lowed closely bilaterally until one exits on the dorsum of the because there is a significant risk of denervation and ischemia
penis between the corpora spongiosum and the corporal body for the bladder neck. The edges of the mucosa and underlying
(Fig. 111.3C). muscle are closed with interrupted sutures of 4-0 polyglycolic
After placement of loops, the urethral plate is dissected acid (Fig. 111.4E). The adjacent denuded muscle flaps are
just on the corporal bodies to the level of the prostate and overlapped and sutured firmly in place with a 3-0 polydiox-
the glans, respectively (Fig. 111.3D). Care is taken to leave anone to provide reinforcement of the bladder neck and ure-
the most distal 1-cm attachment of the mucosal plate to the thral reconstruction (Fig. 111.4F,G). Two or three of the
glans intact. The neurovascular bundles are dissected free overlapping sutures are left long, brought through the rectus
from the corporal bodies only if rotating the corpora over fascia, and tied as bladder suspension to elevate the bladder
the urethra does not straighten the penis. The urethral strip neck (Fig. 111.4G). An 8Fr urethral stent may be used during
is closed in a linear manner from the prostatic opening to the construction but is removed afterward. Exposure is essential
glans over an 8Fr silicone stent with 6-0 polyglycolic sutures. for the creation of a continent bladder neck. Therefore, if
Afterward, the corporal bodies are incised at the point of visualization of the posterior urethra is problematic, the
A B C
Urethral
meatus
Corporal
body
Urethral Corporal
groove bodies
NVB
Mesentery
to
Skin urethral
undermining plate UG
Glans
Prepuce
Glans
Scrotum
D E G H
Incision of
corporal Corporal
body body Urethra
F
Urethral
closure
Corporal
body
NVB
Urethra
J K
Corporal FIGURE 111.3 M odified Cantwell–Ransley epispadias repair. A:
bodies M arking the incision of the urethral groove and mobilizing of the
penile skin and vertical incision of the glans with the IPGAM maneu-
ver. B and C: Separation of the urethral plate from the corporal bod-
ies. D–F: M obilization of the neurovascular bodies from the corporal
bodies, followed by incision and closure with running sutures. G and
H: Closure of corporal bodies dorsally over the closed urethral plate
and burying of the urethra under the corporal bodies. Closure of the
glans over the closed urethral plate. I–K: The urethra beneath the cor-
poral bodies and the mesentery is coming from the foreskin. The ven-
tral foreskin is split and sewn to the corporal margin and to itself in
the midline. (Drawings by Timothy Phelps after Leon Schlossberg.
©2002 Brady Urological Institute, with permission.)
intrasymphyseal bar has to be cut and afterward

approximated with 0 PDS nylon sutures. In this case the child O UTCO MES
should be immobilized postoperatively.
The ureteral stents are removed after 10 to 12 days and the Co mp licat io ns
suprapubic catheter is clamped after 3 weeks, for no longer
than 1 hour for the first time. After residual-free voiding is Failure of the closure is marked by dehiscence, prolapse, or out-
achieved, the suprapubic catheter is removed. The patient is let obstruction. It is possible that these complications are under-
followed up with frequent bladder and renal ultrasounds in reported secondary to patients changing surgeons following an
the first few months. initially undesirable outcome. O steomy is recommended at the
Sites of
B potential
A
reimplants
Peritoneum
Rectus
fascia
Bladder
incised
Trigonium
Incision Sym.
line
C E F
Stenting
catheter
Mucosal
closure
Mucosal
strip Bladder
neck
reconstruction
D
G
Note: No
transverse
muscle incision
Wedges Demucosarized
removed, muscle
wall
elongated Suspension
sutures
FIGURE 111.4 M odified Young–Dees–Leadbetter bladder neck repair. A: Vertical bladder incision with
transverse extension distally. B and C: Ureteral mobilization for ureteral reimplantation. C–E: Use of
mucosal trigone strip to form the bladder neck and prostatic urethra. Lengthening of the denuded muscle
triangles by several incisions. N ote: N o transverse muscle incision. E–G: Double-breasted closure and
exact suture placement of the bladder neck reconstruction. The bladder neck and urethra are unstented at
the end of the operation. (Drawings by Timothy Phelps after Leon Schlossberg. ©2002 Brady Urological
Institute, with permission.)
time of secondary closure in all cases. O utlet obstruction may The incidence of urethrocutaneous fistulas following
develop early following removal of the urethral catheter. Cantwell-Ransley epispadias repair is 19% at 3 months (22).
Surveillance of residual volumes and upper-tract dilation with Some of these will close spontaneously. The majority, how-
ultrasound is important following removal of the urethral ever, will require operative repair as an outpatient procedure.
catheter and prior to removing the suprapubic tube. The devel- Residual chordee is a common indication for revision surgery,
opment of pyelonephritis is likewise a cause for evaluation of usually as an adolescent, prior to becoming sexually active.
the bladder outlet following primary closure. In some cases, cal- It is clear that the bladder needs time to adjust to the in-
ibration and temporary catheter replacement are sufficient. We creased resistance added by the reconstructed bladder neck.
prefer to calibrate under anesthesia with a cystoscope because Bladder spasms and detrusor instability are expected and
this allows for precise catheter placement if needed. should be treated with oral anticholinergics. The biggest
challenge of the child and the parents after bladder neck re- continence following CPRE without additional surgery at the
construction is the initiation of a voiding trial. If the child bladder neck. Comparable continence outcomes of children
cannot void, an 8Fr catheter is placed under anesthesia and undergoing CPRE with subsequent M itchell bladder neck re-
left in place for 5 days and the voiding trial is initiated again. pair have been recently reported (24). Like the M SRE, the re-
Ultimately, if the child is not dry for a period of 3 hours dur- sults of bladder neck repair following CPRE appear to be
ing the day within 12 months of the operation, the bladder related to a successful primary closure, and in one report this
neck reconstruction has failed. M ultiple options are avail- was highly associated with the use of osteotomy (17). There
able for these children to achieve future continence, but few are a number of options for salvage procedures in patients
will void through their urethra. who fail bladder neck repair. Ultimately, however, several se-
ries have reinforced the fact that very few of these children
will obtain continence with volitional voiding (27,28). Upper-
Re sult s tract dilation following exstrophy closure is common, as most
of these children have significant degrees of vesicoureteric re-
The success or failure of the initial closure is highly associated flux. Long-term poor renal outcomes are uncommon follow-
with long-term functional results. Bladders that dehisce or ing ureteral reimplantation at the time of continence surgery
prolapse and require repeat closure are not likely to grow and in the M SRE.
reach the capacity needed for bladder neck reconstruction. In It is important to differentiate between functional and cos-
a review of 23 patients with one or more failed closures, we metic outcomes of genitoplasty. Cosmetic outcomes rely on
found that only 6 children reached sufficient capacity for subjective patient interpretation. From a cosmetic standpoint,
bladder neck reconstruction, with a success rate of 50% (23). VanderBrink (29) recently reported a 92% esthetic satisfaction
The use of osteotomy in conjunction with pelvic and lower ex- rate in 65 male patients undergoing genitoplasty for exstro-
tremity fixation has produced the best success rates at our in- phy/epispadias. N ineteen revision procedures were required to
stitution and is recommended for all closures beyond the first obtain this outcome. The majority of these cases were treated
72 hours of life (i.e., delayed or secondary closures) (20). A re- with a Cantwell–Ransley technique. From a functional stand-
cent presentation of long-term outcomes from the Seattle point, prospective studies of sexually active adults are needed
Children’s experience with CPRE reported dehiscence in 2 of to ascertain this long-term outcome. N orth et al. (30) recently
41 patients closed primarily and during the newborn period reported International Inventory of Erectile Function (IIEF-
(24). In a comparable group of 194 primary M SRE closures at 15) and Female Sexual Function Inventory (FSFI) scores for a
Johns H opkins, 63 of which had simultaneous osteotomy, group of adult exstrophy males and females, respectively.
there were 4 failures (2 dehiscence and 2 prolapse) (25). When compared to controls, adult males with exstrophy re-
Interpretation of continence rates requires consideration for ported similar scores for erection, orgasm, desire, and satisfac-
the definition applied and the manner in which the child voids/ tion. Females, on the other hand, had poor sexual satisfaction
empties. The ultimate goal remains continence, day and night, and lower scores when compared to controls in all FSFI do-
with volitional voiding and stable renal function. Daytime dry mains. The reason for this gender dichotomy is not clear.
intervals vary in the literature from 1 to 3 hours. “ Social” con-
tinence refers to an adequate daytime dry interval with bedtime
wetness. The use of catheterizable stomas, with or without
bladder augmentation and additional outlet procedures such CO NCLUSIO N
as artificial urinary sphincters, slings, or bladder neck, should
likewise be noted when reviewing published continence rates. The modern treatment of bladder exstrophy can be quite suc-
Chan et al. (26) reported complete and social continence rates cessful in experienced hands. A successful initial closure can
of 77% and 91% , respectively, with urethral voiding follow- place the child on the road to eventual continence and voli-
ing bladder neck repair in children treated exclusively at Johns tional voiding, while failed closures are likely to result in a less
H opkins. Preoperative bladder capacity measured under anes- satisfactory outcome that often involves augmentation or con-
thesia appears to be the primary determinant of success in tinent diversion. These surgeries should be performed in
these patients. Patients with capacities 100 mL are good exstrophy centers if at all possible in order to give the child
candidates for modified Young–Dees–Leadbetter procedures born with this major birth defect the best chance at a good
(18). A small number of children have been reported to attain quality of life.
References
1. Gearhart J, M athews R. Exstrophy/epispadias. In: Cam pbell-Walsh 7. Lowentritt BH , Van Z ijl PS, Frimberger D, et al. Variants of the exstrophy
Urology 9th ed. Philadelphia: Saunders, 2007. complex: a single institution experience. J Urol 2005;173(5):1732–1737.
2. Trendelenburg F. The treatment of ectopia vesicae. A nn Surg 1906;44:981. 8. Gearhart JP, Ben-Chaim J, Jeffs RD, et al. Criteria for the prenatal diagno-
3. Young H . Exstrophy of the bladder: the first case in which a normal blad- sis of classic bladder exstrophy. O bstet G ynecol 1995;85(6):961–964.
der and urinary control have been obtained by plastic operations. Surg 9. Wilson CJ, Pistrang N , Woodhouse CR, et al. The psychosocial impact
G ynecol O bstet 1942;74:729. of bladder exstrophy in adolescence. J A dolesc H ealth 2007;41(5):
4. Jeffs RD. Functional closure of bladder exstrophy. Birth D efects O riginal 504–508.
A rticle Series 1977;13(5):171–173. 10. Diseth TH , Emblem R, Schultz A. M ental health, psychosocial functioning,
5. Cendron J. [Bladder reconstruction. M ethod derived from that of and quality of life in patients with bladder exstrophy and epispadias: an
Trendelenbourg]. A nn Chir Infant 1971;12(6):371–381. overview. World J Urol 1999;17(4):239–248.
6. Grady RW, M itchell M E. Complete primary repair of exstrophy. J Urol 11. N ovak TE, Lakshmanan Y, Frimberger D, et al. Polyps in the exstrophic
1999;162(4):1415–1420. bladder. A cause for concern? J Urol 2005;174(4 Pt 2):1522–1526.
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12. Cain M , M etcalfe P, Rink R. Urinary diversion. In: Docimo S, ed. Kelalis- 22. Surer I, Baker LA, Jeffs RD, et al. The modified Cantwell-Ransley repair
King-Belm an Tex tbook of Clinical Pediatric Urology. 5th ed. London: for exstrophy and epispadias: 10-year experience. J Urol 2000;164(3 Pt 2):
Informa, 2007:911–946. 1040–1042.
13. Stockle M , Becht E, Voges G, et al. Ureterosigmoidostomy: an outdated ap- 23. Gearhart JP, Ben-Chaim J, Sciortino C, et al. The multiple reoperative blad-
proach to bladder exstrophy? J Urol 1990;143(4):770–774. der exstrophy closure: what affects the potential of the bladder? Urology
14. Schrott K. Komplette einzeitige Aufbauplastik der Blasenekstrophie. In: 1996;47(2):240–243.
Schreiter F, ed. Plastisch-rek onstruk tive chirurgie in der urologie. Stuttgart: 24. Shnorhavorian M , Grady R, Andersen A, et al. Long-term follow-up of the
Georg Thieme-Verlag, 1999:430–438. complete repair of exstrophy: the Seattle Children’s experience. American
15. Baka-Jakubiak M . Combined bladder neck, urethral and penile reconstruc- Academy of Pediatrics N CE, San Francisco, 2007.
tion in boys with the exstrophy-epispadias complex. BJU Int 2000;86(4): 25. Schaeffer A, Purves T, King J, et al. Complications of primary newborn
513–518. closure of classic bladder exstrophy. American Academy of Pediatrics
16. Baird AD, M athews RI, Gearhart JP. The use of combined bladder and N CE, San Francisco, 2007.
epispadias repair in boys with classic bladder exstrophy: outcomes, compli- 26. Chan D, Jeffs RD, Gearhart JP. Determinants of continence in the blad-
cations and consequences. J Urol 2005;174(4 Pt 1):1421–1424. der exstrophy population: predictors of success? Urology 2001;57(4):
17. Gearhart JP, Baird A, N elson CP. Results of bladder neck reconstruction 774–777.
after newborn complete primary repair of exstrophy. J Urol 2007;178(4 27. Cervellione RM , Bianchi A, Fishwick J, et al. Salvage procedures to achieve
Pt 2):1619–1622. continence after failed bladder exstrophy repair. J Urol 2008;179(1):
18. Baird AD, N elson CP, Gearhart JP. M odern staged repair of bladder exstro- 304–306.
phy: a contemporary series. J Pediatr Urol 2007;3(4):311–315. 28. Burki T, H amid R, Duffy P, et al. Long-term followup of patients after redo
19. M athews R, Gearhart JP, Bhatnagar R, et al. Staged pelvic closure of ex- bladder neck reconstruction for bladder exstrophy complex. J Urol 2006;
treme pubic diastasis in the exstrophy-epispadias complex. J Urol 2006; 176(3):1138–1141.
176(5):2196–2198. 29. VanderBrink BA, Stock JA, H anna M K. Esthetic outcomes of genitoplasty
20. M eldrum KK, Baird AD, Gearhart JP. Pelvic and extremity immobilization in males born with bladder exstrophy and epispadias. J Urol 2007;178(4
after bladder exstrophy closure: complications and impact on success. Pt 2):1606–1610.
Urology 2003;62(6):1109–1113. 30. N orth A, N elson C, Gearhart J, et al. Patient-reported sexual and repro-
21. O kubadejo GO , Sponseller PD, Gearhart JP. Complications in orthopedic ductive function among adults born with classic bladder exstrophy.
management of exstrophy. J Pediatr O rthop 2003;23(4):522–528. American Academy of Pediatrics N CE, San Francisco, 2007.
CHAPTER 112 ■ CO NGENITAL ANO MALIES

O F THE SCRO TUM
SEAN T. CO RBETT AND DAVID R. RO TH
Isolated congenital anomalies of the scrotum, including inclu-

sion cysts, the bifid or hypoplastic scrotum, penoscrotal trans- INDICATIO NS FO R SURGERY
position, and webbed penis, are unusual. M ost often these
anomalies are found in association with other abnormalities: Timing of the surgical repair of urogenital anomalies is impor-
penoscrotal transposition and bifid scrotum with hypospa- tant with regard to feasibility of the surgery, safety of the
dias, bifid scrotum and scrotal ectopia with exstrophy, and surgery to the patient, and the psychological impact of the
scrotal hypoplasia with cryptorchidism. When these anom- anomaly and surgery. Because congenital scrotal anomalies do
alies occur in conjunction with other genital abnormalities, not interfere with urinary function, repair can be scheduled
the scrotum can be surgically repaired with excellent results at at the time that is most appropriate for the infant and most
the time of the procedure to correct the primary anomaly. It is convenient for parents and physicians. Technically, from the
important, however, that neonatal circumcision be avoided in surgeon’s point of view, there is little to be gained by delaying
boys with genital anomalies because the prepuce may be surgery beyond the child’s fourth to sixth month because by
required for reconstruction of the penis and its presence will that time the genitalia have developed to sufficient size for
allow greater flexibility for the surgeon. easy reconstruction. With optical magnification and the stan-
dardization of fine sutures, excellent results can be expected
even in the very young child. In addition to the degree of
DIAGNO SIS scrotal development, the safety of anesthetics has always
been a concern in determining the minimum age at which
The diagnosis of scrotal congenital anomalies is made by an operation seems appropriate. H owever, as a result of the
physical examination. Rarely do these anomalies occur as soli- proliferation of specially trained and dedicated pediatric anes-
tary lesions, and the patient should be appropriately evaluated thesiologists, the anesthetic complication rate has reached a
for associated anomalies. The physician should examine the nadir at approximately 3 months of age. To delay repair be-
scrotum for its relative position to the penis, rectum, and me- yond that time is no longer necessary in centers dedicated to
dian raphe. The appearance of the scrotum should be noted pediatric surgery.
with attention to symmetry and distribution of its rugations. Psychological concerns limit the opposite end of the time
The testes, penis, urethra, and rectum should be inspected to spectrum (1). The child’s anxiety concerning hospitaliza-
ensure that they are normal. tion, gender identity, and subsequent sexual development
must be considered. If genital surgery is performed before

the child is 18 months of age, he neither remembers the
surgery nor associates the experience with an abnormality
of his penis or scrotum. Therefore, a window (4 to 18
months) exists for surgery, limited on the younger side by
both anesthetic and technical concerns and on the older side
by memory and psychological issues. Parents need to deter-
mine a time during that 14-month period that is best for
their schedules. Because most of these surgical repairs re-
quire only external relocation of skin, they usually can be
performed on an outpatient basis and only rarely with a
hospital stay of a single night. A further consideration is
that it is easier for parents to care postoperatively for a boy
who is younger and not yet walking.
Certain technical points are relevant to all of these oper- FIGURE 112.1 A: In the moderately severe case of penoscrotal trans-
ations and warrant mentioning. For instance, optical magni- position, the phallus is circumscribed and freed of supporting tissue.
fication has proved to be very useful. Several companies An incision is made cephalad to the base of the phallus. B: The penis
now make loupes in powers of 2.5 to 4.5 that practition- can then be brought back through the new opening and the skin
sutured about it. The original opening is then sewn closed.
ers have found to be invaluable when performing delicate
surgery on the genitalia. Also helpful are the fine (6-0 to 8-
0) absorbable (plain, chromic) sutures, which are excellent
materials with which to repair a child’s scrotum. They do Pe no scro t al Transp o sit io n
not have to be removed and are absorbed quickly, so skin
tracks are unlikely to form. The use of tissue expanders for Various degrees of penoscrotal transposition exist, ranging
progressive skin dilatation, as in the cases of hypoplastic/ from the complete form, in which the scrotum is actually ante-
absent scrotum, has offered a viable alternative to myocuta- rior and cephalad to the base of the penis, to incomplete forms,
neous flaps, which often result in a poor cosmetic result in in which the penis emerges from the center of the scrotum, and
the pediatric population. Finally, prophylactic antibiotics the milder forms, in which only the superior edges of the scro-
are seldom necessary in uncomplicated cases with the prepu- tum lie anterior to the penis. For correction of the anomaly, the
bertal child. two hemiscrotums are mobilized, swept inferiorly and medi-
ally, and sutured together. It may be necessary to transpose the
penis cephalad to the scrotum. This can be achieved by using a
skin bridge (Fig. 112.1) or by dividing the abnormal scrotum in
ALTERNATIVE THERAPY its midline cephalad and caudal to the phallus and swinging
both halves below the penis (Fig. 112.2) (2). Some authors sug-
There are no alternatives to surgical correction of the congen-
gest leaving a segment of skin intact cephalad to the penis to
ital anomaly. O n the other hand, nontreatment is an option,
avoid jeopardizing the vascularity and lymphatic drainage of
and reconstructive surgery can be delayed until the boy can
the penile shaft skin. O ther authors advocate the creation of a
participate in the decision to proceed. The psychological
advantage of earlier surgery would need to be weighed against
the importance of allowing the youngster to be involved in the
decision-making process.
SURGICAL TECHNIQ UE
Bifid Scro t um
Isolated bifid scrotum is rare. When it occurs, the corpus
spongiosum appears to be continuous with a prominent me-
dian raphe of the scrotum, a fibrous band that separates and
divides the scrotum into two individual parts. Surgical re-
approximation of the two hemiscrotums can be achieved after
excision of the fibrous midline band. The underlying urethra
must be preserved and allowed to fall away from the dense
band. This requires mobilization of each hemiscrotum to the
extent that it can be elevated and moved medially to the mid-
line. Closure is accomplished in at least two layers. Deep ab-
sorbable sutures allow fixation and reconstruction of the FIGURE 112.2 A: In the more severe case of penoscrotal transposi-
tion, each hemiscrotum is circumscribed. B: O nce each side is freed to
midline. Fine absorbable sutures should be used to close the rotate caudally and medially the two portions are sewn together. Some
skin. In general, interrupted simple sutures are used, but a authors suggest leaving a bridge of skin cephalad to decrease the pos-
running subcuticular closure may also be utilized. sibility of a vascular insult.
Chap t e r 112: Cong e nital Anomalie s of the Scrotum 733
child (9). The ectopic scrotal tissue can be found on the inner
aspect of the thigh or caudal and inferior to the external in-
guinal ring. O ften, the ipsilateral testis can be found within
the ectopic tissue. Correction is accomplished by relocating
the ectopic tissue, by way of a flap or graft, or by utilizing the
normally positioned contralateral hemiscrotum as a reservoir
for both gonads and discarding the ectopic tissue (10). The
latter can be accomplished by stretching local tissue either pri-
marily or after pretreatment with parenteral testosterone
enanthate (2 mg/kg intramuscularly). The ectopic scrotal tis-
sue in that case can then be excised.
We b b e d Pe nis
In boys with a webbed penis, scrotal skin is tethered to the
ventrum of the penile shaft. This tethering produces a web of
FIGURE 112.3 A and B: In the mild case of penoscrotal transforma- skin stretching from the penis to the scrotal base. The webbed
tion, a V-shaped wedge of ectopic scrotal skin is excised. C: The defect penis causes no problem during childhood. H owever, as the
is then closed, thereby eliminating the ectopic scrotal skin. scrotal skin is hair-bearing, future intercourse could be diffi-
cult or uncomfortable. Therefore, a webbed penis should be
corrected during infancy. A modified circumcision can often
suprapubic buttonhole through which the penis can be deliv-
correct the defect. The circumcision incision is brought more
ered (3,4). For less severe cases of penoscrotal transposition,
distal than normal on the ventrum, thereby preserving all pe-
the wedge of ectopic scrotal skin is removed and the resultant
nile shaft skin possible in that location. After the inner
defect closed, thereby eliminating the problem (5). This
preputial skin is excised, the additional length on the ventrum
approach is most appropriate when there is incomplete mild
allows the scrotum to fall away from the glans and penis. If
penoscrotal transposition (Fig. 112.3). The penoscrotal angle
necessary, skin from the dorsum can be mobilized and swept
can be recreated by anchoring sutures applied to the underly-
ventrally to provide additional shaft skin (Fig. 112.4). A sec-
ing fascia and corresponding skin. Fixation of the penopubic
ond type of repair can be performed by incising the web trans-
angle can also be performed in a similar fashion. The anchor-
versely and closing it longitudinally, thereby separating the
ing sutures may have the additional benefit of stabilizing penile
penis from the median raphe of the scrotum. A circumcision
length (6,7).
should be considered at the same time because it facilitates the
approximation of the skin (Fig. 112.5).
In more severe cases of webbed penis, a U-shaped incision
Scro t al Hyp o p lasia is made about the phallus (11). This releases the penis from
Scrotal hypoplasia is almost always restricted to boys with the dependent scrotum. Flaps are developed to allow ventral
cryptorchidism. A limited course of androgen stimulation closure of the penis with fine absorbable sutures. The scrotum
(testosterone enanthate 2 mg/kg intramuscularly) will induce is closed in a side-to-side manner (Fig. 112.6). In a manner
scrotal development and enlargement in addition to increasing
penile length and glans circumference (8). This allows easier
surgical placement of either a testis or prosthesis in the poorly
developed scrotum at the time of inguinal surgery for the un-
descended testis. The hormonal treatment should be under-
taken only in conjunction with either an orchiopexy or
placement of a testicular prosthesis because the effects of the
testosterone are temporary; if the scrotum is not distended, it
may revert to its hypoplastic appearance. In severe cases of
scrotal hypoplasia or the rare case of congenital scrotal agene-
sis, tissue expanders may be used as another alternative where
there is inadequate space for the testis or prosthesis. The ex-
panders can be used to progressively dilate the scrotum to an
adequate size (3). Placement of a testicular prosthesis before
puberty is not routinely advocated as these children will out-
grow their prosthesis and need a larger size at a later date.
Scro t al Ect o p ia
FIGURE 112.4 In the mildly webbed penis, a modified circumcision
Although less common than either scrotal transposition or a may be all that is required. With the ventral incision made at the phi-
bifid scrotum and usually associated with cloacal exstrophy, motic band, the ventral skin can be repositioned to cover the penile
scrotal ectopia on occasion is found in the otherwise normal shaft appropriately.
FIGURE 112.6 A: In a severely webbed penis, an incision is made

between the penis and scrotum. B: Skin flaps are elevated in all direc-
tions so that the surgical defect can be closed. C: A two-layer closure
is used to stabilize and approximate the skin and underlying tissues.
FIGURE 112.5 In the moderately webbed penis, the defect can be

repaired by (A) transversely incising the web and (B) closing it longi- with an imperforate anus. Both are located in the median
tudinally. As in the mild cases, a modified circumcision incision with raphe and can be multiple. Because cysts can lead to calculi
preservation of all the ventral skin can be helpful in recovering the formation or infection, local excision should be considered.
penile shaft.
O UTCO MES
similar to cases of penoscrotal transposition, the penoscrotal
angle can be recreated by the placement of anchoring sutures Co mp licat io ns
securing the skin to the underlying fascia.
Complications from these surgeries are in general uncommon.
Superficial infections can be treated with antibiotics.
Scro t al Inclusio n Cyst s
M idline scrotal inclusion cysts are in general dermatoid in ori- Re sult s
gin and can be managed by local excision (12). H owever, care
must be taken not to confuse these with the sinus associated The cosmetic results of this surgery are usually excellent.
References
1. Schultz JP, Klykylo WM , Wacksman J. Timing of elective hypospadias re- 7. Casale AJ, Beck SD, Cain M P, et al. Concealed penis in childhood: a spec-
pair in children. Pediatrics 1996;97:590–594. trum of etiology and treatment. J Urol 1999;162:1165–1168.
2. Glenn JF, Anderson EE. Surgical correction of incomplete penoscrotal 8. Gearhart JP, Jeffs RD. Use of parenteral testosterone therapy in genital
transposition. J Urol 1973;110:603–605. reconstructive surgery. J Urol 1987;138:1077–1078.
3. Janoff DM , Skoog, SJ. Congenital scrotal agenesis: description of a rare 9. Lamm DL, Kaplan GW. Accessory and ectopic scrota. Urology 1977;9:
anomaly and management strategies. J Urol 2005;173:589–591. 149–153.
4. Kolligian M E, Franco I, Reda EF. Correction of penoscrotal transposition: 10. Spears T, Franco I, Reda EF, et al. Accessory and ectopic scrotum with
a novel approach. J Urol 2000;164:994–997. VATER association. Urology 1992;40:343–345.
5. Redman JF. The surgical correction of incomplete scrotal transposition 11. Perlmutter AD, Chamberlain JW. Webbed penis without chordee. J Urol
associated with hypospadias. J Urol 1983;129:565–567. 1972;107:320–321.
6. Borsellino A, Spagnoll A, Vallasciani S, et al. Surgical approach to 12. H amada Y, Sakiyama H , N akashima K, et al. M edian raphe cysts and
concealed penis: technical refinements and outcome. Urology 2007;69: canal of the penis. Eur Urol 1982;8:312–313.
1195–1198.
CHAPTER 113 ■ PEDIATRIC CRYPTO RCHIDISM,
HYDRO CELES, AND HERNIAS
KENNETH G. NEPPLE AND CHRISTO PHER S. CO O PER
Between 3% and 5% of full-term boys are born with an unde-

scended testicle. O ften associated with the undescended testi- CRYPTO RCHIDISM
cle is a patent process vaginalis that predisposes to hydrocele
and hernia formation. The urologist treating the infant with Cryptorchidism includes the strict definition of a hidden or
an undescended testicle must therefore be familiar with the nonpalpable testicle as well as a testicle that is undescended
anatomy (Fig. 113.1) and operative techniques employed in but palpable in the inguinal canal. True undescended testicles
treating this common condition. This familiarity assists with stop along the normal path of descent into the scrotum. They
orchiopexy and hydrocele and hernia repair. may remain in the abdominal cavity (least common), in the
FIGURE 113.1 Anatomy of inguinal orchiopexy. A: Relationship of the vas deferens, spermatic vessels,
and processus vaginalis to investing fascial layers. The transversalis fascia is contiguous with internal
spermatic fascia. B: With tension applied to the cord (arrow ), the orientation of the fibers of the interme-
diate stratum investing the retroperitoneal spermatic cord is changed so that fibers become parallel to
cord structures. Freeing the vas and vessels from this investing fascia is the most important step in achiev-
ing distal testicular displacement. (From H utcheson JC, Cooper CS, Snyder H M III. The anatomical ap-
proach to inguinal orchiopexy. J Urol 2000;164:1702–1704, with permission.)
735
inguinal canal (canalicular), or just outside the external ring There is controversy whether orchiopexy decreases the risk of
(suprascrotal, most common). Testes may also pass through malignancy, but placement of an undescended testicle in the
the external ring and then be located ectopically, most scrotum assists physical examination of the testis. Because his-
commonly in a superficial inguinal pouch. The incidence of tologic changes related to fertility occur in the undescended
undescended testicles increases from 3% to 5% in full-term testicle as young as 1 year of age and spontaneous descent
infants to 30% in premature infants. Low birth weight has rarely occurs after 6 months of age, the optimal time for surgi-
also been shown to be a predictor of cryptorchidism, indepen- cal correction is around 6 months of age.
dent of gestational age. M ost of these testicles descend within Almost 90% of undescended testes have an associated
the first 6 months of life, and by 1 year of age the prevalence patent processus vaginalis. If a patient with cryptorchidism
is 1% . The left testicle is affected more often, and 1% to 2% presents with an incarcerated or strangulated inguinal hernia,
of children with cryptorchidism will have both testicles repair at the time of presentation along with orchiopexy
affected. Twenty percent of boys who present with cryp- should be undertaken. O therwise, the hernia should be re-
torchidism have one nonpalpable testis. O f nonpalpable paired at the time of orchiopexy. O ccult inguinal hernia in
testes, 20% are intra-abdominal, 40% are canalicular, scrotal, patients with untreated undescended testis can present at any
or ectopic testes, and 40% are atrophic or absent. time with the typical symptoms or complications, including
incarceration.
Diag no sis
The diagnosis of cryptorchidism relies on the physical exami-
nation. Absence of an identifiable testicle with ultrasound, H ormonal therapy is an option in the treatment of cryp-
computed tomography, or magnetic resonance imaging does torchidism because the condition may be related to hypo-
not prove testicular agenesis and therefore does not alter the gonadotropic hypogonadism. H CG is the only hormone
need for surgical exploration. The testicular examination in approved for use in the treatment of cryptorchidism in the
the infant and young child requires two hands and patient United States. Side effects of administration of H CG include
relaxation. O ne hand is placed near the anterior superior iliac enlargement of the penis, growth of pubic hair, increased tes-
spine and the other on the scrotum. The first hand is swept ticular size, and aggressive behavior during administration.
from the anterior iliac spine along the inguinal canal to gently The likelihood of success with hormonal therapy is greatest
express any retained testicular tissue into the scrotum. Placing for the most distal undescended testes or for testes that have
soap on the fingertips of the palpating hand may improve the been previously descended (4). Some suggest that hormonal
sensitivity of palpation. A true undescended or ectopic in- therapy is effective only for retractile and not truly unde-
guinal testis may slide or “ pop” under the examiner’s fingers scended testes (5). Although hormonal therapy may not be
during this maneuver. A low ectopic or retractile testis will be effective in achieving testicular descent, it may improve fertil-
felt by the second hand as the testis is milked toward the scro- ity in cryptorchid boys (6).
tum by the first hand. To distinguish a retractile testicle, the
testicle is brought into the scrotal position; holding it in place
for at least 1 minute fatigues the cremaster muscle. After this Surg ical Te chniq ue
maneuver, a retractile testicle remains in the scrotum, whereas
an ectopic or undescended testis immediately springs out of Prior to any surgical intervention, the patient is re-examined
the scrotum. If a testis cannot be palpated in the inguinal canal while under anesthesia because on occasion a retractile testicle
or the scrotum, or in the typical ectopic sites, evaluation for a descends under anesthesia or a previously nonpalpable testicle
nonpalpable testis must be performed. becomes palpable. A bimanual examination with a finger in
A child with bilateral nonpalpable testes should undergo the rectum may permit detection of an intra-abdominal testi-
hormonal evaluation for testicular absence (1). Elevations in cle. For a palpable testicle an open inguinal approach is per-
luteinizing hormone (LH ) and follicle-stimulating hormone formed. For the nonpalpable testicle in a child a laparoscopic
(FSH ) and absence of detectable müllerian inhibiting substance approach is preferred, but an open inguinal approach may be
(M IS) suggest testicular absence (2). Testicular absence is con- performed.
firmed by a negative human chorionic gonadotropin (H CG)
stimulation test. The H CG stimulation test is performed by Ing uinal O rchio p e xy
the administration of intramuscular H CG (2,000 IU per day Preoperative antibiotics (cefazolin 25 mg/kg) are adminis-
for 3 to 4 days) (3). Raised gonadotropin levels (FSH and LH ) tered and operating loupes can be used for magnification. A
and a lack of a testosterone rise from H CG indicate bilateral 3- to 4-cm incision along the lines of Langer is made in a
absent testes and a formal surgical exploration is not neces- groin crease one third of the way between the pubic tubercle
sary. When one or both components are lacking or there is de- and the anterior superior iliac spine (Fig. 113.2). The inci-
tectable M IS, surgical exploration is warranted. sion is carried through subcutaneous fat and the fascia of
Scarpa to the level of the anterior aspect of the inguinal canal
using M etzenbaum scissors. O verlying fat and fascia are
Ind icat io ns fo r Surg e ry cleared off the external oblique fascia to its lateral shelf. An
ectopic testicle may be visualized exiting through the exter-
Treatment of the undescended testicle offers the possibility of nal ring. The external ring is visualized and the anterior as-
improved fertility, correction of patent processus vaginalis, pect of the inguinal canal is incised by nicking the fascia with
prevention of testis torsion, and improvement in body image. a scalpel blade. An incision placed too far medial makes cord
Chap t e r 113: Pe d iatric Cryp torchid ism, Hyd roce le s, and He rnias 737
FIGURE 113.3 Isolation of cord structures during orchiopexy.
fibers of the intermediate stratum attenuate and the structures

(vas, vessels, processus vaginalis) are enveloped by the internal
spermatic fascia, which is an extension of the transversalis fas-
cia from the floor of the inguinal canal. To free the remaining
anterior and medial retroperitoneal attachments to the sper-
FIGURE 113.2 Incision for left orchiopexy.
matic vessels and vas deferens, the internal spermatic fascia
must be divided, allowing separation of the processus and con-
identification more difficult, while an incision too far lateral tiguous peritoneum from the vas and vessels and complete ac-
makes fascia closure more difficult. M etzenbaum scissors cess to the retroperitoneum (Fig. 113.3).
with the tips facing upward are inserted into the nick and With a nonpatent processus vaginalis, a hemostat provid-
used to spread the adjacent tissue away while taking care to ing anterior traction on the tip of the peritoneal reflection
identify and protect the underlying ilioinguinal nerve. The permits dissection of the underlying cord from the internal
roof of the inguinal canal is then opened along the course of spermatic fascia binding it to the peritoneum. With a patent
its fibers downward toward and through the external ring. processes vaginalis, the posterior cord is exposed, the internal
The spermatic cord is identified and elevated and dissected spermatic fascia is swept off the cord structures, and the
free of the anterior cremaster fibers using blunt dissection processus vaginalis is freed to the level of the peritoneum.
and DeBakey forceps. If no cord structures are identified, at- The processus vaginalis is incised and the edges can be held
tention is turned to the level of the internal ring, and by ap- and the processus can be flattened and readily dissected from
plication of abdominal pressure and retraction in the internal the underlying cord. The processus is twisted and ligated at
ring frequently a testicle may be identified just inside the in- the level of the peritoneum with a 3-0 or 4-0 Vicryl suture.
ternal ring. If no testicle is identified, the peritoneum is The anterior and medial retroperitoneal attachments to the
opened and a search is made for either a testicle or a blind- cord may be approached by placing a retractor anterior to the
ending vas and vessels (see below). Blind-ending spermatic vessels in the internal ring, allowing the bands of the retroperi-
vessels must be identified to confirm absence of a testicle as a toneal fascia to be bluntly dissected from the vessels to obtain
blind-ending vas does not guarantee testicular absence. increased cord length. The beginning of the retroperitoneum is
After identification of the testicle and spermatic cord in the marked by the divergence of the vas medially and inferiorly.
canal, the gubernaculum is divided sharply after placement of The circumferential dissection of the vessels can be extended
4-0 Vicryl sutures. Placement of a hemostat on the proximal in the retroperitoneum up to the level of the renal hilum if the
end for traction provides a means of manipulating the testicle need arises to gain additional cord length so the testicle can
and cord structures safely. Care must be taken at this point to reach the scrotum without tension. True skeletonization of the
avoid a long-looped vas deferens that sometimes extends dis- vas and vessels should be avoided as this can lead to testicular
tally. Elevation of the cord permits blunt sweeping dissection atrophy. The limiting factor on length is most often the sper-
of the inferior cremaster fibers proximally to the level of the matic vessels rather than the vas deferens (Fig. 113.4). To gain
internal ring. By placing a retractor in the internal ring and additional length a Prentiss maneuver can be performed by us-
pulling the cord and attached peritoneum medially, the suring a right angle to puncture through the floor of the inguinal
geon gains access to the retroperitoneal space along the lateral canal near the pubic tubercle and then passing the testicle
aspect of the internal ring, which is enveloped in the en- directly under the transversalis fascia towards the scrotum, in
dopelvic fascia. The cord and peritoneum may then be swept effect moving the course of the vessels toward the midline
anterior and medial with blunt dissection in the retroperi- with alignment of the internal and external rings.
toneal space. With an absent testicle, blind-ending vas and vessels may
The intermediate stratum, an extension of connective tissue be encountered in the inguinal canal. The tubular structures in
that envelopes the spermatic vessels and vas deferens in the the canal must be traced proximally to the internal ring, where
retroperitoneum, is located between the inner striatum (connec- the divergence of the vas and vessels helps the surgeon posi-
tive tissue of the peritoneum) and the outer striatum (transver- tively identify the spermatic vessels. With identification of
salis fascia). As the vas joins the vessels in the inguinal canal, the blind-ending spermatic vessels, no further exploration for a
FIGURE 113.4 After dissection, adequate spermatic cord length is

demonstrated.
testis is indicated. H owever, a blind-ending vas deferens is not

sufficient reason to stop the exploration because there are
patients with a wide separation of the vas and an intra-
abdominal testis. When no spermatic cord structures are iden-
tified in the inguinal canal, the dissection is carried to the FIGURE 113.6 Incision for subdartos pouch.
internal ring and into the retroperitoneum. If no structures are
identified, the peritoneum is opened and the testicle or blind-
ending spermatic vessels are sought. Scro t al Fixat io n (Sub d art o s Po uch)
Repeat inguinal exploration for a failed orchiopexy is associ- Multiple methods have been described for fixing the testis to the
ated with scar tissue surrounding the testicle and spermatic cord scrotum, although the subdartos pouch is our preferred method
causing adherence to the underside of the external oblique fas- because it avoids transparenchymal sutures. Following a trans-
cia. Following the inguinal incision, the testicle should be identi- verse incision in the hemiscrotum (Fig. 113.6), a pocket for the
fied and freed from surrounding scar tissue. Once this is testicle is created by dissecting the scrotal skin superiorly and
accomplished, the cord can usually be freed along its posterior inferiorly from the adherent underlying dartos using Ragnell
aspect extending through the inguinal canal. No attempt is made orchiopexy scissors (Fig. 113.7). Care must be taken not to
to dissect the cord from the scar extending along its anterior sur- develop the pouch too lateral or too inferior because this could
face and the overlying external oblique fascia. By cutting the fas- result in an ectopic testis location. The testicle is exposed by
cia along the medial and lateral sides of the cord and then opening the tunica vaginalis. A testicular biopsy is not routinely
connecting these incisions above the internal oblique muscle, a indicated. O nce adequate cord length has been obtained, the
strip of fascia is left attached to the cord as described by testicle is passed down from the inguinal incision using a hemo-
Cartwright et al. (Fig. 113.5). The peritoneum may then be stat attached to the gubernaculum. The testicle is brought
opened and the spermatic vessels freed as described above. At through the dartos and placed in the pouch, taking care to
the peritoneal level there is rarely any significant scar tissue. avoid any torsion of the cord. For additional security, the inlet
FIGURE 113.5 Reoperative orchiopexy demonstrating external oblique fascial incisions lateral and
medial to the cord structure. The adherent scar tissue is dissected with the spermatic cord and no attempt
is made to dissect the spermatic cord from the scar. (From Cartwright PC, Velagapudi S, Snyder H M III,
et al. A surgical approach to reoperative orchiopexy. J Urol 1993;149:817–818, with permission.)
with interrupted 3-0 Vicryl suture, taking care not to close the
external ring too tightly, followed by closure of the subcuticular
tissue with 4-0 Vicryl and skin with absorbable suture. For
postoperative pain control, anesthesia can administer a caudal
block, or a local nerve block with 0.25% M arcaine can be per-
formed by the surgeon just prior to closure.
Transp e rit o ne al O rchio p e xy

O pen transperitoneal orchiopexy has been in large part re-
placed by laparoscopic exploration. In cases where an open
approach is undertaken, an incision is made transversely or
in the midline with subsequent intraperitoneal exploration.
The spermatic vessels may be dissected free from their at-
tachments cephalad to the level of their origin/insertion.
With intra-abdominal testicles, this dissection should leave a
broad leaf of peritoneum attached to the vas deferens along
the medial aspect in case transection of the spermatic vessels
is required (see below). A new external inguinal ring is cre-
ated lateral to the pubic tubercle to provide the most direct
route into the scrotum.
Despite a high retroperitoneal dissection, some testicles
may not reach a scrotal location due to short spermatic
FIGURE 113.7 Creation of dartos pouch using Ragnell orchiopexy vessels. O ften, these testicles can be identified after opening
scissors. the peritoneum by applying traction to the testicle and observ-
ing minimal caudal displacement and no redundancy in the
spermatic vessels. In this case the surgeon must consider either
into the pouch may be narrowed with a single polyglycolic acid
bringing the testicle down as low as possible, with an antici-
suture at a diameter less than that of the testis but not so nar-
pated reoperative orchiopexy in 6 to 12 months, or Fowler–
row as to compromise the blood supply of the testis. A small
Stephens orchiopexy, with transection of the spermatic vessels
portion of the parietal tunica vaginalis or spermatic cord adven-
with immediate or secondary orchiopexy. A Fowler–Stephens
titia is incorporated into this stitch for further fixation. The use
bleeding test involves occluding the spermatic vessels for
of an absorbable suture may heighten the inflammatory reac-
5 minutes with atraumatic bulldog clamps and then incising
tion around the testis and create a greater degree of scarring and
the tunica albuginea toward the testicular upper pole and
fixation. The scrotal skin is then closed with subcuticular su-
watching for testicular bleeding. If there is adequate bleeding
tures (Fig. 113.8). For the inguinal incision, the fascia is closed
a Fowler–Stephens orchiopexy is performed by ligating the
spermatic vessels while a broad-based medial pedicle of peri-
toneum and the vas deferens are mobilized. This procedure
relies on collateral blood flow to the testicle from the vas
deferential artery, a branch of the inferior vesical artery, and
cremasteric vessels, which branch off the inferior epigastric
artery. Spermatic vessel ligation should not be done for a
failed previous inguinal orchiopexy or when the vas has been
skeletonized during initial orchiopexy because the collateral
blood supply along the vas deferens will have been compro-
mised and is unreliable.
An alternative is the staged testicular vessel transection or-
chiopexy, which involves ligation at the initial stage without
mobilization to provide time for vasal collateral blood supply
development. After several months, at the second stage the
vessels are divided and the testicle is brought into a scrotal
location after a dissection similar to that described above. A
final option that is rarely utilized is testicular autotransplanta-
tion with anastomosis to the inferior epigastric artery and vein
by an experienced microvascular surgeon.
Scro t al O rchio p e xy
The high transscrotal incision for testicular mobilization in-
cluding ligation of an associated inguinal hernia through one
incision has been applied to primary and secondary cryp-
torchidism, although the increased technical difficulty of in-
guinal herniorrhaphy and concern for gaining adequate cord
FIGURE 113.8 Successful orchiopexy shows both testes in the scrotum. length through this approach have limited its popularity. The
scrotal approach may be especially suited to ectopic or

ascended testes, including those that have failed prior or- HYDRO CELE/ HERNIA
chiopexy. Bassel et al. (7) recently reported that scrotal incision
orchiopexy was highly successful in a select group of children A hydrocele consists of a collection of fluid in the tunica vagi-
with palpable undescended testis that can be brought down nalis around the testicle. In children this is almost always
following induction of anesthesia to the scrotum with caudal found in association with a patent processus vaginalis that
traction by the surgeon. The processus vaginalis is dissected permits flow of peritoneal fluid into the tunica vaginalis (com-
free of cord structures and, if patent, then high suture ligation municating hydrocele). An indirect inguinal hernia forms
is performed. An alternative procedure is a low scrotal inci- when bowel or any other tissue from the abdominal cavity
sion, with addition of an inguinal incision if a patent processus protrudes into the patent processus vaginalis. Between 0.8%
is encountered. A scrotal incision is made and blunt dissection and 4.4% of newborns and up to 30% of premature infants
is used to expose the processus vaginalis. The processus is have an inguinal hernia. Boys are six times more likely than
opened and then the testis is delivered. The processus is probed girls to have a hernia and right-sided hernias occur twice as
and, if patent, an inguinal incision is made. frequently as left-sided hernias, with bilateral hernias occur-
ring about 10% of the time.
O ut co me s Diag no sis
Co mp licat io ns Children with a hydrocele or hernia present with swelling in
Retraction is the most common complication of orchiopexy the groin and scrotum/labia. This swelling can be persistent
and usually occurs secondary to an incomplete initial dissec- or intermittent and may not be observed by the physician.
tion and tension on the testicle. It is possible that some cases O ften, it is noted by the parents only when the child is crying
of retracted testicle after an orchiopexy occur because of or straining and the intra-abdominal pressure is elevated. In
dislodgement of the testis from the scrotum. To prevent this this case, the diagnosis depends on a reliable history from
possibility, straddle toys are avoided for at least 3 weeks fol- the parents describing the intermittent groin and scrotal
lowing the operation. swelling. O lder children may be examined while standing
The most significant complication is testicular atrophy, and performing a Valsalva maneuver to increase the intra-
which occurs in 1% to 2% of cases of orchiopexy, while abdominal pressure. Rarely children will present with large
complete devascularization of the testis is rare. The dissection abdominoscrotal hydroceles that cross the internal inguinal
of the testicular vessels and/or postoperative swelling and ring and contain an intra-abdominal component resulting in
inflammation can result in ischemic injury with subsequent a palpable abdominal mass.
testicular atrophy. The failure rate with orchiopexy is 8% for With increasing size of the hydrocele, the testicle becomes
distal undescended testes and 26% for intra-abdominal more difficult to palpate and often is not palpable. Usually, a
undescended testes (8). O ther potential complications include hydrocele becomes narrow at the level of the internal ring and
ascent of the testis requiring reoperative orchiopexy, infec- the examiner is able to detect this narrowing and get above the
tion, bleeding, ilioinguinal nerve injury, or damage to the vas swelling. With a hernia, the swelling extends through the in-
deferens. ternal ring. The fluid in a hydrocele sac will transilluminate;
however, bowel can also be transilluminated, making this
a nonspecific finding for either a hydrocele or a hernia.
Re sult s
Ultrasonography may help define the testicle and rule out any
Successful therapy, as defined by a viable testis positioned in testicular pathology, as well as help differentiate a hydrocele
the scrotum, is dependent on the preoperative anatomic posi- from a hernia.
tion of the testis. Success rates are 74% for the abdominal
testis, 87% for canalicular, and 92% for those distal to the ex-
ternal ring. Success rates for various operative techniques are Ind icat io ns fo r Surg e ry
89% for the standard inguinal orchiopexy, 67% for
Fowler–Stephens, 77% for staged Fowler–Stephens, 81% for The majority of infant hydroceles resolve by 18 months of age
transabdominal, 73% for two-stage, and 84% for microvas- as the patent processus obliterates. If a hydrocele persists be-
cular (9). All of these results suggest an advantage to main- yond 18 months, then it is unlikely to undergo spontaneous
taining intact vessels where possible. resolution and surgical treatment is indicated. When the fluid
Paternity rates among men who had attempted to father in a hydrocele sac is easily reduced, it suggests the size of the
children were 65% , 90% , and 93% in men with bilateral patent processus vaginalis is larger than with a hydrocele that
cryptorchidism, unilateral cryptorchidism, and normally de- does not have easily reducible fluid. This examination finding
scended testicles, respectively (10). If only one testis is unde- and a history of waxing and waning size of the hydrocele may
scended, the sperm count will be subnormal in 25% to 33% serve as an indication for surgical correction before 18 months
and the serum FSH concentration will be slightly elevated (11, of age.
12). The presence of these abnormalities suggests that both A healthy child presenting with an incarcerated hernia
testes are abnormal, perhaps congenitally, although only one should undergo attempts at manually reducing the hernia.
fails to descend. If both testes are undescended, the sperm This may require sedation and placement of the child in the
count usually will be severely subnormal and the serum testos- Trendelenburg position. O nce the hernia is reduced, surgical
terone may be reduced (12). correction should be performed within the next several days
because an inguinal hernia will not resolve spontaneously and sac. As this is done, the cord structures are separated from
the child is at risk for repeat incarceration. If the hernia is not the hernia sac by passing a hemostat from lateral to medial
reducible, an emergent operation should be performed. Preterm and spreading at a 90-degree angle to separate cord from
infants with a reducible hernia may be observed during their hernia sac. When the cord structures are completely freed,
stay in the intensive care unit until they are thought to be med- the sac is transected and then dissected up to the internal in-
ically stable enough to undergo a surgical procedure. guinal ring. It is important to identify the internal spermatic
Because of the high incidence of a contralateral patent fascia and break this down so that when the sac is twisted
processus, some surgeons routinely explore the contralateral and ligated, the cord structures will not become incorpo-
groin during hernia surgery. We do not routinely explore the rated.
contralateral groin as there is only a 20% chance of develop- The hernia sac is twisted and high ligation is performed
ing a clinical contralateral hernia. Some physicians will per- with two 4-0 Vicryl sutures and divided close to the level of
form laparoscopy through the hernia sac and examine the the internal ring. The distal sac or hydrocele is then deliv-
contralateral inguinal ring to determine if a contralateral groin ered along with the testicle into the wound, and the sac is
exploration and hernia repair is required, and others will per- opened down to the level of the testicle, taking care not to
form a pneumoperitoneum and feel for crepitance in the con- injure the cord structures. The authors routinely evert and
tralateral groin as an indication to operate on this side. sew the hydrocele sac behind the cord or testis in a Bottle
technique with an absorbable suture to prevent the possible
reformation of the hydrocele. Repair of the dilated internal
Alt e rnat ive The rap y inguinal ring may be required and is accomplished by ap-
proximation of the transversalis fascia to itself at the level of
There are no alternative therapies. the internal ring, taking care not to strangulate the cord.
The conjoined tendon may also be sutured to the shelving
edge of the inguinal ligament. The testicle is then drawn
Surg ical Te chniq ue back into the scrotum with traction on the scrotal skin and
gubernaculum. The external oblique aponeurosis and wound
A similar inguinal incision is made for indirect hernias or are then closed with 3-0 Vicryl suture as described above.
communicating hydroceles as previously described in surgi-
cal technique of inguinal orchidopexy. After the inguinal
canal is opened, the cremaster fibers may be spread off the O ut co me s
anterior aspect of the spermatic cord. The bulging shiny
hernia sac or patent processus vaginalis, which is typically Co mp licat io ns
located anterior and medial, is identified and grasped with a Recurrence or persistence of the hernia or hydrocele may oc-
hemostat. By elevation of the hernia sac the cord is brought cur if the patent processus is not well ligated. Injury to the un-
up and freed from surrounding cremaster attachments, per- derlying spermatic and/or vas deferens vessels may result in
mitting the surgeon’s finger to be placed beneath the entire testicular atrophy. Displacement of the testicle to an ex-
spermatic cord and hernia sac. Extensive dissection of cre- trascrotal location may occur after surgery. To prevent this
masteric fibers need not be performed. The sac is teased off complication, every hydrocele and hernia repair should be
the underlying cord by breaking apart the internal sper- concluded by confirmation of the testis location in its normal
matic fascia that encases the cord structures and the hernia dependent scrotal position.
References
1. Jarow JP, Berkovitz GD, M igeon CJ, et al. Elevation of serum go- 7. Bassel YS, Scherz H C, Kirsch AJ. Scrotal incision orchiopexy for unde-
nadotropins establishes the diagnosis of anorchism in prepubertal boys scended testes with or without a patent processus vaginalis. J Urol 2007;
with bilateral cryptorchidism. J Urol 1986;136:277–279. 177:1516–1518.
2. Lee M M , Donahoe PK, Silverman BL, et al. M easurements of serum 8. Docimo SG. The results of surgical therapy for cryptorchidism: a literature
müllerian inhibiting substance in the evaluation of children with nonpalpa- review and analysis. J Urol 1995;154:1148–1152.
ble gonads. N Engl J M ed 1997;336:1480–1486. 9. H utcheson JC, Cooper CS, Snyder H M III. The anatomical approach to in-
3. Grant DB, Laurance BM , Atherden SM , et al. hCG stimulation test in children guinal orchiopexy. J Urol 2000;164:1702–1704.
with abnormal sexual development. Arch Dis Child 1976;51:596–601. 10. Lee PA, Coughlin M T. Fertility after bilateral cryptorchidism. Evaluation
4. Kaleva M , Arsalo A, Louhimo I, et al. Treatment with human chorionic by paternity, hormone, and semen data. H orm one R es 2001;55:28–32.
gonadotropin for cryptorchidism: clinical and histological effects. Int J 11. Lipshultz LI, Caminos-Torres R, Greenspan CS, et al. Testicular function
A ndrol 1996;19:293–298. after orchiopexy for unilaterally undescended testis. N Engl J M ed 1976;
5. Rajfer J, H andelsman DJ, Swerdloff RS, et al. H ormonal therapy of cryp- 295:15–18.
torchidism. A randomized, double-blind study comparing human chori- 12. Werder EA, Illig R, Torresani T, et al. Gonadal function in young adults
onic gonadotropin and gonadotropin-releasing hormone. N Engl J M ed after surgical treatment of cryptorchidism. Br M ed J 1976;4:1357–1359.
1986;314:466–470.
6. Demirbilek S, Atayurt H F, Celik N , et al. Does treatment with human
chorionic gonadotropin induce reversible changes in undescended testes in
boys? Pediatr Surg Int 1997;12:591–594.
CHAPTER 114 ■ LAPARO SCO PIC
MANAGEMENT O F THE UNDESCENDED
TESTICLE
DANIELLE D. SWEENEY, MICHAEL C. O ST, AND STEVEN G. DO CIMO
Cryptorchidism is defined as the absence of a testicle; one that resonance imaging or magnetic resonance angiography,
is not present in the scrotum, or one that cannot be manipu- herniorrhaphy, venography, and arteriography, has been shown
lated into the scrotum on physical examination. These testicles to have limited value in detection or localization of nonpalpable
may be truly absent, due to agenesis or intrauterine torsion, or testicles (5,6). Even when a good examination is not obtained in
more commonly, they may have not completed their normal the office setting, examination under anesthesia at the time of
path of descent into the scrotum. This condition is reported in surgical exploration is generally more cost-effective than preop-
3.4% to 5.8% of full-term boys, and the incidence decreases erative radiographic imaging (7). Surgical intervention, either
to about 1% at year one of life (1). Cryptorchidism is reported open or laparoscopic, has been the only modality proven to ac-
to be bilateral in 10% of cases (2). curately diagnose, localize, and concurrently treat the nonpal-
O f the boys diagnosed with cryptorchidism, as many as 20% pable testicle (7). H ormonal therapy has been used to promote
will have a nonpalpable testis (3). In this subset of patients, testi- testicular descent; however, this is best reserved for those with
cles may be absent, intra-abdominal, or within the inguinal bilateral nonpalpable testis and is unlikely to be cost-effective in
canal (canalicular). Prior to the 1970s, surgical management of those with unilateral cryptorchidism (8). In patients with bilat-
the nonpalpable testicle consisted of inguinal exploration with eral nonpalpable testicles and a phenotypically male appear-
extension of the dissection into the peritoneum if a testis, nub- ance, it is very important to rule out congenital adrenal
bin, or blind-ending vessels could not be identified. However, hyperplasia and other intersex conditions.
Cortesi (4) described using diagnostic laparoscopy for nonpalpa-
ble testis in 1976, revolutionizing the diagnosis and surgical
management of the undescended testicle. This technique has be- SURGICAL INTERVENTIO N
come the gold standard for the diagnosis of the intra-abdominal
testis, and in urology for its surgical management. Timing o f Surg e ry
O ptimal timing of surgery should be prior to the child’s sec-
PREO PERATIVE ASSESSMENT ond birthday, and ideally between 6 and 12 months of age,
since spontaneous testicular descent has been noted as late as
Upon the initial evaluation, a thorough history and physical 4 to 6 months of age. The overall goals of orchiopexy are to
examination must be obtained. Antenatal as well as maternal preserve testicular function and fertility, to relocate the testicle
history for the use of gestational steroids or hormones should to the scrotum for easier neoplasm examination, and to pre-
be elicited, as well as the birth history and physical examina- vent testicular torsion and trauma. In some cases, there is a
tion at the time of delivery. The presence of palpable gonads, psychological benefit of relocating the testicle to its anatomi-
hypospadias, genital surgery, or inguinal herniorrhaphy should cally correct position.
be noted, as well as a family history of cryptorchidism or other At birth, the undescended testis has been shown to have
urologic syndromes. normal histology; however, delayed germ cell development has
A careful physical examination in a nonthreatening, warm been described in the older infant, and this appears to be pro-
environment, with warm lubricant, is crucial to identifying a gressive over time. H istology correlates with testicular posi-
subtle but palpable testicle. In children with a referral to a uro- tion, with worse features seen in higher testicles.
logic specialist for an undescended testicle, approximately 80% Early surgical intervention has been shown to improve tes-
will have a palpable testicle on examination (5). Contralateral ticular growth (9) and adult Leydig cell function (10). In chil-
testicular size should be documented to assess for compensatory dren over the age of 2, the decision to perform an orchiopexy
hypertrophy in cases of nonpalpable or atrophic testis. versus orchiectomy is based on the risks and benefits of the
testicle to the individual. In prepubertal children the useful-
ness of androgen production must be considered, especially in
DIAGNO STIC ASSESSMENT cases of a solitary testicle. In postpubertal presentation of the
undescended testis, sperm are rarely noted (11) and the testes
In general, radiographic imaging in the evaluation of cryp- are at significant risk for malignant change, leading some
torchidism is not cost-effective or warranted. Radiologic test- authors to recommend orchiectomy in all healthy, postpuber-
ing, including inguinal/abdominal ultrasound, magnetic tal cryptorchid males under 50 years of age (12).
742
Chap t e r 114: Lap aroscop ic Manag e me nt of the Und e sce nd e d Te sticle 743
Jordan and Winslow (16) extended the technique to introduce

Diag no st ic Lap aro sco p y laparoscopic orchiopexy. Lindgren (17) reported a 93%
success rate in the treatment of 44 nonpalpable testes in 36 pa-
The indications for diagnostic and therapeutic laparoscopy
tients with no evidence of testicular atrophy. In a large multi-
are identical to the goals of open surgical management: to
institutional analysis, Baker et al. (18) reported excellent
determine if a testicle is present and viable, and if so, to relo-
success rates superior to that of historical open orchiopexy and
cate the testicle into the scrotum. H istorically, laparotomy was
no significant difference in success or complication rates be-
performed to localize an intra-abdominal testis or diagnose
tween low- and high-volume centers. When compared to open
blind-ending vessels if cord vessels were not observed on ini-
orchiopexy, laparoscopic orchiopexy is a successful approach
tial inguinal exploration. This was most often accomplished
with low risk in the management of the impalpable, unde-
with a high inguinal (i.e., Jones incision) or Pfannenstiel inci-
scended testicle.
sion. It is now standard practice at most centers to proceed
During diagnostic laparoscopy for nonpalpable testis, if a
with diagnostic laparoscopy when the testicle is nonpalpable.
testicle is present, it is evaluated for size and location. If the
Approximately 10% of boys with nonpalpable testis are found
testicle appears to be atrophic or grossly abnormal, then or-
at the time of diagnostic laparoscopy to have blind-ending
chiectomy should be considered. If the testicle appears rela-
vessels, indicating the absence of testicular tissue (7).
tively normal, the ability to mobilize it to the scrotum is
During diagnostic laparoscopy for the nonpalpable testis,
assessed, based on the distance of the testicle to the internal in-
there are three scenarios that may be encountered. If blind-
guinal ring and redundancy of the spermatic vessels.
ending vessels and vas deferens are present proximal to the
Deciding whether to perform a single-stage procedure leav-
internal ring, a vanishing testis is diagnosed and no further
ing the vessels intact or to perform a one- or two-stage
action is required. If the vessels and vas deferens are present and
Fowler–Stephens procedure has been challenging since no spe-
appear to enter the internal ring, then inguinal or scrotal explo-
cific set of criteria has been determined. As part of the decision-
ration is warranted. The final scenario includes the presence of
making process, intraoperative measurement of the distance
an intra-abdominal testis, which can be located in a variety of
between the testis and the internal ring, observation of the cord
positions. At this point the surgeon will need to assess which
anatomy, or assessment of the ability of the intra-abdominal
therapeutic modality is the most appropriate for treatment.
testicle to reach the opposite inguinal ring after dissection
Recent studies report blind-ending cord structures or an
can be helpful. Baker et al. (18) reported the incidence of tes-
intra-abdominal testis found during laparoscopic evaluation of
ticular atrophy after primary laparoscopic (2.2% ), one-stage
nonpalpable testis between 31% and 83% of the time (7,13).
Fowler–Stephens (22% ), and two-stage Fowler– Stephens
Barqawi et al. (13) reviewed 27 patients who had undergone
(10% ) orchiopexy. When counseling preoperatively, parents
previous negative inguinal exploration and reported that 67%
or guardians should be aware of the approximately 8% to
had a viable intra-abdominal or inguinal testicle. Cisek et al.
25% risk of testicular atrophy associated with performing an
(7) reported that laparoscopic findings precluded unnecessary
orchiopexy regardless of operative technique (14). Ultimate
abdominal exploration in 13% of cases and that the typical
“ success” of laparoscopic orchiopexy will therefore be mea-
surgical incision for inguinal exploration would have left the
sured by maintenance of the testicle in proper scrotal position
surgeon compromised in 66% of the cases. In many of these
without evidence of atrophy. Equally important is avoiding
patients, diagnostic laparoscopy can eliminate the need for fur-
the rare complications possible during this laparoscopic pro-
ther exploration or facilitate open or laparoscopic orchiopexy.
cedure. In light of this, it is critical to know the different steps
Ultimately, the decision to proceed with an inguinal or la-
that will maximize successful outcomes.
paroscopic abdominal exploration depends on the surgeon’s
confidence in the physical examination. H owever, the evidence Diag no st ic Lap aro sco p y Te chniq ue
clearly suggests that if an initial open inguinal exploration is
Prior to obtaining access, re-examination of the patient in an
inconclusive, laparoscopic exploration should be the next step
anesthetized state is essential. Approximately 18% of boys
in the diagnosis and treatment of the nonpalpable testis. O ur
with a previously nonpalpable testis will have a palpable testis
current protocol is to perform an examination under anesthe-
when examined under anesthesia (7). In the instance of a uni-
sia. If any tissue suggestive of a scrotal nubbin is felt, then open
lateral nonpalpable testicle, assessment of the size and length
scrotal exploration is performed. If this is negative or inconclu-
of the contralateral testicle may be helpful in predicting if the
sive, only then do we perform laparoscopic exploration.
intra-abdominal testicle is present. A contralateral palpable
testicle length exceeding 2 cm and an average volume exceed-
Lap aro sco p ic O rchio p e xy ing 2 cc for example, have been cited as being predictive of
monorchia in over 90% of cases (19), although not reliably
The driving force behind the success of laparoscopic or- enough to forgo exploration.
chiopexy has been the need to improve upon the technique of An open dialogue with the anesthesia team is essential.
open orchiopexy for the high undescended testis. In a meta- Inhaled N O 2 should be avoided in order to avoid bowel dis-
analysis of open orchiopexy techniques, Docimo (14) reported tention, and an oral gastric tube should be inserted to maxi-
success rates by type of procedure (inguinal 89% ; mize visualization in the abdomen. After induction of general
Fowler–Stephens 67% ; staged Fowler–Stephens 77% ; trans- anesthesia, the patient is secured to the bed in the supine po-
abdominal 81% ; two-stage 73% ; microvascular 84% ) and sition with his arms tucked, and the legs are placed in a
concluded that the high failure rates left significant room for slightly abducted position. The patient is secured to the bed
improvement. Bloom (15) started the era of therapeutic la- with wide tape at the level of the chest and low thigh. Care is
paroscopy with clip ligation of the spermatic vessels in prepa- taken to place the tape without tension over the chest and
ration for an open second-stage Fowler-Stephens orchiopexy. legs and not to restrict ventilation. Adequate space should
an additional 3- or 5-mm trocar on the contralateral side (lat-

eral to the rectus and just caudal to the umbilicus) is reserved
for the need of an additional working port or use of a 5-mm
clip applier. Clinical circumstances in which this would be nec-
essary include if an atrophic nubbin is to be excised, and if a
viable testicle is found far from the internal ring and a staged
Fowler-Stephens orchiopexy is to be performed.
In the case of a unilateral undescended testicle, the internal
ring of the descended testicle is examined first to gain an ap-
preciation of the anatomy. Possible findings on inspecting the
affected side of the “ nonpalpable” testicle may include blind-
ending vessels, cord structures entering the internal ring, or an
intra-abdominal testis. N ote the status of the processus vagi-
nalis: most undescended testicles are associated with a patent
processus.
Blind -End ing Te st icular Ve sse ls

Blind-ending gonad vessels indicate a “ vanishing” testicle.
This is the result of in utero testicular torsion that is either an
FIGURE 114.1 Preferred setup for a left single-stage laparoscopic intra-abdominal or intrascrotal event. Vessels will have a
orchiopexy. A 5-mm radial dilating trocar is placed at the umbilicus. “ horse tail” appearance; they diverge, do not exit the internal
Two 3-mm working ports are placed lateral to the rectus muscles just
inferior to the umbilicus. Care is taken to avoid injury to the epigastric ring, and do not supply obvious testicular tissue (Fig. 114.2).
vessels. In the event a larger port is needed to accommodate a clip If found during exploration, no further investigation is needed
applier, a 5-mm trocar would be used on the contralateral side to and the procedure is terminated. It is important to note that
ligate the testicular vessels. A 10-mm scrotal port is placed in the final the finding of a blind-ending vas deferens during laparoscopy
stage of the case when the mobilized intra-abdominal testicle is deliv-
is insufficient to conclude the absence of testicular tissue.
ered into the scrotum.
Further cephalad inspection toward the aortic origin of the
gonadal vessels is then necessary.
also be left for access to the scrotum. Securing the child to the
table permits Trendelenburg or laterally rolled positions. Co rd St ruct ure s Ent e ring t he Int e rnal Ring
When preparing and draping the patient, plan for an open Cord structures may be visualized entering a closed internal
procedure and drape accordingly. In the sterile field an appro- ring or a patent processes vaginalis (open ring) (Fig. 114.3).
priately sized Foley catheter is placed. Figure 114.1 demon- In the instance of a closed internal ring, a groin or scrotal ex-
strates the preferred setup and trocar placement for ploration may be performed (Fig. 114.4). If a patent proces-
performing a laparoscopic orchiopexy. sus vaginalis is present, the laparoscope may be used to
Access into the peritoneum is achieved in an open fashion inspect the inguinal canal antegrade. Alternatively, gentle
at the umbilicus. Blind access for pneumoperitoneum with a manual retrograde pressure can be placed over the inguinal
Veress needle or trocar is less commonly used in the pediatric canal in an attempt to push groin contents (viable testicle ver-
population as an overly compliant abdomen may increase the sus nubbin) intra-abdominally. In the instance of a nubbin or
risk of injury to intra-abdominal structures. It is our prefer-
ence to use the Bailez technique for open access (20), modified
to employ the use of a radially dilating trocar. In our current
technique a 2-0 Vicryl suture is placed in the umbilicus to pro-
vide continual anterior tension. A 3-mm hidden infraumbilical
incision is made in the skin and a scissor is then used at an ap-
proximately 15- to 20-degree angle cephalad to cut through A
the umbilical fascia into the underlying adherent peritoneum.
Alternatively, the rectus fascia and underlying peritoneum
may be entered sharply at 90 degrees under direct vision.
For the umbilical camera port, we utilize a 5-mm radially B
dilating trocar to accommodate a 5-mm camera with a 0-
degree lens. The child is placed in Trendelenburg position and
the abdomen is insufflated at 1 to 2 liters/minute to a pressure
of 10 to 12 cm H 2 O . A general survey of the abdomen is un-
dertaken, inspecting the underlying bowel for injury that might
have occurred during port placement. N ext, attention is
focused on the evaluation of the pelvis. If an instrument is
needed to aid in the inspection, a 3-mm port is placed on the
FIGURE 114.2 Finding blind-ending and divergent testicular vessels
ipsilateral side of the nonpalpable testis, lateral to the rectus (A) is evidence of a vanishing testicle. The sole finding of a blind-
and just caudal to the umbilicus. An atraumatic 3-mm instru- ending vas (B) is insufficient evidence to conclude that there is absence
ment may then be used to sweep bowel cephalad. Placement of of ipsilateral testicular tissue.
intrascrotal. Although an intra-abdominal testicle may remain

hormonally active indefinitely, spermatogenic potential tends
to decline after 18 months.
The initial measured distance of the testicle from the inter-
nal ring will determine which laparoscopic approach should be
utilized and is therefore a predictor of success rates. “ Peeping
testes” or those located in close proximity to the internal ring
( 2 cm away) can usually be mobilized into the scrotum in a
single stage without dividing the testicular vessels (Fig. 114.5).
It is important to counsel parents that intra-abdominal ectopic
testes and those located 2 cm from the internal ring are at in-
creased risk for surgical failure.
SINGLE-STAGE LAPARO SCO PIC

O RCHIO PEXY
FIGURE 114.3 Laparoscopic view of a left patent processus vaginalis
(hernia) with normal cord structures exiting the internal rings. Left In 1991, Bloom (15) reported using laparoscopy to ligate the
groin exploration revealed a high viable intracanalicular testicle.
Inguinal orchiopexy with hernia sac ligation was performed.
testicular vessels in the first stage of a Fowler-Stephens ap-
proach. Jordan and Winslow (16) further advanced the role of
laparoscopy as a therapeutic modality when they reported the
testicular remnant, laparoscopic orchiectomy is performed. first laparoscopic orchiopexy. There have been many subtle
This is accomplished by either clipping or dividing the cord variations described for performing this procedure (21).
contents or using a 5-mm instrument designed to seal and di-
vide smaller vessels (i.e., LigaSure or H armonic Scalpel). The
specimen is grasped and removed from the contralateral Est ab lishing a Pe rit o ne al Pe d icle Flap
5-mm port. This incision can be widened as needed by
spreading the fascia with any clamp while under direct vision Following abdominal access, insufflation, and additional tro-
from the camera port. car placement, as outlined above, attention is focused on the
ipsilateral testicle and internal ring. Figure 114.6 demonstrates
the surgical “ map” needed to mobilize a triangular flap of peri-
INTRA-ABDO MINAL TESTIS toneum demarcated by the testicular vessels laterally and vas
deferens medially. The preliminary goal is to create two contin-
There are three minimally invasive reconstructive options to uous peritoneotomies parallel to the testicular vessels and
address an intra-abdominal testicle: (i) primary laparoscopic- vas in order to mobilize the testicle on a well-vascularized
orchiopexy, (ii) one-stage laparoscopic Fowler–Stephens orc- peritoneal pedicle.
hiopexy, and (iii) two-stage laparoscopic Fowler–Stephens The testicle, epididymis, and extent of vasal descent dis-
orchiopexy. Laparoscopic orchiectomy is reserved for an tally into the inguinal canal are evaluated. It is critical from
intra-abdominal nonviable testis (atrophic nubbin) or a testis the onset to define the gubernacular attachments and iden-
that cannot be brought into the scrotum based on an extreme tify a long-looping vas, if present. Scissors are used in the
ectopic location (retrovesical, pararenal, pararectal), limiting preliminary dissection. Care must be taken not to activate
blood supply length. O lder children ( 10 years of age) found cautery in proximity to the vessels and vas. The first perito-
to have an intra-abdominal testis may be better served with a neotomy is made lateral to the testicular vessels at the most
laparoscopic orchiectomy, provided the contralateral testicle is proximal position. The incision is directed toward the internal
FIGURE 114.4 Bilateral closed

processus vaginalis with nor-
mal cord structures exiting the
internal rings. This morbidly
obese 8-year-old boy under-
went exploratory laparoscopy
for a “ nonpalpable” left testi-
cle. The findings on diagnostic
Left Right laparoscopy of cord structures
exiting the left internal ring
proceeded to a left groin explo-
ration. A high viable intra-
canalicular testicle was found
and open orchiopexy was per-
formed.
indication that dissection has maximized the flap length is that

the testicle can reach the contralateral internal ring without
tension. The ipsilateral ring is not closed since there is not an
increased risk for a clinically significant hernia to develop.
The patent processus is ablated by the peritoneal incisions,
division of the gubernacula, and, if necessary, incision of the
anterior peritoneum. Subsequently, peritoneal regrowth oblit-
erates the previously patent tract.
Cre at ing a Ne o ing uinal Hiat us and

Te st icular De live ry int o t he Scro t um
Various methods to deliver the testicle into the scrotum have
been described. It is our belief that the testis may be most
safely and effectively delivered to the scrotum using 2- or
3 mm instruments and a radially dilating trocar system (22).
FIGURE 114.5 Bilateral intra-abdominal “ peeping” testicles at the A 12-mm ipsilateral scrotal incision is first made and a sub-
internal rings in a 6-month-old with nonpalpable gonads. Bilateral
single-stage laparoscopic orchiopexies were performed. dartos pouch is created. A 2-mm laparoscopic grasper is
placed through the ipsilateral 3-mm lateral trocar directed to-
ward the scrotal incision. Care is taken to place the instru-
ring. O ften after the first incision, pneumoperitoneum will ment over the pubis and between the medial umbilical
diffuse into the plane between the peritoneum and pelvic side ligament and epigastric vessels. The surgeon’s free hand
wall. In this regard, CO 2 can aid in isolating the peritoneum should palpate the pubic area and scrotal incision to ensure
to be dissected. the instrument is being guided over the pubis and through the
The second line of dissection will again begin at the level of scrotal incision. After the instrument is passed through the
the internal ring distally but will parallel the vas medially. scrotum, the Foley catheter is checked for hematuria. A blad-
Care is taken not to injure the iliac vessels and ureter that lie der injury, which is very rare, would most likely occur during
beneath the vas. It is also critical that dissection is not per- this step of the procedure. Proper placement of the instru-
formed within the distal triangular area enclosed by the go- ment in the position described above should minimize the risk
nadal vessels and vas (Fig. 114.7). Critical collateral of this complication (Fig. 114.8). The step sheath is then
microvasculature within this flap will flow from the vasal passed onto the end of the 2- or 3-mm instrument ex vivo and
artery to the testicle and should be maintained if possible. This brought through the scrotum. The 5- or 10-mm trocar obtu-
is especially relevant if a single-stage Fowler–Stephens rator, depending on the size of the testicle, is then inserted,
orchiopexy is performed; dividing the testicular vessels and creating the neoinguinal hiatus. A locking grasper is intro-
interrupting collateral blood flow will invariably lead to testic- duced into the abdomen through the scrotal trocar and the
ular atrophy. Widely mobilizing the peritoneal flap laterally testicle is grasped at the gubernaculum and then delivered
and medially leaves only the distal gubernacular attachments. into the scrotum (Fig. 114.9). It is imperative for the surgeon
A window is created distally, allowing the gubernaculum to be to personally monitor the tension on the cord during scrotal
divided while visualizing the course of the vas deferens. An delivery so the vessels are not avulsed.
FIGURE 114.6 A left intra-abdominal testicle in an

8-month-old boy at the internal ring. The dark lines repre-
sent where peritoneotomies are made parallel to the testicu-
lar vessels (lateral) and vas deferens (medial) in order to
mobilize the testicle on a vascularized peritoneal pedicle flap.
The insert shows the same landmarks when an nonpalpable
intracanicular testicle is milked into the abdomen and then
mobilized via laparoscopic orchiopexy.
B
FIGURE 114.7 After lateral mobilization, medial dissection follows
the course of the vas deferens (A). Collateral paravasal blood supply
to the testicle is visualized. Cephalad traction following release of the
distal gubernacular attachments (B) demonstrates the extent of the
peritoneal flap and clarifies the boundaries where the neoinguinal hia-
tus is to be created between the inferior epigastric vessels and the me-
dial umbilical ligament.
FIGURE 114.8 During delivery of the testicle into the scrotum, the
bladder edge (arrow s) is at risk for perforation. The risk is increased if
Gaining Ad d it io nal Co rd Le ng t h and the neoinguinal hiatus is not created anterior to the pubis and lateral
to the medial umbilical ligament. Following delivery of the testicle me-
Se curing t he Te st icle dial to the ligament in a right laparoscopic orchiopexy, there was con-
cern that the bladder was perforated (A). Filling the bladder
After delivering the testicle into the scrotum, if there is tension demonstrated no evidence of a leak (B). After delivery of the testicle
and/or additional length is needed, further dissection can be through a 12-mm scrotal trocar in the final stage of a left laparoscopic
carried out laterally and cephalad toward the kidney. In most orchiopexy, there is little concern of a bladder injury. The neohiatus
was created in a plane lateral to the medial umbilical ligament and
instances the cord length will still be inadequate and addi-
medial to the epigastric vessels (C).
tional maneuvers are required. An option at this point is to di-
vide the peritoneum overlying the testicular vessels to provide
extra cord length and release any remaining tension (Fig. the higher risk of testicular atrophy after a one-stage Fowler–
114.10). If incising the peritoneum has not helped, considera- Stephens maneuver.
tion can be given to dividing the testicular vessels, therefore When the testicle lies tension-free in the scrotum, the
performing a one-stage Fowler–Stephens orchiopexy. The con- orchiopexy can be completed (Fig. 114.11). The testicle is har-
tralateral 3-mm port must be upsized to a 5-mm port in order nessed in the dartos pouch and the scrotal skin is closed by
to accommodate a clip applier. Consideration must be given to any of the preferred technique(s) utilized by the surgeon.
A B
C D
FIGURE 114.9 Delivering the testicle into the scrotum requires developing a neohiatus (A–C) to
facilitate passage of the testicle, epididymis, and cord structures into the scrotum without resistance. This
technique minimizes the risk of an avulsion injury (D).
A B
FIGURE 114.10 Delivering the testicle into the scrotum provides the traction and assistance of a “ third
arm.” If there is tension and/or additional length is needed, further dissection can be carried out laterally
and cephalad. The peritoneum overlying the testicular vessels (A) may also be divided (B) to release
tension and provide extra cord length.
Final fascial stitches are placed in the umbilical port, the skin
is closed, and dressings are applied.
SECO ND-STAGE
FO WLER–STEPHENS PRO CEDURE
As a general rule, the further the intra-abdominal testicle lies
from the internal ring (i.e., 2 cm) the higher the likelihood
that a staged procedure is necessary. Staging the procedure will
enable delivery of the testicle into the scrotum without tension
and at a decreased risk for atrophy. This may be accomplished
by ligating the testicular vessels by using a 5- mm stapler
through the contralateral port (Fig. 114.12). A laparoscopic
second-stage Fowler–Stephens orchiopexy will be performed
approximately 6 months later, when collateral blood flow from
the deferential artery has matured.
FIGURE 114.11 Antegrade view of a left neoinguinal hiatus cre-
ated between the inferior epigastric vessels (A) and the medial
umbilical ligament (B). The testicle is fixed to the scrotum after
maximal length on the cord has been reached without residual BILATERAL NO NPALPABLE
tension.
TESTES AND LAPARO SCO PIC
O RCHIO PEXY
Clo sure and Exit ing t he Ab d o me n Bilateral nonpalpable testicles in a newborn should raise the sus-
picion of an intersex condition, especially with coincidental gen-
The abdomen is surveyed a final time and the pneumoperi- ital ambiguity (i.e., proximal hypospadias). Other possibilities
toneum pressure is lowered. Any occult bleeding should be include bilateral anorchia or bilateral intra-abdominal testis. It is
identified and addressed at this time. While maintaining pneu- urgent to institute a workup to rule out life-threatening intersex
moperitoneum, the two lateral ports are removed sequentially conditions such as congenital adrenal hyperplasia (CAH). Once
and inspected for bleeding. The fascial layers of these trocar an intersex disorder has been excluded, endocrine studies, in-
sites are closed with 2-0 Vicryl sutures through the fascia. The cluding a human chorionic gonadotropin (hCG) stimulation test
laparoscopic view is maintained on the port sites during and or serum müllerian inhibitory substance (MIS), will be use-
closure to ensure that it is airtight and free of any intra- ful in differentiating anorchia from bilateral nonpalpable testis
abdominal contents (i.e., bowel or omentum). Through the (23). Regardless of such laboratory findings, however, ex-
umbilical port the pneumoperitoneum is evacuated. Larger ploratory laparoscopy will be needed for a gonadal biopsy, go-
tidal volumes given by the anesthesiologist and mild abdomi- nadectomy, or orchiopexy (Fig. 114.13). Bilateral laparoscopic
nal pressure help with the expulsion of CO 2 . The umbilical orchiopexies can be performed simultaneously or at separate
trocar and camera are removed while inspecting for bleeding. procedures, depending on perceived risk of atrophy.
FIGURE 114.12 A right intra-abdominal testicle in a 9-month-old boy was found 2 cm from the internal
ring. The testicular vessels were clipped in the first stage of a two-stage Fowler–Stephens reconstruction.
Note that clips are applied without dissecting the peritoneal attachments free from the vessels.
FIGURE 114.13 Eight-month-old XY phenotypic boy with bilateral unde-

scended testicle and müllerian inhibiting substance (M IS) deficiency. M IS hor-
mone level was 0.1 ng/mL (normal 48–83). Diagnostic laparoscopy revealed
bilateral intra-abdominal testicles (A) with müllerian (uterus) and wolffian (vas)
structures intimately associated (B). Left laparoscopic orchiopexy was per-
formed, aided by releasing the contralateral round ligament (C).
working space also sets up the potential for injury to the vis-
CO MPLICATIO NS ceral structures from the laparoscopic working elements.
For this reason, open peritoneal access has been associated
Complication rates in contemporary series of adult laparo- with fewer complications than when a Veress needle is used.
scopic procedures range from 12% to 16% (24). Although As previously mentioned, we prefer to gain access using an
the same issues reported in the adult literature are experi- open technique. Surgical planning and an appreciation for the
enced in children, there is little published information regard- anatomic landmarks within the pelvis will aid in avoiding
ing laparoscopic complication rates in the pediatric complications. During testicular mobilization, care must be
population, particularly in the urologic literature. H owever, taken to avoid injury to the vas, testicular, femoral, and iliac
the number of complications associated with laparoscopic or- vessels and the ureter. When mobilizing the vas on the medial
chiopexy compares quite favorably to that of an open ap- aspect of the peritoneal flap, these structures lie directly poste-
proach. In a large multi-institutional review, Baker et al. (18) rior and medial (Fig. 114.14). In general, complications can be
reported a major complication rate of 3.0% and a minor limited by careful intra-abdominal mobilization, using cautery
complication rate of 2.0% . M ajor complications that have in short bursts, and execution of meticulous technique. The la-
been reported include acute testicular atrophy, bowel perfora- paroscopic approach facilitates this by allowing extensive and
tion, cecal volvulus, vascular injury, bladder perforation, high retroperitoneal mobilization of the testicular vessels in an
ileus, laceration of the vas, testicular vessel avulsion, and atraumatic manner.
wound dehiscence/infection. Today the learning curve for pediatric laparoscopy is de-
The prevention of complications associated with creasing as trainees are entering the field with far more laparo-
laparoscopy starts with proper positioning and padding to scopic experience gained during general urology residency.
reduce the risk of neuromuscular injuries. Although injuries
are less likely to occur with pelvic laparoscopy, extremes in
table positioning are often necessary. Close attention to place- CO NCLUSIO NS
ment of straps and/or tape and adequate padding should limit
positioning-related injuries. As in adults, abdominal visceral Laparoscopic orchiopexy is now commonplace in the pediatric
injuries related to access are encountered; however, an under- urologist’s armamentarium, since evolving from a diagnostic
standing of the unique anatomic aspects of the pediatric ab- procedure to the surgical treatment of choice when managing
dominal wall can decrease these risks. The pediatric abdomen the intra-abdominal testicle. The option of what type of
requires less force for entry, so penetration injury to the procedure to be performed is reflective of the intra-abdominal
abdominal viscera can easily occur. The smaller pediatric positioning of the testicle and its distance from the internal
FIGURE 114.14 Pelvic view during a right laparoscopic orchiopexy. During medial mobilization of the
vas deferens, the cord structures (arrow ) are held cranially and laterally. Care must be taken not to injure
the iliac vein (A), iliac artery (B), or ureter (C), which lie immediately posterior to the mobilized
peritoneal flap.
ring. Success rates for these techniques are comparable to or risk of testicular atrophy. Although there is a learning curve
better than those reported in open series. M aintaining a mobi- associated with this minimally invasive technique, it is sur-
lized testicle on a wide peritoneal flap free from tension is mountable.
the key to maintaining scrotal position and minimizing the
References
1. Berkowitz GS, Lapinksi RH , Dolgin SE, et al. Prevalence and natural his- 14. Docimo SG. The results of surgical therapy for cryptorchidism: a literature
tory of cryptorchidism. Pediatrics 1993;92:44–49. review and analysis. J Urol 1995;154:1148–1152.
2. Scorer CG, Farrington GH . Congenital D eform ities of the Testis and 15. Bloom DA. Two-step orchiopexy with pelviscopic clip ligation of the sper-
Epididym is N ew York: Appleton-Century-Crofts, 1971. matic vessels. J Urol 1991;145:1030–1033.
3. Cendron M , H uff DS, Keating M A, et al. Anatomical, morphological and 16. Jordan GH , Winslow BH . Laparoscopic single-stage and staged orchiopexy.
volumetric analysis: a review of 759 cases of testicular maldescent. J Urol J Urol 1994;152:1249–1252.
1993;149:570–573. 17. Lindgren BW. Laparoscopic orchiopexy: procedure of choice for the non-
4. Cortesi N , Ferrari P, Z ambarda E, et al. Diagnosis of bilateral abdominal palpable testis? J Urol 1998;159:2132–2135.
cryptorchidism by laparoscopy. Endoscopy 1976;8:33–34. 18. Baker LA, Docimo SG, Surer I, et al. A multi-institutional analysis of
5. H rebinko H L, Bellinger M F. The limited role of imaging in managing chil- laparoscopic orchidopexy. BJU Int 2001;87:484–489.
dren with undecended testes. J Urol 1993;150:458–460. 19. Belman AB, Rushton H G. Is an empty left hemiscrotum and hypertrophied
6. Kanemoto K, H ayashi Y, Kojima Y, et al. Accuracy of ultrasonography and right descended testis predictive of perinatal torsion? J Urol 2003;170:
magnetic resonance imaging in the diagnosis of nonpalpable testis. Int J 1674–1676.
Urol 2005;12:668–672. 20. Docimo SG. Re: Experience with the Bailez technique for laparoscopic ac-
7. Cisek LJ, Peters CA, Atala A, et al. Current findings in diagnostic laparo- cess in children. J Urol 2004;171:806.
scopic evaluation of the nonpalpable testis. J Urol 1998;160:1145-1150. 21. Docimo SG, M oore RG, Adams J, et al. Laparoscopic orchiopexy for the
8. Docimo SG. Re: Is human chorionic gonadotropin useful for identifying high palpable undescended testis: preliminary experience. J Urol 1995;
and treating nonpalpable testis? J Urol 2001;166:1010–1011. 154:1513–1515.
9. N agar H , H addad R. Impact of early orchiopexy on testicular growth. Br J 22. Ferrer FA, Cadeddu JA, Schulam P, et al. O rchiopexy using 2-mm laparo-
Urol 1997;80:334–335. scopic instruments: 2 techniques for delivering the testis into the scrotum.
10. Lee PA, Coughlin M T. Leydig cell function after cryptorchidism: evidence J Urol 2000;164:160–161.
of the beneficial result of early surgery. J Urol 2002;167:1824–1827. 23. Jarow JP, Berkovitz GD, M igeon CJ, et al. Elevation of serum go-
11. Rogers E, Teahan S, Gallagher H . The role of orchiectomy in the manage- nadotropins establishes the diagnosis of anorchism in prepubertal boys
ment of postpubertal cryptorchidism. J Urol 1998;159:851–854. with bilateral cryptorchidism. J Urol 1986;136:277–179.
12. O h J, Landman J, Evers A, et al. M anagement of the postpubertal patient 24. Cadeddu JA, Wolfe JS, N akada S, et al. Complications of laparoscopic pro-
with cryptorchidism: an updated analysis. J Urol 2002;167:1329–1333. cedures after concentrated training in urological laparoscopy. J Urol 2001;
13. Barqawi AZ , Blyth B, Jordan GH , et al. Role of laparoscopy in patients 166:2109–2111.
with previous negative exploration for impalpable testis. Urology 2003;
61:1234–1237.
CHAPTER 115 ■ PEDIATRIC LAPARO SCO PIC
PYELO PLASTY
PASQ UALE CASALE AND WALID A. FARHAT
H istorically, open pyeloplasty has been the standard treatment introduction of refined instrumentation and more experience
for congenital or acquired ureteropelvic junction (UPJ) ob- with intracorporeal suturing allows reconstructive laparo-
struction in adults and children, with overall success rates of scopy to be implemented in the pediatric population, with
90% to 100% (1). Although endopyelotomy and retrograde multiple techniques of pyeloplasty described in the literature
dilation are alternative methods of managing UPJ obstruction (7). O ne of the earliest descriptions of the transperitoneal
in children (2), the success of these two procedures is inferior Anderson–H ynes laparoscopic pyeloplasty in pediatric pa-
to that reported for conventional dismembered pyeloplasty tients by Tan (8) recommended that it should not be per-
(3). Advances in technology have enabled the introduction of formed in children 6 months of age. The advent of improved
laparoscopic and robot-assisted laparoscopic pyeloplasty over 3-mm instrumentation and laparoscopic telescopes has al-
the last few years. lowed better suture manipulation and visualization, making
Laparoscopic pyeloplasty was introduced in adults in 1993 it feasible even in infants 6 months of age (9). The key
(4). In the initial reports, the operative time ranged from 3 to point to performing a laparoscopic pyeloplasty in the infant
7 hours, but the procedure has gradually gained in popularity is based on the geometry of the patient’s body habitus. A tri-
and acceptance, with a reported success rate of over 95% (5). angle is constructed utilizing the umbilicus as the apex, with
the remaining points being lateral to the ipsilateral rectus
muscle subcostal and at the level of the anterior superior iliac
DIAGNO SIS spine.
Yeung et al. (10) reported their initial experience with
Approximately 1% of prenatal ultrasounds detect hy- retroperitoneal laparoscopic pyeloplasty in 13 children, 1 requir-
dronephrosis in the fetus. In 50% of these cases, UPJ obstruc- ing open conversion. The mean operative time was 143 minutes
tion causes the condition. UPJ obstruction is more common in (range 103 to 235 minutes). El-Ghoneimi (11) reported on
male patients and affects the left kidney more often than the 50 retroperitoneal laparoscopic pyeloplasties in children aged
right. About 10% to 30% of cases occur in both kidneys between 22 months and 15 years. Conversion to open surgery
(bilaterally) (6). Congenital abnormalities are the most com- was necessary in four cases due to technical difficulties during
mon cause of UPJ obstruction in children. The condition often suturing. M ean hospital stay was 2 days, and return to full
results from an abnormality in the muscles that surround the activities occurred within 5 days of surgery. The longer time
UPJ, causing an intrinsic narrowing. It may also be caused by needed for the retroperitoneal approach is almost certainly
an abnormality in the structure or position of the ureter, such related to the limited working space, which renders suturing
as a high insertion onto the renal pelvis. Lower-pole renal more difficult.
blood vessels crossing over the ureter can cause an obstruction As laparoscopic pyeloplasty is technically challenging, this
as well. O ther etiologies are compression of the ureter caused procedure was initially restricted to those medical centers with
by inflammation, retroperitoneal fibrosis, kidney stones, or advanced laparoscopic surgeons, and long-term outcome data
scar tissue from previous surgery to correct UPJ obstruction. are still being evaluated. With increasing experience, however,
Symptoms are typically seen in older children but can be seen laparoscopic pyeloplasty in children is more commonly being
in infants; they include back or flank pain, hematuria, failure considered as the initial treatment for UPJ obstruction. This
to thrive, flank mass, and pyelonephritis. procedure maintains the benefits of the endoscopic approaches,
N eonatal patients are evaluated for the obstruction using including decreased postoperative pain, short hospitalization,
renal ultrasound and diuretic renography. M agnetic resonance and reduced postoperative recovery time, while demonstrating
urography is also an option, and a voiding cystourethrogram success rates comparable to those of the conventional open
(VCUG) might be utilized to rule out vesicoureteral-associated approach (12,13).
reflux.
ALTERNATIVE THERAPY
INDICATIO NS
O pen pyeloplasty remains the gold standard, with a high suc-
The indications for laparoscopic pyeloplasty are similar to cess rate for a flank, dorsal lumbotomy, or anterior muscle-
those for an open pyeloplasty and include increasing hy- splitting incision. Proponents have shown that this procedure
dronephrosis, progressive deterioration of renal function, can be done without an indwelling ureteral stent and with
recurrent urinary tract infection, and persistent pain. The simple percutaneous drainage.
752
Chap t e r 115: Pe d iatric Lap aroscop ic Pye lop lasty 753
Endopyelotomy and retrograde dilation are also alter-

native methods of managing UPJ obstruction in children.
Endopyelotomies are performed in the same fashion as in
adults either by a percutaneous approach or ureteroscopically
in a retrograde manner. The long-term success rate of endopy-
elotomy is less than with the standard open or laparoscopic
approaches (8,9). Retrograde dilation has virtually no role in
pediatrics due to its high failure rate, requiring a subsequent
procedure (14).
SURGICAL TECHNIQ UE
AND STEPS
Initial cystoscopy and ureteric stenting is left to the discretion
of the surgeon and may not be necessary (10,15). An in-
dwelling Foley catheter is placed to gravity drainage.
Positioning of the patient is crucial as it facilitates optimal
ergonomics for the surgeon and increased access to the opera-
tive space. For both a transperitoneal and retroperitoneal ap- FIGURE 115.2 Port placement for retroperitoneal approach.
proach, the patient is placed in a lateral or semilateral
decubitus position in close proximity to the posterior edge of
the table. The table is flexed, the kidney rest is elevated, ap- 10 mm from the lower border of the tip of the 12th rib
propriate padding is applied, and the patient is secured with (Fig. 115.2). O ur preferred method to achieve access to the
2-inch tape and a safety belt. An option for the retroperitoneal retroperitoneal space is that the Gerota fascia is approached by
approach described by Yeung et al. (10) is a modified semi- a muscle-splitting blunt dissection, then opened under direct
prone position with the left flank up or a 45-degree right lat- vision. A working space is created by gas insufflation dissec-
eral decubitus position (for right-sided obstruction) to allow tion, and the first trocar is fixed with a pursestring suture ap-
the subsequent ureteropelvic anastomosis using the right hand plied around the deep fascia to ensure an airtight seal. Another
(for a right-handed surgeon). Another option utilized for the approach to create the retroperitoneal space is a modification
transperitoneal approach is to place the patient supine with a of Gaur balloon technique to dissect the retroperitoneum. Two
slight 30-degree rotation of the ipsilateral side. The patient is index fingers of a powder-free surgical glove are placed one in-
then secured to the table with 2-inch silk tape (Fig. 115.1). side the other and ligated onto the 5/10-mm trocar sheath. The
The table can then be rotated as needed after visualization of dissection is then performed by instilling 500 mL of warm
the intraperitoneal field. This approach can be utilized on the saline through the insufflation channel of the trocar. After
left side, allowing the colon to stay lateral to the left kidney so completed dissection, the trocar is reinserted without the bal-
a transmesenteric window is unobstructed. loon and pneumoretroperitoneum is established (maximum
pressure 12 mm H g, or age dependent). A 5- or 10-mm 0-
degree telescope is inserted through the first trocar. A second 3-
Re t ro p e rit o ne o sco p ic Ap p ro ach mm trocar is inserted posteriorly near the costovertebral angle,
while the third 3-mm trocar is inserted 10 mm above the top of
Appropriate placement of the trocars is of the utmost impor- the iliac crest at the anterior axillary line. To avoid transperi-
tance, and three or four laparoscopic ports are inserted at toneal insertion of this trocar, the working space is fully devel-
the surgeon’s discretion. Retroperitoneal access is achieved oped and the deep surface of the anterior wall muscles
through the first trocar incision, which is 15 mm long and identified before the trocar is inserted. The insufflation pres-
sure is 12 mm H g and the flow rate of CO 2 is progressively
increased from 1 to 5 L/min.
The kidney is approached posteriorly, the Gerota fascia is
incised parallel to the psoas muscle, and the perirenal fat is
dissected to reveal the lower pole of the kidney, in which the
renal pelvis is first identified and then mobilized. The UPJ is
identified and minimally dissected to free the UPJ from con-
nective tissue, and small vessels are divided after bipolar elec-
trocoagulation. The anterior surface of the UPJ is cleared to
identify any polar crossing vessels. In order to dissect the UPJ
adequately with minimal trauma, stay sutures of 5-0 Prolene
are placed at the UPJ for easy manipulation (Fig. 115.3).
The traction sutures not only help to mobilize the UPJ but
also facilitate the alignment of the ureter to the trocar axis so
that spatulation and suturing are easily accomplished.
FIGURE 115.1 Supine positioning for transperitoneal approach in O nce complete dissection of the UPJ is done, the renal
left-sided and bilateral cases. pelvis is partly divided by scissors at the most dependent part,
FIGURE 115.3 Retroperitoneal view of 5-0 suture as a

hitch stitch at the right UPJ.
and then the ureter is partly divided and spatulated. At all length were tied together and one was colored utilizing a sur-
times, the anterior surface of the kidney is left adherent to the gical marker, thus eliminating a cumbersome step of tying in-
peritoneum so that the kidney is retracted medially away from tracorporeally. O nce the ureter is approximated to the pelvis,
the anastomosis. N evertheless, if inadvertent dissection of the the UPJ is maintained on traction and the suture line stabi-
kidney anteriorly is performed, a fourth trocar (3 mm) is in- lized. O nce half of the anastomosis is accomplished, a 4.7Fr
serted lateral to the lumbosacral muscles near the iliac crest to polyurethane ureteral stent is inserted through the suture line
facilitate medial retraction on the kidney. to the bladder at the end of the anterior-layer reconstruction.
The pelviureteric anastomosis begins using 6-0 polydiox- O ur preferred method for this is through a percutaneous
anone sutures and a tapered 3/8 circular needle. To facilitate placement of a 12Fr angiocatheter; however, the stent
passage of the needles through the 3-mm trocars, needles can also be inserted through the costovertebral trocar
may be flattened out in the shape of a ski and lubricated. The (Fig. 115.4). To ascertain the position of the stent in the bladder,
first suture is placed from the most dependent portion of the retrograde filling of the bladder with methylene blue saline is
pelvis to the most inferior point or vertex of the ureteric done. The stent remains indwelling for 4 to 6 weeks. Perirenal
spatulation. In the initial few cases, the suture is tied using drainage in the form of a Penrose drain is used. The Foley
the intracorporeal technique with the knots placed outside catheter is left in situ in all patients for 24 hours after surgery.
the lumen. In order to facilitate the suturing part of this Prophylactic antibiotics (third-generation cephalosporin) are
procedure, two 6-0 undyed polydioxanone sutures 6 cm in routinely prescribed.
FIGURE 115.4 Retroperitoneal view of the double-pigtail

ureteral stent inserted through a trocar traversing the ureter
antegrade.
Chap t e r 115: Pe d iatric Lap aroscop ic Pye lop lasty 755
Transp e rit o ne al Ap p ro ach

The first trocar is placed at the umbilicus either through a
small open technique or after insufflation with a Veress nee-
dle. Utilization of 3- or 5-mm trocars depends on the patient
size. In patients under a year of age, 3-mm trocars are suffi-
cient. H owever, in any age group, 5-mm trocars with 3-mm
instrumentation have been proven the easiest for suture
passage in our experience. The abdomen is insufflated with
low pressures and high flow to accommodate for suture pas-
sage and potential loss of pneumoperitoneum. A 3- or 5-mm
0-degree telescope is inserted through the first trocar. A second
trocar is inserted subcostally lateral to the ipsilateral rectus
muscle, while the third trocar is inserted 10 mm above the top
of the iliac crest lateral to the ipsilateral rectus muscle. A
transmesenteric window is performed if the UPJ obstruction is
on the left kidney. If the UPJ obstruction is on the right, the
colon is mobilized to expose the UPJ (Fig. 115.5). FIGURE 115.5 Transperitoneal view of right lower-pole crossing
vessels.
The UPJ is identified and mobilized as just described above
for the retroperitoneal approach with stay sutures and a hitch
stitch. The hitch stitch is placed through the anterior abdomi-
nal wall, traversing the renal pelvis, then back through the an- Sp e cial Co nsid e rat io ns
terior abdominal wall. It is held in place with a clamp to allow
traction control to lift and relax the pelvis as necessary. O nce Although various reconstructive methods of laparoscopic
complete dissection of the UPJ is done, the renal pelvis is pyeloplasty such as dismembered or Y–V-plasty have been
partly divided by scissors at the most dependent part, and then reported, it remains to be determined which methods are
the ureter is partly divided and spatulated. most appropriate for which cases of obstruction. For
The anastomosis and percutaneous stent placement are per- instance, when an aberrant crossing vessel is identified, the
formed as described in the previous section on retroperitoneo- polar vessel is dissected and dismembered pyeloplasty is per-
scopic pyeloplasty (Fig. 115.6). The stent remains indwelling formed to enable the UPJ transposition. After placing the
for 4 weeks. N o perirenal drainage is used. The Foley catheter is stay suture, the ureter is completely divided and the UPJ and
left in situ in all patients for 24 hours after surgery. Prophylactic pelvis are delivered anterior to the vessels with the help of
antibiotics (third-generation cephalosporin) are routinely pre- the stay suture. In some retroperitoneoscopic cases when we
scribed until the catheter is removed. The patients are placed on encounter a long segment of obstruction that precludes the
prophylactic antibiotics until the stent is removed. creation of a tension-free anastomosis, we perform a
FIGURE 115.6 Completed posterior anas-

tomosis and stent in place. The stent was
placed percutaneously after completion of
the posterior anastomosis as described.
When comparing the gold standard open approach to the

laparoscopic approach (16), the mean operative time was sig-
nificantly shorter in the open surgery group versus the la-
paroscopy group (96 minutes [range 50 to 150] versus 219
[range 140 to 310], p 0.0001). O n the other hand, the mean
postoperative use of analgesics and hospital stay were less in
the laparoscopy group. The major disadvantage of the la-
paroscopic approach is that it is clearly a technically challeng-
ing and lengthy surgical procedure because of the high
proficiency required for intracorporeal suturing. Although
automated devices that facilitate suturing (18) are available,
the need for accurate suture placement and unavailability of
small sizes for pediatric application preclude their use.
Development of novel alternatives to suturing, such as fibrin
glue and laser welding, may enhance the utilization of the la-
paroscopic approach; however, the results with these meth-
ods alone have not yet matched the success of conventional
sutures in providing adequate tensile strength of the anasto-
mosis (19).
FIGURE 115.7 Concomitant stone extraction. N ote the insert show-

ing the ureteroscopic view seen during the procedure. The stone is ex-
tracted with a basket though an accessory port. Co mp licat io ns
Potential complications include bleeding, wound infection,
transperitoneal laparoscopic approach, and a Y–V-plasty hernia at the port site, thermal damage to tissues or organs,
can be performed more readily. A concomitant caliceal or trocar or insufflation needle damage to viscera or vessels, per-
renal calculus that cannot be easily accessed via a laparo- sistent leakage of urine, stent migration, reobstruction (tran-
scopic procedure is not an absolute contraindication if sient and persistent), and urinary tract infection with stent in
access to the stone is possible using ureteroscopy through place.
one of the access trocars (Fig. 115.7).
CO NCLUSIO NS
O UTCO MES
Reports on the retroperitoneal approach in laparoscopic
Although controversy still goes on concerning which laparo- pyeloplasty are less common, despite wide use of this ap-
scopic approach to choose (i.e., transperitoneal or retroperi- proach in laparoscopic nephrectomy. In our experience, the
toneal), arguments to advocate one approach over another are retroperitoneal approach has been difficult in the following
more theoretical than true evidence-based criteria. We believe scenarios: (i) children under 15 kg with extremely large re-
that surgeons who have started with laparoscopic nephrec- nal pelvis and (ii) previous violation of the retroperitoneal
tomy using a retroperitoneal approach will be able to natu- space. For a relatively long obstructed UPJ segment associ-
rally extend the indications to pyeloplasty without changing ated with a hydronephrotic extrarenal pelvis, several flap
their habits. N evertheless, the longer time needed for the pyeloplasty techniques, such as a Culp–Deweerd spiral,
retroperitoneal approach is probably related to the limited Scardino–Prince vertical flap, and a dismembered tubular-
working space, which makes suturing more difficult. ized renal pelvic wall flap described by Kaouk et al., have
It is true that the gold standard of pediatric open renal been performed (19).
surgery is the retroperitoneal approach and that minimal inva- The level of difficulty of manipulation certainly increases in
sive surgery should follow the same rules (16). The major ad- the retroperitoneal space, but we believe that difficulty of ma-
vantage of the retroperitoneoscopic approach is that it nipulation in the retroperitoneal space can be overcome with
provides a direct access to the UPJ without interference with improvement in operative skill, especially in ambidextrous su-
intra-abdominal structures. Furthermore, the complication of turing technique. This approach has some advantages. First, it
urine leakage would be better tolerated in the retroperitoneal can avoid dissemination of urine into the peritoneal cavity.
space than in the intraperitoneal cavity. H owever, in our expe- Second, it can theoretically minimize the risk of injury to in-
rience with the transperitoneal approach with stenting, the traperitoneal organs.
rate of urinary leakage from the anastomosis into the abdom- The success rate of laparoscopic pyeloplasty is equal to
inal cavity has disappeared. that of conventional open pyeloplasty. Transperitoneal and
Laparoscopic pyeloplasty in children has been demonstrated retroperitoneal approaches are reported to have comparable
to be feasible and to have satisfactory results (8,11,16,17). outcomes (11). We believe that laparoscopic dismembered
Although there are only a few published series on the long-term pyeloplasty for UPJ obstruction in infants is technically
outcomes to date, the short-term data suggest that outcomes are possible and that an indwelling stent is helpful but not
similar to those of open pyeloplasty in children (11,12). mandatory.
Chap t e r 116: Pe d iatric Lap aroscop ic Ne p hre ctomy and Partial Ne p hre ctomy 757
References
1. Brooks JD, Kavoussi LR, Preminger GM , et al. Comparison of open and 10. Yeung CK, Tam YH , Sihoe JD, et al. Retroperitoneoscopic dismembered
endourologic approaches to the obstructed ureteropelvic junction. Urology pyeloplasty for pelvi-ureteric junction obstruction in infants and children.
1995;46:791–795. BJU Int 2001;87:509–513.
2. Tan H L, N ajmaldin A, Webb DR. Endopyelotomy for pelvi-ureteric junc- 11. El-Ghoneimi A. Laparoscopic management of hydronephrosis in children.
tion obstruction in children. Eur Urol 1993;24:84. World J Urol 2004;22:415.
3. Ahmed S, Crankson S, Sripathy V. Pelviureteric obstruction in children: 12. Bauer JJ, Bishoff JT, M oore RG, et al. Laparoscopic versus open pyeloplasty:
conventional pyeloplasty is superior to endo-urology. A ustr N Z J Surg assessment of objective and subjective outcome. J Urol 1999;162:692–695.
1998;68:641. 13. Soulie M , Thoulouzan M , Seguin P, et al. Retroperitoneal laparoscopic ver-
4. Kavoussi LR, Peters CA. Laparoscopic pyeloplasty. J Urol 1993;150: sus open pyeloplasty with a minimal incision: comparison of two surgical
1891–1894. approaches. Urology 2001;57:443–447.
5. Ben Slama M R, Salomon L, H oznek A, et al. Extraperitoneal laparoscopic 14. Tan H L, Roberts JP, Grattan-Smith D. Retrograde balloon dilatation of
repair of ureteropelvic junction obstruction: initial experience in 15 cases. ureteropelvic obstructions in infants and children: early results. Urology
Urology 2000;56:45–48. 1995;46:89.
6. Schwab CW 2nd, Casale P. Bilateral dismembered laparoscopic pediatric 15. M unver R, Sosa RE, Del Pizzo JJ. Laparoscopic pyeloplasty: history, evolu-
pyeloplasty via a transperitoneal 4-port approach. J Urol 2005;174(3): tion, and future.J Endourol 2004;18:748–755.
1091–1093. 16. Bonnard A, Fouquet V, Carricaburu E, et al. Retroperitoneal laparoscopic
7. Casale P, Grady RW, Joyner BD, et al. Comparison of dismembered and versus open pyeloplasty in children. J Urol 2005;173:1710–1713.
nondismembered laparoscopic pyeloplasty in the pediatric patient. J 17. Peters CA, Schlussel RN , Retik A. Pediatric laparoscopic dismembered
Endourol 2004;18(9):875–878. pyeloplasty. J Urol 1995;153:1962–1965.
8. Tan H L. Laparoscopic Anderson-H ynes dismembered pyeloplasty in chil- 18. Chen RN, M oore RG, Kavoussi LR. Laparoscopic pyeloplasty. Indications,
dren. J Urol 1999;162(3 Pt 2):1045–1048. technique, and long-term outcome. Urol Clin N orth A m 1998;25:323–330.
9. Kutikov A, Resnick M , Casale P. Laparoscopic pyeloplasty in the infant 19. Kaouk JH , Kuang W, Gill IS. Laparoscopic dismembered tubularized flap
younger than 6 months: is it technically possible? J Urol 2006;175(4): pyeloplasty: a novel technique. J Urol 2002;167(1):229–231.
1477–1479.
CHAPTER 116 ■ PEDIATRIC LAPARO SCO PIC

NEPHRECTO MY AND PARTIAL NEPHRECTO MY
GLENN M. CANNO N, JR., AND RICHARD S. LEE
Since the initial description of a laparoscopic heminephrec- moiety (e.g., 5% to 10% function by dimercaprosuccinic
tomy in a 14-year-old by Jordan and Winslow in 1993 (1), a acid study) is identified, nephrectomy or partial nephrectomy
large amount of literature has been devoted to laparoscopic may be considered. Further imaging is usually not warranted,
renal ablative surgery in children. With its decreased length unless there is a history of a continued day and night wetting
of stay, decreased postoperative opioid requirements, im- and possible ureteral ectopia. In these instances M RI urogra-
proved cosmesis, and equivalent operative times to open phy may be beneficial. In cases of a renal mass, abdominal
surgery, laparoscopic nephrectomy and partial nephrectomy CT or M RI is typically obtained to further delineate the
have become widespread procedures in pediatric urology. In mass. In all cases, particular attention should be paid to
a cost analysis from the United Kingdom, the laparoscopic vascular anatomy, the presence and appearance of the
approach to nephrectomy in children was 54% less expen- contralateral kidney, the presence and appearance of the
sive than the open approach (2). Currently, robotic systems ipsilateral and contralateral adrenal glands, and any degree
such as the da Vinci Surgical System (Intuitive Surgical, of lymphadenopathy.
Sunnyvale, CA) are being utilized for more complex recon-
structive procedures such as partial nephrectomy. Future re-
search will determine its utility as compared to conventional INDICATIO NS FO R SURGERY
laparoscopy.
Indications for laparoscopic nephrectomy or partial nephrec-
tomy in children include nonfunctioning kidney, upper- or
DIAGNO SIS lower-pole moieties with duplicated collecting systems, or re-
nal mass. Typical causes include obstruction, reflux, or
Children with prenatal or postnatal hydronephrosis and/or ureteral ectopia. Symptoms can possibly include pain, hyper-
febrile urinary tract infection are often imaged with renal ul- tension, infections, or stone formation. Laparoscopy can also
trasound, voiding cystourethrogram (VCUG), and possibly be applied when bilateral nephrectomy is required of nonfunc-
radionucleotide renal scanning. If there is no evidence of vesi- tioning kidneys causing hypertension, infections, or nephrotic
coureteral reflux (VUR), nuclear renography is performed to syndrome prior to renal transplantation. Removal of poten-
determine if there is significant obstruction and/or salvage- tially malignant renal masses is not usually approached in a
able function. If a clinically significant nonfunctioning renal laparoscopic fashion in children.
ALTERNATIVE THERAPY
O pen nephrectomy or partial nephrectomy is the alternative to
a laparoscopic approach. Percutaneous renal ablative proce-
dures such as cryogenic and radiofrequency ablation are not
performed in children. An open procedure may be considered
if the kidney is large or extensive intra-abdominal adhesions
are present. Retroperitoneal laparoscopy can be considered if
there is a history of previous abdominal surgery, and transperi-
toneal laparoscopy can be considered if there is a history of
retroperitoneal open surgery.
SURGICAL TECHNIQ UE
The following descriptions refer to laparoscopic partial
nephrectomy in children. Specific mention is made when the
steps of the procedure differ from the performance of a com-
plete nephrectomy. O therwise, the steps are identical.
Although ultimately the surgical approach will be chosen by
an individual surgeon’s comfort level and experience, Borzi
and Yeung (3) proposed selecting an approach based on the
specific type of procedure performed. Reporting an experience
of 179 laparoscopic procedures, they recommended a poste- FIGURE 116.1 Port placement for a left-sided laparoscopic nephrec-
tomy and partial nephrectomy.
rior retroperitoneal approach for isolated renal excision with-
out extended ureterectomy, a lateral retroperitoneal approach
for complete ureterectomy or access to horseshoe and pelvic
kidneys, and a transperitoneal approach when complete moi- divided. If there is no VUR the distal end can be left open. If
ety excision with lower urinary reconstruction is planned. there is VUR, the distal ureter is ligated with an absorbable
stitch. The affected pole is manipulated by using the divided
proximal ureter as a handle (Figs. 116.2 and 116.3).
Transp e rit o ne al Ap p ro ach The proximal nonfunctioning ureter is mobilized and
passed posterior to the main renal hilum. During this mobi-
Preoperatively, patients receive a clear liquid diet for 24 hours lization, the nonfunctioning ureter is dissected away from the
and a rectal suppository the night before surgery. Depending remaining ureter by mobilizing the adventitia of the nonfunc-
on surgeon preference, cystoscopy is performed prior to the tioning ureter toward the remaining ureter. This maneuver is
start of the partial nephrectomy. A ureteral stent can be placed critical to preserve the blood supply of the remaining ureter.
in the nonfunctioning moiety to assist in identification if nec- The nonfunctioning ureter is mobilized to the kidney and
essary. A bladder catheter and orogastric tube are placed. the Gerota fascia is opened. The ureter is passed posterior to
The affected side is elevated by a 30-degree wedge, and the the main renal hilum. Suprahilar, cephalad traction on the
patient is carefully secured to the operating table. The table is ureter should provide access to the upper-pole (nonfunction-
rotated to flatten the patient’s abdomen. With the patient’s ing) hilum. If the blood supply is not clearly identified, laparo-
abdomen flat, transperitoneal port access is gained using ei- scopic bulldogs may be placed on the presumed upper-pole
ther a Veress needle or with the modified H asson technique. vessels. A clear demarcation between the upper and lower
A camera port (12 mm) is placed at the umbilicus (Fig. pole should be visible. The upper-pole vessels are clipped and
116.1). A second port is placed superior to the umbilicus in divided. The renal pelvis of the nonfunctioning moiety is sepa-
the midline approximately 10 cm from the umbilical port. A rated from the normal parenchyma using blunt dissection to
third working port (5 or 8 mm) is positioned at the anterior better identify the demarcation between the functioning and
superior iliac spine laterally at a 45-degree offset and 10 cm nonfunctioning moiety. Large hydronephrotic moieties can be
from the umbilical port. If necessary, a fourth 5-mm port is opened to help delineate the separation between the upper and
placed. The fourth port is often helpful in right-sided cases to lower pole. The nonfunctioning moiety is excised using elec-
lift the liver edge and expose the upper pole of the kidney. trocautery or the harmonic scalpel along the line of vascular
The table is angled to raise the affected side into a 60-degree demarcation. Any collecting system injuries to the remaining
flank position. If the da Vinci Surgical System is utilized, the pole should be closed with an absorbable suture. Perirenal fat
robot is positioned on the ipsilateral side of the patient and is used as a bolster prior to closing the cut surface of the re-
angled over the shoulder. The three robotic arms are then en- maining moiety with 4-0 absorbable monofilament suture.
gaged to the laparoscopic ports. A 30-degree lens is used in If a complete nephrectomy is to be performed, after the
the down position. ureter is divided and Gerota fascia open, the renal vessels are
The kidney is exposed by medial reflection of the colon. dissected and divided using clips or an endovascular stapler.
The ureter from the nonfunctioning moiety (or the single The kidney is mobilized and removed.
ureter for a complete nephrectomy) is identified and mobilized After inspection for hemostasis, a retroperitoneal drain is
as distally as the iliac vessels. The nonfunctioning ureter is placed and the specimen is removed through the camera port. If
Chap t e r 116: Pe d iatric Lap aroscop ic Ne p hre ctomy and Partial Ne p hre ctomy 759
FIGURE116.2 Laparoendoscopic right upper-

pole partial nephroureterectomy. A: The ureter
is clipped and divided in the region of the
midureter. B and C: The ureter has been dis-
sected from beneath the main renal pedicle
and the upper-pole vasculature has been
clipped. The hydronephrotic cap is dissected
off with the parenchyma minimally divided.
D: The ureter is left attached as the remain-
ing wall of the ureter is dissected and ligated
at the bladder wall.
FIGURE 116.3 Laparoendoscopic left upper-pole partial

nephroureterectomy. A: The ureter is clipped and divided
in the region of the midureter and dissected in a rostral
direction. B and C: The upper-pole segmental vessels are
clipped and the cap of the kidney allowed to demarcate.
The plane of amputation is marked, an endoscopic bull-
dog is applied to the major pedicle, and the upper-pole
cap is amputated. D: The ureter is dissected in a caudal
direction to the point of the common vascularity and
there amputated with the stump left open.
a complete nephrectomy is performed, a drain is typically not

placed. Local anesthetic is injected into the port sites. M ost pa-
tients, if not all, do not require epidural analgesia. The bladder
catheter is removed on the first or second postoperative day, de-
pending on whether further bladder work is required. The drain
is removed when there is minimal drainage. The patient is dis-
charged when comfortable with diet and oral analgesics.
Re t ro p e rit o ne al Ap p ro ach
Retroperitoneal access to the kidney can be obtained by either a
prone or a flank approach. The posterior prone retroperitoneal
approach has been recommended for children with end-stage
renal disease who may require immediate peritoneal dialysis
(4). In the prone approach, initial retroperitoneal access is
gained at the costovertebral angle using an open technique.
Balloon inflation to 15 to 20 mm H g of pressure is utilized to FIGURE 116.4 Port placement for right-sided prone retroperitoneal
dissect and create the retroperitoneal space. Working ports are laparoscopic renal surgery.
placed under direct vision inferior to the camera port and just
above the iliac crest (Fig. 116.4). In this position, the kidney with subsequent identification and division of the ureter. In par-
will move anterior by gravity, thereby exposing the hilar vessels. tial nephrectomy, minimal mobilization of the remaining vessels
The psoas muscle is identified as a landmark. During nephrec- and moiety should be performed to prevent vasospasm of the
tomy, exposure and dissection of the hilum are performed first remaining moiety. The affected vessels should be divided and
the nonfunctioning moiety removed as in the transperitoneal open surgery. Compared to open partial nephrectomy, the la-
approach. The ureter is used as a handle to manipulate and iso- paroscopic approach was eventually associated with equiva-
late the affected moiety. Collecting system injuries should be lent operative times, significantly shorter length of stay, and
closed appropriately, and the edges of the remaining moiety less postoperative opioid requirements.
may be sutured together for further hemostasis. A retroperi-
toneal drain is typically left in place.
The flank approach is similar except that the working space CO MPLICATIO NS
is developed with the camera port just below the tip of the
twelfth rib. The working ports are placed along a transverse The most severe complication that can occur during laparo-
line with the camera medially and laterally after dissection of scopic nephrectomy and partial nephrectomy is a major vascu-
the peritoneum from the anterior abdominal wall. The remain- lar injury. This is most likely to occur during trocar insertion or
der of the procedure is identical to that of the prone approach. during the hilar dissection. Trocar injuries may be prevented by
using an open approach. M eticulous attention must be paid
during the hilar dissection. The vascular anatomy needs to be
O UTCO MES clearly defined prior to division of the renal vessels. When en-
dovascular staplers are utilized, the surgeon must confirm that
Janetschek et al. (5) presented the first series of pediatric only the renal vessels are included within the stapler.
laparoscopic heminephrectomy. In 12 cases, 7 upper renal O ther complications can include bowel injury, bleeding, in-
poles were removed for ectopic refluxing megaureter and fection, or urine leak resulting in urinoma formation. Bowel
obstructive ureteroceles. Five lower poles were removed for injuries can occur with inadvertent trocar placement or during
reflux nephropathy. Their blood loss was minimal (10 to 30 dissection secondary to instrument handling or electrocautery
mL), there were no complications, and mean operative time misuse. Urine leaks are often discovered by elevated postoper-
was 222 minutes. H orowitz et al. (6) later reported a series of ative drain output. They are often managed with bladder de-
14 laparoscopic upper-pole heminephrectomies with a mean compression, with or without ureteral stent placement.
operative time of 100 minutes. Asymptomatic postoperative retroperitoneal fluid collections
To assess for potential benefits of laparoscopic renal ablative can be observed. Symptomatic retroperitoneal fluid collec-
surgery over open procedures, Robinson et al. (7) retrospectively tions may require percutaneous drainage and assessment for
compared 22 consecutive partial nephrectomies of which 11 creatinine. A late complication that can occur is loss of func-
were performed laparoscopically and 11 performed open in a tion in the ipsilateral remaining moiety, eventually resulting in
nonrandomized fashion. Although the mean operative time was hypertension or worse loss of the moiety. If severe, this may
significantly longer for the laparoscopic group (200 minutes vs. require completion nephrectomy. This complication may be
114 minutes), there was no difference in mean hospital stay. prevented with meticulous dissection and minimal mobiliza-
Patients in the laparoscopic group had a significantly lower opi- tion of the hilum and kidney of the functioning moiety to pre-
oid requirement than the open group. Piaggio et al. (8) com- vent any intimal vascular injury or vasospasm.
pared intraperitoneal laparoscopic partial nephrectomy to an As experience with laparoscopic nephrectomy and hem-
open retroperitoneal approach. They noted that length of hospi- inephroureterectomy increases, operative time and estimated
talization was shorter in the laparoscopic group and stated that blood loss can improve. Yucel et al. (11) retrospectively re-
the procedure is feasible even in infants under 6 months of age. viewed their experience with laparoscopic ablative renal
Success in laparoscopic partial nephrectomy has also been surgery performed by one surgeon over a 6-year period. In the
reported via a retroperitoneal approach. Castellan et al. (9) fourth year of their experience, they noted a statistically sig-
also reported their experience utilizing both transperitoneal nificant improvement in operative time for laparoscopic
and retroperitoneal heminephrectomy. Their overall complica- nephrectomy and in estimated blood loss for laparoscopic
tion rate was 10% , which included urine leak, pneumothorax, heminephroureterectomy. They concluded that their experi-
urinary tract infection, and hypertension. Lee et al. (10) per- ence should continue to encourage pediatric urologists to per-
formed an age-matched comparison of pediatric patients un- form laparoscopic renal surgery.
dergoing retroperitoneal laparoscopic partial nephrectomy to
References
1. Jordan GH , Winslow BH . Laparoendoscopic upper pole partial nephrec- 7. Robinson BC, Snow BW, Cartwright PC, et al. Comparison of laparoscopic
tomy with ureterectomy. J Urol 1993;150(3):940–943. versus open partial nephrectomy in a pediatric series. J Urol 2003;169(2):
2. Cervellione RM , Gordon M , H ennayake S. Financial analysis of laparo- 638–640.
scopic versus open nephrectomy in the pediatric age group. J L aparoendosc 8. Piaggio L, Franc-Guimond J, Figueroa TE, et al. Comparison of laparo-
A dv Surg Tech A 2007;17(5):690–692. scopic and open partial nephrectomy for duplication anomalies in children.
3. Borzi PA, Yeung CK. Selective approach for transperitoneal and extraperi- J Urol 2006;175(6):2269–2273.
toneal endoscopic nephrectomy in children. J Urol 2004;171(2,Pt 1): 9. Castellan M , Gosalbez R, Carmack AJ, et al. Transperitoneal and retroperi-
814–816; discussion 816. toneal laparoscopic heminephrectomy—what approach for which patient?
4. Gundeti M S, Patel Y, Duffy PG, et al. An initial experience of 100 paedi- J Urol 2006;176(6,Pt 1):2636–2639; discussion 2639.
atric laparoscopic nephrectomies with transperitoneal or posterior prone 10. Lee RS, Retik AB, Borer JG, et al. Pediatric retroperitoneal laparoscopic
retroperitoneoscopic approach. Pediatr Surg Int 2007;23(8):795–799. partial nephrectomy: comparison with an age matched cohort of open
5. Janetschek G, Seibold J, Radmayr C, et al. Laparoscopic heminephro- surgery. J Urol 2005;174(2):708–711; discussion 712.
ureterectomy in pediatric patients. J Urol 1997;158(5):1928–1930. 11. Yucel S, Brown B, Bush N C, et al. What to anticipate with experience in
6. H orowitz M , Shah SM , Ferzli G, et al. Laparoscopic partial upper pole pediatric laparoscopic ablative renal surgery. J Urol 2008;179(2):697–702;
nephrectomy in infants and children. BJU Int 2001;87(6):514–516. discussion 702.
CHAPTER 117 ■ URO GENITAL SINUS AND
CLO ACAL ANO MALIES
JEFFREY A. LESLIE AND RICHARD C. RINK
Anomalies of the urogenital sinus occur on a spectrum rang-

ing from a mild distal communication between the urethra
and vagina to a very complex confluence between the urethra,
vagina, and rectum. For this last-mentioned complex group a
distal common channel for all of these structures drains to a
single perineal opening (Fig. 117.1A). The clinical presenta-
tion of this single opening results from persistence of the
cloaca and is essentially a severe urogenital sinus abnormality
with a high imperforate anus (Fig. 117.1B). In addition to a
more bizarre and diverse internal anatomy, patients with cloa-
cal anomalies have a high incidence of other serious midline
congenital anomalies. Important elements of baseline evalua-
tion and surgical management of urogenital sinus and cloacal
anomalies are discussed in detail in this chapter.
Urogenital sinus abnormalities (no rectal involvement) in
general occur in one of two forms: pure urogenital sinus
anomalies and females with disorders of sexual development
(DSD, formerly known as intersex) conditions. The latter
group is much more common. In these children surgical man-
agement must address not only the urinary and vaginal com-
munication but also the virilization of the clitoris and labia. A
DIAGNO SIS
The majority of children with urogenital sinus abnormalities
are detected at birth due to genital ambiguity. The initial eval-
uation in this group of children requires a team approach to
gender identification with appropriate rapid chromosomal
and endocrinologic studies. The history and physical examina-
tion are often helpful in establishing a correct diagnosis.
Congenital adrenal hyperplasia (CAH ) secondary to 21-
hydroxylase deficiency is by far the most common etiology.
Some children may be identified antenatally on ultrasound by
noting a fluid-filled mass (distended vagina) posterior to the
bladder and indeterminant genitalia. Persistence of the cloaca
is suspected in utero when large fluid-filled pelvic structures
are noted associated with bilateral hydroureteronephrosis,
oligohydramnios, and ascites. A 46 XX karyotype is found.
H ydrometrocolpos due to retention of urine and secretions re-
sults in upper-tract distention, and ascites occurs due to retro-
grade flow through the genital tract into the peritoneum. The
rectum and bladder may also be filled with urine, giving rise to
the other fluid-filled structures. B
Prematurity and multiple congenital defects are common in
FIGURE 117.1 A: Urogenital sinus. The confluence of the vagina
children with cloacal anomalies. Initial evaluation of these with the urethra is near the bladder neck and thus “ high.” A Fogarty
children should therefore include medical stabilization and catheter is in the vagina. B: Cloacal anomaly with the urethra, vagina,
evaluation for midline abnormalities. Abdominal distention is and rectum all exiting a single perineal opening.
761
common and may result in respiratory embarrassment. more appropriate to postpone the vaginoplasty until the child
Cardiac, renal, and upper gastrointestinal anomalies and is pubertal. Delayed postpubertal vaginoplasty, however,
spinal dysraphism are frequently identified. Although these in- could easily be done by the same techniques described in this
fants are uniformly female, ambiguity of the genitalia may oc- chapter.
cur and should be investigated. A single perineal opening is
noted anteriorly, and the anus is absent. The perineum is in
general flat with variable amounts of labial tissue mounded DECO MPRESSIO N THERAPY
around the anterior orifice. O ccasionally, a prominent phallic
structure is found. The buttocks are often poorly developed, While most of those with a urogenital sinus undergo recon-
and the sacrum may be deficient on abdominal plain film. struction in the first few months, the complex nature of
Renal ultrasound reveals anomalies of number and fusion. cloacal anomalies and their high incidence of other congeni-
M agnetic resonance imaging (M RI) clarifies the complex tal defects, may necessitate a delay in formal reconstruction
pelvic relationships, evaluates the structural quality of the while the child is stabilized. Certainly, temporary diversion
sphincter complex, and defines the anatomy of the lum- of the gastrointestinal tract by colostomy is essential, and
bosacral spine and distal spinal cord. A gender assignment decompression of the urinary tract may be required. This
committee is convened to determine gender identity. The child may be done by clean intermittent catheterization, but if this
must be stabilized. Genitography is of utmost importance to is not adequate, a temporary cutaneous vesicostomy may be
help determine the anatomy (i.e., length of common sinus, necessary. Rarely a vaginostomy is needed, but this is a last
location of vaginal confluence, status of bladder, presence or resort as it tethers the vagina to the abdominal wall, making
absence of vesicoureteral reflux, or vaginal duplication). later vaginoplasty difficult. In the current era of M alone an-
Patients with cloacal anomalies will show communication tegrade continence enema (M ACE appendicocecostomy)
between the urogenital tract and rectum, and vesicoureteral re- procedures to achieve fecal continence, nearly all will ulti-
flux is commonly identified. Ultrasonography of the pelvis and mately undergo complete reconstruction, including a rectal
kidneys is also of help to identify the uterus, ovaries, and any pull-through.
vaginal distention, or, in the case of cloacal anomalies, it may
reveal hydronephrosis or increased echogenicity suggestive of
renal dysplasia. The adrenal glands in CAH may be prominent SURGICAL TECHNIQ UE
with a cerebriform appearance. M RI of the pelvis is an excel-
lent tool to determine pelvic anatomy and note the presence of All children with a very high vaginal confluence or a cloacal
lumbosacral spinal cord anomalies that may be present. anomaly receive a polyethylene glycol electrolyte solution
Pure urogenital sinus anomalies are in general not detected bowel preparation and prophylactic parenteral antibiotics
early because of normal external genitalia. These patients are preoperatively. Those with a low to midlevel confluence receive
usually found at puberty with hydrometrocolpos or difficulty only a preoperative enema and broad-spectrum antibiotics.
with tampon insertion. Some children are identified earlier Endoscopy is performed with the child in the lithotomy
with incontinence and urinary tract infection (UTI) from urine position. This is one of the most important steps in recon-
pooling within the vagina. Those with pure urogenital sinus struction, as it defines the level of vaginal confluence and al-
anomalies are also more likely to have other organ system lows identification of any other lower genitourinary
abnormalities than those with a urogenital sinus associated pathology, such as vaginal duplication, ectopic ureter, and so
with DSD. forth. We believe that the distance of the vagina from the blad-
der neck is the most critical aspect and dictates the type of
vaginoplasty. Endoscopy also allows placement of a Fogarty
INDICATIO NS FO R SURGERY catheter into the vagina, which is left indwelling with the bal-
loon inflated. Correct placement is confirmed by repeating en-
It is important for the reader to understand that there is a doscopy. The Fogarty balloon will aid in identification of the
great deal of controversy surrounding feminizing genitoplasty. vagina during the reconstruction. A separate small Foley
There are proponents of (a) very early neonatal reconstruc- catheter is passed into the bladder.
tion, (b) delayed postpubertal reconstruction (this usually in- H istorically, urogenital sinus surgery has been performed
volves vaginoplasty), and (c) no surgery unless the patient with the child in the lithotomy position. While this position is
requests it. There are obvious advantages and disadvantages acceptable, we have found it much easier to prepare the entire
to each of these approaches. All children with genital ambigu- lower portion of the body circumferentially to allow access to
ity should be evaluated promptly by a gender assignment team the abdomen and perineum and to allow the child to be supine
consisting of a neonatologist, geneticist, endocrinologist, pedi- or prone (Fig. 117.2A and B). The supine portion of the pro-
atric urologist, and psychiatrist who are all working with and cedure is done with the child “ frog-legged,” with the buttocks
for the child and family. For the purposes of this presentation elevated on towels. This position dramatically improves visu-
we will assume that the family and gender assignment team alization for the surgical assistants. By far the most common
agree to proceed with surgery. It is our belief that early recon- group of patients with a urogenital sinus anomaly to require
struction is most appropriate with all three steps (clitoroplasty, surgical reconstruction is the group with congenital adrenal
vaginoplasty, and labioplasty) completed in a single stage. A hyperplasia, who have not only a urogenital sinus but also
revisional vaginoplasty is often needed at puberty due to virilization of their external genitalia. This includes clitoral
stenosis of the introitus, which should be conveyed to the par- hypertrophy, absence of the labia minora, and anteriorly
ents preoperatively. This is usually a minor procedure. In the placed labia majora. Therefore, most patients will undergo cli-
rare situation of the very small and very high vagina, it may be toroplasty, labioplasty, and vaginoplasty.
Chap t e r 117: Urog e nital Sinus and Cloacal Anomalie s 763
FIGURE 117.3 Proposed initial incisions. N otice the omega-shaped

perineal flap. The meatus is encircled.
bifurcation of the corporal bodies is exposed ventrally. With

the entire clitoris now exposed, a tourniquet is placed at its
base. A vertical ventral midline incision is made along the en-
tire length of each corporal body to the glans (Fig. 117.4A).
The erectile tissue is exposed and excised, with care taken not
to injure the Buck’s fascia, the tunica albuginea, the neurovas-
cular bundle, or glans. This is performed bilaterally from the
glans to the level of the bifurcation (Fig. 117.4B). The proxi-
mal end of each corporal body is oversewn with 4-0 polygly-
colic acid sutures to prevent bleeding. With the Buck fascia
folded, the glans is now secured to the corporal stumps with
4-0 polydioxanone sutures. We had previously sutured the
glans to the pubis but found that this technique prevents ap-
B propriate concealment of the glans. At times the glans is quite
large, but one should resist aggressive glans reduction. If any
FIGURE 117.2 Total lower body preparation. A: Supine position
allows access to perineum and abdomen. B: Child has been rotated reduction is done, it should only occur on the ventral aspect of
prone, allowing access for a posterior sagittal approach. the glans to prevent loss of sensation (1).
Clit o ro p last y Vag ino p last y

In cases of genital ambiguity the operation begins with place- The most complex component of reconstruction of the uro-
ment of a traction suture in the glans clitoris. Using a skin genital sinus is the vaginoplasty. While multiple techniques of
scribe, the proposed incisions are outlined as shown in vaginal reconstruction have been described, they all fall in
Fig. 117.3. H istorically, a very wide-based inverted U-shaped general into four types: (a) cut-back vaginoplasty, (b) flap
perineal flap has been created. Improved cosmesis occurs, vaginoplasty, (c) pull-through vaginoplasty, and (d) vaginal re-
however, if the flap has a narrower base similar to an omega, placement. The type of vaginoplasty is determined by the loca-
avoiding the appearance of a triangular introitus. After inject- tion of the confluence between the vagina and the common
ing 0.5% lidocaine with 1:200,000 epinephrine subcuta- urogenital sinus.
neously along the proposed suture lines, the clitoroplasty is The cut-back vaginoplasty is applicable only for minor
begun. The initial incision is carried out dorsally well proxi- labial fusion and is in fact contraindicated for any true uro-
mal to the glans to preserve the inner preputial layer for a cli- genital sinus anomaly. In this procedure the sinus is opened
toral hood. The entire clitoris is degloved by creating a plane with a midline vertical incision that is then closed transversely
between the Buck’s fascia and the dartos circumferentially. in a H eineke-M ikulicz fashion. It is of historical significance
Ventrally, the incision is carried around the urogenital sinus only and will not be addressed further.
meatus. The rounded apex of the perineal flap should extend
to near the meatus. This flap is elevated with its underlying Lo w Vag inal Co nflue nce
subcutaneous and adipose tissue to expose the urogenital For the low confluence a flap vaginoplasty is performed. This
sinus. Dorsally, the suspensory ligament is divided and the procedure leaves the vagina in the same anatomic location but
A B
FIGURE 117.4 Clitoroplasty. A: The longitudinal incisions must be ventrally placed to avoid injury to
the neurovascular supply. B: The erectile tissue is removed. There is no excision of any of the tunic, and
the neurovascular pedicles are never manipulated.
opens the sinus to provide a larger common opening for the malleable retractor, providing excellent exposure of the ante-
urethra and vagina. It is contraindicated in patients with a rior wall of the vagina and its confluence with the urethra (2).
high vaginal confluence. The previously elevated perineal flap Stay sutures on the vagina are very helpful. With the vagina
must be long enough to allow a tension-free anastomosis to separated from the urethra and sinus, the opened sinus is
the normal-caliber proximal vagina. Redundancy of the flap, closed in layers over a catheter, allowing the sinus to become
however, will create a lip of tissue at the introitus. The ex- the urethra. Unfortunately, “ pull-through” is at times a mis-
posed ventral aspect of the sinus is opened in the midline, and nomer: Even following complete circumferential vaginal mo-
the incision is carried through the narrowed distal one third of bilization, the vagina may not reach the perineum. In these
the vagina into the normal-caliber proximal vagina. It is very situations the perineal flap will create the distal posterior vagi-
important to open into the normal-caliber vagina to prevent nal wall and the anterior wall can be created by either a
later vaginal stenosis. It is also noteworthy that the flap preputial or labial flap. In extreme situations, bowel interposi-
vaginoplasty does not change the vaginal location or conflu- tion may be required to create the distal vagina. A Penrose drain
ence but merely exposes the vagina by widely opening the in- is left in the vagina, and the Foley remains in the urethra.
troitus. Because the anterior and lateral aspects of the vagina
are untouched, stenosis is less common.
Lab io p last y
Hig h Vag inal Co nflue nce
If the vaginal confluence is near the bladder neck, a flap H aving completed the clitoroplasty and vaginoplasty, only the
vaginoplasty is contraindicated, as it will result in severe fe- labial reconstruction remains. The phallic skin is unfurled and
male hypospadias with urine pooling. Deep spatulation of the divided in the midline longitudinally (similar to Byar flaps),
sinus and posterior vagina may permanently open and injure stopping short of the base to allow a clitoral hood (Fig. 117.5A).
the sphincteric mechanism. Therefore, a pull-through vagino- These skin flaps are now sutured in place inferiorly along either
plasty is required, which allows a complete separation of the side of the vagina to create labia minora. The anteriorly dis-
vagina from the sinus. The sinus is closed in layers to create a placed labia majora are mobilized posteriorly by making lateral
urethra, and the vagina is brought to the perineum. In this incisions in a Y–V fashion (Fig. 117.5B). The mobilized labia
technically demanding procedure, the vagina is completely majora are now sutured to the labia minora and to the apex of
separated from the sinus. The dissection of the anterior wall of the perineal flap. This step moves the labia posteriorly to their
the vagina from the urethra and bladder neck is the most diffi- normal location on either side of the vagina.
cult part of the procedure, and if not done with care and excel-
lent exposure it may result in injury to the urethra or
sphincteric mechanism. The initial portion of this procedure is Clo acal Ano malie s
identical to the flap vaginoplasty. It is important to expose the
entire posterior wall of the vagina by dividing the bulbospon- Surgical management of children with cloacal anomalies oc-
giosus muscle and sweeping the rectum posteriorly. The sinus curs in several important steps, but the formal reconstruction
is opened in the midline until the Fogarty balloon is exposed is best performed in a single stage. N eonates require early di-
in the vagina. At this time we rotate the patient to the prone verting colostomy. H endren (3) prefers a right colostomy to
position and elevate the posterior wall of the vagina with a leave adequate distal length and an intact blood supply for
A B
FIGURE 117.5 A: The phallic skin is divided in the midline and used to create labia minora. The incision
should stop well short of the base to allow creation of a clitoral hood. B: Y-V plasty of the labia majora
moves the labia inferiorly to place the urethra and vagina between the labia in a more normal location.
subsequent rectal pull-through. A long distal colonic segment, vagina(s) and rectum and a Foley catheter in the bladder, the
however, can allow persistent retention of urine in the mucus patient is placed prone on the chest and pelvic rolls. The
fistula and result in refractory hyperchloremic metabolic aci- sphincter complex is stimulated, and the optimal positions for
dosis. Preliminary mapping of the anorectal sphincter com- the anus, perineal body, vagina, and urethra are marked. The
plex provides prognostic information for future rectal perineum is incised in the midline from the tip of the spine to
pull-through. the posterior margin of the single perineal orifice. The sphinc-
Decompression of the genitourinary tract is performed dur- teric muscles are split in the midline and tagged to facilitate
ing endoscopic investigation of the cloacal anatomy. Inspissated subsequent reconstruction. The rectal communication is
mucus and meconium debris are drained. Because the bladder sharply dissected off the common channel, and the distal
neck and vagina are often closely related, the vagina passively colon is mobilized for pull-through. O ccasionally abdominal
retains voided urine. If vaginal voiding is a problem, intermit- exploration is required to achieve adequate rectal mobiliza-
tent catheterization of the common channel will allow decom- tion. At this time the entire urogenital system is circumferen-
pression, with the catheter most likely entering the vagina rather tially mobilized toward the perineum by the Peña technique of
than the bladder. Poor emptying is suspected in children with total urogenital m obilization. Even if this maneuver cannot
persistence of hydronephrosis postnatally. Alternatively, if the bring the vagina to the perineum, it does improve exposure to
common channel is narrow and more urthrallike, it can be the confluence for completion of a pull-through vaginoplasty.
opened distally to facilitate voiding. If the above measures fail, Duplicate vaginas are often encountered and are combined by
cutaneous vesicostomy is performed. Cutaneous vaginostomy division of the vertical septum. Vaginal agenesis or atresia re-
allows free drainage but tethers the vagina anteriorly and com- quires bowel interposition for vaginoplasty, and again this is
plicates the subsequent vaginoplasty. best performed at the time of rectal pull-through and urethro-
Severe anomalies of other organ systems should be cor- plasty.
rected early. O ther urinary tract abnormalities that may com-
promise long-term renal function should be addressed.
Colonization of the urinary tract is common, but symptomatic To t al and Part ial Uro g e nit al Mo b ilizat io n
infections mandate aggressive therapy. Assuming that all other
congenital issues have been satisfactorily addressed, formal re- Total urogenital m obilization (T UM ), described by Peña
pair of the cloaca with the Peña posterior sagittal anorecto- in 1997 (4), entails complete circumferential dissection of the
vaginourethroplasty (PSARVUP) is planned for 6 to 12 months intact urogenital sinus, urethra, and vagina from the pubis
of age. This demanding procedure should be completed in a (Fig. 117.6A). This was originally proposed for cloacal anom-
single stage, capitalizing on the virgin tissue planes for both alies but has since been often applied to those with a urogeni-
anorectal and urogenital reconstruction. tal sinus only. TUM allows the midlevel vagina to be moved to
The initial preparations for repair of the persistent cloaca the perineum easily, thus avoiding a pull-through vagino-
are similar to those described above for the high-confluence plasty, and while the high-confluence vagina may still require
urogenital sinus. After a circumferential lower-body prepara- a pull-through vaginoplasty, the separation of the vagina from
tion and endoscopic placement of Fogarty catheters in the the urinary tract is much more easily performed.
B
A
FIGURE 117.6 A: Total urogenital mobilization. Complete circumferential mobilization of the intact
sinus with the dissection well above the pubis. B: Partial urogenital mobilization. The anterior dissection
ceases at the pubourethral ligament.
The initial incisions are similar to those described previously, (5) have shown that this is important tissue to save for the re-
but the urogenital sinus is mobilized intact off the corporal construction. If the vagina does not reach the perineum, then
bodies and is carried out between their bifurcation through the sinus is mobilized between the corporal bifurcation and
the pubourethral ligament. At this time the dissection is con- off the pubis (TUM ). When these avascular attachments from
tinued posteriorly in the midline, separating the rectum from the pubis are divided, the sinus moves toward the perineum. If
the posterior wall of the vagina. The Fogarty balloon within the sinus is near the perineum, we still believe a flap vagino-
the vagina is palpated, and an incision is made into the vaginal plasty should be performed to prevent vaginal stenosis. The
wall posteriorly near the confluence. If the vagina reaches the redundant sinus is then split ventrally to create a mucosa-lined
perineum, no further dissection is performed and instead par- vestibule (Fig. 117.7A and B) (6). Recently, we described split-
tial urogenital mobilization (PUM ) is used. In Peña’s original ting the sinus laterally to create a posterior vaginal wall
description the mobilized sinus was amputated, but Rink et al. (Fig. 117.8) (7). This is also a form of flap vaginoplasty, but
A B
FIGURE 117.7 Low confluence with flap vaginoplasty. A: The mobilized sinus is opened on the ventral
side. B: The opened sinus provides a mucosal-lined vestibule.
FIGURE 117.8 The mobilized sinus is split laterally to allow rotation of the flap to create a posterior
vaginal wall.
the posterior flap is native urogenital tissue rather than per- mobilized tissue for improved cosmesis and function as de-
ineal skin. If the vagina is high following the TUM , then the scribed previously for the TUM . In the majority of urogenital
vagina is separated from the sinus as described previously for sinus anomalies, PUM is adequate to exteriorize the vagina
a pull-through vaginoplasty. This vaginal separation is again when combined with a flap vaginoplasty.
more easily achieved by placing the patient prone over chest
rolls. The mobilized sinus is split dorsally, and the opened si-
nus is rotated to create an anterior vaginal wall (Fig. 117.9). O UTCO MES
Due to concerns for potential sphincteric injury from ag-
gressive retropubic dissection, Rink et al. (8) described partial This is a time of widespread evaluation of all aspects of femi-
urogenital m obilization (PUM ). In the PUM , the dissection an- nizing genitoplasty. There is little agreement on any compo-
teriorly ceases at the pubourethral ligament (Fig. 117.6B). We nent, including the timing of the procedure or even the
believe this procedure is less risky yet still allows use of the necessity of some aspects, such as clitoroplasty. While virtually
inferiorly occurs with unacceptable frequency. Early PUM re-

sults are similarly promising. All neurologically normal chil-
dren older than 2 who have undergone PUM in our hands are
dry and voiding (9). Long-term data are lacking, of course, as
these techniques are relatively new and have been applied
mainly to young girls. These issues are complex and will only
be solved by long-term prospective multi-institutional studies.
We believe that virtually all CAH patients can be treated with
a PUM technique, avoiding the more aggressive TUM .
From an anatomic and cosmetic standpoint, surgical recon-
struction of cloacal anomalies is now satisfactory in the ma-
jority of cases. Unfortunately, the functional success of the
urinary and rectal elements of the reconstruction also depends
upon sacral nerve function and the quality and innervation of
the sphincteric complexes. The bladder neck and intrinsic
sphincter may be inherently deficient with a high confluence.
N o natural plane exists between the bladder neck or trigone
and the vagina, and therefore the continence mechanism may
be further compromised as the vagina is dissected off the blad-
der neck. The external sphincter may also be congenitally de-
ficient or may be injured during reconstruction. Due to
abnormal sacral nerve function, these patients may require in-
FIGURE 117.9 The sinus is opened dorsally for a pull-through
vaginoplasty and rotated to create an anterior vaginal wall. termittent catheterization or further reconstruction, such as
outlet resistance enhancement or augmentation cystoplasty, to
achieve continence (9).
all surgeons believe they achieve excellent cosmetic results, O utcomes of vaginoplasty in cloacal anomalies are as re-
blinded studies have questioned this. Unfortunately, there are ported with the high-confluence urogenital sinus. Total uro-
few data available on long-term results from current surgical genital mobilization appears to reduce the incidence of
techniques. There is debate about both the psychological as- stenosis and the need for a pull-through procedure, although
pects of having genital surgery and the psychological aspects long-term pubertal follow-up is pending. Introital revision
of not having the surgery and growing up with genital ambi- may be required at puberty after vaginoplasty in infancy.
guity. Clitoroplasty is controversial, as no one knows if it is a O ne of the most important issues in functional outcome
clinical problem to have an enlarged clitoris, and there re- after repair of a persistent cloaca is the long-term preserva-
mains a concern that even modern techniques may alter sensation of renal function. M any of these children have congeni-
tion. Should the parents make the decision about early tal renal dysplasia related to vesicoureteral reflux and/or in
surgery, or should it be postponed until the patient can decide? utero infravesical urinary tract obstruction. Persistent postna-
If the latter, then what are the social implications of growing tal hydronephrosis should be aggressively addressed with di-
up with ambiguous genitalia? Virtually all agree that the version if necessary. Chronic renal failure may occur even in
vagina must be exposed to allow egress of menstrual fluid, but the fortunate subset of patients who achieve a normal nadir
when this should be done remains controversial. Early TUM creatinine in infancy (10). This is usually due to abnormal
results are promising, and incontinence does not seem to be a lower-urinary-tract dynamics. Therefore, even after appar-
problem in children who are otherwise neuroanatomically ently successful lower-urinary-tract reconstruction, these pa-
normal. And while the procedure is technically easier, the tients require urodynamic evaluation and vigilant monitoring
long-term results may show that sphincteric injury with incon- to prevent upper-urinary-tract deterioration due to silent
tinence or stress incontinence from moving the bladder neck bladder dysfunction.
References
1. Rink RC, Adams M C. Feminizing genitoplasty: state of the art world. JP, Rink RC, M ouriquand PDE, eds. Pediatric urology. Philadelphia: WB
J Urol 1998;16:212–218. Saunders, 2001.
2. Rink RC, Pope JC, Kropp BP, et al. Reconstruction of the high urogenital 7. Rink RC, Cain M P. Urogenital mobilization for urogenital sinus repair.
sinus: early perineal prone approach without division of the rectum. J Urol Br J Urol Int 2008;102:1182–1197.
1997;158:1293–1297. 8. Rink RC, M etcalfe PD, Kaefer M , et al. Partial urogenital mobilization: a
3. H endren WH . Cloacal malformations: experience with 105 cases. J Pediatr limited proximal dissection. J Pediatr Urol 2006:3(5):351–356.
Surg 1992;27:890–901. 9. Rink RC, Leslie JA, Kaefer M , et al. O utcomes and risk factors in urogeni-
4. Peña A. Total urogenital mobilization—an easier way to repair cloacas. tal mobilization. Data presented at meeting of American Academy of
J Pediatr Surg 1997;32:263–268. Pediatrics. San Francisco, O ct. 2007.
5. Rink RC, M etcalfe PD, Cain M P, et al. Use of the mobilized sinus with 10. Warne SA, Wilcox DT, Ledermann SE, et al. Renal outcome in patients with
total urogenital mobilization. J Urol 2006;176:2205–2211. cloaca. J Urol 2002;167:2548–2551.
6. Rink RC, Yerkes EB. Surgical management of female genital anomalies,
intersex (urogenital sinus) disorders and cloacal anomalies. In: Gearhart
CHAPTER 118 ■ SURGERY TO CO RRECT
AMBIGUO US GENITALIA (46XX DISO RDER
O F SEXUAL DEVELO PMENT)
ANTHO NY J. CASALE
A m biguous genitalia and intersex are historical terms used to appearance and role assignment in childhood. The validity of
describe a congenital condition where the appearance of the this approach has recently been questioned and is the subject
genitalia is neither classically male nor female. M odern of widespread study at this time. At present, intrauterine and
nomenclature has been proposed to replace the old, and this postpartum androgen exposure of the central nervous system
group of disorders is now described as disorders of sexual de- seems to be the dominant factor in determining gender iden-
velopment (DSD). The condition affects both external geni- tity. Exactly how to reliably measure the gender of the brain
talia (phallus, labia, scrotum, and introitus) and internal remains an unsolved question.
reproductive structures (vagina, urethra, urogenital sinus). In Genital ambiguity is a result of an abnormality in sexual
these cases there is usually a conflict between the genetic sex, determination resulting from a defect in genetic, gonadal, or
gonadal sex, and apparent gender as based on genital appear- genital tissue differentiation and has been classified histori-
ance. The genital appearance may be gender neutral and give cally into four categories: female pseudohemaphrodite (now
little indication of the genetic or gonadal sex. O n the other called 46XX DSD), male pseudohemaphrodite (46XY DSD),
hand, the genitalia may have an appearance more consistent mixed gonadal dygenesis (sex chromosome DSD), and true
with the opposite gender, as with females with severely viril- hermaphrodite (ovotesticular DSD). Female genital recon-
ized congenital adrenal hyperplasia (CAH ). When patients struction, also called feminizing genitoplasty, is restricted to
with these conflicts reach adulthood they face significant hur- female pseudohemaphrodite (46XX DSD), mixed gonadal dy-
dles in both reproduction and sexual activity. genesis (sex chromosome DSD), and true hermaphrodite
The historical goal of surgery for ambiguous genitalia has (ovotesticular DSD) individuals who have the potential to
been to provide the child with genitalia that have the appear- have normal female sexual function. CAH is a form of 46XY
ance of and are functional as either male or female gender and DSD and is by far the most common condition causing am-
that are consistent with the genetic and gonadal sex when pos- biguous genitalia. CAH is responsible for over 70% of cases
sible. Fem inizing genitoplasty is the term used to describe a of ambiguous genitalia and the vast majority of patients
series of surgical procedures designed to create classic female treated with feminizing genitoplasty.
genitalia from a truly ambiguous genital state. This surgery Candidates for feminizing genitoplasty have two distinct
has usually been applied to female patients with partially mas- problems: (i) the fusion of their internal reproductive system
culinized genitalia, and in those cases surgery brings the with the urinary tract as a urogenital (UG) sinus with a single
genetic, gonadal, and genital sex back into alignment. Rarely, external orifice and (ii) the virilization of the external geni-
this surgery has been used to reassign the gender of genetic talia, with fused labioscrotal folds and clitoral enlargement.
and gonadal male patients with what was felt to be inadequate The internal anatomy can cause problems by pooling of urine
phallic tissue to the female gender. It is this later group of within the vagina and uterus and inadequate vaginal drainage
patients who have had more difficulties with gender dissatis- for secretions and menses. There is no adequate external vagi-
faction, and their experience has brought the principle of gen- nal orifice for sexual intercourse. Infants with a UG sinus may
der assignment under question. This chapter will discuss the present with urinary infection or an abdominal mass from a
technical aspects of feminizing genitoplasty. poorly drained vagina or uterus. Today many present on pre-
Society dictates that the appearance of the infant’s genitals natal ultrasound screening that reveals a dilated bladder,
and therefore its apparent gender is the subject of great and vagina, or upper urinary tract. The external genitalia are a
urgent interest for the immediate and extended family and concern primarily for sexual function and the potential psy-
friends, making ambiguous genitalia a cause of intense con- chological damage that may result from gender ambiguity.
cern and confusion for all. It is this powerful interest that has There have been great advances in the surgical technique of
driven physicians and families to treat the condition as an feminizing genitoplasty over the past half-century, resulting in
emergency, even though there are often no immediate health more normal appearance and sexual function. Despite appar-
risks. The historical approach to this issue has been to assign ently successful surgery, some adult patients have expressed
gender based on several factors, including the potential for re- profound dissatisfaction with their childhood genital recon-
production, the technical limits of surgical reconstruction (i.e., struction and gender. Because of this concern, more long-term
our limited ability to create a male phallus without adequate outcome studies that include all patients with these rare condi-
corpora), and the belief that gender was determined by genital tions must be undertaken in order to understand the most
769
FIGURE 118.2 Pelvic ultrasound demonstrates the uterus in the mid-

line position posterior to the urinary bladder.
FIGURE 118.1 This intersex female patient demonstrates labial/

scrotal fusion and a hypertrophied phallus with a distal urogenital identified on pelvic ultrasound of the newborn as a 1-cm solid
sinus opening.
midline mass just posterior to the bladder (Fig. 118.2). The
uterus can often be identified on a genitogram with a cervical
impression outlined by the contrast in the vagina.
appropriate management of these complex patients. The chal- During the initial investigation the family is advised to de-
lenge of these studies is to make them comprehensive in sur- lay naming the child and reporting the child’s gender to others
veying medical, sexual, and psychological health. until the gender is established, and to state only that the child
The first task for the physician faced with a child with in- had some developmental problems that need to be investi-
tersex is to correctly diagnose the underlying condition re- gated. It is during this period that the gender assignment team
sponsible for the appearance of the genitalia. A team including should carefully educate and counsel the family about the na-
a pediatric urologist, pediatric endocrinologist, neonatologist, ture of their child’s problem and the limitations and potential
and either pediatric psychologist or psychiatrist provides the inherent in the exact condition. The family should be prepared
best approach for this complex process. to face the options of therapy, including reconstructive
The first step in diagnosis is a thorough physical examina- surgery, so that when the diagnosis is clear they can make an
tion. The initial caregivers in the nursery are usually alerted to informed decision. This is a difficult and often painful process
the possibility of gender ambiguity if the phallus is small or for both family and team, and it is critical that every option be
curved and if the labioscrotal folds are partially fused explored and discussed with the family and that this counsel-
(Fig. 118.1). The pediatric urologist should then document the ing is documented in the medical record.
length and diameter of the phallus and the position and num- There are actually two decisions to be made by the parents:
ber of external perineal openings, including the position of the gender that they will raise the child and whether to have
any potential urogenital orifices as well as the rectum. The state reconstructive surgery. Gender decisions have always been
of fusion of the labioscrotal folds and their location are impor- considered urgent, while surgical reconstruction decisions
tant, as is the presence or absence of palpable gonads. The may be made later as long as there is not a health concern be-
presence of a palpable gonad almost always is consistent with cause of inadequate drainage of urine. The medical team must
male gender. H yperpigmentation of the labioscrotal skin is explain the surgical options, including advantages, risks, and
common in cases of CAH . The blood pressure should be mea- potential complications of delaying surgery, performing the
sured carefully because of the threat of hypertension with CAH . external genital reconstruction (clitoroplasty), and performing
Chromosomal studies should be sent immediately. In the the internal genital reconstruction (urogenital sinus repair).
immediate newborn period the presence of functioning testicu-
lar tissue can be determined by measuring serum testosterone,
which is elevated in the first few days of life. CAH is diagnosed TIMING O F SURGERY
by finding elevated plasma levels of 17-hydroxyprogesterone
and androstenedione and urine levels of pregnanetriol and O nce the decision for feminizing genitoplasty has been made,
17-ketosteroids. CAH can be a life-threatening condition the timing of the procedure is of some importance. In cases of
because adrenal insufficiency commonly causes salt wasting CAH , glucocorticoid and mineralocorticoid replacement ther-
leading to hyponatremia and hyperkalemia and could result in apy will diminish androgen production by the adrenal and
lethargy, vomiting, and eventual hypotension. lead to partial reversal of the clitoral hypertrophy. For this
Imaging studies of the infant should include a pelvic ultra- reason the external genital surgery should be delayed until at
sound looking for the presence of a uterus and retrograde in- least 6 months of age. In some cases hormone replacement
jection of contrast into the UG sinus (genitogram) to identify therapy decreases the size of the clitoris so that surgery on
the presence of a vagina and uterus. The uterus can usually be this structure is not necessary. Since most complaints about
Chap t e r 118: Surg e ry to Corre ct Amb ig uous Ge nitalia (46XX Disord e r of Se xual De ve lop me nt) 771
childhood genital surgery involve dissatisfaction with clitoral the most distal portion of the UG sinus and injecting contrast
reconstruction, most surgeons have currently limited this while imaging from the anterior, lateral, and oblique perspec-
surgery to the most extreme cases of enlargement and with the tives. This gives the surgeon important information about the
family’s clear support. Some surgeons have refused to perform length of the UG sinus, the point of confluence of the vagina
clitoral reconstructive surgery altogether. The decision about and urethra, and their relative lengths and position within the
clitoral reconstruction is the most difficult issue to face in the pelvis. The level of this confluence, either high (UG sinus over
care of these children and must be considered carefully by the 3 cm) or low (UG sinus 3 cm), ultimately determines the sur-
family and medical team. gical approach. Further imaging of the pelvic organs may be
Some surgeons prefer to delay reconstruction of the inter- necessary in complex cases and can be done with magnetic
nal structures until adolescence if the child does not have resonance imaging or computerized tomographic scanning
problems with urine retention and urinary tract infections be- with good visualization.
cause historically patients who had reconstruction early in life Finally, an examination under anesthesia is needed, includ-
might require a secondary procedure at adolescence to correct ing cystoscopy and vaginoscopy. It is often easier to measure
vaginal stenosis. O n the other hand, those children who have the length of the UG sinus and determine the height of the
early reconstruction need only dilations or simple revisions of confluence with the scope than with imaging. The length of
the vagina at adolescence, in contrast to the child who delays the UG sinus can be measured by placing the tip of the scope
the major reconstruction until later in life. We prefer to do a at the point of confluence and marking the scope at the level
complete reconstruction at 6 months of age and explain to the of the external meatus. When the scope is withdrawn, the
family that a second minor procedure may be needed later. length of the UG sinus is estimated by measuring the distance
from the mark on the barrel to the tip of the scope. These
measurements of the UG sinus, vagina, and urethra, along
PREO PERATIVE EVALUATIO N with the position of the confluence of all three, are important
in order to plan what techniques may be necessary for repair.
Each child suspected to have ambiguous genitalia should have
a complete anatomic, endocrine, and genetic evaluation. A
karyotype is necessary not only to determine the correct ge- SURGICAL PO SITIO NING
netic sex but to look for other chromosomal errors that may
be present. A complete endocrine evaluation should focus on M ost of the surgery for ambiguous genitalia can be performed
potential gonadal function as well as concerns related to the in the lithotomy position. The lithotomy position is ideal for
endocrinopathy of CAH . the clitoroplasty and reconstruction of the labia and introitus.
A comprehensive definition of the anatomy is imperative in The lithotomy position, however, does not always provide ad-
planning for and accomplishing the reconstruction. The upper equate exposure of the higher forms of urogenital sinus.
urinary tract should be imaged with ultrasound and, if the H endren and Atala (1), Peña (2), and Rink and Adams (3)
kidneys are not normal, a diuretic (Lasix) renal scan. The have demonstrated the superior exposure provided by the pos-
lower urinary tract should be imaged with a retrograde geni- terior prone approach to the pelvic organs. We follow
togram (Fig. 118.3). This is performed by placing a catheter in H endren’s recommendations to prepare the patient circumfer-
entially while applying sterile wrapping to the lower legs to al-
low the patient to be turned from the lithotomy to the prone
position as necessary during the operation. It is wise to have
all positioning options available for this challenging surgery.
Surgery usually begins in the lithotomy position and the cli-
toroplasty is done first, followed by the vaginoplasty, and fi-
nally the labioplasty.
SURGICAL TECHNIQ UE
Re p air o f t he Ext e rnal Ge nit alia

Clit o ro p last y
O nce the decision has been made to surgically reconstruct the
clitoris, the goal of clitoroplasty is to reduce the size of the en-
larged clitoris to one that is within the range of normal for
females. M odern clitoroplasty developed after M ollard et al.
(4) realized that the erectile tissue of the corpora was primar-
ily responsible for the large size of the organ and that it caused
problems during sexual engorgement. The glans clitoris must
be preserved for sensation, but the corpora should be short-
FIGURE 118.3 Genitogram demonstrates confluence of the urethra
ened. M ollard mobilized the neurovascular bundle that sup-
anteriorly and vagina posteriorly. N ote cervical impression at the apex plied the glans and excised the corpora from the level of their
of the vagina and contrast within the cervix. union at the pubis to the distal tip. H e then sewed the glans
FIGURE 118.4 Corporotomy incisions are extended from the 10 and

2 o’clock positions laterally from just below the corona to 0.5 cm
above the pubis. The corporal bodies are ligated at their base and the
bodies excised, leaving the dorsal strip of fascia, including the neu-
rovascular bundles, preserved with the glans.
back to the stumps of the corpora cavernosa, resulting in a

functional clitoris that could become engorged to an appropri-
ate size and was sensate. The dissection of the neurovascular
bundle is somewhat difficult and can potentially lead to com-
promise of the nerves or infarction, so we prefer a variant of
the M ollard procedure that was described by Gonzales and
Fernandes (5).
A circumferential incision is made on the clitoris just prox-
imal to the coronal sulcus and the clitoris is degloved from
skin and subcutaneous tissue. The urethral plate and rudimen-
tary corpus spongiosum may be divided distally and dissected
with the subcutaneous tissue or just mobilized from the cor-
pora cavernosa while leaving it attached both proximally and
distally. We prefer to divide the urethral plate from the glans
during this dissection. Incisions are made in the tunica albug-
inea of the corpora at the 2 and 10 o’clock positions using
needle-point electrocautery. These incisions are extended and
joined across the ventral aspect of the corpora at the subcoro-
nal level distally and 0.5 cm above the pubis proximally
(Fig. 118.4). The dorsal tunica albuginea (including the en-
closed neurovascular bundle) is dissected from the erectile tis-
sue and remaining tunica of the corpora. The erectile tissue
bodies and their ventral and lateral fascia can be dissected
from the dorsal fascia and excised. A 4-0 polyglycolic acid su-
ture can be used to ligate each corporal body at its base. The
rim of fascia on the glans can be sewn to the fascia on the
stumps of the corpora with 4-0 suture to reseat the glans and
stabilize it. The dorsal fascia, which contains the neurovascu-
lar bundle, is allowed to fold under the skin cranial to the
glans. The urethral plate, which was previously separated
from the glans, can now be shortened and partially split in the
midline to flatten the introitus and to shorten the distance FIGURE 118.5 The urethral plate is used to shorten the distance be-
from the vagina to the clitoris (Fig. 118.5). tween the clitoris and the vagina, producing a more normal introitus.
The glans clitoris is often quite large, and several proce-

dures have been described to reduce its size. We have preferred
not to decrease the overall size of the glans but instead to con-
ceal some of the dorsal glans with the glans hood. A small
patch of the dorsal glans epithelium at the base can be excised,
leaving the erectile tissue intact, and the glans hood can be
sewn to this area and allowed to fold over the remainder of the
glans. This leaves the glans with its full erectile capability, leaves
it accessible, and covers it appropriately with a skin hood.
Lab io p last y
The goal of labioplasty is to create a normal-appearing and
normal-functioning female perineum and introitus. The shaft
skin and dorsal prepuce of the clitoris can be utilized to form
the labia minora and to fashion a clitoral hood. The original
skin incision had degloved the clitoris and left all skin based
on the dorsal pedicle. This skin can then be split in the midline
for approximately two thirds of its length (Fig. 118.6). At the
proximal end of the incision a transverse incision is made and
curved proximally at each end for a few millimeters to develop
a flap that is used for the clitoral hood. The two long sides of
the shaft skin are folded to form long, thin, vertical two-sided
flaps that will form the labia minora. The horizontal central
FIGURE 118.7 The dorsal preputial skin flaps are mobilized laterally
flap is folded under itself to form a two-sided hood for the cli- and advanced toward the vagina. There, they are sewn to the lateral
toris. The clitoral hood is sewn to the base of the dorsal aspect edge of the urethral plate as a labial flap. The labioscrotal folds are
of the clitoris and around each side to the approximate 3 and then sewn to the lateral edge of the labia minora to form labia majora.
9 o’clock positions. Each of the three flaps is sewn into shape
using 5-0 absorbable suture.
The labia minora are created with the two lateral strips of
shaft skin. They are dissected on their pedicles to allow them
to extend to the vagina or midperineum (Fig. 118.7). They are
then sewn to the lateral aspect of the urethral plate, which
now lies in the midline between vagina and clitoris. A three-
way stitch is used to fasten the labia minora to the introitus
and to narrow their base so that they maintain their character
and their base does not spread and flatten. The labioscrotal
folds are then sewn to the labia minora to form the labia ma-
jora. All sutures are absorbable 4-0 and 5-0, and while some
suture lines can be created using a running 5-0 suture, any
point of potential tension, such as at corners, should be fixed
with an interrupted 4-0 skin suture.
Re p air o f t he Uro g e nit al Sinus

Lo w -Co nflue nce Uro g e nit al Sinus
The goal of urogenital sinus reconstruction is to create sepa-
rate functional openings for the urinary and genital tracts. The
low-confluence UG sinus has a long urethra and vagina that
join near the perineal surface, resulting in a short common
channel or sinus (Fig. 118.8). There are two good options for
A managing these anomalies. John Lattimer introduced the pos-
terior flap vaginoplasty in 1964, and it is still a useful technique.
A U-shaped incision is made in the perineum with the open
end facing caudally and the proximal point at the orifice of the
UG sinus. This incision isolates a posteriorly based skin flap
(Fig. 118.9). This flap was originally designed to be wide-
based but it needs to be no wider than half of the circumfer-
ence of the proposed vagina (a 1- to 1.5-cm flap in infants).
B The excellent blood supply of the tissue allows a narrower
FIGURE 118.6 The dorsal preputial skin is split in the midline and flap, which results in a more normally functional and cosmetic
reconfigured to create a clitoral hood. introitus.
orifice (Fig. 118.12). This dissection is continued around the

sinus while providing constant traction on the sinus with mul-
tiple stay sutures. The entire sinus vagina and urethra can then
be mobilized caudally, delivering the confluence of the ure-
thra, vagina, and sinus to the level of the perineal skin (Fig.
118.13). Peña originally described this technique for use in
cloacal reconstruction and stressed that the dissection must
extend high in the pelvis, but this is not always necessary in
the low-confluence UG sinus. The dissection can be consid-
ered complete when the confluence is at the level of the
perineum.
If the vagina and urethra reach the appropriate level and
are wide enough to be functional, then the distal UG sinus can
be amputated and discarded (Fig. 118.14). If the vagina is too
narrow, the posterior wall of the vagina can be split and a pos-
teriorly based perineal skin flap can be inserted to widen it.
Hig h-Co nflue nce UG Sinus

The high-confluence UG sinus with a short urethra and vagina
and a long common urogenital sinus channel is much more of
a challenge to reconstruct because of the position of the con-
fluence high within the pelvis and the relative lack of suitable
tissue for reconstruction. In this condition the urethra and
FIGURE 118.8 This illustration demonstrates a low-confluence uro- vagina are short and tethered far from the introitus by soft tis-
genital sinus with a short common urogenital sinus channel draining
the urinary bladder and vagina. sue attachments within the pelvis.
Early attempts to repair these children were made using
techniques that were more suitable for low-confluence vari-
O nce the skin flap is isolated, it is mobilized from the ants, and this fact may explain many of the poor surgical re-
deeper tissue and folded back to expose the caudal wall of the sults now apparent in older patients. The posterior flap repair,
UG sinus (Fig. 118.10). A fine-tipped hemostat can be placed which was very useful for less severe cases, did not provide
in the orifice and the sinus split using electrocautery in the enough length to reach the high confluence and left the child
midline to the level that exposes the confluence of the sinus with a short, hypospadiac urethra and inadequate tissue to re-
vagina and urethra. The vagina is split as deep as the apex of construct the vagina to the introitus. H endren pioneered the
the posterior skin flap will reach. With a catheter in the ure- dissection separating the bladder and vagina, allowing the
thra, the posterior skin flap is sewn in position starting at the vagina to be advanced toward the perineum. This dissection
apex and using interrupted absorbable 4-0 sutures. This ad- between the urinary and genital tract is very difficult and can
vancement of the flap into the sinus and vagina both widens result in vesicovaginal fistula and bladder dysfunction. Even
the introitus and the vagina and reorients the vagina into a more with the vagina completely dissected from the posterior blad-
vertical position, improving passive drainage (Fig. 118.11). der, it often would not reach the perineum, and the gap was
The other option for the low UG sinus is a limited total bridged with complex skin flaps that were sometimes less than
urogenital mobilization (TUM ) technique as described origi- ideal.
nally by Peña (2). This is a relatively simple technique and is Peña’s TUM procedure is a perineal-based approach that is
initiated by a circumferential incision around the UG sinus based on circumferential dissection of the UG sinus, vagina,
A B
FIGURE 118.9 Inverted-U incision produces a posterior-based perineal skin flap used to reconstruct the
posterior wall of the vagina.
If the vagina and urethra reach the appropriate level and

are wide enough to be functional, then the distal UG sinus can
be amputated and discarded (Fig 118.14). This is usually not
the case, however, and the distal vagina is usually too narrow.
In this case the vagina can be divided from the sinus, dissected
away from the urethra and bladder, and split in the midline
dorsally. The mobilized sinus can also then be split in the mid-
line dorsally and the sinus can be folded back on itself ven-
trally and advanced into the vagina as a flap to widen the
vagina. If the vagina is still too narrow, the posterior vaginal
wall can be split as well and a posteriorly based perineal skin
flap can be inserted (Fig. 118.11). The TUM has allowed UG
sinus reconstruction and minimized the need to perform the
difficult dissection between bladder and vagina.
We prefer to approach the child with high UG sinus as an
individual who may need various techniques for successful re-
pair. The options are TUM , mobilization of the vagina from
the urethra/bladder, and various flaps to augment the vagina
from either the UG sinus tissue or perineal skin. The less se-
vere cases may need only TUM and a posterior skin flap,
FIGURE 118.10 The caudal portion of the urogenital sinus is ex- while the most severe cases need all techniques in order to
posed by deflecting the perineal skin flap inferiorly. The sinus can then have a successful outcome.
be mobilized intact or split in the midline ventrally to the level of the Dressing and drains are strictly up to the surgeon and the
vagina in a very low-confluence case.
difficulty of the procedure. A simple genitoplasty may need
only antibiotic ointment or, at most, overnight catheter
drainage. M ore complex procedures always merit catheter
and urethra and advancement of these structures toward the drainage of the bladder, and complex vaginoplasties may be
perineal surface. This approach leaves the child with a urethra aided with a vaginal Penrose drain or in some cases a pressure
of normal length by lowering the bladder and vagina in the dressing of fluffed gauze and elastic tape crisscrossing the per-
pelvis. The TUM also lowers the proximal vagina and uterus ineum. Some surgeons believe in keeping these patients in bed
in the pelvis, allowing the vagina to be reconstructed with less and relatively immobile for 48 hours, but we often allow them
outside tissue. The TUM has become an important tool in the to move about at will and to be held by their mother immedi-
reconstruction of children with UG sinus, particularly those ately after surgery.
with a high confluence.
The initial circumferential dissection around the UG sinus
is performed just as with the lower-confluence variant. O UTCO MES
M ultiple stay sutures are placed and the dissection can be per-
formed in the lithotomy position. Unlike the lower-confluence Co mp licat io ns
UG sinus, those who have a high confluence need much more
extensive dissection to allow the vagina to come close enough The most common complication of genitoplasty is bleeding,
to the perineum for satisfactory reconstruction. The dissection both immediate and delayed. The tissue is very vascular and
usually must reach the level of the pubis both anterior and the use of injected dilute epinephrine during the procedure
posterior to the UG sinus. may be helpful. Late bleeding may originate from the corpora
A B
FIGURE 118.11 Advancement of the perineal skin flap widens the posterior wall of the introitus and
reorients the vagina in a more vertical plane.
FIGURE 118.13 Total urogenital sinus mobilization for the high uro-
genital sinus requires a more extensive circumferential cranial dissec-
tion that takes down all the attachments to the pubic bone.
in this area is the prime reason to close with longer-lasting ab-

sorbable sutures.
Re sult s
At this time surgical results are consistently good in terms of
B appearance and potential for function. There are, however,
FIGURE 118.12 Total urogenital sinus mobilization (TUM ) for the few long-term outcome data for feminizing genitoplasty, and
urogenital sinus begins by circumferential dissection around the com- the studies that have been done are, by necessity, evaluating
mon channel. With cranial dissection the entire sinus can be mobilized the surgical technique that was in fashion 25 years ago. The
and delivered to the level of the perineal skin. If the vagina reaches the techniques have improved, and while we can see superior cos-
perineum easily, the excess sinus can be amputated. If the vagina is
metic and functional results in young children and adolescents
narrow, it can be split in the midline posteriorly and the posterior per-
ineal skin flap inserted as part of the posterior vaginal wall. treated more recently, we still need to observe and evaluate
these patients as they mature.
The question of gender assignment is one of great impor-
cavernosa or vaginal wall and can usually be controlled with tance and intense study at this time. While it is necessary to
pressure dressing. Pressure dressing must be carefully applied learn from our patients, we must learn from all of them and
since it is possible to cause vascular compromise of the glans not focus on only those who have been dissatisfied with their
clitoris in the immediate postsurgical period. treatment. We now know that gender identity is much more
The neurovascular pedicle of the glans clitoris can be in- complex than to be dependent on genital appearance and gen-
jured during the original dissection. This potential injury is der roles. While we must continuously re-evaluate our man-
minimized by leaving the entire dorsal fascia, including the agement of these difficult problems, we should not lose faith
bundles, intact during and after dissection. Infections in the in the ability of surgery to create urogenital structures that can
urine or wound are also possible but uncommon. It is not un- function normally and have an appearance consistent with the
usual to find a small dehiscence of the wound at the posterior classic norm of the human body. Feminizing genitoplasty, like
apex of the labial incisions due to tension from movement. all surgery, has demonstrated that the most difficult question
These heal without surgical intervention. They can be bathed remains the choice of the correct procedure for the proper
normally and dressed with antibiotic ointment. The skin stress patient.
A B
FIGURE 118.14 If the vagina does not reach the introitus easily, ad-
ditional length can be obtained by splitting the urogenital sinus wall
dorsally and folding the sinus mucosa back onto itself and inserting it
C as part of the anterior vaginal wall.
References
1. H endren WH , Atala A. Repair of high vagina in girls with severely mas- Passerini-Glazel G. A new one-stage procedure for clitorovaginoplasty
culinized anatomy from the adrenogenital syndrome. J Pediatr Surg 1995; in severely masculinized female pseudohermaphrodites. J Urol 1989;142:
30:91–94. 565–568.
2. Peña A. Total urogenital mobilization: an easier way to repair cloacas. Ludwinkowski B, O esch H ayward I, Gonzalez R. Total urogenital sinus
J Pediatr Surg 1997;32:263–268. mobilization: expanded applications. BJU Int 1999;83:820–822.
3. Rink RC, Adams M C. Feminizing genitoplasty: state of the art. World Schober JM . Long-term outcomes and changing attitudes to intersexuality.
J Urol 1998;16:212–218. BJU Int 1999;83:39–50.
4. M ollard P, Juskiewenski S, Sarkissian J. Clitoroplasty in intersex: a new Aaronson IA. The investigation and management of the infant with
technique. Br J Urol 1981;53:371–373. ambiguous genitalia: a surgeon’s perspective. Curr Problem s Pediatr 2001;
5. Gonzalez R, Fernandes ET. Single-stage feminization genitoplasty. J Urol 31:168–194.
1990;143:776–778. Lee PA, H ouk CP, Ahmed SF, et al. Consensus statement on management of
Fortunoff S, Lattimer JK, Edson M . Vaginoplasty technique for female intersex disorders. Pediatrics 2006;118:e488–e500.
pseudohermaphrodites. Surg G ynecol O bstet 1964;118:545.
CHAPTER 119 ■ CIRCUMCISIO N
IRENE M. MCALEER AND GEO RGE W. KAPLAN
Currently about 1.2 million newborn boys in the United States more prevalent. M edical benefits to the boy circumcised in
are circumcised annually, making circumcision probably the infancy include reduced urinary infections in infancy (3), de-
most commonly performed surgical procedure on boys or men creased incidence of sexually transmitted disease (2,4,5), and
(1,2). The incidence of circumcision in the United States is marked reduction in the incidence of penile carcinoma (6), but
highest in whites (88% ) and less frequent in African these benefits must also be weighed against the risks of the
Americans (73% ) and H ispanics (42% ) (2). The frequency of procedure: bleeding, infection, and poor outcome (7).
newborn circumcision is much lower in other countries, such The American Academy of Pediatrics in 1999 (8) con-
as Canada (35% ) and Australia (10% ), and is generally much cluded that there were benefits from neonatal circumcision
8% in Europe and most parts of Asia (1). but the benefits gained did not warrant universal routine cir-
cumcision. Conversely, there are some opponents who feel
that neonatal circumcision is never warranted (9).
Recently, with the increased incidence of human immuno-
DIAGNO SIS deficiency virus (H IV) in sub-Saharan Africa of epidemic pro-
N o diagnostic studies are needed preoperatively. Comorbidities, portions, where over 90% of H IV-positive men in Africa
such as excessive prematurity, inherited or transient bleeding acquire the virus through vaginal intercourse, clinical trials of
disorders associated with infancy, and congenital abnormalities adult male circumcision in large groups of men have found a
of the skin such as epidermolysis bullosum and of the penis reduced risk of 50% in the populations studied (Kenya,
such as exstrophy, hypospadias, penoscrotal webbing, or mi- Uganda, South Africa). Even though the risk behavior of the
cropenis, would all mitigate against circumcision, particularly circumcised men was no different from the uncircumcised
routine newborn circumcision (Fig. 119.1). men, the risk of contracting H IV was substantially decreased
(2,5). In the uncircumcised man, the inner preputial skin has
more Langerhans cells with densely concentrated CD4 recep-
tors needed by H IV for entry into the body than do the glans,
INDICATIO NS FO R SURGERY outer preputial skin, or penile shaft skin; as a result, the inner
preputial skin, which is retracted and telescoped during inter-
Circumcision is often performed in the neonatal period, in- course, facilitates H IV entry into the body (2,5).
fancy, or childhood for cultural or religious reasons and is also Because circumcision is so common, there are a number of
performed after the newborn period, when phimosis, paraphi- misguided ideas and practices that have crept into American
mosis, balanoposthitis, or sexually transmitted diseases are medical practice leading to some circumcisions being done for
reasons that are not completely medically sound. At birth the
prepuce, in over 90% of infants, is fused to the glans and is
not retractable. As studied by Gairdner in 1949 (10), the fore-
skin progressively retracts on its own with age, so that only
10% of 3-year-olds will have nonretractable foreskins, and
O ster et al. (11) found that only 1% of 17-year-olds will not
have retractable foreskins. It is not necessary for parents or
physicians to retract the prepuce as retractability occurs with
penile growth, erection, and smegma formation; the smegma
that forms will generally spontaneously be discharged from
under the prepuce and does not need to be removed.
Balanoposthitis is not a mandatory indication for circumci-
sion in children as the prepuce in that area of the penis after
such an episode will be permanently separated from the glans
and should not produce recurrences of balanoposthitis.
Forcible retraction of the prepuce causes the child pain and
can produce paraphimosis or a dense cicatrix and perhaps
subsequent balanitis xerotica obliterans (BXO ) (Fig. 119.2).
Phimosis becomes pathologic when the opening of the fore-
skin develops a tight cicatrix usually caused by BXO . According
to Shankar and Rickwood (12), BXO represents the one absolute
FIGURE 119.1 Webbed penis with paucity of shaft skin. indication for circumcision. BXO is a chronic dermatologic
778
Chap t e r 119: Circumcision 779
FIGURE 119.3 Photo of paraphimosis with topical granulated sugar.
is to place granulated sugar over the swollen penile tissue,

with a resultant osmotic gradient pulling the fluid out.
FIGURE 119.2 Photo of pathologic phimosis due to balanitis xerotica Another alternative to reduce swelling is the application of ice
obliterans. (Fig. 119.3). The paraphimosis is reduced by grasping the
penis between the second and third fingers of both hands and
pulling the shaft skin distally while simultaneously applying
condition, analogous to lichen sclerosus et atrophicus, of cephalad pressure with both thumbs. If this maneuver is
the glans and prepuce but can also involve the meatus and unsuccessful, a dorsal slit is necessary to open the phimotic
the anterior urethra, especially if the glans is extensively constriction ring. Circumcision can be performed after the
involved (13). inflammation and edema have resolved and should not be at-
M ost of the series where BXO is reviewed have found that tempted at the time that the acute paraphimosis is present.
most of the patients affected are older boys, primarily those
whose ages range from 5 to 15 years old (12–15). Previously,
it was thought that the incidence of BXO was relatively rare in
boys (range from 0.6% to 6% ) (12,15), but recent reviews
SURGICAL TECHNIQ UE
have shown that the BXO occurs more frequently in boys than The goal of the operation is to remove an adequate amount of
previously reported. Circumcision is thought to be about 96% the prepuce such that the glans is exposed and balanoposthi-
curative of BXO , but it is concerning that in more obese boys, tis, phimosis, BXO , and paraphimosis are prevented. Too
especially those with prominent pubic fat, more severe disease much or too little skin should not be removed, as the former
is prevalent and recurrent (13). can tether the penis and on occasion produce chordee, while
the latter may produce continued risks of phimosis or para-
phimosis.
ALTERNATIVE THERAPY All circumcisions should take place with an anesthetic: dur-
ing the newborn period, local anesthesia with 1% lidocaine is
O bservation, intermittent medical treatment for balanoposthi- generally used with or without topical anesthesia (EM LA
tis, and dorsal slit are common alternatives to circumcision. 2.5% to 2.5% lidocaine–prilocaine). EM LA should be used
Recently the use of topical steroid creams, typically 0.1% cautiously as methemoglobinemia can occur in newborns. In
triamcinolone or 0.05% betamethasone cream (16–18), to older children and adolescents, general anesthesia is usually
the preputial opening for about 4 to 8 weeks has success- used. The penis is cleaned and draped and the foreskin re-
fully treated phimosis and obviates the need for circumcision tracted by taking down all the adhesions between the glans
in 85% to 87% of boys reported to be using the steroid pre- and the inner preputial skin. If a dense phimosis prevents this
parations. retraction, a dorsal slit may be necessary as a preliminary ma-
Paraphimosis occurs when the prepuce is retracted behind neuver by placing one blade of a straight clamp inside the
the glans penis and, because the preputial orifice is tight, be- preputial sac in the dorsal midline (ensuring that the blade is
comes trapped in this position after it is retracted, with resul- not within the urethral meatus) and then placing the other
tant swelling of the glans that prevents its reduction. If blade on the outer skin. The clamp is closed and left in place
untreated, paraphimosis can lead to infection, significant for a few minutes, crushing the tissue and producing tempo-
penile swelling and pain, and occasionally loss of penile tissue. rary hemostasis, and then the crushed area is incised with scis-
The edema can often be reduced by injecting hyaluronidase sors. M arking the coronal ridge (as seen through the shaft
into the edematous tissue, thereby allowing for easier reduc- skin) in ink helps identify where to place the circumferential
tion of the paraphimosis. M any healthcare providers are un- incision about the shaft skin. In the adult or older child the
likely to inject anything into such a swollen and painful penis, proposed line of incision in the inner preputial sac is marked
so an easy and effective treatment for the paraphimotic edema with ink about 3 to 4 mm below the coronal sulcus.
FIGURE 119.4 A: An incision is made on the shaft. B: A second incision is made below the coronal sulcus.
C: Removing the excessive preputial skin. D: The wound edges are coapted and sutured together.
A common method of excising the prepuce, called a “ sleeve edges. Acceptable surgical results have been obtained as long
technique,” is performed by incising the two previously marked as the skin edges are closely approximated and the adhesive is
lines of incision circumferentially about the penis and dividing not extensively used on subcutaneous tissue (Fig. 119.5).
the tissue between the layers. H emostasis is secured generally
with judicious use of cautery, although vessels can also be in-
dividually ligated. The skin and the inner preputial epithelium Ne o nat al Circumcisio n
are then coapted with fine absorbable sutures (Fig. 119.4).
Alternatively, an older method involves putting the prepuce In newborns, circumcisions performed without anesthesia pre-
on stretch by applying a hemostat to the dorsal and ventral as- viously were common. H owever, local anesthesia using an
pects of the preputial orifice. The area of the shaft skin previ- agent such as lidocaine or bupivacaine as a dorsal penile block
ously marked as overlying the coronal ridge is pulled forward or, more importantly, a ring block at the base of the penis can
beyond the tip of the glans and a straight clamp is applied, alleviate most of the pain experienced by the newborn at the
taking care to ensure that the glans is not included in the time of the circumcision. The anesthetic dose must be adjusted
clamp. The prepuce distal to the clamp is amputated with a for the weight of the patient.
knife, the clamp is removed, hemostasis is secured, and the In newborns, circumcision is in general accomplished using
skin edges are coapted. some type of device. The common devices in use in the United
With the advent of synthetic tissue adhesives such as States are the Gomco clamp, the Plastibell, and the M ogen
Dermabond (2-octyl cyanoacrylate, Ethicon), circumcisions can clamp. The methodology for the Gomco clamp and Plastibell
be performed quickly and safely with good cosmetic results in is similar. After local anesthesia has been provided and the
most children with minimal surgical time, few if any sutures skin cleansed, the area of the coronal ridge is marked as previ-
required, and minimal tissue handling, thereby decreasing ously described, followed by a dorsal slit being performed.
postsurgical swelling and possibly postsurgical pain (19). The Gomco device has three parts—a bell of variable size that
fits over the glans, a plate, and a screw that completes the as-
sembly. After the dorsal slit is performed and all the adhesions
De rmab o nd Circumcisio n are released, the bell is then placed over the glans; a safety pin
placed through the distal corners of the previously incised pre-
Either a typical sleeve circumcision is performed or a Gomco puce that keeps the edges aligned may be helpful. Then the
clamp is used to prepare the tissue for the adhesive, which is plate is placed over the glans, the shaft skin is pulled up until
applied directly to the apposed penile shaft and coronal skin the marked area can be seen emerging from the hole in the
Chap t e r 119: Circumcision 781
plate, and then the screw is placed and tightened. The device is
left in situ for several minutes and the prepuce distal to the
plate is then excised with a knife. Electrocautery must never
be applied to the Gomco device, as this has resulted in total
necrosis of the penis. The device is then removed, reversing the
order in which it was applied. By loosening the screw, the
plate can be disengaged from the bell and removed. The cut
skin edges of the penis are then gently teased over the edge of
the bell to ultimately remove the bell and complete the circum-
cision; rarely are sutures needed for hemostasis for this type of
clamp circumcision (Fig. 119.6).
The Plastibell follows the same principles as the Gomco de-
vice. After the bell is applied, a heavy string is tied over a groove
at the base of the bell at the level of the previously marked area
on the shaft. The distal prepuce is then excised. The stem distal
to the bell is snapped off, leaving a plastic ring under the inner
preputial epithelium. In roughly 1 week, the skin distal to the
ligature sloughs and the ring comes off spontaneously.
The M ogen clamp is a clothespin-like device, and the
methodology of its application is akin to the older open surgi-
cal method described above. After the skin is cleansed and the
FIGURE 119.5 Photo of circumcision using 2-octyl-cyanoacrylate area of the coronal ridge as seen through the shaft skin is
(Dermabond). marked with ink, the adhesions between the glans and the
FIGURE 119.6 Gomco circumcision. A: Line of incision for dorsal

slit. B and C: Application of the device. D: Excision of the prepuce.
O UTCO MES
Co mp licat io ns
O ccasionally complications do occur, but most are minor and
rarely portend a bad result. Bleeding is the most frequent com-
plication and occurs in approximately 0.1% of cases. M ost
episodes of bleeding are minor and respond to pressure alone.
Some require cautery or suture for control, particularly in the
area of the frenulum. M ost infections are minor and superfi-
cial, manifested by redness and occasionally purulence at the
circumcision site that usually responds to local wound care. A
common complication of neonatal circumcision is meatal
FIGURE 119.7 Traumatic amputation of portion of glans from
M ogen clamp circumcision. stenosis, probably produced by a chemical meatitis from am-
moniacal urine exposure on the tip of the penis while the
patient is still wearing diapers. Serious complications, fortu-
nately, are rare but include recurrent phimosis, wound separa-
inner prepuce are lysed with a blunt probe. It is usually not tion, major tissue loss, concealed penis, skin bridges between
necessary to perform a dorsal slit when using the M ogen the shaft and the glans, inclusion cysts, urethrocutaneous fis-
clamp. The prepuce is pulled distally and the clamp applied, tula, and loss of some of the glans or, extremely rarely, all of
taking care to ensure that the glans is not included in the the penis.
clamp. The clamp is closed and left in situ for a few moments.
The prepuce distal to the clamp is excised and the clamp is re-
moved. This type of clamp device is the easiest to use by those Re sult s
first performing neonatal clamp circumcisions, but it is the
one most likely to have associated complications, typically A circumcision should remove a sufficient amount of the pre-
partial or complete amputation of the glans if the glans is in- puce so that the glans is exposed, significantly reducing the
advertently enclosed in the clamp and cut when the tissue in risk of developing phimosis, paraphimosis, BXO , or bal-
the clamp is incised (20) (Fig. 119.7). anoposthitis.
References
1. Alanis M C, Lucidi RS. N eonatal circumcision: a review of the world’s 12. Shankar KR, Rickwood AM K. The incidence of phimosis in boys. BJU Int
oldest and most controversial operation. O bstet G ynecol Surv 2004;59(5): 1999;84:101–102.
379–395. 13. Gargollo PC, Kozakewich H P, Bauer SB, et al. Balanitis xerotica obliterans
2. M orris BJ. Why circumcision is a biomedical imperative for the 21st in boys. J Urol 2005;174:1409–1412.
century. Bioessays 2007;29:1147–1158. 14. Kiss A, Kiraly L, Kutasy B, et al. H igh incidence of balanitis xerotica oblit-
3. Wiswell TE, H achey WE. Urinary tract infection and the uncircumcised erans in boys with phimosis: prospective 10-year study. Pediatr D erm atol
state: an update. Clin Pediatr 1993;32:130–134. 2005;22(4):305–308.
4. Parker SW, Stewart AJ, Wren M N , et al. Circumcision and sexually trans- 15. Yardley IE, Cosgrove C, Lambert AW. Paediatric preputial pathology: are
missible disease. M ed J A ust 1983;2:288–290. we circumcising enough? A nn R Coll Surg Engl 2007;89:62–65.
5. Kahn JG, M arseille E, Auvert B. Cost-effectiveness of male circumcision 16. Z ampieri N , Corroppolo M , Camoglio F, et al. Phimosis: stretching meth-
for H IV prevention in a South African setting. PL oS M ed 2006;3(12): ods with or without application of topical steroids? J Pediatr 2005;147:
e517. 705–706.
6. Persky L, deKernion J. Carcinoma of the penis. CA Cancer J Clin 1986;36: 17. M cGregor TB, Pike JG, Leonard M P. Pathologic and physiologic phimosis:
258–273. approach to the phimotic foreskin. Can Fam Physician 2007;53:445–448.
7. Kaplan GW. Complications of circumcision. Urol Clin N orth A m 1983; 18. Berdeu D, Sauze L, H a-Vinh P, et al. Cost-effectiveness analysis of treat-
10:543–549. ments for phimosis: a comparison of surgical and medicinal approaches
8. American Academy of Pediatrics Task Force on Circumcision. Policy state- and their economic effect. BJU Int 2001;87:239–244.
ment. Pediatrics 1999;103:686–693. 19. Elmore JM , Smith EA, Kirsch AJ. Sutureless circumcision using 2-octyl
9. Schoen EJ. The status of circumcision of newborns. N Engl J M ed 1990; cyanoacrylate (Dermabond): appraisal after 18-month experience. Urology
322:1308–1312. 2007;70(4):803–806.
10. Gairdner D. Fate of the foreskin: a study of circumcision. Br M ed J 1949; 20. Taeusch H W, M artinez AM , Partridge JC, et al. Pain during M ogen or
2:1433–1437. Plastibell circumcision. J Perinatol 2002;22:214–218.
11. H untley JS, Bourne M C, M unro FD, et al. Troubles with the foreskin: one
hundred consecutive referrals to paediatric surgeons. J R Soc M ed 2003;
96:449–451.
CHAPTER 120 ■ AUGMENTATIO N
CYSTO PLASTY IN CHILDREN
HANS G. PO HL
D edicated to W. H . H endren, M .D ., w hose creative use of required in order to provide adequate bladder volume in cases
intestine in urologic reconstruction I have been honored to of classic exstrophy, cloacal exstrophy, and cloacal malforma-
observe. tions. Bladder dysfunction should initially be treated with anti-
N europathicity, bladder outlet obstruction, or embryologic cholinergic medications and clean intermittent catheterization
abnormalities may result in a bladder too small or too overac- (CIC) in an effort to diminish uninhibited bladder contractions,
tive to provide normal storage of urine. The goal of augmenta- improve compliance, and provide regular and effective bladder
tion cystoplasty in the pediatric patient is to provide a emptying. When urodynamic evidence exists that nonoperative
sufficiently capacious reservoir that stores urine at low pres- measures have failed, augmentation cystoplasty is indicated.
sure and as a result improves urinary continence and prevents Intravesical storage pressure that has been demonstrated to be
upper urinary tract deterioration. 40 cm H 2 O is the most robust indication for augmenting the
bladder. Incontinence and urinary tract infections, with or
without vesicoureteral reflux (VUR), are associated symptoms
that may benefit from enterocystoplasty. H owever, a thorough
DIAGNO SIS evaluation is warranted in order to ascertain what type of aug-
mentation to perform and whether a secondary procedure is in-
Evaluation should include imaging of the upper tracts, urody-
dicated in addition to enterocystoplasty to provide continence
namic evaluation and evaluation of the bladder outlet, and
and/or prevent upper tract deterioration. Since the combina-
urine culture. In the child with no prior history of bowel resec-
tion of urinary infection, detrusor hyperreflexia, and VUR
tion or gastrointestinal comorbidity, it is in general not neces-
poses a significant risk for renal scarring, antireflux surgery
sary to evaluate the intestinal tract. H owever, radiologic
should be considered at the time of augmentation cystoplasty
imaging is essential with intestinal atresia, intestinal malrota-
when reflux is high grade or recurrent symptomatic urinary in-
tion, and imperforate anus because it is likely that anatomic
fection has occurred. H owever, reimplanting ureters into a
abnormalities or prior surgical intervention would obviate the
thick-walled bladder is challenging technically and has been as-
use of specific bowel segments.
sociated with postoperative ureteral obstruction, leading some
to consider augmentation without ureteral reimplantation.
When children with neuropathic bladders and VUR have un-
INDICATIO NS FO R SURGERY dergone augmentation cystoplasty alone, VUR has resolved or
been significantly downgraded without the need for reimplan-
The majority of pediatric patients requiring augmentation tation even in high-grade VUR (1) (Table 120.1). If bladder
cystoplasty have small-capacity, noncompliant, or overactive outlet surgery is entertained in conjunction with enterocysto-
bladders as a result of neuropathicity (from myelodysplasia or plasty, the incontinence procedure should be performed prior
traumatic spinal cord injury) or myogenic failure (from poste- to opening the peritoneal cavity in order to minimize insensible
rior urethral valve). O ccasionally, augmentation cystoplasty is fluid loss.
TA B LE 1 2 0 . 1
RESOLUTION OF VESICOURETERAL REFLUX FOLLOWIN G AUGMEN TATION CYSTOPLASTY
ALON E IN PATIEN TS WITH N EUROPATHIC BLADDER DYSFUN CTION
None I II III IV V
N asrallah Preop 5 6 8 1
and Aliabadi, Postop 12 1
J Urol., 1991
Pereira et al., Preop 4 14
J Urol., 1994 Postop 13 1 2
783
TA B LE 1 2 0 . 2
ALTERNATIVE THERAPY
TYPES OF COMPLICATION S FOLLOWIN G PEDIATRIC
Alternatives are either continued medical management or AUGMEN TATION CYSTOPLASTY
urinary diversion.
Preoperative Counseling and Informed Consent
Bleeding (pelvic hematoma)

SURGICAL TECHNIQ UE Infection (more common after colonic than ileal anastomosis)
Preoperative preparation must include a thorough review of Small bowel obstruction
the anticipated goals of the surgery with the parent and patient, Urinary leak
when he or she is an older child or adolescent. During this Ureteral stricture
meeting, the family’s ability to comply with the postoperative Vesicoureteral reflux
care of a bladder augmented with bowel must be assessed. Bladder calculi
When CIC has been performed preoperatively, the postopera- M etabolic abnormalities
tive catheterization and irrigations are more readily adhered Poor somatic growth
to (2). Urinary infection, bladder calculi, or perforation may H ematuria–dysuria syndrome
result when routine emptying and augment cleansing are not
Excoriation around stoma site
performed regularly. Table 120.2 outlines the most common
complications of augmentation cystoplasty in the early and
late postoperative period.
There is no ideal segment of bowel for augmentation cysto-
plasty; each has a set of characteristics that are advantages or a significant benefit in the absence of preoperative bowel
liabilities depending on the clinical scenario (Table 120.3). It cleansing. Considering that the majority of children who will
should be noted that none of these complications are seen undergo augmentation cystoplasty have ventriculoperitoneal
following ureterocystoplasty, making it the ideal tissue for shunts that are prone to infection, there appears to be a ratio-
bladder augmentation. H owever, it is a procedure ideally per- nale to continuing the practice of preoperative clean-outs (3).
formed in a patient with a severely dilated ureter that subtends The patient is positioned supine on the operating table.
a nonfunctioning kidney. General anesthesia with endotracheal intubation is manda-
Bowel cleansing is typically performed prior to augmenta- tory; however, if no spinal abnormality exists that contraindi-
tion cystoplasty (Table 120.4). While expedited bowel cleansing cates the use of an epidural catheter, consideration should
protocols (or complete omission) are replacing standard regi- be given to regional anesthesia as well. The surgical field is
mens in adults, there are few studies in children demonstrating prepared and draped from the xiphoid process inferiorly,
TA B LE 1 2 0 . 3
COMPARISON OF GASTROIN TESTIN AL SEGMEN TS IN PEDIATRIC AUGMEN TATION
CYSTOPLASTY
Advantages Disadvantages
Ileum M ost compliant Diarrhea

Less mucus Vitamin B12 deficiency
Short mesentery
H yperchloremic acidosis
Poor muscle backing
Sigmoid Readily mobilized Unit contractions
Easily implanted Lower compliance
Good muscle backing M ucus
H yperchloremic acidosis
perforation risk
Ileocecal Valve as antireflux/continence mechanism Diarrhea
Good-capacity reservoir N ot always available
Constant blood supply Contractile
Stomach Short gut/radiation H ypochloremic alkalosis
Chloride pump Rhythmic contractions
M inimal mucus H ematuria–dysuria
Fewer infections
Ease of implantation
Good muscle backing
Chap t e r 120: Aug me ntation Cystop lasty in Child re n 785
TA B LE 1 2 0 . 4 created, it must be sufficiently long to open the bladder

widely. If the cystotomy is too short, the augmented segment
COMMON LY UTILIZED BOWEL CLEAN SIN G may behave as a diverticulum, thus facilitating urinary stasis
PERFORMED PRIOR TO AUGMEN TATION and stone formation. O nce the bladder has been prepared, the
CYSTOPLASTY
midline incision is carried above the umbilicus and the peri-
GoLytely-Based Bowel Preparation toneum is entered.
Weight Vol. infused Total vol. infused

(kg) every 10 min (cc) (cc) Ile o cyst o p last y
10 80 1,100
Ileum is by far the most popular segment used for bladder
10–20 100 1,600 augmentation. The segment, 20 to 25 cm long, is based on a
20–30 140 2,200 pedicle that is supplied by branches of the superior mesenteric
30–40 180 2,900 artery and that is sufficiently mobile to be brought into the
40–50 200 3,200 pelvis (Fig. 120.2). O n occasion an abnormally thick, fatty, or
50 240 4,000 short mesentery can limit mobility of the vascular pedicle,
N eomycin base 25 mg/kg 3 thus necessitating extensive division of the mesentery posteri-
Erythromycin base 20 mg/kg 3 orly. The terminal 15 to 20 cm of ileum, as measured from the
Saline enemas until clear ileocecal valve proximally, is spared in order to retain bile salt
absorption, thus preventing steatorrhea and vitamin B12 defi-
ciency (Fig. 120.3). The portion of ileum to be used is mea-
sured and 5-0 silk sutures are used to mark the proximal and
distal limits of resection. Prior to dividing the mesentery, the
including the genitalia. A Foley catheter is inserted urethrally. vascular supply to the isolated segment should be observed by
A midline incision is created beginning at the symphysis pubis transillumination and the proposed incisions in the mesentery
and extending superiorly toward the umbilicus. Retraction marked. Beginning at the mesenteric border of the bowel,
can be provided by an O mni or Bookwalter retractor. In order the mesentery is divided between pairs of fine hemostats and
to avoid the insensible loss of heat and water from peritoneal the vascular arcades are ligated with 5-0 silk suture ties. The
surfaces, it is recommended that any concomitant procedures bowel is then divided between atraumatic bowel clamps that
on the bladder or bladder neck be performed through a lim- have been applied at the proximal and distal limits of resec-
ited incision that does not enter the peritoneal space. tion. O nce the ileal segment reaches into the pelvis without
When a continent diversion is not planned, a midline cysto- tension on the vascular pedicle, no further mesenteric division
tomy suffices to prepare the bladder for augmentation. is needed. An ileoileal anastomosis is performed cephalad to
Ureteral reimplants can be easily performed at this point the isolated ileal segment and the mesenteric trap is closed.
(Fig. 120.1). H owever, when a continent catheterizable stoma The bowel clamps are removed and a thorough lavage of
is planned, either a paramedian or transverse cystotomy the ileal segment is performed with sterile saline. The segment
should be considered since these incisions create bladder flaps is folded 180 degrees and the adjoining serosal surfaces are
that facilitate the creation of a long submucosal tunnel for the sutured with 4-0 PGA. The antimesenteric border of the ileal
appendix or ileal tube. Regardless of the bladder incision segment can then be opened using scissors or the cutting current
FIGURE 120.1 A: Preparation of the bladder for “ clam” augmentation cystoplasty. B: Sagittal incision is
made to create two bladder flaps.
FIGURE 120.2 Blood supply to the jejunum, ileum, and ascending

and transverse colon. (From H inman F Jr, ed. Gastrointestinal tract.
In: H inm an’s A tlas of Urosurgical A natom y, Chapter 6. Philadelphia:
WB Saunders, 1993, with permission.)
FIGURE 120.3 Ileocystoplasty. A 20- to 40-cm segment of ileam at

least 15 cm from the ileocecal valve is removed and opened on its an-
timesenteric border. Ileoileostomy reconstitutes the bowel. B: The
opened ileal segment is reconfigured. This can be done in a U, S, or W
configuration. It can be further folded as a cup patch. C: The recon-
figured ileal segment is anastomosed widely to the native bladder.
(From Adams M C, Joseph DB. Urinary reconstruction in children.
In Cam pbell–Walsh Urology, 9th ed., Chapter 124. Philadelphia: WB
Saunders, 2007, with permission.)
with little concern for bleeding, which usually ceases sponta-

neously. An optional second suture line is created by placing
4-0 PGA through the full thickness of the bowel wall in a con-
tinuous fashion. O nce the ileal cap has been formed, it is anas-
tomosed to the opened bladder beginning at the most
posterior portion of the bladder incision. H emostatic clamps
may be left on the short ends of the tied sutures in order to
identify the most posterior limit of the anastomotic line, thus
facilitating placement of the second, reinforcing suture layer
between the serosal surfaces of the bladder and ileum. A
suprapubic catheter is placed through the bladder wall prior
to completion of the first anastomotic closure.
Rig ht Co lo cyst o p last y and Mainz

Ent e ro cyst o p last y
Enterocystoplasty with a segment of ascending colon is based
on vascular supply from the ileocolic artery (Fig. 120.2).
Dissection begins at the inferior edge of the cecum and pro-
gresses cephalad along the line of Toldt, the peritoneal reflec-
tion lateral to the right colon. At the hepatic flexure, the
hepatocolic ligament must be divided. N ext, the omental
attachments to the colon are divided and the omentum is
packed into the left upper quadrant with moist laparotomy
sponges. The ascending colon is divided at the watershed be-
tween the ileocolic and right colic arteries, approximately mid-
way between the cecum and hepatic flexure. The ileum is
divided close to the ileocecal valve. An ileocolonic anastomosis
is performed and the mesenteric trap is closed. If the appendix
will not be used to create a continent catheterizable stoma, an
appendectomy is performed at this point. The bowel is folded
180 degrees and the serosal surfaces are sutured with 4-0 PGA.
The bowel is incised along its antimesenteric border and the
edges are sutured full thickness with 4-0 PGA placed in a con-
tinuous fashion. The resulting colonic plate is folded once
again. This time the full-thickness suture line is placed first and
reinforced with a second continuous line of 4-0 PGA. The re-
sulting cup is inverted and anastomosed to the bladder opening
as described for the ileocystoplasty. An alternative approach
that has gained wide popularity is the M ainz augmentation, in
which 15 to 30 cm of terminal ileum is isolated in continuity
with the right colon and detubularized, anastomosed to each
other, and sutured to the cystotomy (Fig. 120.4).
FIGURE 120.4 M ainz Ileocecocystoplasty. A and B: The ileal seg-
ment is twice the length as the cecal segment. C and D: It is opened on
Sig mo id o cyst o p last y the antimesenteric border. E and F: The ureters can be opened into the
opened cecal segment if necessary. G and H: The ileocecal segment is
anastomosed to the native bladder. (From Thuroff JW, et al. The
Since the diameter of the sigmoid is much greater than that of M ainz pouch. In: King LR, Stone AR, Websterm GD, eds. Bladder
the ileum, a shorter segment is necessary in order to perform a R econstruction and Continent Urinary D iversion. Chicago: Year
successful augmentation cystoplasty. The isolated segment de- Book, 1987, with permission.)
rives its blood supply from the sigmoid branches of the infe-
rior mesenteric artery (Fig. 120.5). A mesenteric incision is
created proximally and distally and bowel clamps are applied distal ends of the segment are closed and the bowel is opened
to minimize fecal soiling. The sigmoid is divided and a sigmoi- along its antimesenteric border and sutured to the bladder
dosigmoidostomy performed lateral to the mesentery of the opening. In the second, the bowel is opened along its antime-
isolated segment (Fig. 120.6). It is advisable for each surgeon senteric border first, then folded 180 degrees into a U shape
to standardize the side where he or she performs the sigmoi- prior to suturing it to the bladder. The latter method likely dis-
dosigmoidostomy in the event that reoperation is necessary in rupts the high unit contractions of the sigmoid more than the
the future. Two methods are available for anastomosing the first; however, it requires that a greater length of sigmoid be
bowel segment to the bladder. In the first, the proximal and isolated.
FIGURE 120.5 Blood supply to the descending and

sigmoid colon and rectum. (From H inman F Jr, ed.
Gastrointestinal tract. In: H inm an’s A tlas of
Urosurgical A natom y, Chapter 6. Philadelphia: WB
FIGURE 120.6 Sigmoidocystoplasty. A: A sigmoid segment of ade-

quate length is removed from the gastrointestinal tract and a colo-
colostomy is performed. B: In the M itchell technique, the two opened
ends are closed. The antimesenteric border is incised and the segment
is anastomosed to the bivalved bladder. It may be rotated 180 degrees
to allow an easy fit. C: The opened sigmoid segment can be reconfig-
ured into a U or S configuration, which may lower pressure. (From
Adams M C, Joseph DB. Urinary reconstruction in children. In
Cam pbell–Walsh Urology, 9th ed., Chapter 124. Philadelphia: WB
inferiorly. If the vascular pedicle is too short, additional

Gast ro cyst o p last y branches between the gastroepiploic artery and the stomach
must be divided. The stomach is sutured to the bladder begin-
The bladder may be augmented with a gastric segment derived
ning along the posterior aspect of the cystotomy.
from either the antrum or the body of the stomach. When
antral gastrocystoplasty is performed, the enteric stream is re-
constructed using a Billroth I anastomosis (gastroduodenos-
tomy). This procedure is now rarely performed in children Ure t e ro cyst o p last y
because resection of the antrum has been associated with de-
layed gastric emptying, gastric dumping syndrome, and feed- Unlike enterocystoplasty, ureterocystoplasty does not require
ing difficulties. Currently, most surgeons prefer the use of the a midline transperitoneal incision. The entire procedure can be
stomach body instead. A segment between 10 and 20 cm is performed retroperitoneally through a flank incision, to per-
marked along the greater curvature of the stomach and drawn form the nephrectomy and harvest the proximal portion of the
as a rhomboid that extends toward the lesser curvature, end- ureter, and a Pfannenstiel incision, through which the augmenta-
ing 1 cm from the edge so as not to interrupt branches of the tion is performed. Only a midline incision should be considered
vagus nerve. Two arterial supplies exist to the greater curva- when two functioning kidneys exist, since a transureter-
ture of the stomach: (i) the right gastroepiploic artery, derived oureterostomy will be required in order to re-establish continu-
from the right gastric artery, and (ii) the left gastroepiploic ity of the upper urinary tract after the distal ureter has been
artery, from the splenic artery (Fig. 120.7). If the right gas- harvested (Fig. 120.9). Following the nephrectomy, careful
troepiploic artery is chosen, the gastric segment should be ob- mobilization of the ureter from its retroperitoneal location in-
tained from higher on the greater curvature, lower if based on cludes dissection of all surrounding adventitia away from the
the left (Fig. 120.8). The gastroepiploic arteries supply the peritoneal lining toward the ureter itself. The ureter is then
stomach with anterior and posterior branches that must be di- passed into the pelvis. A midline cystotomy is created such
vided before the segment can be excised from the stomach. that the posterior portion of the incision includes the
Atraumatic intestinal clamps are applied in parallel at the pro- ureterovesical junction. The ureter, too, is incised along its an-
posed incision sites on the stomach. Alternatively, an intestinal terior aspect. A spherical reservoir can be created by folding
stapling device can be used to divide the stomach; however, the proximal end of the ureter toward the cystotomy in an in-
the staples must be removed later. The vascular pedicle must verted U and suturing the adjoining edges of the ureter to it-
be retroperitonealized in order to prevent internal hernia for- self. The remainder of the anastomosis between the ureter and
mation. A window is created in the transverse mesocolon that the bladder is performed as in enterocystoplasty, beginning at
accepts the gastric augment and its vascular pedicle. The seg- the posterior aspect of the cystotomy and proceeding in an an-
ment is passed posterior to the mesocolon and exits a second terior fashion. Drainage tubes are placed through the native
window that has been created in the small bowel mesentery bladder muscle tissue.
FIGURE 120.7 Blood supply to the anterior aspect

of the stomach and greater omentum. (From H inman
F Jr, ed. Gastrointestinal tract. In: H inm an’s A tlas of
Urosurgical A natom y, Chapter 6. Philadelphia: WB
FIGURE 120.8 Gastrocystoplasty using the

body of the stomach. A: A gastric segment of
the body is mobilized on the right gastroepiploic
artery. The left vessel may also be used; neither
vessel as a pedicle should be free-floating
through the peritoneum. B: A longer gastric seg-
ment along the greater curvature with a wider
apex provides more surface area for augmenta-
tion. C: The gastric segment is anastomosed to
the bivalved bladder with the mucosa inverted.
(From Adams M C, Joseph DB. Urinary recon-
struction in children. In Cam pbell–Walsh
Urology, 9th ed., Chapter 124. Philadelphia:
WB Saunders, 2007, with permission.)
FIGURE 120.9 Ureterocystoplasty. A: A transverse cystotomy is

made and carried through the anterior wall of the dilated ureter. The
ureter is folded in an inverted-U configuration and anastomosed to
itself before augmenting the bladder. The patch is folded over onto the
cystotomy. B: A transureteroureterostomy is created when the dilated
ureter subtends a functioning kidney. The distal ureter is treated in the
same fashion as with a standard ureterocystoplasty. C: Ectopic ureters
should be transected distally and the periureteral adventitial tissue
preserved as a vascular pedicle to the ureter. An inverted-U shape is
created in order to perform the augmentation.
Urinary and Ab d o minal Drainag e Me t ab o lic Effe ct s

Fo llo w ing Aug me nt at io n Cyst o p last y
Ile o cyst o p last y and Co lo cyst o p last y
If an incontinence procedure has not been performed, an ap- Despite the incorporation of intestine into the urinary tract, its
propriately sized urethral Foley catheter is used. H owever, absorptive and secretory capacity is retained: chloride, ammo-
since the retention balloon can cause pressure necrosis of the nium, hydrogen ions, and organic acids are readily absorbed
bladder neck following incontinence procedures, some sur- and bicarbonate ions are secreted into the urine. The resultant
geons would instead use a Robnel catheter or Silastic feeding hyperchloremic metabolic acidosis is driven by the absorption
tube, which may be secured with 3-0 silk sutures passed of ammonium ions that are followed by chloride in an attempt
through the bladder and abdominal wall and tied over a cot- to maintain electroneutrality. Acidosis is rarely seen in patients
ton bolster. Additionally, a suprapubic M alecot catheter with normal renal function, and any measurable increase in
should be placed through a separate incision in the native serum chloride and decrease in serum bicarbonate is subtle.
bladder and brought out through the anterior abdominal wall. M ild cases of metabolic acidosis can be managed with oral
It is advised that this tube in particular be secured with 3-0 sodium bicarbonate (1 to 3 mEq/kg/day) with the goal being
nylon sutures, since it will remain until after a cystogram has an increase in serum bicarbonate to a value 20 mEq/L.
demonstrated a healed anastomosis and the patient is success- Severe acidosis requires intravenous administration of bicar-
fully catheterizing the reconstructed bladder, approximately bonate, usually as dextrose 5% with one-quarter normal
3 weeks. Irrigation with sterile saline should be instituted on saline and 50 mEq/L of sodium bicarbonate. H yperchloremic
postoperative day 3 in an effort to cleanse the newly aug- metabolic acidosis may occur following augmentation with
mented bladder free of the copious amounts of mucus that the ileum, cecum, colon, or sigmoid but is most common following
enteric segments produce. A closed-system vacuum drain is sigmoidocystoplasty.
employed briefly following surgery and removed when mini- Use of jejunum is associated with a pattern of metabolic
mal peritoneal drainage exists. In patients with ventriculoperi- derangement distinct from any other segment of bowel: a
toneal shunts, cerebrospinal fluid can be confused for hypochloremic, hyponatremic, hyperkalemic metabolic acido-
persistent urinary drainage; it can be discriminated by its sis. For this reason, it is recommended that jejunum not be
lower creatinine level than urine. used in pediatric augmentation cystoplasty, especially when
renal function is poor.
As a consequence of the net secretion of chloride and hydro-
gen ions across the gastric mucosa, augmentation with stomach
O UTCO MES results in a hypochloremic metabolic alkalosis in 3% to 24% of
the patients. This effect can be used to advantage in patients
Gast ro int e st inal Effe ct s with renal dysfunction and acidemia, who will demonstrate
decreased serum chloride and increased serum bicarbonate
The two most likely gastrointestinal complications following following gastrocystoplasty. In those patients whose renal dys-
augmentation cystoplasty in children are diarrhea and vita- function is characterized by a concentrating defect, gastroin-
min B12 deficiency (each in up to 23% ). Small bowel obstruc- testinal illness with vomiting can precipitate significant alkalosis
tion may occur in approximately 3% of patients and is no that must be treated with intravenous fluid containing sodium
more likely with any one particular segment of bowel. chloride. M ilder cases can be treated with oral salt supplemen-
Gastrocystoplasty is associated with a greater risk for small tation, or inhibitors of histamine-2 (i.e., cimetidine) or the gastric
bowel obstruction as a function of the difficulty in retroperi- acid H /K ATPase pump (omeprazole). It has also been re-
tonealizing the vascular pedicle to the gastric patch. The po- ported that alkalosis occurs in the absence of gastrointestinal
tentially free-floating pedicle can permit internal herniation of illness and may still be severe enough to require resection of a
bowel loops that in later stages compromises vascularity to portion of the gastric segment. Alternatively, addition of ileum
the gastric patch itself. may balance the metabolic abnormality.
Diarrhea, a complication most often found following the
use of the ileocecal valve (up to 23% ), may also be seen after
standard ileocystoplasty, although less frequently (11% ). For Blad d e r Co mp liance
this reason, use of the ileocecal valve is not advocated when
other segments will serve just as well. The sigmoid, for in- The immediate goal of augmentation cystoplasty should be
stance, dilates and lengthens as a consequence of constipation, that intravesical storage pressure decreases well below the
thus affording the surgeon a more redundant segment with threshold of 40 cm H 2 O , thus averting progressive upper tract
which to augment. An additional advantage of sigmoid is its deterioration. Although any gastrointestinal segment can pro-
proximity to the bladder. vide a sufficiently compliant augment if it is very long and
Vitamin B12 deficiency can be avoided by limiting the fully detubularized, most authors agree that, for a given length
length of small bowel harvested and in particular by preserv- of bowel, ileum provides the greatest compliance of any seg-
ing the terminal 20 cm of ileum, the major site of B12 absorp- ment. O f 323 patients who had undergone enterocystoplasty
tion. Ileocecal augmentation cystoplasty carries a greater risk in one large review, 6% required an additional augmentation
for vitamin B12 deficiency (23% ) as compared with standard because of persistently elevated intravesical pressure.
ileocystoplasty (11% ), yet one is unlikely to encounter this de- Colocystoplasty and gastrocystoplasty patients were 10 times
ficiency at all since in the majority of circumstances a limited more likely to need a repeat procedure as compared with
portion of nonterminal ileum is employed. those having undergone an ileocystoplasty (4).
symptoms; shoulder pain secondary to diaphragmatic irrita-

Urinary Tract Infe ct io n tion from urine in the peritoneal cavity has also been reported.
Which gastrointestinal segment carries the greatest risk of per-
Regardless of the segment chosen, persistent bacteriuria is
foration is debatable (8). Any child is potentially at risk irre-
common following augmentation cystoplasty, occurring in up
spective of the segment used. The underlying etiology for all
to 95% of patients. The Indiana group reported symptomatic
perforations is believed to be ischemia within the bowel wall
urinary tract infection in 23% of ileocystoplasties, 17% of
as a consequence of either overdistention from infrequent
colocystoplasties, 13% of cecocystoplasties, and only 8% of
emptying or high-pressure contractions or even reconfigura-
gastrocystoplasties, which suggests that bacterial colonization
tion by detubularization (9).
may be impeded by the reduced urine pH in bladders aug-
Patients suspected of having bladder perforation should
mented with stomach (5). Symptomatic cystitis may be more
undergo fluid resuscitation and receive intravenous broad-
likely when CIC is performed sporadically and incompletely
spectrum antibiotics and Foley catheter drainage while the
or when mucus and stones serve as a nidus for colonizing
evaluation is underway. A standard cystogram may miss up to
bacteria.
33% of bladder perforations; therefore, computerized tomog-
raphy cystograms are advocated. While some have successfully
employed nonoperative management, surgical exploration
Calculi Fo rmat io n and Mucus Pro d uct io n with resection of necrotic tissue and primary closure of the de-
fect should be performed in a gravely ill patient, or when the
The reported incidence of bladder calculi has ranged between patient fails to improve during nonoperative management (10).
8% and 52% of patients following augmentation cystoplasty,
yet the occurrence of bladder calculi may not be a specific
complication of augmentation cystoplasty (6,7). Instead, poor He mat uria–Dysuria Synd ro me
patient compliance with CIC, colonization with urea-splitting
bacteria, and the presence of mucus to serve as a nidus for the This syndrome, occurring in 9% to 70% of patients who have
aggregation of salts may be the trifecta that results in calculus undergone a gastrocystoplasty, presents with perineal pain,
formation. By virtue of lesser mucus production and bacteri- dysuria, hematuria, and skin excoriation around either the
uria than either ileum or colon, stomach is least likely to be as- urethral meatus or the stoma of a catheterizable channel (11).
sociated with bladder calculi. M ucus production from ileal A recent study of 10 children with hematuria–dysuria identi-
segments does decrease over time as a result of villous atrophy, fied a positive correlation between the presence of infecting
a feature not characteristic of colonic epithelium. H elicobacter pylori, reduced urine pH , and the presence of
symptoms following gastrocystoplasty (12). The authors rec-
ommend evaluating all patients who are under consideration
Blad d e r Pe rfo rat io n for a gastric augment for the presence of H . pylori and treat-
ing the infection before performing surgery. O ral therapy with
Perforation is the most serious complication of augmentation histamine-2 or H /K ATPase blockers should be helpful in
enterocystoplasty, and patients may present critically ill de- symptomatic patients. If prolonged catheterization is antici-
spite few localizing signs and symptoms. The condition should pated, then bladder irrigations should be performed with a
immediately be suspected when an augmented patient pre- sodium bicarbonate–containing solution.
sents with fever and abdominal pain no matter how mild the
References
1. Woods C, Atwell JD. Vesico-ureteric reflux in the neuropathic bladder with 7. Khoury AE, Salomon M , Doche R, et al. Stone formation after augmenta-
particular reference to the development of renal scarring. Eur Urol 1982; tion cystoplasty: the role of intestinal mucus. J Urol 1997;158:1133–1137.
8:23–28. 8. Rink RC. Bladder augmentation. O ptions, outcomes, future. Urol Clin
2. Joseph DB, Colodny AH , M andell J, et al. Clean, intermittent catheteriza- N orth A m 1999;26:111–123.
tion of infants with neurogenic bladder. Pediatrics 1989;84:778–782. 9. Pope JC, Albers P, Rink RC, et al. Spontaneous rupture of the augmented
3. Yerkes EB, Rink RC, Cain M P, et al. Shunt infection and malfunction after bladder: from silence to chaos. Proceedings of the Annual M eeting of the
augmentation cystoplasty. J Urol 2006;165(6, pt 2):2262–2264. European Society of Pediatric Urology, Istanbul, Turkey, 1999.
4. M itchell M E, Piser JA. Intestinocystoplasty and total bladder replacement 10. Slaton JW, Kropp KA. Conservative management of suspected bladder
in children and young adults: follow-up in 129 cases. J Urol 1987;138: rupture after augmentation enterocystoplasty. J Urol 1994;152:713–715.
579–584. 11. Leonard M P, Dharamsi N , Williot PE. O utcome of gastrocystoplasty in
5. Rink RC, H ollensbe D, Adams M C. Complications of bladder augmenta- tertiary pediatric urology practice. J Urol 2000;164:947–950.
tion in children and comparison of gastrointestinal segments. A UA Update 12. Celayir S, Goksel S, Buyukunal SN . The relationship between H elicobacter
Series 1995;14:122–127. pylori infection and acid–hematuria syndrome in pediatric patients with
6. Barroso U, Jednak R, Fleming P, et al. Bladder calculi in children who per- gastric augmentation, II. J Pediatr Surg 1999;34:532–535.
form clean intermittent catheterization. BJU Int 2000;85:879–884.
CHAPTER 121 ■ THE MITRO FANO FF
PRO CEDURE IN PEDIATRIC URINARY TRACT
RECO NSTRUCTIO N
MARK P. CAIN
The M itrofanoff principle offered a major advancement to

continent urinary reconstruction for children and adults.
Earlier innovations—including clean intermittent catheteriza-
tion (CIC), bladder augmentation, and a variety of bladder
neck tightening procedures—created the foundation that made
continent bladder reconstruction possible. The technically dif-
ficult problem was creating a bladder outlet that was tight
enough to ensure continence but wide enough to allow reli-
able catheterization over a lifetime. In addition, many of these
patients have physical disabilities that prevent easy access to
the urethra, making independent urethral catheterization chal-
lenging. The concept of a continent catheterizable abdominal
channel was introduced by Paul M itrofanoff in 1980 (1) and
has since been widely adopted as an integral part of urinary
tract reconstruction for continence in most pediatric centers
worldwide. This principle involves creation of a flap-valve
continence mechanism for a conduit that is tunneled into a
low-pressure urinary reservoir that can then be catheterized
and emptied via an abdominal stoma (Fig. 121.1).
There are multiple surgical options for creating the
M itrofanoff channel. Appendicovesicostomy has by tradition
been used because of the availability and the reliable blood
supply, adequate lumen for catheterization, and supple mus-
cular wall. Long-term follow-up has shown that appendi-
covesicostomy provides a durable channel with minimal late
complications (2,3). In the absence of a suitable appendix, or
in conditions where the appendix is used for an alternate pro-
cedure (such as for a M alone antegrade continence enema
[M ACE channel]), there are several other options that have
FIGURE 121.1 Umbilical M itrofanoff stoma allowing catheteriza-
been described. The most reliable alternatives have been the tion in the sitting or standing position.
M onti–Yang ileovesicostomy, ureterovesicostomy, and conti-
nent bladder tube.
useful in wheelchair-bound patients who cannot access their
perineum independently and also in patients with normal ure-
DIAGNO SIS thral sensation, in whom catheterization can be traumatic
The M itrofanoff procedure can be performed with essentially both physically and psychologically.
any underlying bladder pathology. The most frequent diagno-
sis for children undergoing the procedure is neuropathic blad-
der, usually due to myelomeningocele. This procedure has also INDICATIO NS FO R SURGERY
been described for reconstruction in patients with exstrophy–
epispadias, cloacal anomalies, prune belly syndrome, poste- In the past, the primary indication for bladder reconstruction
rior urethral valves, and other conditions. Although many of was for upper urinary tract preservation. In the era of aggressive
these children will require a bladder outlet procedure to pro- use of anticholinergics and intermittent catheterization in young
vide urinary continence, some will have an intact and conti- patients, the more common indication for a M itrofanoff channel
nent bladder outlet and the M itrofanoff channel will provide is for urinary continence and convenient, independent bladder
an alternative to urethral catheterization. This is especially management for the patient. All patients should undergo a
793
trial of CIC to demonstrate that they are reliable and able to

comply with a daily routine prior to bladder reconstruction.
ALTERNATIVE THERAPY
The most common alternative to continent bladder recon-
struction with a M itrofanoff stoma is anticholinergic therapy
with clean intermittent urethral catheterization. With careful
attention to catheterization schedules and fluid intake, social
dryness can be achieved in many patients with neuropathic
bladder and other underlying bladder pathology without the
need for surgical intervention.
Less frequently used alternatives are long-term incontinent
cutaneous vesicostomy and conduit urinary diversion.
Although these are both considered suboptimal in the era of
continent urinary reconstruction, there will be a subset of pa-
tients who are unable to care for themselves because of physi-
cal, mental, or psychosocial problems, and the incontinent
diversion provides a safer long-term option for these patients.
In the rare patient with a completely nonusable bladder, a
continent urinary reservoir with a continent catheterizable
channel is another alternative.
FIGURE 121.2 Vascular anatomy of appendicular artery.
SURGICAL TECHNIQ UE lower-quadrant appendicovesicostomy or in a wide U-shaped

All patients are admitted the day before surgery for intra- anterior bladder incision for an umbilical stoma. The appen-
venous antibiotics to sterilize the urinary tract and for a me- dix is detached from the cecum either sharply or with a sta-
chanical and antibiotic bowel preparation. This is particularly pling device, and the cecum is closed with absorbable and
important for patients with ventriculoperitoneal shunts, who permanent sutures. The mesentery to the appendiceal artery
have a risk of shunt infection. Potential sites for stomal loca- can be freed from the cecal mesentery to allow complete mobi-
tion should be determined preoperatively, with the patient in lization of the appendix if needed (Fig. 121.3). The terminal
the sitting and supine position. end of the appendix is then opened and irrigated with antibi-
Surgical exposure is usually obtained through a midline otic solution, and a 12Fr catheter is passed to ensure that the
transabdominal incision that is carried around the umbilicus appendix has an adequate lumen. If necessary the appendix
to leave enough fascia to close the abdomen without compro- can be gently dilated with serial sounds. If bladder augmenta-
mising an umbilical stoma. A lower transverse Pfannenstiel in- tion is to be performed, the segment of bowel is isolated,
cision will also allow adequate exposure for both bladder
augmentation and the M itrofanoff stoma in thin patients.
Laparoscopy has been used to assist in mobilization of the ap-
pendix and colon, allowing a smaller abdominal incision to
complete the reconstruction without compromising exposure.
Ap p e nd ico ve sico st o my
The right colon is mobilized beyond the hepatic flexure to al-
low maximal freedom of the appendiceal mesentery. If the ap-
pendix is retrocecal in location it is mobilized carefully from
the cecal attachments with extra caution to avoid injuring the
appendiceal artery, which is a branch of the ileocolic artery
(Fig. 121.2). In some cases there is significant peritoneal in-
flammation due to the presence of a ventriculoperitoneal
shunt, and the peritoneal incision must be carried medial to
the ileocecal valve to adequately mobilize the appendix. When
the length of appendix is inadequate, it can be extended by in-
corporating a segment of distal cecum as described by Cromie
et al. (4). Prior to detaching the appendix, the bladder is mobi-
lized to ensure that the bladder and appendix can easily reach
the chosen site for the abdominal stoma without tension. The FIGURE 121.3 The mesentery to the appendix can be mobilized care-
bladder is then opened to the left of the midline for a right fully, taking care not to injure the appendicular artery.
Chap t e r 121: The Mitrofanoff Proce d ure in Pe d iatric Urinary Tract Re construction 795
harvested, and reconfigured appropriately. If an additional

segment of intestine is required for the M itrofanoff (e.g.,
M onti–Yang) channel, it can be harvested simultaneously. The
site of the bladder hiatus is then selected, again ensuring that it
can easily reach the posterior abdominal wall fascia without
tension. The site of the hiatus is opened wide enough to allow
the appendix to pass without any tension, and a vessel loop is
passed through the hiatus for traction. A submucosal bladder
tunnel is then created using sharp dissection. Placing several
traction sutures on the bladder to flatten out the posterior
bladder wall facilitates this dissection. The orientation of the
tunnel should be directed away from the bladder outlet and
trigone to prevent painful catheterization postoperatively. The
tunnel length should be at least 2.5 cm in length. It is occa- FIGURE 121.4 The bladder is secured to the posterior abdominal
fascia to avoid redundancy in the extravesical channel, which can be a
sionally helpful to inject 1:200,000 epinephrine along the path source of late catheterization problems.
of the submucosal tunnel to facilitate the dissection and mini-
mize bleeding. The terminal end of the appendix is then
passed through the bladder hiatus and submucosal tunnel. The stoma is then catheterized multiple times with the bladder
The appendix is spatulated and secured distally with two 4-0 both distended and empty to ensure that there is no angula-
absorbable sutures incorporating full-thickness bites of the ap- tion in the channel. A 12Fr catheter is left indwelling for
pendix and detrusor muscle and mucosa. The remainder of 3 weeks before initiating intermittent catheterization.
the anastomosis is completed using 4-0 or 5-0 absorbable su- When both M itrofanoff and M ACE channels are indicated,
tures, securing the bladder mucosa to the appendix. The ap- and the appendix is of adequate length to create both chan-
pendix is also secured at the level of the bladder hiatus using nels, it can be split, with the majority of the mesoappendix left
several 4-0 absorbable sutures. The channel is catheterized intact with the M itrofanoff segment, basing the blood supply
with a 12Fr or 14Fr catheter to ensure that it passes easily to the appendiceal stump off the cecal artery. In some cases the
across the hiatus and submucosal tunnel. The stomal site is appendix is too short to use for both channels, but in this cir-
then selected, taking care to ensure that the bladder hiatus can cumstance the appendix can still be used for both channels,
reach the posterior fascia without tension. A U-shaped (umbil- utilizing one of the described stapling techniques to extend the
ical) or V-shaped skin incision is made at the stomal site, and appendix into the cecum for the M ACE channel (5,6).
the flap is freed sharply to the level of the fascia. A cruciate in-
cision is made in the fascia and widened to allow passage of an
index finger. The appendix is then brought through the fascial Mo nt i–Yang Ile o ve sico st o my
opening and the appendiceal/bladder hiatus is secured to the
posterior fascial wall using 3-0 absorbable sutures, taking care The concept of retubularized ileum as a replacement for the
not to angulate or compress the appendiceal mesentery appendicovesicostomy was introduced in 1997 (7,8), and it
(Fig. 121.4). This maneuver ensures a short, straight extraves- has quickly become the ideal alternate to appendix as a choice
ical appendix channel. The cecal end of the appendix is then for the M itrofanoff channel. Large series with longer follow-
spatulated on the antimesenteric side, and if there is redun- up have confirmed the equivalent outcomes for the M onti–
dant appendix it is amputated. The stomal anastomosis is Yang channel and appendicovesicostomy (9). The growing
secured using interrupted 4-0 absorbable sutures (Fig. 121.5). indications for and use of the M ACE channel have led to
FIGURE 121.5 The skin stoma is com-

pleted by securing the wide-based V flap
of skin into the spatulated channel.
FIGURE 121.6 A 2.5- to 3-cm segment of ileum is harvested, distal to

the segment of intestine to be used for augmentation (if indicated).
preservation of the appendix for the appendicocecostomy

stoma and the need for alternatives for a bladder channel.
Because many of the children will also undergo bladder aug-
mentation at the time of reconstruction, the M onti–Yang
channel can be easily constructed from a segment of the bowel
harvested for augmentation.
A 2.5- to 3-cm segment of intestine is harvested with a well-
vascularized segment of mesentery (Fig. 121.6). If ileal augmen-
tation is planned, the Monti–Yang segment can be easily
harvested from the distal end of the segment with a shared
mesentery. The ileal segment is opened on the antimesenteric
side (Fig. 121.7). It can be opened slightly off the midline to pro-
vide a longer segment for implanting into the bladder. The
opened segment is then retubularized transversely in two layers B
over a 14Fr catheter. The bowel mucosa is approximated with
FIGURE 121.8 A: The channel is closed with two layers of
running 5-0 or 6-0 absorbable sutures and the muscular layer absorbable sutures. The stomal end is either closed with interrupted
is closed with running or interrupted 4-0 absorbable sutures sutures or not closed to allow adequate spatulation at the skin stoma.
(Fig. 121.8). The stomal end is not closed initially, providing B: O perative photo of completed M onti channel.
wide spatulation of the antimesenteric side of the tube for later
stomal anastomosis. The technique of implanting the tube into
the bladder and creating a stoma is identical to that for appendi- the tube can be implanted into a segment of bowel using an ex-
covesicostomy (Fig. 121.9). The Monti–Yang tube can be cre- travesical technique. Care must be taken to secure the entire tun-
ated out of any segment of intestine with good results. If there is nel length to the posterior fascial wall to prevent breakdown
inadequate bladder volume for creation of a submucosal tunnel, of the thin muscular backing during repetitive bladder filling,
with the potential for late incontinence. A 12Fr catheter is
left across the channel for 3 weeks before initiating intermit-
tent catheterization. The M onti channel can also be used for
the M ACE channel, with two channels created side by side
(Fig. 121.10).
When the M onti channel does not provide adequate length
for the extravesical section to reach the abdominal stomal site
without tension, then two M onti tubes can be reconfigured and
connected (the “ double Monti” ). This can provide a longer
limb to reach the skin stoma but also introduces additional
postoperative complications of diverticulum, angulation, and
perforation at the anastomosis of the two channels (10). To
avoid this complication, Casale (11) described a long ileovesi-
costomy technique using a single piece of bowel to create a
channel 10 to 14 cm in length. This technique involves a 3.5- to
4-cm segment of bowel that is isolated on its mesentery and di-
FIGURE 121.7 The M onti segment is detubularized on the antime-
senteric side. This incision can be between the 9 and 12 o’clock posi- vided into two equal segments for approximately 80% of the
tions depending on the desired length of intravesical tunnel. bowel circumference, leaving the two segments attached on the
FIGURE 121.11 Diverticula in channel directly outside the bladder

hiatus. This complication occurs from repetitive difficult catheteriza-
tion due to a long and tortuous extravesical portion of the
M itrofanoff channel.
FIGURE 121.9 The M onti channel can be brought out either to a

lower-abdominal stoma or to the umbilicus. The mesentery is mobi- in the umbilicus, presumably due to extravesical channel elon-
lized from the pedicle of the bladder augmentation to provide a
gation and tortuosity over time and development of a perihi-
tension-free skin anastomosis.
atal diverticulum (Fig. 121.11) (12).
Co nt ine nt Ve sico st o my
Small subsets of patients require creation of only a catheteriz-
able bladder channel without bladder augmentation or other
intra-abdominal procedures. These patients are good candi-
dates for extraperitoneal continent vesicostomy. The largest
reported experience is using the procedure described by Cain
and Rink (13) utilizing an intravesical submucosal-mucosal–
lined tunnel to create the continence mechanism. This proce-
dure has been successfully used with a variety of underlying
bladder pathologies.
The bladder is opened to allow creation of either a midline
or lateral full-thickness bladder flap (Fig. 121.12A). Incisions
are extended intravesically, leaving a 2.5-cm plate of mucosa.
The mucosa is sharply dissected off the underlying detrusor
muscle laterally and medially to allow tension-free mucosal
closure (Fig. 121.12B). The intra- and extravesical mucosal
tube is created over a 14Fr catheter with running 6-0
absorbable suture (Fig. 121.12C). The detrusor muscle of the
extravesical portion of the tube is then closed with 4-0 ab-
sorbable sutures (Fig. 121.12D). The continence mechanism is
then created by closing the lateral edges of the bladder mucosa
over the mucosal tube using running 5-0 absorbable suture
(Fig. 121.12E). The stoma can be created in either the lower
FIGURE 121.10 The “ dual M onti,” utilizing a M onti channel for abdomen or umbilicus. An indwelling 12Fr catheter is left in
both the M alone antegrade continence enema and M itrofanoff place for 3 weeks.
channels.
mesenteric side. The two loops of intestine are opened close to Ure t e ro ve sico st o my
the mesentery on opposite sides, allowing the bowel to unfold
in opposite directions, creating a long flat plate of intestine that The ureter can be used as a catheterizable channel but has
can be retubularized after trimming the redundant lateral edges. been less popular than bowel channels due to the additional
Late follow-up has demonstrated comparable results between upper urinary tract reconstruction required and the higher risk
the M onti and Casale-M onti, with the exception of slightly of skin stenosis and stomal leakage (14,15). When there is a
higher open revision rates for the longer spiral M onti placed unilateral nonfunctioning kidney with a nonrefluxing distal
A D
B
E
FIGURE 121.12 A: A 2.5-cm full-thickness bladder tube is harvested
with adequate length to reach an abdominal stomal site. B: Intravesical
mucosal incisions are made, leaving a 2.5-cm mucosal strip. The mu-
cosal incisions should extend approximately 2.5 cm into the bladder.
The lateral mucosal edges are mobilized sharply. C: The mucosal
channel is closed using running 6-0 suture. D: The detrusor muscle of
the extravesical portion of the bladder tube is closed with running 4-0
suture. E: The lateral mucosal edges are closed over the intravesical
mucosal tube to create the continence mechanism.
ureter, a ureteral channel should be considered, but this unfor-

tunate situation should be avoidable in the present era of care-
ful management of these patients from early in life. Several
reports have also documented successful distal ureteral reim-
plantation at the time of the ureterovesicostomy. O bviously,
careful mobilization of the ureter to prevent proximal and dis-
C tal stenosis is an important technical factor.
occasion reoperation will be necessary, and the patient and sur-

O UTCO MES geon should be prepared to replace the entire tube if required.
Complications will usually occur within the first year but
Co mp licat io ns may occur many years after construction of a M itrofanoff
channel, and long-term follow-up with these patients is
Potential complications of the M itrofanoff channel are listed mandatory, especially when the M itrofanoff channel is the
in Table 121.1. The most common complication is stomal sole means to empty the bladder (2,16).
stenosis, occurring in 10% to 20% of channels in most series.
The continent vesicostomy has a much higher rate of stenosis
than either appendix or M onti–Yang channels. A short period Re sult s
of passive catheter dilation for 7 to 10 days will avoid the need
for surgical intervention in some patients. If necessary, revi- M ost large series have reported long-term success in up to
sion of the stoma with a well-vascularized flap of skin is usu- 96% to 98% of M itrofanoff channels (2,17). Because appen-
ally successful to manage significant stenosis. dicovesicostomy has been used since the initial description of
Difficulty catheterizing the channel can occur secondary to the procedure, there are better long-term data for this specific
angulation, perforation/false passage, or stenosis of the chan- procedure, which has been shown to be durable over long pe-
nel. Initially this should be treated conservatively with endo- riods of intermittent catheterization. We recently reported our
scopic placement of an indwelling catheter for 1 to 2 weeks. On results using the M onti–Yang channel in 199 consecutive pa-
tients, achieving 97% success with an average of 3 years of
follow-up, which was identical to our experience with appen-
dicovesicostomy (9). Because of the short continence zone re-
TA B LE 1 2 1 . 1 quired with the mucosal flap-valve technique for continent
vesicostomy, there has been nearly 100% success with this
COMPLICATION S OF MITROFAN OFF CHAN N EL procedure with respect to stomal continence.
Stomal stenosis
Failure to obtain continence can be due to an inadequate
submucosal tunnel, a fistula into the M itrofanoff tube, break-
Stomal incontinence
down of the muscular backing to the submucosal tunnel (espe-
Difficulty catheterizing channel
cially when implanted into a bowel segment), or poor bladder
Intra-abdominal adhesions compliance/high intravesical pressure. In many instances, the
Shunt infection underlying problem will be the bladder, and any patient with a
Abdominal abscess failed M itrofanoff should undergo repeat urodynamic studies
Painful catheterization of the bladder and a trial of anticholinergics. We have had
Prolapsed stomal mucosa good success with reimplanting a previously constructed chan-
Peristomal hernia nel at the time of secondary bladder augmentation when the
Wound dehiscence/infection initial M itrofanoff channel has failed because of changing
bladder dynamics.
References
1. M itrofanoff P. Cystostomie continent trans-appendiculaire dans le traite- 10. N arayanaswamy B, Wilcox DT, Cuckow PM , et al. The Yang-M onti
ment des vessies neurologiques. Chir Pediatr 1980;21:297. ileovesicostomy: a problematic channel? Br J Urol 2001;87:861–865.
2. H arris CF, Cooper CS, H utcheson JC, et al. Appendicovesicostomy: 11. Casale AJ. A long continent ileovesicostomy using a single piece of bowel.
the M itrofanoff procedure—a 15-year perspective. J Urol 2000;163: J Urol 1999;162:1743–1745.
1922–1926. 12. Leslie JA, Cain M P, Kaefer M , et al. A comparison of the M onti and Casale
3. Liard A, Seguier-Lipszyc E, M athiot A, et al. The M itrofanoff procedure: (spiral M onti) procedures. J Urol 2007;178:1623–1627.
20 years later. J Urol 2001;165:2394–2398. 13. Cain M P, Rink RC, Yerkes EB, et al. Long-term follow up and outcome of
4. Cromie WJ, Barada JH , Weingarten JL. Cecal tubularization: lengthening continent catheterizable vesicostomy using the Rink modification. J Urol
technique for creation of catheterizable conduit. Urology 1991;37:41–42. 2002;168:2583–2585.
5. H erndon CDA, Cain M P, Casale AJ, et al. The colon-flap/extension 14. Castellan M A, Gosalbez R, Labbie A, et al. O utcomes of continent
M alone antegrade colonic enema: an alternative to the M onti-M ACE. catheterizable stomas for urinary and fecal incontinence: comparison
J Urol 2005;174(1):299–302. among different tissue options. BJU Int 2005;95:1053–1057.
6. Sheldon CA, M inevich E, Wacksman J. M odified technique of antegrade 15. M or Y, Kajbafzadeh AM , German K, et al. The role of ureter in the
continence enema using a stapling device. J Urol 2000;163:589–591. creation of M itrofanoff channels in children. J Urol 1997;157:
7. Cain M P, Casale AJ, Rink RC. Initial experience using a catheterizable 635–637.
ileovesicostomy (M onti procedure) in children. Urology 1998;52:870. 16. Thomas JC, Dietrich M S, Trusler L, et al. Continent catheterizable
8. M onti PR, Lara RC, Dutra M A, et al. N ew techniques for construction of channels and the timing of their complications. J Urol 2006;176:
efferent conduits based on the M itrofanoff principle. Urology 1997;49: 1816–1820.
112–115. 17. Cain M P, Casale AJ, King SK, et al. Appendicovesicostomy and newer
9. Dussinger AM , Cain M P, Casale AJ, et al. Appendico-vesicostomy versus alternatives for the M itrofanoff procedure: results in the last 100 patients
M onti ileovesicostomy for M itrofanoff channel: the Indiana experience in at Riley Childrens’s H ospital. J Urol 1999;162:749.
over 300 patients. J Urol 2006;175:250–251.
SECTIO N IX ■ LAPARASCO PIC
LEO NARD G. GO MELLA
CHAPTER 122 ■ BASIC PRINCIPLES O F

LAPARO SCO PY: TRANSPERITO NEAL,
EXTRAPERITO NEAL, AND HAND-ASSISTED
TECHNIQ UES
GAURAV BANDI AND LEO NARD G. GO MELLA
Laparoscopic surgery is being increasingly utilized for man- a hand-assisted or an open approach due to failure to progress
agement of urologic conditions that were traditionally man- or management of complications at any point during the
aged by open surgery (1–3). Chapters 124 to 136 include intraoperative or postoperative course. Patients often view la-
laparoscopic procedures commonly performed by urologists paroscopic surgery so favorably that they may expect to have
in the United States. This chapter provides the foundation for no discomfort and immediately return to full activities. The
any laparoscopic procedure and describes techniques to enter patient must understand that interventional laparoscopy is
the intra- or extraperitoneal space, insufflate, place viewing still a surgical procedure with some of the inconveniences and
and access ports (including hand-assist devices), and exit the complications associated with any operation. The patient
abdomen. This chapter outlines the basic laparoscopic tech- needs to be aware of both complications unique to la-
niques and principles utilized for the other laparoscopic proce- paroscopy (e.g., fatal gas embolism, problems owing to hyper-
dures described in this edition, including robotically assisted carbia, postoperative crepitus, pneumothorax, electrosurgical
procedures. bowel injury) and procedure-specific complications (e.g., adja-
cent organ injury).
Although transperitoneal laparoscopy can be performed
for the majority of urologic procedures, significant complica-
INDICATIO NS FO R SURGERY tions, such as bowel or vascular injuries, can occur when
utilizing the transperitoneal approach. Extraperitoneal la-
Laparoscopy provides a minimally invasive approach to
paroscopy decreases the risk of visceral and vascular injury
many standard open surgical procedures. Benefits to laparo-
and may decrease the incidence of shoulder-tip pain, trocar
scopic intervention may include reduced analgesia, shorter
site hernias, postoperative ileus, and adhesions, thereby result-
hospital stay, faster return to normal activity, and enhanced
ing in slightly more rapid postoperative recovery. It is also as-
cosmesis.
sociated with decreased alteration in cardiac and pulmonary
Absolute contraindications to transperitoneal laparoscopy
function and may be especially beneficial in patients with pre-
include inability to tolerate general anesthesia or pneumoperi-
vious transperitoneal surgery. Limitations to the extraperi-
toneum (i.e., severe cardiac or pulmonary disease), intestinal
toneal approach include limited working space, unique
obstruction and/or substantial distention, massive hemoperi-
anatomic orientation, and a steeper learning curve. Excessive
toneum or hemoretroperitoneum, generalized peritonitis, ab-
fat in the extraperitoneal space may obscure the anatomy,
dominal wall infection, uncorrectable coagulopathy, or advanced
especially in the retroperitoneum. The limited retroperitoneal
intra-abdominal malignancy. Relative contraindications in-
working area requires accurate placement of secondary ports
clude morbid obesity, prior abdominal or pelvic surgery, large
and may make entrapment of large masses and intracorporeal
abdominal wall hernias, marked organomegaly, and preg-
suturing difficult. Although there is some evidence to suggest
nancy. This list, in general, also applies to extraperitoneal and
that there may be more CO 2 absorption in the extraperitoneal
hand-assisted laparoscopic procedures. Contraindications to
space, in general it can be managed by aggressive ventilation.
extraperitoneal laparoscopy also include prior surgery or in-
H and-assisted laparoscopy was devised in part to over-
flammation in the extraperitoneal space.
come the learning curve of conventional laparoscopy. H and-
assisted laparoscopy has now been applied to many surgical
scenarios and has been reported to provide many of the same
ALTERNATIVE THERAPY advantages as “ pure” laparoscopy in terms of patient recovery
and morbidity (4,5). The hand-assisted approach can offer
All patients undergoing laparoscopic surgery should be in- some additional benefits over pure laparoscopic techniques: it
formed of the alternate approaches available (including open allows tactile feedback, it may facilitate dissection in challeng-
surgery and nonsurgical approaches) and the team’s experi- ing cases, it may reduce operative times, the hand is a more
ence with the specific procedure. The patient must also be in- facile retractor and dissector than standard rigid instruments,
formed that the procedure may be terminated or converted to and specimens can be easily removed intact. H and-assisted
801
802 Se ct io n IX: Lap arascop ic
laparoscopy bridges the gap between standard open skills and appropriately, can markedly decrease the incidence of iatro-
advanced laparoscopic skills and may be important for train- genic neuromuscular injuries.
ing purposes as the ability to perform rapid hand exchanges is General endotracheal anesthesia is essential for interven-
possible. Drawbacks of hand-assisted laparoscopy include the tional laparoscopy. N itrous oxide anesthesia is discouraged as
creation of a more noticeable (albeit small) incision, the po- it may cause bowel distention. An orogastric tube and a Foley
tential for a slower recovery than pure laparoscopy, and the catheter should be placed prior to any transperitoneal laparo-
increased risk of wound-related complications. scopic surgery to decompress the bowel and bladder, respec-
tively, thereby decreasing the chance of injury during
insufflation and initial trocar placement and facilitating visu-
alization during surgery. Deep venous thrombosis prophylaxis
SURGICAL TECHNIQ UE can be achieved by utilizing pneumatic compression stockings
or by administration of subcutaneous heparin preoperatively.
Pat ie nt Pre p arat io n The field should always be prepared widely should there be
need to convert to an open procedure. In some procedures it is
Careful patient selection and identification of possible relative of advantage to extend the preparation to the knees and to
and absolute contraindications are vital to a successful out- drape the external genitalia into the surgical field to ensure ac-
come of any laparoscopic procedure. A meticulous past his- cess to the urethra for instrumentation (e.g., prostatectomy,
tory and physical examination are the initial steps in patient cystectomy).
evaluation for possible laparoscopic surgery following the
same criteria established for any other significant open surgi-
cal procedure. Patients with severe chronic obstructive pul- Transp e rit o ne al Acce ss: Clo se d Te chniq ue
monary disease and significant cardiac histories should
undergo further evaluation. Serum type and screen are suffi- Initial pneumoperitoneum can be established using a Veress
cient for diagnostic laparoscopy or procedures associated with needle for most transperitoneal laparoscopic procedures and
a low chance of major hemorrhage (e.g., varicocelectomy). for many hand-assisted procedures. The Veress needle has a
M ore extensive laparoscopic procedures (e.g., nephrectomy, spring-loaded, blunt-tipped obturator to help prevent injury.
prostatectomy) may require type and hold or type and ready The site of Veress needle entry depends on the position of
depending on the surgeon’s experience. For extraperitoneal la- the patient and the type of the procedure performed. With the
paroscopic surgery, no bowel preparation is needed. For patient in supine position, the patient is placed in the 10- to
transperitoneal laparoscopic procedures, a light mechanical 20-degree Trendelenburg position and the entry into the ab-
bowel preparation can be given in an effort to decompress the dominal cavity can be performed at the inferior or superior
bowel. Usually, a clear liquid diet and a Dulcolax suppository margin of the umbilicus. The umbilicus is the central point of
or half a bottle of magnesium citrate the day before the proce- the peritoneal cavity, making it an ideal observation site. H ere,
dure is sufficient. A full mechanical and antibiotic bowel the abdominal wall is only two layers thick (fascia and peri-
preparation should be considered if one anticipates encounter- toneum) and easy to traverse percutaneously (Fig. 122.1). If
ing dense intra-abdominal adhesions or if the surgery involves the patient is in a lateral decubitus position, then the Veress
entering the bowel. needle is passed two fingerbreadths medial and two finger-
The role of each operating room personnel (including sur- breadths superior to the anterior superior iliac spine. O ther
geon, assistants, nurses, anesthesiologist, and other support potential insertion sites when the patient is either supine or in
staff) should be clearly defined and established for each la- a lateral decubitus position are the Palmer point (i.e., sub-
paroscopic case. Detailed information on laparoscopic instru- costal in the midclavicular line on the right side) and the cor-
mentation is available elsewhere, and specific instrumentation responding site on the left side.
may be needed for the growing list of specialized procedures Placement of the Veress needle into the abdominal cavity is
(6). The positioning of the monitors depends on the type of a blind procedure with potential for injury to the underlying
the procedure to be performed. For pelvic surgery, a single structures. If the patient has undergone prior surgery, open en-
monitor at the foot is usually sufficient; for procedures such as try using the H asson technique is considered the safest method
nephrectomy and adrenalectomy, monitors on either side of (see following). A small incision is made at the Veress needle
the bed are recommended. All equipment must be fully func- entry site. The abdominal wall can be elevated by grasping the
tional and in operating condition before any laparoscopic pro- periumbilical area with a sponge or with towel clamps. These
cedure is started. A separate tray with open laparotomy maneuvers may raise the umbilicus up and away from the in-
instruments must be ready for immediate use in the event of testines but, more importantly, stabilize the abdominal wall.
complications or problems necessitating conversion to open The needle is grasped like a dart along the shaft to limit its ex-
surgery. cursion into the abdominal cavity, with the angle of entry di-
Positioning of the patient depends primarily on the laparo- rected slightly caudad into the pelvis. Two distinct “ pops” are
scopic procedure to be performed. Careful attention to detail felt as the needle passes through the fascia and peritoneum. It
during patient positioning, including adequate padding of is important to traverse the layers of the abdominal wall in a
bony prominences and securing the patient to the table, is crit- near-perpendicular fashion to avoid “ bouncing off” the peri-
ical for table repositioning during the procedure and avoiding toneum and remaining in the preperitoneal space. The umbili-
neuromuscular complications. Advances in padding and table- cus lies directly over the right iliac vessels, just below the aortic
mounted accessories have enabled the use of newer devices bifurcation at L4-L5 (Fig. 122.1). Deep penetration with the
(e.g., gel pad, lateral support, bean bag), which, when used needle directly posteriorly could produce vascular injury.
Chap t e r 122: Basic Princip le s of Lap aroscop y: Transp e ritone al, Extrap e ritone al, and Hand -Assiste d Te chniq ue s 803
FIGURE 122.1 The Veress needle is most often

placed at the inferior or superior aspect of the umbili-
cus. The needle is directed into the hollow of the
pelvis, below the bifurcation of the great vessels.
O nce the needle is in the peritoneal cavity, confirmatory pneumoperitoneum established, and the injury inspected for
tests are performed prior to insufflation, although none is possible repair. Because of the small size of the Veress needle,
foolproof. These include: the majority of these injuries do not require open operative
intervention.
1. Color test: Aspiration of colored (red, yellow, green, brown) O nce proper needle placement is verified, CO 2 insufflation
or malodorous fluid suggests improper placement. should be started at a “ low flow” (1 L/min) to maintain a
2. D rop test: Apply a drop of saline inside the hub of the nee- pressure of 8 mm H g. A high initial pressure with a low flow
dle and lift the abdominal wall. If in proper position, the suggests improper needle placement. O nce insufflation is un-
drop will enter the abdomen due to the negative intraperi- derway, the abdomen should be observed to assure that a sym-
toneal pressure. metrical pneumoperitoneum is developing. M onitor the
3. A dvancem ent test: If the needle has truly just entered the insufflation by percussion over the liver, noting the character-
peritoneal cavity, then the surgeon ought to be able to ad- istic dull echo tone that indicates proper insufflation. If the
vance the needle 1 cm deeper without the tip meeting any distention appears correct and 0.5 L has entered the abdomen,
resistance. increase to “ high flow” (usually 2 L/min). Initially, the ab-
4. M odified Palm er test: Inject 10 mL of saline into the nee- domen is insufflated to 15 to 20 mm H g to provide maximum
dle and attempt to aspirate. Inability to aspirate suggests distention and assist with atraumatic placement of the early
the fluid has dispersed into the abdomen and the needle is trocars. An adult abdomen will typically require 3 to 6 L of
in correct position. CO 2 to create an adequate pneumoperitoneum, while children
5. Initial pressure reading 8 m m H g. The insufflator is may require as little as 1 to 1.5 L. The working pressure
turned on with no flow to obtain a pressure reading. should be decreased to 12 to 15 mm H g after all trocars are
6. A decrease in pressure w ith elevation of the abdom inal w all. placed to limit barotrauma.
If preperitoneal insufflation occurs, an attempt can be
If perforation of a viscus occurs, the needle should be re- made to open the peritoneum with laparoscopic scissors and
moved and discarded. A new needle may then be inserted at guide the tip of the trocar beneath it. CO 2 gas is then insuf-
another location or the surgeon may choose to obtain open flated into the true peritoneal cavity, compressing the preperi-
access using the H asson technique (see detailed in a later sec- toneal gas. Alternatively, evacuation of the preperitoneal space
tion). O nce insufflation has been completed and the primary with a needle and syringe and reinsertion of the needle at the
trocar has been introduced, the injury can be examined with same or another site (i.e., superior umbilical position) may
the laparoscope and a decision made as to the appropriate be attempted. Simply compressing the abdomen will disperse
management. If blood appears, the Veress needle should be the CO 2 within the preperitoneal space. O pen access (H asson
withdrawn slightly. Its positioning should be retested, the technique) can be used if these techniques are unsuccessful.
FIGURE 122.2 Primary shielded trocar is held with

a finger along the shaft to limit the depth of entry of
the trocar.
is 10 to 12 mm H g, but an initial pressure of 15 to 20 mm H g

Primary Tro car Place me nt is needed until all the trocars are placed to ensure a “ tense”
pneumoperitoneum. White-balance the camera and explore
O nce the pneumoperitoneum is established, the Veress needle
the abdomen to assess for possible injury by the Veress needle
is removed and the primary (laparoscope) trocar is inserted.
or trocar. The chance of a serious injury at the time of the in-
N ondisposable and disposable trocars are available. The tro-
sertion of the primary trocar is much greater than with the
car designation refers to the size of the instrument that can be
Veress needle.
inserted into the trocar and not the overall diameter of the tro-
Lens fogging is caused by passage of the room-temperature
car. Sizes range from 3 to 20 mm in diameter and 5 to 15 cm
laparoscope into the warm, humid abdomen. As the laparo-
in length. A 5- or 10-mm trocar is used in adults to allow pas-
scope warms during the procedure, fogging becomes less
sage of the laparoscope. The incision site used for the Veress
needle should be enlarged and the subcutaneous tissue spread
to the fascia using a hemostat. The skin incision should be suf-
ficient to allow the trocar to pass without resistance. Press the
end of the trocar on the skin to create an impression that
serves as a guide for the size of the incision. Insert a trocar
with firm, steady pressure and a gentle twisting movement. A
finger can be held along the shaft to serve as a brake from
pushing the trocar in too far (Fig. 122.2). Pressure should be
applied using the arm and elbow only. Direct the trocar to-
ward the site of interest within the peritoneum to avoid torque
from the abdominal wall during the rest of the case (Fig.
122.2). The abdominal wall can be lifted and stabilized with
hemostats (Fig. 122.3).
N oncutting dilating trocars and visualizing trocars have
largely replaced the bladed/sharp-tipped and shielded metal
trocars. After the skin incision is made, the laparoscope is
placed into one of the visualizing trocars. Using pressure, a
gentle twisting motion penetrates the layers of the abdominal
wall, monitored under direct visualization of the tip through
the laparoscope. The stopcock on the trocar can be left open
during insertion, causing a rush of gas to escape (“ whoosh
test” ), suggesting intraperitoneal placement. The CO 2 insuf-
flator is connected to the stopcock on the trocar and insuffla- FIGURE 122.3 The abdominal wall can be stabilized with towel clips
tion is resumed. Working pressure of the pneumoperitoneum placed on either side of the umbilicus during primary trocar insertion.
FIGURE 122.4 A: O pen laparoscopy using the H asson technique. The peritoneum is entered under direct
vision. B: A blunt-tipped H asson-style trocar is secured using the stay sutures.
problematic. Fogging can be reduced by heating the laparo- surgeon’s preference. The secondary trocars should be ori-
scope before insertion in warmed sterile saline, applying an- ented toward the surgical site to provide tension-free maneu-
tifogging solutions, and limiting the time the scope is removed verability of the laparoscopic instruments. Their configuration
from the abdomen. If fogging or debris covers the lens, it can should be planned so that neither the tips nor handles of the
be wiped on a clean bowel; touching fat or a blood-tinged sur- cannulas cross or come into close contact with one another,
face may leave a film on the laparoscope. The contact time on respectively (“ crossing swords” and “ rollover” ), such that ad-
the tissue should be limited as the laparoscope tip can become equate working space is provided for all instruments to be
quite warm. H eated circuits connected to the insufflation tub- used during a particular procedure. A general rule is to place
ing and newer laparoscope systems with imaging or heating secondary trocars in the midline or at least 8 cm from the mid-
chips at the distal end can also reduce this fogging. line in adults to avoid the rectus sheath (Fig. 122.5). If the rec-
tus muscle is penetrated by a trocar, there is an increased risk
of bleeding. Trocar placement for specific procedures is noted
Transp e rit o ne al Acce ss: O p e n “Hasso n” in the appropriate chapters that follow. At least one larger sec-
Te chniq ue ondary trocar (10 or 10/11 mm) is usually placed to allow the
passage of needles and larger instruments such as a linear en-
M any surgeons use this as the primary access for all patients. dovascular stapler and clip appliers and to allow removal of
O pen access (H asson technique) is also useful both for cor- specimens. Extended-length trocars are available if patients
recting preperitoneal insufflation and in the patient at high have particularly thick abdominal walls.
risk for multiple adhesions. The advantage is that entry into The placement of secondary or “ working” trocars can be
the peritoneal cavity is under direct vision, minimizing the risk carefully monitored externally and internally to reduce the
of injury; however, it requires a larger incision and increases risk of injury. After full pneumoperitoneum is achieved, the
the chances of port-site gas leakage during the procedure. selected site for the secondary trocar is gently pushed with
An infraumbilical incision is made and two stay sutures are the index finger while the site is observed through the laparo-
placed through the fascia on either side. The fascia and peri- scope. The room is darkened and the light from the laparo-
toneum are directly visualized and opened (Fig. 122.4A). After scope is used to transilluminate the anterior abdominal wall
visual and digital confirmation of entry into the peritoneal to confirm that there are no underlying vessels or bowel. A
cavity, the stay sutures are repositioned and the H asson can- skin incision of appropriate diameter to accommodate the
nula is advanced through the incision into the peritoneal cav- trocar is made. It is useful to spread the subcutaneous tissue
ity. The stay sutures are either attached to the cannula to hold down to fascia with a clamp until the impression of the
it in position (Fig. 122.4B), if needed, or secured with hemo- clamp tip is visible on the peritoneum. The trocar is intro-
stats for use during closure. Insufflation tubing is attached to duced with the same technique described for the primary tro-
the H asson-style trocar, and immediately “ high flow” can be car except that the progress into the abdomen is followed on
selected. the monitor. N ewer trocars have intrinsic stability threads
that limit accidental removal. Suturing trocars to the skin us-
ing a heavy silk tether to prevent accidental removal during
Se co nd ary Tro car Place me nt the case may be needed occasionally. The robotic surgical
systems have specific trocars that should be used that me-
The number, size, and sites of the secondary trocars depend on chanically connect to the robotic arm to allow control of the
the procedure to be performed, the patient’s anatomy, and the instrument more precisely.
FIGURE 122.5 Secondary trocars should be placed in

the midline (linea alba) or at least 8 cm from the midline
to avoid injury to the rectus or the epigastric vessels.
the end of the needle using laparoscopic guidance. O nce en-

Tro car Re mo val gaged, the device is withdrawn with the attached end of the
suture. The trocar is removed and the ends of the suture are
At the end of the procedure, the pneumoperitoneum should be
tied from the outside using laparoscopic control. Another
lowered to 5 mm H g or less to observe for any bleeding that
may have been tamponaded by the working pressure. A brief
survey of the abdomen should verify that there was no injury
outside the operative field. Trocar sites should be examined
prior to and after removal of the sheaths for bleeding or herni-
ation. During trocar removal and fascial closure, bowel can
become trapped along the trocar pathway. Trocar removal
and suturing should always be observed laparoscopically;
10 mm and larger trocars require fascial suturing in adults.
Fascial closure can be accomplished by a variety of tech-
niques. A 0 or 2-0 absorbable suture (i.e., Vicryl) on a small
curved needle (i.e., CT-3 or UR-6) can be used to close the fas-
cia externally. Fascial edges are grasped with either a toothed
forcep or Scanlon clamps. Army-N avy retractors facilitate ex-
posure. Laparoscopic closure needles (i.e., Endo Close, US
Surgical, N orwalk, CT) are also available that are similar to a
Stamey-style needle. A free 0 or 2-0 absorbable suture is en-
gaged and passed percutaneously along the side of the trocar,
through the fascia, and into the abdominal cavity using la-
paroscopic guidance. (N ote: If stability threads were used to
secure the trocar, they may interfere with passage of the
closure device. Release the thread and slide it out of the inci-
sion while maintaining the trocar in the abdominal cavity.)
The end of the suture is held with a laparoscopic grasper FIGURE 122.6 O ne technique to close the trocar site uses a device
such as the Endo Close fascial closure needle. H ere, the 2-0 ab-
while the spring-loaded end is depressed to release the suture sorbable suture has been passed into the abdomen alongside the tro-
(Fig. 122.6). The closure device is then passed on the opposite car. The suture is grasped and the needle is withdrawn and passed on
side of the trocar, with the free end of the suture placed in the opposite side of the trocar.
closure method utilizes the Carter-Thomason suture-passing

device (Inlet M edical, Eden Prairie, M N ). A suture guide (5 or
10 mm) device is placed into the trocar site and the suture-
passing device is loaded with a 2-0 absorbable suture and the
suture passed inside. The suture is released, the needle is
placed in the opposite hole, and the suture is retrieved and re-
moved through the opposite guide hole. The guide is removed
and the suture is tied from outside the body.
After fascial sutures have been placed in all 10-mm port
sites, each 5-mm port is removed under endoscopic control at
5 mm H g pressure. Then each of the non-endoscope-bearing
10-mm ports can be removed under endoscopic control, and
the fascial suture can be tied and the closure inspected endo-
scopically. The final 10-mm port is removed with the endo-
scope in place to assess for any bleeding along the tract. In
this manner, each port is visually assessed for any bleeding at
5 mm H g, thereby precluding the possibility of removing a
port and missing an injured vessel. After removal of all ports,
the CO 2 is allowed to pass out passively through the 5-mm
port sites. This will reduce postoperative shoulder pain due to
diaphragmatic irritation from the CO 2 gas. If pneumoscrotum
is present, this should also be manually decompressed at this
time.
The skin site should be thoroughly irrigated prior to clo-
sure. H erniation is most often associated with trocars larger
than 10 mm, and when it does occur it is often due to a wound
infection rather than improper fascial closure. Skin sites are
closed with either subcutaneous sutures reinforced by Steri-
Strips or with a skin adhesive.
RETRO PERITO NEAL

LAPARO SCO PY
This is often called “ retroperitoneoscopy” and is used most
often for renal and adrenal procedures. Following the usual
preparation for transperitoneal laparoscopy, the patient is
placed in a standard flank position. A 2-cm transverse skin in-
FIGURE 122.7 For retroperitoneal procedures, the initial trocar is
cision is made just anterior to the tip of the 12th rib in the mi- placed (A) 1 to 2 cm from the tip of the 12th rib or (B) in the triangle
daxillary line. An alternate site for the skin incision is the of Petit, 1 to 2 cm above the anterior superior iliac spine. Additional
triangle of Petit approximately two fingerbreadths above the ports can be placed as needed between the posterior and anterior axil-
anterior superior iliac spine (Fig. 122.7). The posterior layer lary lines.
of the thoracolumbar fascia is identified and two stay sutures
are positioned. The flank muscles are split to the anterior tho-
racolumbar fascia; two additional stay sutures are positioned. and distention of the space can be laparoscopically monitored
The anterior layer of thoracolumbar fascia is incised and the through the clear balloon. The degree of balloon dilation
retroperitoneal space is entered. Index finger palpation of the varies with the patient’s body habitus: 1 to 1.2 L of normal
belly of the psoas muscle posteriorly and the Gerota fascia- saline or room air is average in adults. The balloon is kept in-
covered inferior pole of the kidney anteriorly confirms proper flated for 5 minutes. After balloon removal a blunt-tipped
entry into the retroperitoneal space (Fig. 122.8). The index trocar is inserted into the retroperitoneum. Visualization of
finger is employed to digitally create a space in this precise lo- the psoas muscle confirms proper balloon dilation of the
cation and to sweep the peritoneum away anteriorly. retroperitoneum. The peritoneal envelope may be further mo-
Simple extraperitoneal insufflation will cause the CO 2 gas bilized with sweeping motions of the laparoscope. If difficulty
to track along fascial planes and will not develop the ex- is encountered mobilizing the peritoneum, an operating la-
traperitoneal space. Balloon dissection of this space is the key paroscope can be used to pass a blunt-tipped dissector into the
to performing any procedure in this area. Gaur was the first to retroperitoneum.
describe balloon distention of the extraperitoneal space using The secondary ports can then be inserted under manual or
a simple device consisting of a surgical glove finger mounted laparoscopic control. For manual port placement, the laparo-
on a red rubber catheter secured with a silk tie (7,8). Several scope and cannula are removed and the index finger of the left
commercially available trocar-mounted balloons are now hand (for a right-handed surgeon) is introduced into the
available. An advantage of these devices is that the inflation retroperitoneum. An “ S-shaped” retractor is inserted into the
S-shaped retractor. Secondary trocars are placed based on the

procedure to be performed. Typical placement for retroperi-
toneal procedures is demonstrated in Figure 122.7. N o trocars
are positioned behind the posterior axillary line.
PELVIC EXTRAPERITO NEAL

LAPARO SCO PY
Bladder neck suspension, hernia repair, radical prostatectomy,
and pelvic lymph node dissection can be approached through
the pelvic extraperitoneal space. Patient preparation and posi-
tioning are identical to transperitoneal laparoscopy.
A vertical skin incision is made 1 to 2 cm below the inferior
umbilical crease to avoid the confluence of the anterior and
posterior rectus sheaths at the umbilicus. For procedures such
as bladder neck suspension where lateral exposure at the level
of the iliac vessels is not needed, the incision is made in the
midline about one-third the distance below the umbilicus,
between the umbilicus and pubis. The tissues are spread with
a clamp to the anterior rectus sheath. Two absorbable 0 (i.e.,
Vicryl) stay sutures are placed in each side of the midline.
N ext, the anterior rectus sheath is incised along the linea alba
between the sutures. The two bellies of the rectus muscle are
separated by blunt dissection to expose the posterior sheath
and a finger is passed behind the rectus and above the poste-
rior sheath. Blunt finger dissection is carried out in a caudal
direction until the area of the pubis symphysis is reached. At
this distal location, the fascia transversalis is punctured with
FIGURE 122.8 Technique of trocar-mounted balloon dissection of the fingertip, and gentle side-to-side digital dissection is per-
the retroperitoneal space. formed in the prevesical space, posterior to the pubic bone. A
balloon dilator lubricated with sterile jelly is inserted in this
predeveloped space and distended to create an adequate work-
ing space. Balloon dilation effectively displaces the prevesical
retroperitoneum in such a manner that it lies immediately in fat and reflects the peritoneum cephalad (Fig. 122.9). The bal-
front of the finger (i.e., the retractor is cradled by the finger). loon is left inflated for several minutes, deflated, and inflated a
The fingertip mobilizes and retracts the peritoneum away second time. The balloon is initially inflated in the midline and
from the abdominal wall; the S-retractor prevents inadvertent then reinflated on either side to further expand the working
trocar injury to the surgeon’s finger. With the surgeon’s right area. The balloon is removed and a 10-mm H asson-style can-
hand, the secondary trocars are inserted under bimanual nula or a Bluntport is placed. The extraperitoneal space is in-
control, with the aim being to introduce the trocar onto the sufflated with CO 2 at 15 mm H g to facilitate secondary trocar
FIGURE 122.9 Technique of trocar-mounted

balloon dissection of the preperitoneal space.
placement. Inspection of the preperitoneal space usually con-

firms adequate dissection of the prevesical space.
Additional trocars are placed under direct vision using a
triangular, diamond-, fan-, or W-shaped configuration. Ensure
that the lateral trocars do not traverse the peritoneal cavity
and they are beyond the peritoneal reflection. Unlike with
retroperitoneoscopy, the occurrence of a peritoneotomy dur-
ing extraperitoneoscopy may interfere with the performance
of subsequent extraperitoneal dissection, and conversion to a
transperitoneal technique may be required. After the sec-
ondary trocars are placed, pneumoextraperitoneum is reduced
to 10 to 12 mm H g for the remainder of the procedure as pro-
longed high-pressure insufflation may cause tracking of the A
gas into the subcutaneous tissues.
HAND-ASSISTED LAPARO SCO PY

H and-assisted laparoscopy usually begins with the creation of
an open incision that is approximately equal in length (in cm)
to the surgeon’s glove size, avoiding the use of a “ blind”
Veress needle access. The exact positioning of the incision de-
pends upon the planned procedure, the body habitus of the
patient, and surgeon preference (see subsequent chapters for B
details). The most common sites for hand-port placement in-
clude midline, subcostal, and lower quadrant incisions. O nce
the peritoneal cavity has been entered, the inside surface of the
anterior abdominal wall is inspected for the presence of adhe-
sions, which can be taken down sharply. After the hand-assist
device is placed, a blunt cannula is passed through the hand-
assist device and the abdomen can be insufflated at a high
flow rate. Alternatively, a Veress or H asson pneumoperi-
toneum may be initially established, and the hand-assist device
can then be placed under endoscopic monitoring. After pneu-
moperitoneum is attained, the surgeon’s nondominant hand is
passed into the abdomen and additional secondary ports can
be rapidly and safely placed using the intra-abdominal hand
to palpate the tip of the trocar and hence guide its entry into
the abdomen. Use of brown gloves and Ioban (3M , St. Paul,
M N ) “ sticky drape” is recommended to decrease glare and to
waterproof the surgeon’s hand respectively. A sterile, water-
soluble lubricant applied to the back of the surgeon’s hand en-
sures smooth entry and exit through the hand-assist device.
Recent advances in hand-assist devices have made these in- C
struments easier to place and more comfortable for the sur-
geon. The newer devices rely on compression against the FIGURE 122.10 Devices for hand-assisted laparoscopy. A: The third-
generation two-piece GelPort is relatively easy to assemble and pro-
peritoneal surface and body wall to remain in position. The vides an adequate seal around the surgeon’s wrist while minimizing
GelPort (Applied M edical, Rancho Santa M argarita, CA) em- fatigue. B: The Lap Disc consists of three rings connected by a silicone
ploys a sleeve that is passed into the abdominal cavity and membrane. The lower and middle rings bridge the abdominal wall,
pulled out through the incision. An inner ring holds the sleeve while the upper ring rotates on the middle, acting as an iris to seal the
port around the surgeon’s hand. C: The O mniport hand-assist device.
in place. The sleeve is then rolled on an outer ring that rests on
the anterior abdominal wall. The GelPort covering is then at-
tached to the outer ring. The entire two-piece system (Fig.
122.10A) is relatively easy to assemble once the incision has also creates a seal between itself and the surgeon’s wrist. The
been established in the abdominal wall. The Lap Disc (Ethicon device has a smaller footprint (12 cm), but it must be deflated
Inc., Cincinnati, O H ) consists of three rings connected by a and reinflated each time a hand is exchanged, which loses the
silicone membrane (Fig. 122.10B). The lower and middle rings pneumoperitoneum.
bridge the abdominal wall, while the upper ring rotates on the Prior to beginning the dissection, laparotomy pads can be
middle, acting as an iris to seal the device around the surgeon’s preplaced into the abdominal cavity and used to blot any
hand. The O mniport (Advanced Surgical Concepts, Wicklow, bleeding during the dissection. It is, of course, imperative to
Ireland) is a balloon-like device that anchors itself as one piece remove these pads prior to exiting the abdomen, and a helpful
across the abdominal wall (Fig. 122.10C). The inflated device reminder system should be created with the rest of the operating
room staff instead of relying solely upon sponge counts.

Exiting the abdomen should be carried out with the secondary Co mp licat io ns
sites being closed under direct visualization through a port
Although a Veress needle injury of a major blood vessel, blad-
placed in the hand-assist device. The hand site is closed in the
der, or gastrointestinal tract can be managed expectantly, sig-
standard fashion.
nificant perforation with a trocar should be managed by
immediate laparotomy and repair. The trocar and sheath
should be left in place while opening the abdomen. In selected
PEDIATRIC LAPARO SCO PY instances, laparoscopic repair may be appropriate but often
requires significant advanced skills.
M ost principles of adult laparoscopy can be applied to the pe-
Vascular injury within the abdominal wall, especially the
diatric population, with the following exceptions:
inferior epigastric vessels, can be managed by a through-and-
1. In younger children, the bladder is an intra-abdominal through suture placed on a bolster using a Stamey-style needle or
structure, requiring more care with lower abdominal tro- laparoscopic closure device; it is removed after 24 to 48 hours.
car placement. Anesthetic problems can be caused by the absorption of
2. The peritoneal membrane is loosely attached to the ab- CO 2 or the physiologic effects of the pneumoperitoneum.
dominal wall, making it potentially difficult to pass a Both the intra- and extraperitoneal surfaces can readily absorb
Veress needle. M any authors advocate an open access CO 2 and this may cause hypercarbia. End-tidal CO 2 monitor-
technique for all children. ing by the anesthesia team can often identify this problem be-
3. The total CO 2 to insufflate the abdomen is in general 1 fore it becomes clinically significant. Increasing the minute
to 3 L. Pressures should be kept lower than in adults (8 to ventilation, use of positive end-expiratory pressure, and re-
10 mm H g). duction of intra-abdominal pressure to 10 mm H g can usually
4. The 5-mm trocars are commonly used in children and the keep the blood CO 2 levels in a safe range. H igh intra-abdominal
sites m ust be sutured at the end of the case. pressure (prolonged periods above 15 to 20 mm H g) can lead
5. M any standard laparoscopic instruments will be either too to barotrauma. The initial sign may be hypotension owing to
large or long for pediatric procedures, thereby requiring decreased cardiac output secondary to an acute drop in ve-
specialized equipment. nous return caused by compression of the vena cava. H igh
pressures can also result in subcutaneous emphysema that can
exacerbate hypercarbia, and on occasion cause pneumomedi-
PO STO PERATIVE MANAGEMENT astinum and pneumothorax. The surgeon should desufflate
the abdomen, and once the hemodynamic changes have been
Patients undergoing limited laparoscopic procedures like reversed, reinitiate the pneumoperitoneum at 10 mm H g.
varicocelectomy and diagnostic laparoscopy may be dis- Transient oliguria may occur in patients with increased intra-
charged the same day. M ore extensive procedures may require abdominal pressures, and the urge to aggressively hydrate the
a short hospital stay. O rogastric tubes are removed in the op- patient should be avoided.
erating room but may be left in longer if bowel surgery was Life-threatening gas embolism is rare and most often
performed. The Foley catheter is removed either while the pa- caused by direct insufflation of CO 2 gas into a vessel by the
tient is still in the operating room (pneumoperitoneum 2 Veress needle. Subtle collection of CO 2 gas in the venous sys-
hours) or later in the day or the next morning (pneumoperi- tem through an open vessel can rarely occur. The first sign of
toneum 2 hours) unless a prostatectomy or cystectomy intravascular insufflation is acute cardiovascular collapse. The
was performed. Antibiotics are continued over 24 hours and diagnosis is usually made by the anesthesiologist based on an
laboratory values are obtained in a standardized manner post- abrupt increase of end-tidal CO 2 accompanied by a sudden
operatively. The patient ambulates within 12 hours of surgery decline in oxygen saturation and then a marked decrease in
and pneumatic compression stockings are utilized for deep end-tidal CO 2 . Sometimes, a “ millwheel” precordial murmur
venous thrombosis prophylaxis until the patient is fully can be auscultated. The treatment is immediate cessation of
ambulatory. insufflation and prompt desufflation of the peritoneal cavity.
Depending on the procedure, clear liquids can be given The patient is turned into a left lateral decubitus position and
after the effects of anesthesia have cleared. Diets can then be hyperventilated with 100% oxygen. Advancement of a central
advanced as tolerated. For more extensive procedures (i.e., venous line into the right heart with subsequent attempts to
nephrectomy), it may be necessary to advance the diet more aspirate gas may rarely be helpful.
slowly. Parenteral analgesia is given as needed on the day of In a recent review of 2,775 diverse urologic laparoscopic
surgery and is usually replaced by oral pain medication on the procedures, the current overall complication rate was 22.1%
first postoperative day. The requirement for postoperative and the mortality rate was 0.07% . Transfusions were required
analgesics is usually minimal; excessive pain should raise the in 4.7% of procedures, while open conversion was necessary
suspicion of a complication. Patients should be advised that in only 2.7% (9). The majority were identified in the postop-
delayed postoperative bruising is on occasion encountered. erative period (79% ) and were classified as minor (72% ).
Although each individual procedure had its own characteristic
profile of complications, the four most commonly identified
O UTCO MES complications were vascular injuries (2% ), postoperative
bleeding requiring blood transfusion (1.8% ), ileus that pro-
O utcomes for contemporary laparoscopic interventions are re- longed hospital stay 48 hours (1.6% ), and wound infection
viewed for each specific procedure in the appropriate chapter. (1% ).
Chap t e r 123: Lap aroscop ic Pe lvic and Re trop e ritone al Lymp h Nod e Disse ction 811
Laparoscopic surgery can be more technically demanding and working with others who are involved with laparoscopic
and time-consuming than open surgical intervention. Proper surgery appear to be the best determinants for a successful
patient selection, formal training, the surgeon’s experience, outcome in urologic laparoscopy (10).
References
1. Gomella LG, Albala DM . Laparoscopic urological surgery: 1994. Br J Urol 6. Eichel L, M cDougall EM , Clayman RV. Basics of laparoscopic surgery. In
1994;74:267–273. Cam pbell-W alsh Urology Philadelphia: Saunders-Elsevier, 2007.
2. H edican SP. Laparoscopy in urology. Surg Clin N orth A m 2000;80: 7. Gaur DD. Laparoscopic operative retroperitoneoscopy: use of a new device.
1465–1485. J Urol 1992;148:1137–1139.
3. Jackson CL. Urologic laparoscopy. Surg O ncol Clin N orth A m 2001;10: 8. Gaur DD, Rathi SS, Ravandale AV, et al. A single-centre experience
571–578. of retroperitoneoscopy using the balloon technique. BJU Int 2001;87:
4. N akada SY, Fadden P, Jarrard DF, et al. H and-assisted laparoscopic radical 602–606.
nephrectomy: comparison to open radical nephrectomy. Urology 2001;58: 9. Permpongkosol S, Link RE, Su LM , et al. Complications of 2,775 urological
517–520. laparoscopic procedures: 1993 to 2005. J Urol 2007;177:580–585.
5. Wolf JS Jr, M erion RM , Leichtman AB, et al. Randomized controlled trial 10. See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic complications
of hand-assisted laparoscopic versus open surgical live donor nephrectomy. after formal training in laparoscopic surgery. JA M A 1993;270:2689–2692.
Transplantation 2001;72:284–290.
CHAPTER 123 ■ LAPARO SCO PIC PELVIC AND

RETRO PERITO NEAL LYMPH NO DE DISSECTIO N
HO WARD N. WINFIELD AND WILLIAM J. BADGER
The gold standard for accurate lymph node assessment in

both prostate and testicular cancer continues to be lym- Diag no sis
phadenectomy. While imaging modalities such as computer-
L-PLN D is an additional diagnostic procedure considered af-
ized tomography (CT) and magnetic resonance imaging (M RI)
ter definitive diagnosis of prostate cancer through biopsy or
may detect moderate- to large-volume metastatic disease,
transurethral resection of the prostate.
many microscopic or small lymph node metastases are not
identified with the current limitations of CT and M RI sensitiv-
ity (1). With continued refinements in laparoscopic and ro- Ind icat io ns fo r Surg e ry
botic instrumentation and techniques, the gold-standard
lymphadenectomy can be performed with equal efficacy and L-PLN D is now rarely indicated as an independent staging
decreased morbidity when compared to the open approach. procedure for prostate cancer. L-PLN D should be considered
in patients with clinical stage T2b or T3a cancer of the prostate
whether surgery or radiation therapy is being considered;
LAPARO SCO PIC PELVIC LYMPH stage T1b cancer with Gleason sums of 7 or more; PSA levels
NO DE DISSECTIO N 20 ng/mL; or suspicious lymph nodes visualized on CT that
are not amenable to guided needle biopsy. Additionally, pa-
Laparoscopic pelvic lymph node dissection (L-PLN D) for tients scheduled to undergo perineal prostatectomy,
staging of prostate cancer was first described in 1991 by brachytherapy, external-beam radiotherapy, or laparoscopic/
Schuessler et al. (2). Recently, the importance of pelvic lym- robotic prostatectomy who have a risk of node positivity
phadenectomy has been questioned for patients undergoing 25% should undergo pretreatment L-PLN D or simultaneous
radical prostatectomy. The arguments against pelvic lym- L-PLN D.
phadenectomy include stage migration, an increasing percent- M alignancies other than prostate cancer may be staged
age of patients with a low prostate-specific antigen (PSA) level with L-PLN D, including bladder, urethral, and penile cancers.
and tumor stage, and the practice of omitting lymphadenec- Patients with transitional cell carcinoma of the bladder with
tomy in low-risk patients (PSA 10 ng/mL and/or Gleason an enlarged pelvic lymph node on imaging may undergo
score 7). In patients with high-risk prostate cancer (clinical L-PLN D if the lymph node is inaccessible to other minimally
stage T2c, serum PSA level 10 ng/mL, and Gleason score 7), invasive biopsy techniques (CT-guided biopsy). In patients
however, there is an approximately 38% risk of lymph node with urethral and penile cancers, sampling of enlarged pelvic
metastasis (3). nodes may confirm the presence of metastatic disease and
guide the treatment course. Patients with metastatic disease

may proceed directly to chemotherapy and avoid the morbid-
ity of radical surgery, which would inadequately treat the un-
derlying disease.
Patients with inability to tolerate general anesthesia or
pneumoperitoneum, morbid obesity, numerous previous ab-
dominal or pelvic surgeries, or large aortic or iliac aneurysmal
disease are not considered good candidates for any laparo-
scopic or robotic surgery.

O pen pelvic lymphadenectomy historically has been the gold
standard for lymph node removal. CT or M RI scanning can
be utilized in combination with percutaneous biopsy for sam-
pling of enlarged lymph nodes.
Some authors advocate an extended PLN dissection in pa- FIGURE 123.1 Split-leg operating table (M aquet) allows abduction
tients with carcinoma of the prostate. This dissection reaches of the legs without the need for lithotomy.
above the bifurcation of the common iliac artery and includes
all external iliac, obturator, and hypogastric lymph nodes. A
recent series reported that 45.5% of the detected metastases activated throughout the procedure. After adequate anesthesia
were exclusively located outside of the typically sampled obtu- is obtained, a Foley catheter and orogastric tube are placed in
rator fossa (4). O thers advocate the use of radioisotope- the bladder and stomach, respectively. Patients are placed in
guided sentinel lymph node dissection. In one series of this the supine position with well-padded arms tucked at the side.
approach, 71.4% of the detected metastases were exclusively We utilize a split-leg operating table (M aquet), which allows
located outside of the typically sampled obturator fossa (5). abduction of the legs but without the need for lithotomy
Both the extended lymph node dissection and sentinel lymph (Fig. 123.1). With this approach, the assistant may stand be-
node dissection can be performed laparoscopically. tween the patient’s legs during L-PLN D. A padded chest strap
is used to secure the patient to the table as the Trendelenburg
position will be required.
Transp e rit o ne al Ap p ro ach
Preoperative counseling should include a discussion of the Pneumoperitoneum is achieved by insertion of a Veress needle
risks, benefits, and alternatives to L-PLN D. Although imprac- at the superior or inferior crease of the umbilicus, and carbon
tical to list all possible complications, the most common in- dioxide is insufflated to an initial pressure of 20 mm H g. A
juries should be mentioned, as well as the risk of conversion to 10/11-mm trocar sheath unit can then be placed by enlarging
an open procedure. Informed consent should be obtained and the Veress needle puncture site. Alternatively, the open H asson
documented. technique can be utilized at the same location to obtain pneu-
O n the day prior to surgery, the patient takes only clear flu- moperitoneum. Immediate laparoscopy with a 10-mm or 5-mm
ids by mouth. This preparation helps to maintain good hydra- 30-degree lens should be performed to rule out iatrogenic
tion as well as decompress the bowel to aid in pelvic injuries. Two options for trocar configuration include a four-
intraoperative exposure. All patients receive a single dose of trocar diamond-shaped configuration or a five-trocar inverted-
intravenous antibiotics within 30 minutes of incision. U-shaped configuration as in laparoscopic radical prostatec-
Antiembolic pneumatic compression boots are placed and tomy (Fig. 123.2). After all laparoscopic ports are placed,
FIGURE 123.2 A: The standard diamond config-

uration for trocar placement with the laparoscope
placed in the subumbilical position. B: The horse-
shoe configuration is useful for obese patients.
Ext rap e rit o ne al Ap p ro ach

A 2-cm infraumbilical incision is made and carried through
the rectus and transversalis fascia. Stay sutures are placed in the
incised rectus fascia and a preperitoneal plane is digitally en-
larged. A balloon inflation device is inflated to 800 to 1,000 mL,
then deflated and removed. A H asson-type or balloon cannula
is inserted and secured. Carbon dioxide is insufflated to 15 mm
H g to allow for the remaining port placement. Care should be
taken to avoid traversing the peritoneal membrane to prevent
intraperitoneal insufflation leakage and possible bowel injury.
After the port placement under visual or digital guidance, the
procedure proceeds as described previously for the transperi-
toneal L-PLN D. Ensuring careful lymphostasis with the ex-
traperitoneal approach is essential to prevent the risk of
postoperative lymphocele formation due to the lack of a peri-
toneal window to vent lymph fluid leakage.
Co mp licat io ns
M ost complications related to pelvic lymph node dissection
are either a consequence of trocar placement or vascular in-
FIGURE 123.3 The initial peritoneal incision is made between the
obliterated umbilical artery (medial umbilical ligament) and the inter- jury. An accessory obturator vein is often encountered arising
nal inguinal ring. (From Gomella LG, Kozminski M , Winfield H N , from the distal aspect of the external iliac vein. When present,
eds. L aparoscopic Urologic Surgery, 1st ed. Philadelphia: Raven this vessel must be controlled and divided, or avoided, when
Press, 1994:117, with permission.) managing the distal extent of the lymph node packet.
Dissection deep to the obturator nerve can result in bleeding
pneumoperitoneum is decreased to 15 mm H g and the patient from the obturator vessels. Bleeding from the obturator ves-
is placed in 15-degree Trendelenburg with upward lateral ro- sels can be managed using a hemoclip or bipolar electro-
tation of the side to be operated. The combination of cautery, but bleeding from the iliac vessels can be more
Trendelenburg and lateral rotation allows the loops of bowel difficult to manage laparoscopically. Pressure to an iliac vessel
to fall away from the area of dissection over the iliac/obtura- injury should be applied immediately and maintained for sev-
tor regions. Any bowel adhesions should be carefully mobi- eral minutes, along with the use of hemostatic agents such as
lized to facilitate the dissection. O n the left side it is not oxidized regenerated cellulose or fibrin sealants. Bleeding
uncommon to require takedown of the sigmoid flexure as it from a small venous injury may be controlled with this ma-
often protrudes toward the internal inguinal ring. The poste- neuver, but for a larger injury an attempt can be made to se-
rior peritoneal membrane is incised longitudinally and imme- cure the opening with either hemoclips or sutures. Prompt
diately lateral to the medial umbilical (obliterated umbilical) conversion to open surgery and repair may be required if these
ligament from the pubis to the bifurcation of the iliac vessels attempts are unsuccessful.
(Fig. 123.3). The incision is directed just medial to the pulsat- Great care must be taken to avoid undue traction, elec-
ing external iliac artery. The vas deferens will be exposed after trothermal injury, or transection of the obturator nerve
the posterior peritoneum is incised. The vas deferens should throughout the procedure. Avoid accidental injury to the ob-
be isolated, coagulated, and divided. It should be noted that turator nerve by identifying its course before application of
the ureter is closely approximated to the peritoneum at, or just hemoclips on vessels or lymphatics.
proximal to, the bifurcation of the common iliac artery. Postoperative lymphocele and deep venous thrombosis
The fibrolymphatic tissue adherent to the external iliac vein are the two major morbidities associated with open PLN D.
is elevated and dissected from the anterior and medial aspect of With L-PLN D, postoperative lymphoceles are less common
the vein. The incised edge of the lymph node packet is grasped (6). A transperitoneal laparoscopic approach allows contin-
and retracted medially, and a relatively avascular plane be- uous drainage of lymphatic fluid into the peritoneal cavity
tween the lymph node packet and lateral pelvic sidewall is in the event of a lymphatic leak. Regardless of the approach,
identified and dissected bluntly. Any small perforating vessels however, lymphatic fluid loculations have been reported.
are identified, controlled with bipolar cautery, and divided. Deep venous thrombosis is relatively uncommon after
Dissection is carried proximally to the iliac bifurcation and dis- L-PLN D owing to the steep Trendelenburg position and
tally to the pubis. By retracting the lymph node packet medi- avoidance of venous compression of the iliac veins that can
ally, the obturator nerve and vessels can be identified and occur when using a fixed retractor system during open
avoided. After securing the distal extent of the lymph node surgery. O ne comparative study found a lower total compli-
packet, the packet is then retracted cranially to separate it from cation rate with L-PLN D (0% ) compared with open PLN D
the obturator vessels and nerves. H emoclips or bipolar cautery (21% ) (7).
is used to control lymphatics and vessels at the most proximal Despite the excellent outcomes of L-PLN D, the true indica-
and distal extent of the dissection. The lymph nodes can usu- tions for L-PLN D continue to decrease, primarily due to ad-
ally be removed as a single packet and extracted either through vances in prostate cancer screening with a shift toward earlier
the 12-mm trocar or by placing them in the entrapment sack. diagnosis and lower-stage and -grade disease.
LAPARO SCO PIC Surg ical Te chniq ue

RETRO PERITO NEAL LYMPH O n the day prior to surgery, the patient undergoes a mechani-
NO DE DISSECTIO N cal bowel preparation, which includes a clear liquid diet and
one gallon of GoLYTELY. Type and cross-matching is done
Due to its minimally invasive approach, laparoscopic retroperi- for two units of blood. Janetschek et al. (11) also recommend
toneal lymph node dissection (L-RPLN D) may be part of a that a low-fat diet be started 1 week prior to and continued
new treatment paradigm for patients with clinical stage I non- for 2 weeks after surgery to minimize chylous ascites. The pa-
seminomatous germ cell tumors. L-RPLN D offers a highly tient should have nothing by mouth after midnight on the
accurate and reliable method of evaluating the presence and night prior to surgery.
extent of retroperitoneal lymph node metastases. Refinements RPLN D for patients with stage I nonseminomatous germ
in laparoscopic surgical technique and instrumentation have cell tumors involves either right- or left-sided template surgery,
allowed for the performance of this minimally invasive proce- depending on the testis involved with disease. N erve-sparing
dure with low morbidity. templates are now used, which yield virtually a 100% chance
of maintaining antegrade ejaculation (Fig. 123.4) (12). Surgery
Ind icat io ns fo r Surg e ry for each template will be described.
The use of RPLN D primarily involves patients found to have

nonseminomatous germ cell tumors, as 20% to 30% of these Transp e rit o ne al Ap p ro ach
patients with clinical stage I disease may have retroperitoneal
Right-Sided Template. The patient is positioned on the operat-
lymph node metastases. Of more concern are patients with stage
ing table with the right side elevated 45 degrees upward. This al-
T2 to T4 primary tumors, evidence of lymphovascular invasion,
lows for both supine and lateral decubitus positioning as
and embryonal cell carcinoma, who are in general believed to
needed. Trendelenburg or reverse Trendelenburg positioning can
be at an even higher risk of retroperitoneal and systemic relapse
then be used as indicated. In general, trocar ports are 5 to 12
(8–10). Although the literature is replete with controversy con-
mm and placed in a midline vertical arrangement (Fig. 123.5).
cerning the use of chemotherapy versus RPLND, surgery is often
The initial step in L-RPLN D is to gain wide exposure of the
advocated as a staging, and possibly curative, procedure for such
retroperitoneum. Dissection is begun along the white line of
patients. Under these circumstances RPLND is performed in a
Toldt from the level of the cecum to the hepatic flexure.
unilateral template fashion to preserve antegrade ejaculation. L-
Cephalad, this incision is carried above the level of the trans-
RPLN D has been used as an alternative to open RPLND in this
verse colon and lateral to the duodenum (Kocher maneuver)
select patient group. H owever, upon pathologic confirmation of
along the vena cava up to the level of the hepatoduodenal
metastatic disease following L-RPLND, patients are then up-
ligament.
staged and given chemotherapy in most series. Thus, the thera-
The duodenum and the head of the pancreas are further
peutic effectiveness of L-RPLND alone in such cases is untested.
mobilized medially until the anterior surfaces of the vena
As such, L-RPLND should currently be considered a diagnostic
cava, aorta, and left renal vein crossing the aorta are com-
procedure. However, used as such, this minimally invasive pro-
pletely exposed. The peritoneal incision is also carried later-
cedure aids in identifying patients with pathologic stage I non-
ally around the liver toward the triangular ligaments, allowing
seminomatous testis tumors who can safely be spared
for medial and superior retraction of the liver. This mobiliza-
chemotherapy. L-RPLND is also utilized in stage IIa and IIb pa-
tion is necessary to ensure adequate exposure of the inferior
tients to demonstrate lymph node metastasis prior to adminis-
vena cava and renal vessels. Inferiorly, the incision is extended
tering chemotherapy. The general indications for L-RPLND are
along the spermatic vessels to the level of the internal inguinal
shown in Table 123.1.
ring. Dissection is also extended around the cecum and up-
ward along the root of the mesentery, allowing for medial mo-
Alt e rnat ive The rap y bilization of these structures. At this point, the dissection has
exposed the entire right-sided template. This template includes
Alternative treatment approaches for patients with stage I all preaortic tissue between the left renal vein and the inferior
nonseminomatous germ cell tumors include open RPLN D, mesenteric artery, the interaortocaval nodes, and all tissue on
chemotherapy, and active surveillance. the ventral and lateral surfaces of the vena cava extending lat-
erally to the ureter. The template is bounded superiorly by the
TA B LE 1 2 3 . 1 right renal vessels and inferiorly where the ureter crosses the
iliac vessels. The template extends posteriorly to the level of
IN DICATION S FOR LAPAROSCOPIC
the lumbar vessels. There is recent evidence to suggest that dis-
RETROPERITON EAL LYMPH N ODE DISSECTION
section posterior to the lumbar vessels within the template is
• Clinical stage I, IIa, and IIb nonseminomatous testicular not necessary in clinical stage I patients as no tumor was
cancer found in any patients undergoing laparoscopic lymphadenec-
• N egative testis tumor markers tomy that included this region (12). H owever, this finding re-
• N o absolute contraindications to laparoscopic surgery quires corroboration by further studies.
• Residual isolated abdominal or pelvic mass after After the entire template has been exposed, dissection is be-
chemotherapy in the presence of negative testis tumor gun inferiorly where the spermatic vessels enter the internal
markers inguinal ring. Typically, one should identify a nonabsorbable
stitch, left at the time of radical orchiectomy, that signifies the
A B C
FIGURE 123.4 A: Template for right modified nerve-sparing retroperitoneal lymph node dissection
(RPLN D). B: Template for left modified nerve-sparing RPLN D. C: Anterior view of retroperitoneal
sympathetic fibers. (From Foster RS, Donohue JP. N erve-Sparing R PL N D . AUA Update Series, vol. 15.
Dallas, TX: AUA, 1993, lesson 15, with permission.)
FIGURE 123.5 Trocar placement for

transperitoneal laparoscopic retroperitoneal
lymph node dissection. (From Clayman RV,
ed. L aparoscopic Urology. St. Louis, M O :
Q uality M edical Publishing, 1993:272–308,
with permission.)
distal margin of this dissection. The testicular vein is then dis- tissue from the level of the renal vessels going inferiorly to
sected up to its insertion into the vena cava. Careful dissection where the ureter crosses the iliac vessels. It is important that
is required where the spermatic vein joins the inferior vena the left renal vein has already been clearly identified and ex-
cava to prevent inadvertent disruption and bleeding. The tes- posed to prevent injury to this structure during this part of the
ticular artery is clipped and transected where it crosses the in- dissection. The lymphatic tissue overlying the common iliac
ferior vena cava. artery, starting at the level where the ureter crosses it, is dis-
N ext, the lymphatic tissue overlying the great vessels is dissected free, moving in a cephalad direction until the origin of
sected free. The lymphatic tissue on the anterior surface of the the inferior mesenteric artery is reached. Cephalad to this
inferior vena cava is divided, and the anterior and lateral sur- artery, the lymphatic tissue is divided toward the lateral bor-
faces of the inferior vena cava are dissected free of lymphatic der of the aorta so that all tissue anterior to this vessel is freed
and included with the specimen. If not already done so, during from the lumbar vessels. The lymphatic package is then re-
this part of the dissection the testicular artery is clipped at its moved.
insertion into the aorta. This dissection is continued cephalad
until the right renal artery, traversing the interaortocaval
space, is identified, which marks the superior border of the L-RPLND fo r St ag e II o r III Dise ase aft e r
template. The interaortocaval lymphatic tissue is now excised, Che mo t he rap y
with its posterior border being the level of the lumbar vessels.
Great care must be taken with retraction of the great vessels as L-RPLN D has in general been performed only in a unilateral
vascular injury may result in hemorrhage that is difficult to fashion, and there is only limited experience of L-RPLN D be-
control by laparoscopic means. Lumbar vessels may need to ing performed for stage II or III tumors after chemotherapy. In
be sacrificed to ensure retrieval of all lymphatic tissue. All such cases L-RPLN D may be performed when there has been
sympathetic nerve fibers should be spared, if possible. With a good response to chemotherapy where only smaller tu-
the medial and superior borders of the template freed, atten- mors/masses (5 cm or less) remain, and tumor markers have
tion is paid to the lateral border along the ureter. After the returned to normal. In such cases, dissection is carried out in a
ureter has been identified, all lymphatic tissue medial to it is similar fashion as described for the unilateral templates in-
freed, beginning where the ureter crosses over the common il- volved but focusing primarily on resection of the residual tu-
iac artery and proceeding cephalad to the level of the renal mor mass. Those with experience in such cases have noted
vessels, where the most cephalad portion of the dissection has that, due to chemotherapy, although tissue planes are more
already been completed. The posteriorly located lumbar ves- difficult to identify, mobilization of the bowel and identifica-
sels may also be encountered during this portion of the dissection of the tumor is possible. Due to the desmoplastic reaction
tion. They should be clipped and divided only when needed to typically seen after chemotherapy, careful dissection is re-
facilitate removal of lymphatic tissue. At this point the lym- quired as tumor/residual tissue may be adherent to blood ves-
phatic packages are completely free. They are placed in a spec- sels. Janetschek et al. (11) noted that teratomas are usually
imen bag and removed. O bvious tumor or suspicious well delineated, but other types of tumor-free residual tissue
fibrolymphatic tissue should be sent for pathologic frozen- may be adherent to surrounding venous structures. All vascu-
section interpretation. The colon and duodenum are then lar branches from the tumor must also be carefully dissected
repositioned to their normal anatomic positions. out, clipped, and transected.
Left-Sided Template. The patient is placed on the operating

table with the left side elevated 45 degrees upward. All other Re t ro p e rit o ne al Ap p ro ach
aspects of positioning and port placement (except now for
left-sided dissection) are similar to that as described for right- Since the introduction of the balloon dissecting technique by
sided dissection. Dissection is begun by incising the white line Gaur, the laparoscopic retroperitoneal approach has been used
of Toldt on the left side, from the splenic flexure to the pelvic for a variety of urologic procedures. Rassweiler et al. (13) re-
brim. The incision is extended distally along the spermatic ported use of this technique for L-RPLN D in 17 cases. This
vein all the way to the internal inguinal ring, where a nonab- technique differs from transperitoneal L-RPLN D in how access
sorbable stitch, left at time of radical inguinal orchiectomy, and exposure are obtained. The essential features of this tech-
should be identified. Superiorly, the dissection is carried medi- nique include placing the patient in the flank position without
ally around the splenic flexure just below the edge of the Trendelenburg. O n the side of dissection a small incision
spleen. At this point the colon is mobilized medially until the ( 2 cm) is made in the lumbar (Petit) triangle between the 12th
entire anterior surface of the aorta is exposed. The entire rib and the iliac crest. Blunt dissection is then used to identify
length of the spermatic vein, from the renal vein to the internal the peritoneal membrane and create the retroperitoneal space
inguinal ring, is dissected free and removed. The left renal vein (Fig. 123.6). The retroperitoneal space can be expanded by use
is identified and freed along its anterior and inferior surface at of either balloon dilating devices (commercial or homemade),
this point of the dissection. The ureter, which defines the lat- or through further dissection with the surgeon’s finger.
eral border of the dissection, is then identified. All lymphatic Surgeons who develop the retroperitoneal space with finger
tissue is dissected free from the ureter from the level of the re- dissection place the secondary ports under digital guidance be-
nal hilum to where the ureter crosses the common iliac artery. fore placing a 12-mm port through the initial incision. When
Then, starting where the ureter crosses (the inferior border of the retroperitoneal space is developed with a balloon dilating
the template) the common iliac artery, all lymphatic tissue is device, a 10-mm trocar is placed through the existing incision.
dissected free from the lateral surface of this blood vessel. Placement of secondary trocars is then performed under la-
From here the dissection is continued cephalad along the paroscopic guidance (Fig. 123.7). O nce the laparoscopic ports
lateral surface of the aorta to the level of the inferior mesen- are in place and pneumoretroperitoneum is stable, a wide lon-
teric artery. This artery is preserved during this dissection. gitudinal incision of the fascia of Gerota is created for optimal
Cephalad to the inferior mesenteric artery all lymphatic tissue exposure of the retroperitoneum. L-RPLN D is then performed
on the anterior and lateral surfaces of the aorta is removed. using the same template and landmarks as described for
Dissection is continued in this manner up to the level of the re- transperitoneal L-RPLN D.
nal vein. All lymphatic tissue associated with the renal vein is Use of this approach for L-RPLN D, to date, is limited.
now dissected free. If there is a lumbar vein inserting into the Authors with considerable experience with retroperitoneoscopy
posterior surface of the renal vein it must be divided to dissect reporting on use of this technique classified retroperitoneal
free all lymphatic tissue. As a final step, the lymphatic package L-RPLN D as difficult. O thers have described extraperitoneal
is dissected free posteriorly. The lymphatic tissue is separated L-RPLN D by an anterior approach.
L-RPLN D performed by this technique. Potential complica-

tions associated with L-RPLN D most often relate to intraop-
erative hemorrhaging. O ther complications specifically related
to this procedure include lymphocele formation and chylous
ascites. The cumulative major (0.7% ) and minor (7.8% ) com-
plication rates (intraoperative and postoperative) of this mini-
mally invasive procedure are reasonable. Patients undergoing
L-RPLN D are likely to experience fewer pulmonary complica-
tions than those undergoing open surgery by midline or thora-
coabdominal incisions. Janetschek et al. (11) noted the
presence of chylous ascites in 21% of patients who underwent
L-RPLN D for persistent stage IIb tumor/mass. The authors
believe that this complication is not related to surgical tech-
nique, as all lymphatic tissue was clipped, but rather to the
brief time to oral intake after L-RPLN D compared to open
RPLN D. All such cases resolved with conservative measures
(low-fat/medium-chain triglyceride diet). In the hands of expe-
rienced laparoscopists, complications specifically related to la-
paroscopy, such as bowel injury due to trocar insertion or
FIGURE 123.6 Blunt dissection of retroperitoneal space with index intraoperative manipulation, are less likely.
finger pushing peritoneum medially; the working space is created The largest contemporary series reported that only 3 of 103
between the lumbar aponeurosis and renal (Gerota) fascia. (From
Janetsckek G. Laparoscopic retroperitoneal lymph node dissection. patients required conversion to an open surgery because of in-
Urol Clin N orth A m 2001;28:107–114, with permission.) jury of a small aortic branch, the renal vein in a horseshoe kid-
ney, and a left renal vein ventral to the aorta in one patient
each (12). There were four intraoperative vascular complica-
tions, including lacerations of the vena cava, renal vein, and a
lumbar vein. The authors noted that three of the vascular com-
plications were laparoscopically controlled with compression,
clips, and fibrin glue; a left renal vein injury was controlled by
laparoscopic suturing. M inor postoperative complications in-
cluded asymptomatic lymphocele in three patients, gen-
itofemoral nerve irritation in one patient, and a single
spontaneously resolving retroperitoneal hematoma. N ormal
antegrade ejaculation was reported in 100 (97% ) patients.
Re sult s
A summation of the worldwide experience with L-RPLN D is
FIGURE 123.7 Port placement for laparoscopic retroperitoneal shown in Table 123.2 (high-volume centers with 10 or more
lymph node dissection (L-RPLN D). Surgeon stands at the backside. reported procedures). Review of 311 patients with follow-up
Port I, 12 mm for laparoscope; port II, 10 mm for right hand of for an average 44 months revealed 1 (0.3% ) local recurrence
surgeon; port III, 5 mm for left hand; port IV , 5 mm for assistant. and 12 (3.9% ) distant recurrences; the solitary local recur-
rence occurred in the contralateral surgical field (12). Positive
lymph nodes were demonstrated in 80 (25.7% ) patients, and
PO STO PERATIVE CARE they were subsequently treated with chemotherapy. A 3.5%
open conversion rate is reasonable for this complex proce-
In an otherwise uncomplicated case, the orogastric tube may dure. Antegrade ejaculation was maintained in 99% . Longer
be removed at the end of the operation. Ambulation is initi- follow-up of a larger number of patients is still needed to as-
ated on the following morning, after which time the in- sess the diagnostic efficacy of this procedure.
dwelling urethral catheter and pneumatic compression A major point of discussion relating to L-RPLN D is
stockings may be discontinued. Diet is advanced on postoper- whether this procedure is simply a diagnostic procedure or
ative day 1. After the first 24 hours oral analgesics ordinarily may also be considered therapeutic. As the vast majority of
suffice for pain control. patients found to have retroperitoneal tumors at the time of
L-RPLN D received adjunctive chemotherapy, it is not possi-
ble to determine the potential therapeutic efficacy of this pro-
O UTCO MES cedure. L-RPLN D has been used in a therapeutic fashion for
a limited number of patients who underwent chemotherapy
Co mp licat io ns and had a persistent retroperitoneal mass. Janetschek et al.
(11) described a group of 59 patients (stage IIb, 43 patients;
The predominant approach to L-RPLN D has been by a stage IIc, 16 patients) who underwent chemotherapy, had
transperitoneal route. The data presented here relate to persistent retroperitoneal mass, and subsequently underwent
TA B LE 1 2 3 . 2
WORLDWIDE EXPERIEN CE WITH LAPAROSCOPIC RETROPERITON EAL LYMPH N ODE DISSECTION FOR
CLIN ICAL STAGE I DISEASE AT HIGH-VOLUME CEN TERS WITH 10 REPORTED CASES
N umber
N umber node- Mean Mean Complications Antegrade Recurrences
of positive follow- operating ejaculation
Study patients patients up (mo) time (min) Conversion Minor Major (%) Local Distant
Albqami and
Janetschek, 2005 103 26 62 217 3 9 3 100 1 4
Castillo et al., 2004 96 18 34 138 4 9 5 100 NR 4a
Rassweiler et al.,
2000 34 6 40 247 1 5 3 97.1 0 2
Bhayani et al.,
2003 29 12 72 258 2 2b NR 96.6 0 2
LeBlanc et al.,
2001 20 6 15 230 0 NR 0 100 0 0
Corvin et al.,
2005 18 7 16.7 232 0 1 0 100 0 0
Correa et al.,
2007 11 5 6 323 1 2 0 90 0 0
Total 311 80 44 205 11 28 11 99 1 12
(25.7% ) (3.5% ) (9.0% ) (3.5% ) (0.3% ) (3.9% )
N R, N ot reported
aDid not report location of recurrences
b O nly reported minor postoperative complications
L-RPLN D. These patients all had normalization of tumor patient with stage IIb disease had recurrence at 24 months
markers and a reduction of tumor size after chemotherapy. outside of the surgical margin that was excised laparoscopi-
O f these patients, 21 had mature teratomas, 36 had necrosis cally; the node contained only mature teratoma. L-RPLN D is
and fibrosis only, 1 had active tumor, and 1 had seminoma. believed to be therapeutic in the 18 patients with mature ter-
The one patient with active tumor received two additional atoma. At a mean follow-up of 35 months, there have been
cycles of chemotherapy and has remained disease-free. O ne no relapses in this group.
References
1. Borley N , Fabrin K, Sriprasad S, et al. Laparoscopic pelvic lymph node dis- 8. Bosl GJ, Bajorin DF, Sheinfeld J, et al. Cancer of the testis. In: DeVita VF Jr,
section allows significantly more accurate staging in “ high-risk” prostate H ellman S, Rosenberg SA, eds. Cancer Philadelphia: lippincott Williams &
cancer compared to M RI or CT. Scand J Urol N ephrol 2003;37:382–386. Wilkins, 2001:1491–1518.
2. Schuessler WW, Vancaillie TG, Reich H , et al. Transperitoneal endosurgical 9. H eidenreich A, Sesterhenn IA, M ostofi FK, et al. Prognostic risk factors
lymphadecentomy in patients with localized prostate cancer. J Urol 1991; that identify patients with clinical stage I nonseminomatous germ cell tu-
145:988–991. mors at low risk and high risk for metastases. Cancer 1998;83:1002–1011.
3. Partin AW, M angold LA, Lamm DM , et al. Contemporary update of 10. Sogani PC, Perrotti M , H err H W, et al. Clinical stage I testis cancer: long
prostate cancer staging nomograms (Partin tables) for the new millennium. term outcome of patients on surveillance. J Urol 1998;159:855–858.
Urology 2001;58:843–848. 11. Janetschek G, Peschel R, Bartsch G. Laparoscopic retroperitoneal lymph
4. Lattouf JB, Beri A, Jeschke S, et al. Laparoscopic extended pelvic lymph node dissection. A tlas Urol Clin N orth A m 2000;8:71–90.
nose dissection for prostate cancer: description of the surgical technique 12. Albqami N , Janetschek G. Laparoscopic retroperitoneal lymph node dis-
and initial results. Eur Urol 2007;52:1347–1355. section in the management of clinical stage I and II testicular cancer.
5. Jeschke S, Beri A, Grull M , et al. Laparoscopic radioisotope-guided sentinel J Endourol 2005;19:683–692.
lymph node dissection in staging of prostate cancer. Eur Urol 2008;53: 13. Rassweiler JJ, Frede T, Lenz E, et al. Long-term experience with laparo-
126–133. scopic retroperitoneal lymph node dissection in the management of low-
6. Solberg A, Angelsen A, Bergan U, et al. Frequency of lymphoceles after stage testicular cancer. Eur Urol 2000;37:251–260.
open and laparoscopic pelvic lymph nose dissection in patients with
prostate cancer. Scand J Urol N ephrol 2003;37:218–221.
7. H errell SD, Trachtenberg J, Theodorescu D. Staging pelvic lymphadenec-
tomy for localized carcinoma of the prostate: a comparison of 3 surgical
techniques. J Urol 1997;157:1337–1339.
NEPHRECTO MY AND PARTIAL NEPHRECTO MY
JAMES A. BRO WN
Standard transperitoneal and retroperitoneal laparoscopic Almost all nonfunctioning kidneys and stage T1 and T2
nephrectomy (LN ) were first performed in 1990, and their tumors can be removed laparoscopically. H and-assisted la-
partial nephrectomy (PN ) counterparts followed in 1993 and paroscopy (H AL) is a viable alternative for any case where
1994 (14). H and-assisted laparoscopic nephrectomy (H ALN ) nephrectomy or PN is indicated. H ALN is a particularly use-
was subsequently introduced in 1997. ful alternative for urologists with limited laparoscopic surgi-
Equivalent 5-year cancer cure rates combined with decreased cal experience. Additionally, H ALN may be advantageous
morbidity and recovery time have made LN the current stan- compared to standard LN in cases of donor nephrectomy,
dard of care for surgically treating renal malignancies in nephroureterectomy, tumors 10 cm, and severe perinephric
industrialized countries. Laparoscopy is also the standard scarring secondary to prior surgery or infection (e.g., xan-
today for performing nephrectomy for benign disease. While thogranulomatous pyelonephritis). Difficult standard laparo-
open partial nephrectomy (O PN ) remains the standard of scopic operations can be converted to H AL rather than open
care, laparoscopic partial nephrectomy (LPN ) is increasingly procedures by the surgeon comfortable with H AL.
being performed at high-volume medical centers of laparo- H and-assisted LPN (H ALPN ) and LPN have differing ad-
scopic surgical excellence, and at these centers outcomes ap- vantages and disadvantages. LPN minimizes incision length
proach those of O PN . H owever, concerns regarding warm and morbidity. It further allows for more facile suturing and
ischemia time, control of hemorrhage, urinary extravasation, needle handling. H ALPN has the advantage of allowing for
complications, and difficulties in technique training and tumor palpation, which may increase surgeon comfort during
propagation have promoted ongoing and wide-ranging re- tumor excision. It further allows for the selective perfor-
finements to the LPN procedural technique. mance of polar PN with hand compression rather than hilar
clamping. In this situation, H ALPN may minimize the overall
renal injury from the procedure, and if a positive surgical
DIAGNO SIS margin occurs, a repeat resection might be performed with
less risk for additional renal impairment (5). This is not the
Renal masses are identified during radiologic imaging of pa- case after LPN or H ALPN using hilar clamping.
tients with hematuria or abdominal or flank discomfort.
Additionally, patients are increasingly identified incidentally.
Tumors are typically characterized and staged using ab- ALTERNATIVE THERAPY
dominopelvic computerized tomography (CT) or magnetic
resonance imaging (M RI) scan and chest radiography. O pen radical nephrectomy (O RN ) and O PN may be per-
Preoperative blood work includes metabolic panels including formed. Cryoablation (CA) and radiofrequency ablation
serum creatinine, liver function studies, alkaline phosphatase, (RFA) are also therapeutic alternatives, particularly for pa-
and calcium. If the latter two studies are elevated or if the patients who are elderly or who have significant medical comor-
tient has bone pain or other evidence of metastases, a bone bidities, hereditary forms of renal cancer, or multiple tumors.
scan will be performed. Brain imaging is selectively obtained These ablative procedures can be performed percutaneously
in patients with cerebral symptoms or evidence for metasta- with CT or M RI guidance and laparoscopically. Tumor enu-
sis. N uclear renography is utilized in patients with renal in- cleation may be considered in patients with severe renal in-
sufficiency or if there is concern regarding the function of the sufficiency, a solitary kidney, multiple tumors, or a tumor in a
contralateral kidney. difficult location (e.g., central, hilar). Lastly, observation
alone may be reasonable for patients with small tumors, cys-
tic masses, advanced age, or poor health.
Simple nephrectomy is indicated for benign conditions such PATIENT PREPARATIO N
as chronic pyelonephritis, nephrosclerosis, multicystic dysplas-
tic kidney, postrenal transplantation or renovascular hyper- A formal bowel preparation is not routinely performed, but a
tension, reflux or obstructive nephropathy, and symptomatic clear liquid diet the day before surgery augmented by a
acquired renal cystic or autosomal dominant polycystic kid- Dulcolax suppository or an oral saline cathartic (e.g., magne-
ney disease (ADPKD). Radical nephrectomy is indicated for sium citrate or Fleet Phospho-Soda) is often employed. O ne
tumors worrisome for malignancy. gram of cefazolin (Ancef) is administered preoperatively.
819
Deep venous thrombosis prevention with subcutaneous he- the laparoscope (“ camera” ) port positioned between the
parin (5,000 U 2 hours prior to procedure and continued working ports, which is the author’s preference. Some place it
every 12 hours postoperatively until the patient is ambula- caudad to the working ports. M any surgeons use a 30-degree
tory) and/or pneumatic compressive stockings are used. laparoscope placed through an umbilical port, with working
ports widely spaced in the subxiphoid midline and the far lat-
eral abdomen (anterior axillary line, umbilical level), creating
PATIENT PO SITIO NING a 90-degree angle in relation to the umbilical trocar. O ther
surgeons place the working ports closer to the umbilical tro-
Under general anesthesia, intravenous access and endotra- car, keeping them at least 10 cm apart. O thers reduce the an-
cheal intubation are obtained with the patient supine. gle of the working ports in relation to the umbilicus to
O rogastric and Foley catheters are inserted to decompress the approximately 60 to 70 degrees, creating a trocar “ diamond”
stomach and bladder. The patient is then placed in a modified configuration. Alternatively, one can use a 0-degree laparo-
(30- to 70-degree) lateral decubitus position, with the umbili- scope placed through a trocar lateral to the rectus muscle and
cus over the break in the table. For retroperitoneoscopic pro- just cephalad to the umbilicus, with the working ports shifted
cedures, the patient is placed in or closer to the true lateral slightly cephalad and laterally, respectively, to maintain at
decubitus position. An axillary roll is placed, the table is least 10-cm or five-fingerbreadths distance between trocars.
flexed as necessary (usually minimally compared with open A 5-mm trocar is often placed in the far lateral (anterior to
flank surgery), and a bean bag or padding is positioned to posterior axillary line) position for retraction, and another 5-
support the buttocks and flank. Pillows are placed between mm trocar is often placed below the xiphoid process for
the flexed lower and straight upper leg. The upper arm rests right-sided procedures to elevate the liver using a locking
on a well-padded arm board (or pillows) without tension on the grasper attached to the lateral abdominal wall. O bese pa-
brachial plexus. Three-inch tape is used to secure the patient tients or patients with protruberant abdomens will need to
around the hips, shoulders, and thighs to ensure stability when have the trocars shifted laterally to maintain effective work-
rolling the table to facilitate bowel retraction (Fig. 124.1). ing angles into the retroperitoneum.
Re fle ct io n o f t he Co lo n
SURGICAL TECHNIQ UE The ipsilateral ascending or descending colon must be mobi-
lized to gain access to the kidney and renal hilum. The pari-
Transp e rit o ne al Rad ical o r To t al etal peritoneum is first incised medial to the line of Toldt,
Ne p hre ct o my approximately 1 cm lateral to the mesenteric fat lying lateral
to the colon. This incision is carried from the iliac vessels to
Acce ss the level of the spleen (left) or liver (right). Atraumatic
graspers are used in the nondominant hand to provide coun-
Although various insufflation techniques can be used, most tertension, and a hook electrode, Endoshears (scissors), or
urologists use a Veress needle. It is commonly inserted at the harmonic scalpel is used in the dominant hand to perform the
level of the umbilicus lateral to the ipsilateral rectus muscle. dissection. Endoshears are particularly useful when dissecting
The abdomen is insufflated to 15 mm H g. Some surgeons pre- in close proximity to bowel and when tissue planes are rela-
fer a pressure of 20 mm H g during the trocar placement. tively avascular. Selective use of monopolar cautery through
Typically a 10- or 12-mm trocar is placed lateral to the rectus the instrument or use of a bipolar grasper in the nondominant
at the level of the umbilicus using a visual obturator trocar hand allows for an efficient and elegant dissection by an ex-
(e.g., Visiport, AutoSuture or O ptiview, Ethicon Endo- perienced surgeon. Conversely, the harmonic scalpel excels at
Surgery). O nce the peritoneum has been entered, the in- maintaining hemostasis when tissue planes are more vascular,
traperitoneal contents are inspected for injury or adhesions. and it is an excellent blunt-tipped dissection tool. Less experi-
Trocar site placement varies significantly based on surgeon enced surgeons and surgeons in training may find the har-
preference and patient body habitus. M ost surgeons prefer monic scalpel an easier tool to master. For left-sided
procedures, many surgeons advocate carrying the peritoneal
incision above the spleen laterally, allowing the spleen to fall
medially with the pancreas and colon. O thers prefer to carry
the peritoneal incision through the phrenicocolic ligament to
the spleen but then carry the dissection medially, leaving the
spleen suspended on a “ hammock of peritoneum caudad to
the spleen and extending to the left abdominal sidewall,”
(Fig. 124.2). The splenophrenic attachments are left intact
while the splenocolic and then renocolic fascial attachments
are divided in layers until the descending colon is fully mobi-
lized medially and the left gonadal vein is visible.
For right-sided procedures, the peritoneum just lateral to
the ascending colon is divided and carried to the level of the
FIGURE 124.1 The patient is placed in a modified (70-degree) lat- liver. This peritoneal incision is also carried medially, staying
eral decubitus position, with the umbilicus over the break in the
table. (From Figure 11.3 in Bishoff JT, Kavoussi LR, eds. A tlas of approximately 1 cm away from the lateral border of the
laparoscopic retroperitoneal surgery. Philadelphia: WB Saunders, colonic hepatic flexure. This incision then proceeds cephalad
2000, with permission.) to approximately 1 cm below the liver and back laterally
Chap t e r 124: Lap aroscop ic Ne p hre ctomy and Partial Ne p hre ctomy 821
FIGURE 124.2 M obilization of the colon

using medial traction to demonstrate and di-
vide attachments. (From Figure 4.8 in Bishoff
JT, Kavoussi LR, eds. A tlas of laparoscopic
retroperitoneal surgery. Philadelphia: WB
along the inferior surface of the liver to the sidewall. This ap-
proach will leave a wedge-shaped area of peritoneum cover-
ing the anterior aspect of the right kidney (Fig. 124.3). O nce
the ascending colon is mobilized medially, the duodenum is
subsequently identified and a fascial incision is made approx-
imately 1 cm lateral to its second stage. A Kocher maneuver is
performed to move the duodenum medially. Third, the infe-
rior vena cava (IVC) is exposed by incising the fascia and dis-
secting along its lateral border. For both left- and right-sided
procedures, care is taken to preserve the lateral attachments
of the kidney to prevent it from falling medially, inhibiting
dissection of the renal hilum and the medial aspect of the
Gerota fascia.
Go nad al Ve in Disse ct io n
O nce the colon is fully mobilized, the gonadal vein is identi-
fied. M any urologists find the gonadal vein to be the “ gate-
way” for initiating the nephrectomy portion of the procedure
and carrying the dissection to the renal hilum. For left-sided
nephrectomies, the fascia overlying the gonadal vein is di-
vided and this dissection is carried cephalad to the renal vein.
Care must be taken to dissect anterior to the gonadal vein to
prevent injuring small gonadal venous tributaries or hilar ves-
sels. The harmonic scalpel is useful for dividing these fascial
attachments and maintaining hemostasis. This will allow for
exposure of the anterior aspect of the left renal vein and sub-
sequently the adrenal vein. The adrenal vein may be dissected
using the harmonic scalpel or a gently curved dissector (e.g.,
M aryland). It is subsequently cauterized (e.g., with a paddle
FIGURE 124.3 Diagram of the right-sided nephrectomy demonstrat-
bipolar instrument), clipped (e.g., with H em-O -Lock clips), ing the wedge-shaped configuration. The numbers refer to the three
and divided. The gonadal vein is then divided 1 to 2 cm be- distinct levels of dissection along the medial aspect of the kidney:
low the renal vein in a similar fashion. It is included with the colon, duodenum, and inferior vena cava.
B
FIGURE 124.4 Elevation of ureter and tail of the Gerota fascia (A) to allow dissection to and exposure
of renal vessels (B). (From Figures 5.8 and 5.9 in Bishoff JT, Kavoussi LR, eds. A tlas of laparoscopic
retroperitoneal surgery. Philadelphia: WB Saunders, 2000, with permission.)
radical nephrectomy specimen, particularly for large and after dividing the left adrenal and gonadal veins, if a true rad-
lower-pole tumors. For right-sided procedures, the fascia over ical nephrectomy is to be performed. The adrenal gland and
the gonadal vein may similarly be divided along the course of gonadal vein are spared when performing a simple nephrec-
the vein up to its junction with the IVC. The right gonadal tomy or in select cancer patients. The tail of the Gerota fascia
vein may, particularly for large tumors, be divided and re- is mobilized medial to the gonadal vein from the renal hilum
moved with the specimen. Conversely, the dissection can be to the iliac vessels.
made just lateral to the right gonadal vein for smaller mid-
and upper-pole tumors. The plane of dissection between the Se curing t he Re na l Blo o d Ve sse ls
gonadal vein and the tail of the Gerota fascia (containing the Firm anterolateral elevation of the lower pole is critical in or-
ureter) is developed, and the latter is elevated anterolaterally der to facilitate dissection of the hilum. This is accomplished
(using a laparoscopic Kitner, atraumatic grasper, or suction by placing a laparoscopic Kitner or atraumatic grasping in-
device) to allow dissection to the renal hilum via an inferoan- strument under the tail of the Gerota fascia, the ureter, and
terior approach (Fig. 124.4). the lower pole and lifting to the abdominal sidewall. With the
hilum on tension, a harmonic scalpel, suction instrument,
Disse ct io n o f Ure t e r and Tail o f t he Ge ro t a Fa scia hook electrode, dissector (e.g., M aryland), or Endoshears can
For right-sided procedures, the ureter and tail of the Gerota be used to dissect out the renal artery and vein and any neces-
fascia are elevated anterolaterally and the dissection carried sary tributaries (e.g., lumbar or accessory vessels). Lymphatic
along the gonadal vein to the IVC cephalad and to the iliac vessels and fascial attachments inferior to and occasionally
vessels caudad. For left nephrectomies, the dissection of the encasing the renal artery must be divided bluntly or sharply.
ureter and medial tail of the Gerota fascia is often performed O nce adequate vessel exposure (at least a 1- to 2-cm space) is
created, an endovascular gastrointestinal anastomosis (GIA) is clipped and divided and any remaining posterior or lateral
stapler is used to divide first the renal artery and then the attachments are divided by rotating the kidney as necessary.
vein. Alternatively, a series of at least three H em-O -Lock clips
may be applied to the renal artery, dividing it approximately O rg an Ent rap me nt
1 cm lateral to the clips. In cases of severe perihilar fibrosis or Benign kidneys may be morcellated in a durable entrapment
if individual vessel isolation is difficult, en bloc endovascular sac, but malignant kidneys should be removed intact. The
GIA stapler division of both the artery and vein simultane- risk for tumor spillage and the loss of histologic staging infor-
ously is effective (17). H ilar side branches (gonadal, adrenal, mation virtually always outweigh the morbidity benefits of
lumbar, and accessory) may be ligated and divided in a vari- minimizing the extraction incision. The kidney is placed into
ety of ways. Cauterization with either the LigaSure device or a deployable entrapment sack (e.g., Endocatch II, US Surgical)
three overlapping deployments of a standard paddle bipolar and then brought out through an incision extended from a
cautery is effective. Standard titanium or locking polymer 12-mm trocar site. Alternatively, the specimen may be removed
H em-O -Lock clips may be used. The author favors sequential through a Pfannenstiel incision. Trocar sites larger than 5 mm
paddle bipolar cauterization of the vessel and placement of a should have a fascial closure suture (e.g., interrupted 0 Vicryl)
H em-O -Lock clip on the stay side of the vessel if it won’t be placed prior to specimen extraction. The Carter-Thomason
in the path of the endovascular GIA stapler when dividing the device facilitates placement of these fascial sutures.
renal vessels.
Up p e r-Po le Iso lat io n Hand -Assist e d Lap aro sco p ic

O nce all hilar vessels have been divided, the dissection is car- Ne p hre ct o my
ried superiorly. For right radical nephrectomies (RN s), the
adrenal vein must be identified, ligated, and divided. H em-O - Acce ss
Lock clips, preferably two on the stay side, or an endovascu- For left H ALN , a 7-cm supraumbilical midline incision is
lar GIA stapler may be used. The remaining suprarenal made extending into or skirting the umbilicus. It is useful to
attachments and middle suprarenal arteries are divided with place a 0 Vicryl suture through the anterior rectus fascia and
the harmonic scalpel or stapler (Fig. 124.5). A similar dissec- peritoneum at the midline of the incision bilaterally in order
tion can be performed for left RN s, separating the adrenal to elevate the abdominal wall to facilitate placement of the in-
from the aorta and diaphragm. Alternatively, for simple traperitoneal portion of the laparoscopic hand port (e.g.,
nephrectomies and selectively for small, non-upper-pole renal GelPort, Applied M edical; or Lap Disc, Ethicon Endo-
tumors (with a normal ipsilateral adrenal gland on preopera- Surgery). These current third-generation devices have a nar-
tive abdominal CT or M RI imaging and intraoperative rower base than their predecessors, facilitating subsequent
exam), the adrenal gland can be spared by placing the kidney placement of trocars in slender patients. With a 0-degree la-
on caudad traction and dividing the attachments between the paroscope placed through a 12-mm trocar within the device,
adrenal gland and upper pole, staying adjacent to the adrenal. the peritoneum is inspected for adhesions. Under direct vision
At this point, if it hasn’t been performed previously, the ureter or under fingertip control, 12-mm trocars are then placed lat-
eral to the rectus muscle (midclavicular line) and also approx-
imately two fingerbreadths off the tip of the twelfth rib
(anterior axillary line). Both trocars are positioned at the
level of the hand port device (Fig. 124.6). A 5-mm trocar is
B
FIGURE 124.5 Adrenal gland excision with a right radical nephrec- FIGURE 124.6 H and-assisted laparoscopy port placement for left
tomy specimen. (From Figure 5.14B in Bishoff JT, Kavoussi LR, eds. renal surgery. An optional 5-mm trocar may be placed cephalad
A tlas of laparoscopic retroperitoneal surgery. Philadelphia: WB (shown) or caudad to two 12-mm trocars placed at the level of the
Saunders, 2000, with permission.) hand port or umbilicus.
selectively placed in the left lower quadrant, approximately

10 cm below the 12-mm trocars or along the costal margin,
to use for retraction.
Right-sided H ALN procedures may be performed by the
left-handed or ambidextrous surgeon with ports placed in a
mirror image fashion to the left-sided procedure. Alternatively,
the hand port may be placed in the right lower quadrant
through a 7-cm muscle-splitting incision. It may also be
moved further caudad in the midline using a paraumbilical
incision. This will allow room for placement of the laparo-
scope and the working and liver retraction trocars in the up-
per right quadrant and abdominal midline, cephalad to the
hand port.
Aorta
Pro ce d ure Renal artery
A damp laparotomy sponge, useful for hemostasis, is initially
Renal vein
carried into the abdomen while inserting the hand. The obvi-
ous and only significant difference between H ALN and stan-
dard LN is the use of the hand for palpation and retraction. FIGURE 124.7 Finger and hand position during left renal hilar
Some standard laparoscopic urologic surgeons find the H AL dissection.
technique cumbersome and find that their hand is “ in the
way.” They are able to use retraction instruments more effec-
tively than an intraperitoneal hand. Conversely, expert H AL the incisions are closed. The midline hand port incision is closed
surgeons become adept at utilizing their intraperitoneal hand with interrupted figure-of-eight no. 1 absorbable monofilament
in ways that gain them additional exposure beyond what they sutures (M axon or polydioxanone).
can obtain with standard laparoscopic instruments. Initially, Right H ALN may be performed using a mirror image
the colon is reflected using a harmonic scalpel or Endoshears, technique, with the right hand placed within the peritoneum,
while providing medial bowel traction with the fingertips. or the right-handed surgeon may place the left hand in the ab-
The hand is then placed in a “ C-shaped” configuration while domen. The procedure is accomplished as described for the
operating within the central space between the fingers and standard right LN technique, using the hand to provide ten-
thumb. sion and countertension. The surgeon will often facilitate the
For a left H ALN , fingertips provide gentle tension and hilar dissection by lifting the lower pole anteriorly with a re-
countertension, respectively, on the spleen or kidney and tractor. This will free up the hand to encircle and flatten the
colon while the splenocolic and then renocolic attachments hilum, palpating and placing the artery and vein on stretch.
are divided. As the bowel is increasingly mobilized, it may be This will promote rapid isolation and division. The adrenal
elevated anteriorly with the hand to facilitate separation of gland may be palpated, as can the hilar lymphatics and the
the colonic mesentery from the anterior aspect of the Gerota liver. The H ALN technique is particularly useful if significant
fascia. The gonadal vein and subsequently renal vasculature perihilar lymphadenopathy is present and for very large tu-
are dissected and handled as described for LN . The back of mors impinging on either the IVC or aorta, where a safe dis-
the wrist and hand assist with retraction of the colon to ex- section plane may be difficult to identify with standard
pose the hilum. The fingertips flatten and provide simultane- laparoscopy. The subcutaneous tissues are injected with a
ous cephalad, lateral, and inferomedial tension, facilitating mixture of 0.25% M arcaine and 1% lidocaine prior to ap-
renal vessel dissection and division. The lower pole, ureter, proximating the subcuticular layer with 4-0 M onocryl suture.
and tail of the Gerota fascia are elevated anteriorly by placing Sterile bandages are applied to the trocar sites. Injecting these
the index and middle fingers posteriorly and lifting anteriorly. sites prior to port placement may provide additional anal-
The fourth finger may be placed cephalad to the renal vein to gesic benefit. The hand port incision is covered with a small
further rotate the renal artery into view (Fig. 124.7). gauze dressing and Tegaderm and the trocar sites with sterile
Palpation is used to confirm location of the aorta and renal bandages.
artery or arteries. The remainder of the procedure is accom-
plished in a similar fashion to standard LN . A simpler, less
expensive entrapment sack (Cook Urologic, Spencer, IN ) is
introduced for specimen extraction. It is unrolled on top of Re t ro p e rit o ne al Ne p hre ct o my
the spleen with the posterior opening of the sack flattened
across the body wall using the fifth fingertip to fixate it medi- Acce ss
ally and a grasping instrument to hold it laterally. The third A 2-cm incision is made just below the tip of the twelfth rib in
and fourth fingers of the intraperitoneal hand hold the ante- the midaxillary line. A Kelly clamp is used to separate the
rior aspect of the sack open, and the thumb and index finger subcutaneous fat and expose the flank musculature. The mus-
“ feed” the kidney into the sack. The neck of the sack is tight- cle is bluntly divided, and the underlying thoracolumbar fascia
ened and the specimen is removed through the hand port is pierced to enter the pararenal fat of the retroperitoneum.
incision. The incision may be extended as necessary for speci- “ S” type or Army-N avy retractors are used for exposure, and
mens too large to pass. The retroperitoneum is irrigated and a fingertip is inserted and rotated 360 degrees in order to
palpate the psoas muscle and confirm an appropriate clipped with H em-O -Lock clips, or cauterized and divided.
retroperitoneal location. A balloon dilator is introduced and Circumferential dissection of the Gerota fascia is performed.
filled to 800 cc with room air. During insufflation, a 10-mm O n the right side, cephalad dissection will lead to the adrenal
laparoscope may be introduced to view the dissection. A 10- vein, which will be clipped or cauterized and divided. The
mm blunt-tipped cannula is introduced with 30 cc of air in adrenal vein will also typically be divided during left nephrec-
the balloon (US Surgical). After tightening the outer ring tomy. The ureter is doubly clipped and divided, followed by
sponge to compress the balloon against the inner abdominal division of the remaining retroperitoneal attachments. The
wall, the retroperitoneum is insufflated to 15 to 20 mm H g. specimen is entrapped in a deployable sack and removed
O f note, some surgeons alternatively make the incision mid- through the initial port site by extending the incision horizon-
way between the iliac crest and the tip of the twelfth rib in the tally anterior to the tip of the twelfth rib. M orcellation of be-
posterior axillary line. Additionally, a visual obturator trocar nign kidneys can be performed in an impermeable sack (e.g.,
with a 10-mm 0-degree laparoscope may be used instead to LapSac, Cook Urologic, Spencer, IN ).
enter the retroperitoneal space. Entry must be at a 10-degree The peritoneal cavity may be entered during anterior dis-
anterior angle. Angling too far posteriorly will injure the section of the Gerota fascia, but it does not necessitate con-
quadratus or psoas musculature, whereas too anterior of a version to a transperitoneal technique. Conversion to a
trajectory may allow entry into the peritoneum or cause transperitoneal laparoscopic or open flank nephrectomy ap-
colon injury. proach can be performed in difficult cases. Similar to the
transperitoneal technique, the retroperitoneum is inspected
Pro ce d ure for hemostasis with CO 2 pressure at 3 to 4 mm H g prior at
After obtaining retroperitoneal entry, blunt dissection is per- end of the case. The port sites will not require fascial closure
formed using only the scope. Anteriorly, the peritoneum is but are irrigated, and the skin is closed with 4-0 subcuticular
swept medially, exposing the transversalis fascia. O nce peri- suture.
toneal dissection off the abdominal wall is complete, acces-
sory ports are placed in the upper and lower midaxillary line
and a 5-mm trocar is placed in the anterior axillary line Transp e rit o ne al Part ial Ne p hre ct o my
(Fig. 124.8). Some surgeons eliminate the lower midaxillary
line port (three-port approach), while others maintain this Access and renal exposure are similar to transperitoneal LN .
trocar and add another anterior to it (five-port approach). The renal hilum is identified. At this point the operation will
If balloon dilation was effective, the kidney should be dis- vary somewhat, depending on the PN technique that is em-
placed anteriorly. The psoas muscle is cleaned of fat and the ployed. In most instances, the renal artery and vein are care-
dissection is carried cephalad and medially until the pulsating fully dissected. The Gerota fascia is then opened horizontally
renal artery is visualized. The Gerota fascia is incised and across the anterior midpole, and the perirenal fat is reflected
the renal hilum is dissected, clipping the artery and stapling off the capsule. Some surgeons open the Gerota fascia along
the vein with the endovascular GIA stapler. For left-sided the lateral margin of the kidney. Fat is reflected until the
nephrectomy, the posterior ascending lumbar vein may be en- tumor is visualized and then exposed, leaving it covered with
countered prior to viewing the artery. It should be dissected, fat. Endoshears or the harmonic scalpel is used to separate
the fat from the capsule, with care taken not to get subcap-
sular. Intraoperative sonography is performed, if available,
to assess the depth of the tumor and rule out additional
tumors.
The major challenges of laparoscopic nephron-sparing
surgery are difficulty performing regional hypothermia (cold
ischemia), difficulty maintaining hemostasis if hilar clamping
is avoided, and difficulty completing the procedure within a
30-minute warm ischemic period. Previously, numerous tech-
niques were used in an effort to perform simultaneous tumor
resection and hemostasis. These included the use of electro-
cautery, the Cavitron ultrasonic surgical aspirator, the en-
dovascular GIA stapler, the argon bean coagulator, topical
agents, ultrasonic energy, microwave thermotherapy, and ca-
ble tie compression (32). A 5- to 10-mm rim of normal
parenchyma is marked by scoring the renal capsule with elec-
trocautery using the hook electrode. The excision is initiated
by dissecting perpendicularly into the kidney along the pyra-
FIGURE 124.8 Port placement during right retroperitoneoscopic re- midal lines. A meticulous effort is made to avoid dissecting
nal surgery. The primary port (PP) is inserted by the open (H asson) too superficially into the pseudocapsule or the tumor itself.
technique caudad to the tip of the twelfth rib. The 12-mm lower The tumor is removed with a 5-mm to 1-cm margin of normal
midaxillary line (L M A L ) port is placed 2 to 3 cm cephalad to the iliac parenchyma. The parenchymal defect is inspected to ensure
crest. The 5-mm anterior axillary line (A A L ) port is placed at the
level of the PP. The 5-mm upper midaxillary line (UM A L ) is placed
hemostasis, and if necessary the closure is augmented with
near the tip of the eleventh rib. Care must be taken to avoid adjuvant coagulation (e.g., argon beam) or topical agents
transpleural placement of this trocar. (e.g., fibrin glue). These nonhilar clamping PN techniques
have been only partially effective in preventing perinephric capsule. Pledgets of numerous materials, including fat, surgi-
hemorrhage. They are currently used only selectively, by some cal wrapped Gelfoam, and Gore-Tex (W.L. Gore and associ-
surgeons, on polar or very exophytic tumors. M ore recently, ates) have been used. The author has also found bovine
most surgeons have moved toward an LPN technique more pericardium to be effective. The bulldog clamps are released
closely mimicking the O PN technique, including hilar clamp- and hemostasis assessed. The retroperitoneum is irrigated and
ing and parenchymal closure. Although efforts have been aspirated. If hemostasis is adequate at an insufflation pres-
made to replicate the regional hypothermia caused by ice sure of 5 mm H g, then the perinephric fat is reapproximated.
slush in open surgery, this has been difficult in the laparo- It may be sutured or held in position with clips. A closed sys-
scopic setting due to the technologic and logistical difficulties tem drain (e.g., Jackson-Pratt) is placed outside of the Gerota
involved. Efforts to cool the kidney during laparoscopy are fascia and away from the renal parenchymal closure. The
further hindered by the flow of room temperature CO 2 . specimen is placed in a deployable entrapment sack if not
Currently, surgeons typically clamp both the renal artery done previously and extracted. The incisions are closed.
and vein with laparoscopic bulldog clamps, and without cold
ischemia rapidly resect the tumor with laparoscopic scissors.
This approach causes less tissue distortion than the use of the Hand -Assist e d Lap aro sco p ic Part ial
harmonic scalpel, bipolar cautery, or “ hot scissors” (which Ne p hre ct o my
are ineffective at preventing bleeding or urine leakage) and
allows for a more accurate inspection for a positive surgical The access and renal exposure are similar to H ALN . The
margin or an opening into the collecting system. M ost sur- main disadvantages of H ALPN compared to standard laparo-
geons attempt to close large ( 5mm) urothelial defects with scopic PN are that a 7-cm incision is virtually never required
figure-of-eight absorbable sutures (e.g., 4-0 M oncryl). Lapra-Ty to extract the specimen, it may be risky to provide hemostatic
clips (Ethicon, Cincinnati, O H ) are used by some to speed control with hand compression alone, and suturing “ one-
this process. An interrupted sutured closure of the capsule, handed” may be difficult. There is further concern regarding
often bolstered, is then performed over a Surgicel or Gelfoam increased renal damage due to “ intermittent” vascular occlu-
sponge (Fig. 124.9). The closure is often augmented by hemo- sion, which may occur with hand compression alone.
static agents (e.g., Tisseel or FloSeal) placed directly into the H ALPN proponents claim that this technique more closely
defect or impregnated in the Gelfoam. A roll of Surgicel may mimics what many urologic oncologists do during O PN . The
also be placed into the defect prior to reapproximating the hand is used for tumor palpation during tumor excision and
may be selectively used to provide hemostasis without hilar
clamping. In this situation, the interpolar and opposite polar
blood flow will likely be maintained throughout the case, and
overall renal recovery and function are likely better. Another
advantage is the relative ease of ice slush application through
the hand port if hilar clamping is used.
Intraoperative sonography may be used during H ALPN to
confirm the findings of palpation. The margins of dissection
are marked and the specimen excised sharply, using the hand
to carefully retract and palpate the tumor during the process.
For exophytic polar lesions, a “ fibrin glue bandage” of
Gelfoam impregnated with Tisseel fibrin sealant (Baxter U.S.)
may be used. Prior to this, argon beam coagulation may be
used as an adjunct to promote hemostasis. This can be ap-
plied through a 5-mm trocar with periodic venting of in-
creased pressure. The “ bandage” can be “ welded” to the
capsule with the argon beam. An unfurled Surgicel dressing
may be draped over the “ bandage” and around the kidney.
The specimen is sent for frozen section analysis to confirm
negative margins.
For central or hilar tumors, vascular clamping is em-
ployed, and an interrupted parenchymal closure over a “ fib-
rin glue bandage” or rolled Surgicel, similar to the closure
described for LPN , is utilized. For both LPN and H ALPN ,
ureteral stents may be positioned in the renal pelvis at the ini-
tiation of the case to allow for injection of methylene blue to
assess for urothelial defects. The need for this and further the
need to close urothelial openings prior to closing the renal
parenchyma/capsule has been questioned, and the author
does not place a ureteral stent prior to PN and only closes
FIGURE 124.9 Resection bed of a right upper-pole tumor. Fibrin
large ( 5-mm) urothelial gaps that occur under hilar clamp-
glue-impregnated Gelfoam is placed into the defect. Pledgeted inter- ing control. O nce hemostasis is ensured and the specimen re-
rupted sutures are then used to reapproximate the renal capsule. moved through the hand port, the incisions are closed.
including operative time, blood loss, postoperative analgesia

Re t ro p e rit o ne o sco p ic Part ial requirements, length of hospital stay, and duration of conva-
Ne p hre ct o my lescence, largely favor LRN . H owever, postoperative conva-
lescence varies widely in patients undergoing laparoscopic
Access and renal exposure are as described in the description kidney procedures. A randomized controlled single-center
of retroperitoneoscopic nephrectomy. This technique is typi- trial comparing laparoscopic (transperitoneal) with open
cally performed only by true LPN experts when treating small (flank) simple and radical nephrectomy demonstrated similar,
posterior renal tumors. H ilar dissection and clamping are rapid operative times (105 and 93 minutes, p 0.4) in both
performed selectively. Excision of the tumor is performed as groups (Burgess) (7). Blood loss, complications, and mortality
described for transperitoneal LPN with negative margins con- rates were also similar. The LRN cohort had less postopera-
firmed and the defect covered with a fibrin glue bandage tive pain returned to normal activity 20 days earlier.
if shallow (cortex) or closed with interrupted capsular/
parenchymal sutures if deeper (e.g., into the renal medulla).
O f note, the limited space within the retroperitoneum makes Lap aro sco p ic Part ial Ne p hre ct o my
suturing difficult, and most laparoscopic surgeons prefer to
perform LPN transperitoneally. The specimen is entrapped in In 2006 researchers from Johns H opkins retrospectively re-
a deployable sack and removed, followed by hemostasis con- viewed and reported on 143 stage T1 N 0 M 0 patients who
firmation, drain placement, and closure. underwent LPN (85) or O PN (58) between 1996 and 2004,
with a mean follow-up of 40 18 months (25). They ob-
served 5-year 91.4% disease-free and 93.8% actuarial sur-
PO STO PERATIVE CARE vival rates in the LPN cohort and 97.6% and 95.8% rates,
respectively, in their O PN cohort. They reported that survival
Postoperative care is similar regardless of the laparoscopic analysis revealed no significant differences and that midrange
approach, and, with the exception of drain placement for PN , oncologic results were comparable for pT1 N 0 M 0 tumors.
it is similar for nephrectomy and PN patients. Ketorolac The Cleveland Clinic subsequently reported their 5-year
(Toradol) 15 mg every 6 hours as requested is typically pre- follow-up outcomes in 2007 (18). O ne final surgical margin in
scribed for 36 hours. O ral narcotics are made available if nec- 37 cancer cases was positive. A single local recurrence (2.7% )
essary. A clear liquid diet is resumed immediately and and no distant recurrences were identified. O verall and
advanced as tolerated. The patient ambulates on postopera- cancer-specific survival rates of 86% and 100% , respectively,
tive day 1 and is typically discharged in the evening or the fol- were observed. M edian serum creatinine levels increased
lowing morning. Parenteral antibiotics are discontinued on from 0.9 mg per dL preoperatively to 1.0 mg per dL postop-
postoperative day 1. O ral analgesics are prescribed upon dis- eratively. They concluded that these excellent results are com-
charge. Dulcolax suppositories are given as necessary for parable to O PN and that LPN is an established alternative at
postoperative constipation, and patients are discharged tak- their center. Despite these promising results, they acknowledge
ing a stool softener (e.g., Colace). For PN , the drain is re- that O PN remains the standard of care for small, resectable,
moved when the volume has decreased to 60 to 100 mL per solid renal masses and that LPN is an evolving standard.
day. If a question exists regarding a urinary leak, a drain fluid What then is the current standard LPN technique in this
creatinine level is obtained. evolving process? The Cleveland Clinic proposed in 2005
that preoperative ureteral catheterization, laparoscopic renal
ultrasonography, en bloc renal hilar vascular pedicle clamp-
O UTCO MES ing, tumor excision with cold Endoshears, pelvicalyceal su-
ture repair, and parenchymal closure over Surgicel bolsters
Lap aro sco p ic Ne p hre ct o my with application of a biologic hemostatic agent and selective
use of ice slush for renal hypothermia in cases with antici-
In order for LRN to replace O RN as the standard of care, it pated long warm ischemia times is the standard. O thers have
has to provide equal cancer control with improved patient challenged that a ureteral catheter is not necessary with expe-
morbidity and convalescence at comparable operative effi- rience for tumors 4.5 cm and that suture renorrhaphy is not
ciency. While the latter two issues have been well demon- necessary if the renal sinus or collecting system is not entered,
strated, the remaining most important question is that of given that fibrin glue products will provide adequate hemo-
long-term cancer control. Several series have now reported stasis (3,15). Recently, the Cleveland Clinic group also stated
overall 5-year disease-free and cancer-specific survival rates that omitting bolster renorrhaphy may be reasonable, even
for both LRN and H ALRN at or over 90% . All have con- for select central tumors (33).
firmed that the oncologic efficacy of LRN and H ALRN is
equivalent to that of O RN (8,10,16,26).
In 2007 the Cleveland Clinic reported a 5-year 81% over- CO MPLICATIO NS
all and a 90% cancer-specific survival for their LRN cohort
compared to a 6-year 79% overall and 92% cancer-specific Lap aro sco p ic Ne p hre ct o my
survival for their O RN cohort. The mean tumor size was 6
cm (5.8 and 6.2 cm, p 0.44). Blood loss and operative Laparoscopy is the current surgical standard for routine sim-
times were lower in the LRN cohort (8). O ther recent studies ple and radical nephrectomy due to equivalent cancer control
have continued to demonstrate that perioperative outcomes, and complication rates with decreased patient morbidity and
convalescence. Even when laparoscopic nephrectomy has kidneys, cystic masses, pT2–pT3b tumors, and kidneys with
been expanded to treat complex situations, equivalent or multiple tumors or renal arteries. Retroperitoneoscopic PN
nearly equivalent low complication rates have been observed. has also demonstrated equivalent outcomes, but it is consid-
It is now not only feasible but increasingly reasonable for an ered a more difficult operation than transperitoneal PN due
experienced laparoscopic surgeon to selectively use LN to to decreased working space.
treat patients with large stage T2 tumors, stage pT3b tumors, In a John H opkins University series, a 15% overall con-
hilar lymphadenopathy, kidneys needing autotransplantation, version rate of LPN to LRN (13.6% , 35 patients) and LPN
bilateral renal tumors, horseshoe kidneys, autosomal polycystic to open surgery (1.6% , 4 patients) was observed among 257
kidney disease (ADPKD), xanthogranulomatous pyelonephri- operations started as LPN (27). A fourfold increased rate of
tis, profound obesity, and even level II caval thrombi (30). conversion was noted in patients over 70 years old or with
Although da Vinci (Intuitive, Sunnyvale, CA) robotic-assisted tumors 4 cm. In a review of the Cleveland Clinic’s first
laparoscopic surgery has little role in routine LN , it may have 200 LPN cases, one third (66) had complications (28). These
a future role in certain complex procedures, such as caval included a 9.5% (19) hemorrhage and a 4.5% (9) urine
thrombectomy. leakage rate, 8 of which required double-J stent placement
Technologic malfunction may cause surgical complica- with (2) or without (6) percutaneous drain placement. Two
tions and is an important area of concern for laparoscopic (1% ) patients required open conversion and 4 (2% ) reopera-
surgery. Recent complications secondary to malfunction of tion. In a subsequent report, a 1.7% renal artery pseudo-
polymer self-locking (H em-O -Lock) clips are an example aneurysm rate in 345 cases was observed, and all 6 patients
(21). Bleeding, delayed exploration, and even death were re- were effectively treated with percutaneous embolization.
ported in several patients undergoing LN . The H em-O -Lock Similar LPN complication rates have also been reported
clip is thus no longer recommended for laparoscopic donor from other centers. Importantly, Gill et al. (13) reduced their
nephrectomy renal vessel ligation. This will hopefully stimu- hemorrhagic complication rate from 12% to 3% by apply-
late the future development of an inexpensive and improved ing gelatin matrix thrombin sealant (FloSeal) to the PN de-
vessel-grasping and ligating clip. fect prior to sutured renorrhaphy over a Surgicel bolster.
O f importance, complications do occur at an increased They addressed urinary extravasation by running the defect
rate during a surgeon’s initial learning curve. Improvements bed with 2-0 Vicryl and testing the repair with gentle injec-
in training and skills distribution throughout the urologic tion of indigo carmine through a ureteral catheter. A more
community are therefore needed. Although LN has made great recent 200-case series of LPN at the Cleveland Clinic had
inroads into the academic centers, its adoption into private, a complication rate approaching the level observed with
community practice has lagged behind (1). Laparoscopic-naïve O PN (31).
open renal surgeons currently in practice need to remember Despite improvements, there remain four principal con-
that a significant time investment in retraining is required to cerns with LPN : (a) controlling hemostasis, (b) obtaining
work through an approximately 20-case learning curve (6). It negative margins (particularly during the learning curve),
is also critical that new technology does not inappropriately (c) avoiding lengthy ( 30 minutes) warm ischemic times and
supersede a more appropriate operative procedure, as is renal injury, and (d) treating large, complex, or centrally
highlighted by concerns that LRN may be inappropriately located tumors.
replacing PN in the treatment of small renal tumors (22). Regarding hemorrhage, the more central or endophytic
Lastly, reassessment of the complications and morbidity of the tumor, the greater the risk (5). Upper-pole tumors may
techniques as they evolve is necessary. It is possible that fu- also create hemostasis challenges. N umerous efforts to pre-
ture developments in open and H AL surgery, such as mini- vent bleeding can be categorized as follows: (a) improvement
mization of incision lengths, alteration of incision locations, in PN defect closure, (b) energy application, (c) use of hemo-
and improved analgesia, may minimize current LN advan- static agents or glues, and (d) superselective embolization
tages and warrant re-evaluation of the appropriate role of prior to LPN . The first category includes use of Lapra-Ty or
various surgical procedures. Also, future expansion of indica- H em-O -Lock clips and temporary defect packing. The second
tions for nephron-sparing renal surgery could diminish the category includes use of a saline-irrigated KTP laser, water
role of LRN . jet, TissueLink floating ball monopolar device, and radio-
frequency coagulation prior to PN . Examples of the third
category are gelatin matrix thrombin (FloSeal), fibrin gel
Lap aro sco p ic Part ial Ne p hre ct o my (Tisseel), bovine serum albumin (BioGlue), cyanoacrylate
glue (Glubran), and autologous fibrin glue.
Whereas equivalent LRN and O RN complication rates are In a review of positive surgical margins, Breda et al. (4)
now commonplace, the same is not true for LPN . In 2002 the identified a 2.4% overall rate in 855 U.S. and European LPN
Cleveland Clinic reported that LRN had morbidity advan- procedures. H owever, surgeons in their initial 30 cases of
tages over O PN , but O PN had the long-term renal function LPN or H ALPN may have positive margin rates 10% (23).
advantage (20). The following year, they reported that LPN Fortunately, a large combined review from centers of excel-
has a greater positive surgical margin rate (3% versus 0% , lence demonstrated that a positive margin does not necessar-
p 0.1) and intraoperative complication rate (5% versus ily indicate residual disease (25). N evertheless, efforts to
0% , p 0.02) than O PN (12). Subsequent efforts have been prevent positive margins during LPN should continue.
made to demonstrate the utility and safety of LPN . Feasibility Warm ischemia 30 minutes has historically been consid-
and near-equivalent outcomes have been demonstrated in ered detrimental to renal recovery. Recent studies have found
obese patients, centrally located and hilar tumors, solitary that up to 60 minutes may be well tolerated by the human
kidney, and a review of LPN patients at Johns H opkins ob- and defect closure (24). As expected, several groups have in-
served no significant relationship between warm ischemia vestigated the potential of da Vinci robot-assisted LPN .
and creatinine change and no statistically significant increase Surgeons from the N ational Institutes of H ealth successfully
in serum creatinine postoperatively (2). There is, however, treated 14 complex tumors including hilar location (5), endo-
contradictory evidence that the renal damage caused by phytic (4) and multiple tumors (3) with robotic LPN (29). It
warm ischemia 30 minutes is only partially reversible. A is possible that the da Vinci robot will, like robotic prostatec-
Cleveland Clinic study observed increased risk of renal dys- tomy, decrease the learning curve, allow for more facile sutur-
function with warm ischemic times 30 minutes, advanced ing and tumor excision, and greatly increase the propagation
age, or pre-existing azotemia (9). Porcine studies have found of this procedure into the urologic community.
that clamping the renal artery was beneficial in protecting the In conclusion, LN is the current standard of care in many
kidney only during O PN but not during LPN . Importantly, industrialized countries. LPN outcomes now closely ap-
efforts to identify a practical method of creating laparoscopic proach those of O PN at elite centers. H owever, even at these
renal hypothermia have been numerous, yet none have be- centers, O PN remains the gold standard due to shorter is-
come widely utilized. “ O n demand” hilar clamping has been chemic times, slightly better retained renal function (99.6%
recently proposed, and efforts to address this problem will versus 97.9% at 3 months), reduced postoperative complica-
undoubtedly continue. tions, and decreased subsequent procedures (11). The even-
Given the complexity of standard LPN , surgeons have de- tual fate of LPN hinges upon how well future technologic and
veloped innovative approaches, such as the use of suspension procedural modifications address these concerns and how well
traction sutures, to facilitate tumor exposure, dissection angles, renal tumor ablative procedures perform over the long term.
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226–229.
NEPHRO URETERECTO MY
SCO TT G. HUBO SKY AND MICHAEL D. FABRIZIO
M alignant urothelial tumors of the upper urinary tract ac- is suggested since filling defects are nonspecific findings and
count for about 5% to 10% of all renal tumors and 5% of all because tumor grade will dictate the management strategy.
urothelial tumors. These lesions are relatively rare and have
an observed peak incidence of 10 per 100,000 per year (1).
The most common location of these lesions is the renal pelvis, INDICATIO NS FO R SURGERY
followed by the distal ureter, the midureter, and finally the
proximal ureter. Tumors of the renal pelvis are almost twice M any variables, including tumor size, location, and grade
as common as tumors in the ureter. Bilateral involvement of and extent of disease, need to be considered before choosing a
malignant urothelial tumors of the upper urinary tracts occur surgical therapy. Additionally, the functional status of the
in 2% to 5% of spontaneous cases. Upper tract lesions are renal unit in question as well as the presence or absence of
seen in 2% to 4% of patients with primary urothelial carci- a contralateral kidney will help guide management deci-
noma of the bladder. sions. Kidneys with cortical thinning and marginal functional
status are likely better treated with nephroureterectomy.
Patients with solitary renal units may choose conservative
DIAGNO SIS renal-sparing strategies and accept lower cancer-free rates in
order to avoid the morbidity associated with dialysis follow-
H ematuria and dysuria are the most common symptoms. ing nephroureterectomy (2). Absolute contraindications for
O ften flank pain is present in those with upper tract obstruc- laparoscopic nephroureterectomy include uncorrected coagu-
tion, but sometimes asymptomatic hydronephrosis is seen. lopathies, active untreated abdominal wall infection, or sig-
Patients presenting with ureteral stricture in the absence of nificant hemoperitoneum. Relative contraindications include
overt benign etiologies should be seriously considered for a history of multiple abdominal surgeries or locally advanced
ureteroscopy and biopsy. H owever, a filling defect is the usual disease, both of which may require conversion to open
initial finding on a dedicated upper tract imaging study. surgery.
Rarely, patients will present with urosepsis and hydronephro-
sis necessitating percutaneous nephrostomy tube placement.
An antegrade nephrostogram can also demonstrate filling de- ALTERNATIVE THERAPY
fects consistent with upper tract tumors (Fig. 125.1). Biopsy
Radical nephroureterectomy is considered the gold-standard
therapy for malignant lesions of the upper urinary tracts.
This entails removal of the kidney within the fascia of
Gerota along with the entire length of ipsilateral ureter, in-
cluding en bloc resection of the intramural ureter and ureteral
orifice with surrounding bladder cuff. M ore conservative
alternatives exist and were initially reserved for patients in
whom nephroureterectomy would be contraindicated, such
as patients with solitary kidneys, renal insufficiency, or
significant comorbidities. Endoscopic procedures such as
ureteroscopy and percutaneous nephroscopy can be consid-
ered for those patients with low-grade, low-stage malignan-
cies who are willing to undergo rigorous surveillance
schedules. With high 5-year survival rates in patients with
low-grade tumors, the utilization of ureteroscopy (3) and per-
cutaneous nephroscopy (4) has been extended to patients
with low-grade, low-stage disease with a normal contralat-
eral kidney. Radical nephroureterectomy remains the main-
stay of treatment for high-grade disease. M any advocate this
FIGURE 125.1 Antegrade nephrostogram demonstrating a filling
approach even in patients with solitary kidneys, although
defect in the renal pelvis. This patient presented with urosepsis and others accept percutaneous or ureteroscopic procedures and
hydronephrosis. cite the benefit of avoiding dialysis morbidity against lower
830
Chap t e r 125: Lap aroscop ic Ne p hroure te re ctomy 831
disease-specific survival rates. Urologists who treat upper TA B LE 1 2 5 . 2

tract urothelial lesions were surveyed about how they treat
high-grade lesions in a solitary kidney. Among those respond- CON SIDERATION S IN SELECTIN G A METHOD FOR
ing, 34% favored a nephroureterectomy with the subsequent DISTAL URETERECTOMY
need for dialysis, while 30% and 27% chose to treat the • O pportunity for complete excision of distal ureter and
patient with ureteroscopy or percutaneous resection, respec- bladder cuff
tively (5). Although not curative, endoscopic options are • Location of primary tumor and any other synchronous
attractive in order to minimize gross hematuria and obstruc- upper tract lesions
tion in these patients in an effort to improve quality of • Presence of any synchronous bladder tumors
life. Clayman et al. (6) reported the first laparoscopic nephro- • Presence of pelvic lymphadenopathy
ureterectomy (LN U) in 1991. In stark contrast to open
• H istory of pelvic radiation
nephroureterectomy (O N U), which requires either two sepa-
• Body habitus
rate incisions or a single lengthy incision, early series of both
LN U and hand-assisted laparoscopic nephroureterectomy • Safety of the contralateral ureteral orifice
(H ALN U) very quickly showed a benefit with respect to • N eed for patient repositioning
length of hospital stay, narcotic requirement, and convales-
cence (6–8). Short- and intermediate-term oncologic out-
comes for LN U and H ALN U have shown equivalence to
O N U, and recently long-term oncologic outcomes with me- techniques available, one clear principle shared by all authors
dian follow-up of 74 months (range 60 to 148 months) have is the absolute need to completely resect the entire ipsilateral
shown a 5-year disease-specific survival of 68% , comparing ureter with a cuff of bladder. Earlier studies demonstrated up-
well with many O N U series (9). An admitted limitation of wards of 30% recurrence rates when remnants of ureter are
this retrospective case series was a small patient population left behind after incomplete nephroureterectomy for upper
(n 39), and other large series must be reported before tract urothelial carcinoma (10).
definitive equivalence is determined. In addition, other factors must be considered in choosing a
technique for the distal ureter (Table 125.2). The presence of
synchronous bladder tumors mandates maintenance of a
SURGICAL TECHNIQ UE closed system and precludes transvesical placement of instru-
ments or formal cystotomy to expose the trigone. Ideally,
Just as in O N U, it is useful to consider separate approaches transurethral resection of bladder tumor (TURBT) should be
for the kidney and the distal ureter in LN U. There are multi- performed at a separate setting in order to clear the bladder
ple acceptable laparoscopic approaches to the kidney that of any overt tumors. Knowledge of the primary tumor loca-
have been described, including transperitoneal, retroperi- tion in the upper urinary tract is also critical for surgical plan-
toneal, and hand-assisted techniques. The choice of technique ning. The presence of tumor in the distal or intramural ureter
for renal excision is based primarily on the surgeon’s prefer- typically leads to an open distal ureterectomy with either an
ence and training. All three approaches have the important intravesical or extravesical approach. The need for reposi-
advantage of avoiding a flank incision or an upward exten- tioning and safety of the contralateral ureteral orifice must
sion of a midline incision. H ALN U can be used primarily or also be considered.
as an alternative to standard laparoscopic technique if ad-
vanced or bulky disease is present.
M ultiple options exist for excision of the distal ureter, and Transp e rit o ne al Lap aro sco p ic Rad ical
currently no consensus has been established as to the optimal Ne p hro ure t e re ct o my
method (Table 125.1). Despite the diverse list of options for
The authors prefer a transperitoneal conventional laparo-
scopic approach, which allows for a larger working space,
TA B LE 1 2 5 . 1 while the retroperitoneal approach usually allows for faster
DESCRIBED TECHN IQUES FOR DISTAL URETERAL access to the hilum.
EXCISION TO ACCOMPAN Y LAPAROSCOPIC Preoperative evaluation should include a computerized to-
N EPHROURETERECTOMY mography (CT) urogram to define the location of the upper
tract lesion, to evaluate for any existing lymphadenopathy or
• O pen approach (intravesical or extravesical approach) overt local disease extension, and to define the anatomy of
• Pure laparoscopic approach with stapling of distal ureter the renal vasculature. It is our preference to have biopsy in-
and bladder cuff (8) formation about the lesion in question, which also allows an
• Transvesical laparoscopic detachment and ligation opportunity to evaluate and treat any synchronous bladder
technique (17) tumors. Additional preoperative workup includes chest radi-
• Transurethral resection of ureteral orifice (TURUO ) ography, serum electrolytes, complete blood count, liver func-
• Intussusception tion tests, and coagulation studies. N o formal bowel
• Extravesical en bloc distal ureterectomy with bladder cuff preparation is instituted, but magnesium citrate solution is
during hand-assisted laparoscopic nephroureterectomy (28) given the day before surgery and the patient is asked to stay
• O ne-port transvesical endoscopic cuff technique (26) on a diet of clear liquids that day as well.
• Robot-assisted laparoscopic nephroureterectomy (29) After the adequate administration of general anesthesia,
an orogastric tube and Foley catheter are placed. This helps
to minimize any inadvertent trocar injuries to distended vis-

cera. Spontaneous compression boot devices and intravenous Le ft Lap aro sco p ic Rad ical
antibiotics are given prior to induction. The patient is placed Ne p hro ure t e re ct o my
in a modified decubitus position with the operative side up
and propped 30 to 45 degrees from the horizontal plane. A The 10- to 12-mm umbilical port is used to place a 10-mm,
blanket roll is placed under the shoulders and hips in order to 30-degree laparoscope, and the surgeon works with instru-
help support this position. An axillary roll is also placed at ments through the lateral and subxiphoid ports. M any elec-
this time. The top of the patient’s iliac crest should align with trosurgical ligation devices are available, but we prefer to use
the top of the kidney rest on the operating room table. The monopolar electrosurgical scissors and a 10-mm LigaSure de-
table is then flexed about 20 to 30 degrees in order to help vice. Alternatively, the harmonic scalpel is also useful.
maximize the space between the costal margin and the ante- Laparoscopic bipolar forceps are very useful in controlling
rior superior iliac spine. The ipsilateral arm is brought across small points of bleeding, especially around the hilum.
the torso and supported either with pillows or preferably an Initial survey of the abdominal contents will allow identi-
elevated arm rest. The contralateral arm is placed on the fication of vital structures, including the colon, spleen, and
usual arm board perpendicular to the operating table. Pillows iliac vessels. The kidney, although not directly visible, is easily
are placed between the legs. The downside leg is flexed at the palpable with the laparoscopic instruments. Laparoscopic
knee and all pressure points must be adequately padded. The DeBakey instruments are very useful in providing counter-
patient is then carefully secured to the table with 3-inch tape traction and help in identification of the white line of Toldt. A
at the level of the shoulders, hips, and legs just above the combination of sharp and blunt dissection is utilized to reflect
knees. This position is then checked for stability. the colon from the splenic flexure down to the level of the in-
Access to the peritoneal cavity is achieved with a Veress ternal ring. This includes division of the phrenocolic and
needle placed in the area of the ipsilateral midclavicular splenorenal ligaments. Division of splenophrenic ligaments
line between the umbilicus and the anterior iliac crest. allows for upward retraction of the spleen and better expo-
Alternatively, the Veress needle can be placed just superior to sure to the anterior surface of the kidney. O nce the colon is
the umbilicus and pointed in the cephalad direction. Gentle mobilized, the colorenal ligaments are easily identified. The
injection of saline and failure to aspirate any abdominal colonic mesentery must be dissected free from the anterior
contents through the needle help ensure that no bowel or surface of the fascia of Gerota. A subtle color difference in
vascular structures have been entered. Carbon dioxide insuf- the fat of these two structures is appreciable and helps direct
flation is commenced and opening pressures should be the surgeon to the correct plane of dissection. M esenteric fat
10 mm H g until the abdomen is symmetrically distended. is a lemon-yellow shade, while the fat around the fascia of
Insufflation is maintained at a pressure of 15 to 20 mm H g Gerota is more of a pale-white color. Division of the colore-
for the case. nal ligaments must be achieved in order to expose the renal
Typically a three-port technique is employed, with the oc- hilum. Dissection of these ligaments usually proceeds from
casional additional 5-mm port added as necessary to help inferiorly to superiorly.
with retraction (Fig. 125.2). After pneumoperitoneum is N ext the psoas muscle is identified off the lower pole of
achieved, a 1-cm incision is made in the midclavicular line at the kidney, and the psoas tendon is usually easily recognized.
the level of the umbilicus. A 10- to 12-mm port is inserted Within the confines of retroperitoneal fat the gonadal vein
with the use of a zero-degree 10-mm laparoscopic lens. This and ureter should be identified. The ureter is now secured,
allows for direct visualization of the initial port placement with care to leave surrounding adventitia for adequate
and the peritoneal cavity is easily identified upon entry. The achievement of a good surgical margin. At this point in the
abdominal contents are surveyed. The second 10- to 12-mm dissection, the ureter can be traced as inferiorly as possible,
port is placed at the umbilicus using a periumbilical incision. which will facilitate later complete distal ureterectomy with
Finally, the third port is placed between the umbilicus and the bladder cuff excision. After this is achieved, attention can be
xiphoid process. For right-sided cases an additional 5-mm returned to the renal dissection.
port is added just off the tip of the 12th rib to allow for up- Careful elevation of the ureter allows for upward retrac-
ward retraction of the liver. If colonic retraction is necessary, tion of the undersurface of the kidney, lower pole, and hilar
an additional 5-mm port can be placed in the midline structures. Tracing the gonadal vein superiorly helps identify
between the umbilicus and the pubic symphysis. the inferior aspect of the renal vein. Just as in open surgery, a
FIGURE 125.2 Port placement for laparoscopic nephro-

ureterectomy. The camera is placed in the umbilical port
and the surgeon works through the other two ports, mak-
ing use of triangulation to optimize visualization and
ergonomics. To better access the distal ureter, an additional
port can be placed in the midline between the umbilicus
and pubic symphysis.
split-and-roll technique is employed by gently grasping the duodenum. The duodenum is easily swept medially once the
surrounding adventitia, pulling away from the vein and care- overlying adventitia is carefully incised. The inferior vena
fully splitting the adventitia with laparoscopic scissors in cava is readily identified once the duodenum is dissected free.
order to expose the anterior surface of the vein. O nce the an- With upward traction of the posterior portion of the kidney,
terior surface is exposed, hilar fat around the vein must be the renal vein is identified and dissection is similar to that for
carefully dissected out. This is achieved by gently grasping the left side.
surrounding adventitia and hilar fat with a laparoscopic
DeBakey grasper, which provides excellent countertraction
and allows one to sweep the edge of the vein free with a blunt Hand -Assist e d Lap aro sco p ic
suction-irrigator device. Ultimately, all tributaries of the left Ne p hro ure t e re ct o my
renal vein can be carefully dissected out this way, including
the gonadal, lumbar, and adrenal veins. The laparoscopic H and-assisted laparoscopy greatly facilitates LN U due to the
DeBakey should be able to be easily placed behind any vein versatility of the approach in addressing the distal ureter and
prior to its division. The 10-mm LigaSure device provides for the fact that the hand speeds ureteral mobilization, especially
safe division of the gonadal, adrenal, and lumbar veins within cases of inflamed or adherent ureters. M any H ALN U series
out the use of clips. This allows for easier future placement of have been reported in the literature and demonstrate good
the Endo-GIA vascular stapling device across the main renal oncologic control and safety parameters (7,11–13). The hand
vein without having to consider the avoidance of surrounding port not only allows for the nephrectomy portion of the case
clips. Some surgeons feel the 10-mm LigaSure device is too but is also used in performing complete ureteral dissection
large or cumbersome to secure some of the left renal vein trib- with excision of bladder cuff. The port placement for left
utaries, and this is sometimes the case, especially with the H ALN U is shown in Figure 125.3. In a left-sided case, the
lumbar vein. In this event, the tributaries can be taken with surgeon inserts the left hand with use of any of the available
clips, as described by many authors. O f the tributaries of the hand ports. This is done through a 7-cm midline incision that
left renal vein, the gonadal is usually encountered and taken starts at the umbilicus and extends downward. This is slightly
first, followed by the lumbar vein. If adrenalectomy is lower than the midline incision used for hand-assisted laparo-
planned, then the adrenal vein should be taken as well. scopic nephrectomy (H ALN ). A 10- to 12-mm port is placed
O nce the renal vein is mobilized and its tributaries are di- just lateral to the rectus muscle at the level of the hand port,
vided as needed, the renal artery is usually identified just pos- and this supports the laparoscope. A second 10- to 12-mm
terior and superior to the vein. Gentle upward traction of the port is placed about two fingerbreadths anterior to the tip of
kidney allows for identification of the renal artery from a pos- the 12th rib. In a left H ALN U, the surgeon uses the right
terior position. A combination of sharp and blunt dissection is hand to operate the laparoscopic instruments. After the
used to free the edges of the artery, and ultimately this struc- nephrectomy portion of the case, the opposite hand is placed
ture is taken with a 10-mm endoscopic GIA stapler with 2.5- in the hand port position and attention is turned toward the
mm or 2.0-mm staples. The vein is taken in a similar fashion. distal ureter. The left hand is then used to operate laparo-
After hilar division, the kidney can be retracted superiorly scopic instruments as the ureter is dissected down to the blad-
and any remaining posterior or lateral attachments are di- der hiatus. An additional 5-mm port can be placed in the
vided. If the adrenal gland is being taken, then superior me- midline below the hand port to aid in medial retraction of the
dial attachments are carefully taken down with either an bladder. The intracorporeal hand allows for multidirectional
endo-GIA stapler or the LigaSure device. Care must be taken ureteral traction until the ureter is followed all the way down
to avoid the tail of the pancreas. The kidney should be freed to the bladder. Under direct vision the bladder is entered
from all attachments at this point and should still remain superiorly and medially to the ureteral orifice. The Foley
with the ureter intact and attached.
Rig ht Lap aro sco p ic Rad ical

Ne p hro ure t e re ct o my
Laparoscopic port placement is essentially a mirror image of
the right side. An additional 5-mm port is almost always
needed to help with retraction of the liver. This additional
port is well placed just off the tip of the 12th rib. Care must
be taken not to place this additional port too close to the iliac
crest, as this will limit the ability to point the trocar in the
necessary cephalad direction. O nce the liver is retracted ante-
riorly, the upper pole of the right kidney is easily seen and the
ascending colon is easily swept medially after taking down
the white line of Toldt. Great care must be taken to identify
and avoid the duodenum, which is readily seen after the colon
is mobilized. We strongly advocate performance of a laparo-
scopic Kocher maneuver with cold laparoscopic scissors. A
laparoscopic DeBakey grasper is very helpful in providing FIGURE 125.3 Port and hand-assist device placement for left hand-
countertraction for the overlying adventitia anterior to the assisted laparoscopic nephroureterectomy.
catheter balloon should be readily visible, as should be the the distal ureter. The approach is versatile and can be com-
contralateral ureteral orifice. The cystotomy can be left open bined with a conventional laparoscopic renal excision, whether
or sutured closed. The entire specimen is then removed in an performed via the transperitoneal or retroperitoneal route. It
entrapment sack through the midline hand incision. In addi- can also be performed in concert with H ALN U. The presence
tion to this method, the midline hand incision can be ex- of an open incision is acceptable by most who perform LN U
tended down to the pubic symphysis if the surgeon prefers an or H ALN U due to the preference for intact specimen re-
open approach to distal ureterectomy. This results in a mid- moval, which is essential in determining the need for adjuvant
line incision from the umbilicus to the pubic symphysis, chemotherapy in higher-stage disease.
which may be considered large by many laparoscopic sur- During LN U or H ALN U the ureter should be dissected as
geons but is still well tolerated and much less invasive than inferiorly as possible, which is usually at least to the level of the
two separate incisions or a midline incision spanning the dis- iliac vessels. If H ALN U is being performed, then the midline
tance from xiphoid to pubic symphysis. hand incision should be extended to the pubic symphysis. If
conventional LN U is performed, then a variety of options are
available, including a lower midline incision, a Pfannenstiel
Surg ical Ap p ro ache s t o t he Dist al Ure t e r incision, or a Gibson incision. If there is difficulty with ureteral
dissection laparoscopically, then a Gibson incision may be
There is no clear consensus for the ideal minimally invasive used, which can be extended to reach the upper mid- to prox-
approach to the distal ureter during LN U or H ALN U. N o imal ureter if needed. If a partial flank position is employed
prospective randomized trials exist comparing the various for the LN U, the lower abdominal incision can be fashioned
techniques, and the number of cases is relatively small, mak- by merely rotating the table, thus avoiding the need for pa-
ing level 1 evidence unavailable. N umerous retrospective sur- tient repositioning.
gical series have been published and many make use of Access to both the peritoneal cavity and retroperitoneum
different techniques as the specific patient situation dictates. is possible through the three incisions mentioned above and
Perhaps the consensus should be that no single technique is is utilized depending on the approach to the kidney. O nce
ideal in every situation. the ureter is identified, it should be clipped distal to the pri-
In choosing a technique, the location of the primary tumor mary tumor to minimize downward migration of any tumor
and any other synchronous tumors must be known. While cells. As the ureter is followed into the pelvis, the vas defer-
many distal ureteral techniques will be successful for tumors ens or round ligament will be encountered and should be
in the renal pelvis or proximal ureter, they may be completely taken. It is possible to spare the vas deferens in young men,
inappropriate for tumors located primarily in the distal ureter although this can compromise exposure. Classic open de-
(Fig. 125.4). The following descriptions are of the most pop- scriptions of distal ureterectomy direct the surgeon to isolate
ular techniques found in the current literature. and divide the superior vesicle artery as it crosses the ureter
(14). The medial umbilical ligament should also be identified
O p e n Ap p ro ach and divided to maximize exposure to the distal ureter as it
An open approach to the distal ureter is still considered the enters the detrusor.
gold standard from an oncologic viewpoint. It is probably the In order to resect the bladder cuff and ureteral orifice, an
most appropriate technique when the primary lesion is in intravesical or extravesical approach can be employed. If the
intravesical route is chosen, an anterior cystotomy is per-
formed with the bladder full. The trigone and ureteral orifice
are readily visualized. A 5Fr feeding tube can be inserted into
the affected ureteral orifice and stitched to the surrounding
bladder urothelium. This allows for upward and radial re-
traction of the intraluminal ureter as the urothelium is scored
with needle-tip electrocautery. The intramural ureter is identi-
fied and resected out of the surrounding detrusor muscle un-
til perivesical adipose tissue is seen. The kidney, ureter, and
bladder cuff are then completely removed en bloc through the
skin incision after being placed in an entrapment sack. The
resected ureteral orifice can be closed through the bladder in
layers with absorbable suture. Finally, the anterior cystotomy
is closed in layers, also with absorbable suture. A Jackson-
Pratt drain is placed in the perivesical space. N o suprapubic
tube is necessary, and a Foley catheter is kept in place for
4 days and then removed after a cystogram is performed. The
main advantage of an intravesical approach is complete visu-
alization of both the affected and contralateral ureteral ori-
fices. This lends to complete resection of the intramural
ureter with bladder cuff and safe preservation of the con-
tralateral orifice. A closed system is not maintained, however,
and a cystoscopy should be done prior to nephroureterec-
FIGURE 125.4 Computerized tomography scan demonstrating a dis-
tomy to ensure no synchronous bladder tumors are present.
tal ureteral tumor in the left intramural ureter, thus confirming the An extravesical approach can also be used in which the
importance of acknowledging tumor location. distal ureter is dissected free of detrusor down to the
ureterovesical junction. With upward traction on the ureter,

the ureteral orifice is stretched away from the urothelium of
the bladder and a right angle is clamped down. The ureteral
orifice is then transected and the posterior bladder oversewn.
The advantage of this technique is maintenance of a closed
system and avoidance of anterior cystotomy. The disadvan-
tages are potentially difficult exposure, predisposing to in-
complete resection of the affected intramural ureter, and no
direct visualization of the contralateral ureter, which may be
inadvertently resected or sewn over. The administration of in-
digo carmine to the patient intravenously after sewing over
the posterior cystotomy can give reassurance of the status of
the contralateral ureteral orifice if blue urine is seen in the
Foley collection bag.
Pure Lap aro sco p ic Ap p ro ach w it h St ap ling

o f Dist al Ure t e r and Blad d e r Cuff
This technique involves conventional laparoscopic nephrec-
tomy with extended dissection of the ureter deep within the
pelvis. An additional lower midline abdominal port is required
to complement those traditionally placed in a triangular fash-
ion for nephrectomy (15). The umbilical port always supports
the camera. During kidney and proximal ureteral dissection,
the upper midline and lateral ports are used. The lower midline
and lateral ports are utilized during mid- and distal ureteral
mobilization. Dissection is performed until the entire intra-
mural ureter is made extravesical. Ultimately, a GIA endovas-
cular stapler with an articulating head is used to come across
the ureterovesical junction while the ureter is placed on upward
tension (Fig. 125.5). This separates the distal ureter from the
bladder and simultaneously closes the bladder. M orcellation
has been performed in cases with proximal lesions or low-
grade disease. Alternatively, the specimen can be placed in an
entrapment sack and removed through a small incision.
Cystoscopic unroofing was initially described with this
technique using a flexible cystoscope and Bugbee electro-
cautery (8). The Bugbee was used to score around the ureteral
orifice and a portion of the intramural ureter. Some accounts FIGURE 125.5 Pure laparoscopic nephroureterectomy with distal
ureter and bladder cuff taken with stapling technique. Articulating
of this technique involve using a 5-cm-long ureteral dilating heads on the stapler and upward traction on the ureter allow for op-
balloon placed in the intramural ureter. Cautery then incises timal placement.
the intramural ureter over the balloon in the 12 o’clock posi-
tion up to but not through the ureterovesical junction. After
extensive distal ureteral dissection, the ureter is retracted up- Transve sical Lap aro sco p ic De t achme nt
ward, putting the intramural ureter and orifice on stretch. A and Lig at io n Te chniq ue
laparoscopic endo-GIA stapler is fired across the detrusor, in- This technique was developed at the Cleveland Clinic in 1999
corporating the intramural ureter and orifice with the speci- and requires formal cystoscopy in the dorsal lithotomy posi-
men. Simultaneous flexible cystoscopy can be performed to tion prior to LN U. With a full bladder and a rigid cystoscope
ensure safety of the contralateral ureteral orifice. According viewing the inside of the bladder, two 5-mm balloon-tipped
to the authors, after an extravesical recurrence, they modified laparoscopic ports are placed suprapubically into the bladder
the technique to perform unroofing of the ureteral orifice af- from above (17,18). A 2-mm endoloop is inserted through
ter nephrectomy and staple ligation of the distal ureter. M ore one of the suprapubically placed trocars from above. Through
often than not, an orifice is seen cystoscopically and unroofed the cystoscope, a 5-mm ureteral catheter is placed through
until a staple line is seen, which is then coagulated with a the endoloop and into the affected ureteral orifice. A grasper
rollerball electrode. Using a porcine model, the authors verify is placed through the second suprapubic port to provide trac-
that viable cells are definitely found within the staple line of tion on the ureteral orifice while a Collins knife is used to
the bladder. They also report no recurrences of urothelial car- score the affected orifice and intramural ureter. When perivesi-
cinoma within their series, which has up to 13 years follow- cal adipose tissue is exposed, the ureteral catheter is removed
up. Furthermore, no stone formation has been noted after a just after the endoloop is secured around the dissected intra-
mean of 27 months of follow-up on the titanium staples, mural ureter. N o formal closure of the bladder is performed,
which remain in contact with urine. The authors concede that and the Foley catheter is left for 2 weeks.
if urothelial carcinoma is known to be present in the distal Possible advantages include intact en bloc excision of the
ureter, then an alternative strategy such as open distal ureterec- intramural ureter under direct vision and observation of the
tomy is warranted (16). endoloop tie. Disadvantages include the need for repositioning,
fluid extravasation with suprapubically placed laparoscopic survival at 7 years, which they compared to a contemporary
ports, and a significant learning curve. The authors of this open series showing 82% cancer-specific survival at 7 years.
technique admit it should not be used when there is distal or There was no statistical difference in survival between the
intramural ureteral tumor or active bladder tumors. Additionally, two groups. A larger series has also been recently reported in
they advise caution in morbidly obese patients and those with which 39 patients were followed for a median of 74 months
a history of pelvic radiation. (range 60 to 148 months), and 68% cancer-specific survival
was noted at 5 years (9). O f note, 80% of these patients had
Transure t hral Re se ct io n o f Ure t e ral O rifice high-grade disease preoperatively. These series show equiva-
(TURUO ) (Pluck Te chniq ue ) lent cancer control with respectable follow-up and compare
This technique involves aggressive transurethral resection well to O N U series in the literature (21,22).
around the ureteral orifice until adipose tissue is seen. This is Complications are seen in LN U and H ALN U that are
done prior to LN U, at which point the distal ureter is then common to other laparoscopic renal procedures. A recent
plucked out of the bladder using upward traction on the ureter. meta-analysis of reported complications during various la-
Every attempt is made to clip the ureter as soon as possible to paroscopic renal procedures identified 56 published series
avoid urine draining down the ureter and into the retroperi- each containing at least 20 patients (23). Among these renal
toneum. The bladder is typically not closed. This procedure has procedures were LN U and H ALN U. Access-related complica-
fallen out of practice by most due to the concern of leaving a tions occurred in 0.5% . Intraoperative complications in-
portion of intramural ureter after the pluck maneuver. Also, tu- cluded hemorrhage in 1.4% . Bowel injury, solid organ injury,
mor seeding of the retroperitoneum has been reported after this diaphragmatic injury, and neuromuscular injury were all seen
maneuver (19). TURUO should also not be performed in the in 0.5% of cases. Postoperative complications included
setting of distal, intramural, or perimeatal lesions and is best ileus in 1.5% , deep vein thrombosis in 0.7% , and bowel ob-
avoided in patients with active bladder lesions. struction and incisional hernia in 0.5% . Among the various
laparoscopic renal procedures reviewed, LN U ranked highest
in both frequency for neural injuries from positioning and for
O UTCO MES postoperative complications. This is not entirely surprising,
given that LN U can be a relative lengthy procedure and is
In the 1990s various urologic procedures for cancer treat- usually performed in elderly patients with multiple comor-
ment were adapted to a laparoscopic form in the endeavor to bidities.
provide equivalent cancer control with less morbidity via An obviously distressing complication of LN U is that of
smaller incisions. This has definitely been the case with LN U. laparoscopic port site seeding. Fortunately this is a rare oc-
Early case series reported on the feasibility of the procedure currence, and there are seven reported cases, which represent
and reported mostly perioperative data and short-term onco- an approximately 1.6% incidence (24). The majority of these
logic results. As multiple laparoscopic series have matured we cases have been high-grade disease in which the specimen was
now have intermediate and some long-term data with respect extracted without an entrapment sack or the sack was rup-
to cancer outcomes (Table 125.3). The series with the longest tured during specimen removal. In one case, a ureteral stent
follow-up for LN U has a median follow-up of 100 months, placed previously during ureteroscopic biopsy was seen ex-
with a range of 60 to 148 months (20). In this series 26 pa- truding from the renal pelvis during subsequent LN U (25).
tients were followed and the distal ureter was addressed ei- The authors cautioned against overly aggressive uretero-
ther with TURUO or with an open approach if distal ureteral scopic biopsy, although no evidence of retroperitoneal recur-
tumors were present. The authors report 72% cancer-specific rence was seen.
TA B LE 1 2 5 . 3
ON COLOGIC RESULTS OF CON TEMPORARY LAPAROSCOPIC AN D OPEN N EPHROURETERECTOMY SERIES
Cancer-Specific Median Local Recurrence

Series n Method Distal Ureter Survival Follow-up (mo) Rate
M untener 2007 (9) 39 LN U Stapling, open 68% 74 5%
Bariol 2004 (20) 26 LN U O pen, TURUO 72% 100 4%
M atin 2005 (27) 60 LN U TDL, stapling, open 85% 23 7%
Chung 2007 (7) 39 H ALN U O pen 89% 48 3%
Wolf 2005 (13) 54 H ALN U TURUO , 94% 12 8%
TEC 86% 24
80% 36
Bariol 2004 (20) 40 ONU 82% 96
H attori 2006 (21) 60 ONU 81% 35
H sueh 2006 (22) 77 ONU 72% 60
LN U, laparoscopic nephroureterectomy; H ALN U, hand-assisted laparoscopic nephroureterectomy; O N U, open nephroureterectomy; TURUO ,

transurethral resection of ureteral orifice; TDL, transvesical detachment and ligation; TEC; transvesical endoscopic cuff.
Chap t e r 126: Lap aroscop ic Re nal Proce d ure s: Re nal Cyste ctomy, Biop sy, and Ne p hrop e xy 837
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CHAPTER 126 ■ LAPARO SCO PIC RENAL

PRO CEDURES: RENAL CYSTECTO MY, BIO PSY,
AND NEPHRO PEXY
CHAD A. LAGRANGE AND STEPHEN E. STRUP
Laparoscopic surgery has become the standard of care for the advantages of increased effectiveness and decreased risk
many renal procedures. The benefits of laparoscopic renal in certain high-risk patients.
surgery, including less postoperative pain, shorter hospitaliza-
tion, and quicker recovery, have led surgeons to apply this
technique to many different types of renal procedures. Renal LAPARO SCO PIC RENAL
pathology such as renal cyst disease and nephroptosis, which CYSTECTO MY
were historically performed using an open approach, can be
effectively treated in a laparoscopic fashion. In addition, pro- Simple cysts are the most common lesions of the kidney. It is
cedures traditionally performed percutaneously, such as renal estimated that 50% of the adult population have renal cysts.
biopsy, can be performed laparoscopically, which may offer The incidence of cysts increases with age; simple renal cysts
occur with an incidence of at least 20% by age 40 years and Another alternative is open surgical marsupialization, which
33% by age 60 years (1). can be performed when more conservative approaches fail or
laparoscopic surgery is contraindicated.
Diag no sis
The diagnosis of renal cysts was traditionally made during in-
travenous urography with tomography. Today, ultrasound (US) Re t ro p e rit o ne al Ap p ro ach
and computerized tomography (CT) are the principal diagnostic Standard positioning and preparation are carried out with the
tools, and most cysts are incidental findings. O ccasionally, a patient in the flank position. Port placement is depicted in
patient with a very large simple cyst may present with vague ab- Figure 126.1. A 1.5-cm incision is made at the tip of the 12th
dominal or flank discomfort and fullness on physical examina- rib and dissection is carried down to the lumbodorsal fascia,
tion. H owever, most patients are asymptomatic. which is then pierced with a tonsil clamp to enter the
The sonographic criteria for simple cysts are absence of in- retroperitoneal space. Finger dissection is then performed
ternal echoes, increased through-transmission of sound, and along the psoas muscle to mobilize the posterolateral aspect
a sharply defined simple wall. O n CT, simple cysts are sharply of the kidney. A 10- to 12-mm visual balloon dissector trocar
marginated, nonenhancing, and clearly demarcated from sur- is then placed and the space is dilated. The dilating balloon is
rounding renal parenchyma with no calcifications. The atten- then removed and a blunt-tip balloon trocar is placed.
uation values should be in the range of water ( 10 to 20 Pneumoretroperitoneum is established to 15 mm H g and a
H ounsfield units). O n magnetic resonance imaging (M RI), 5-mm trocar is placed in the posterior axillary line below the
simple cysts appear as round, homogenous, and low intensity 12th rib. A third trocar is inserted approximately two finger-
(dark) on T1-weighted images and increased intensity breadths above the iliac crest in the anterior axillary line.
(bright) on T2-weighted images. Laparoscopic ultrasound may be used in cases where cysts are
difficult to locate. An additional instrument for dissection
and countertraction of large cysts can be placed via a 5-mm
Ind icat io ns fo r Surg e ry trocar midway between the iliac crest and the 12th rib in the
posterior axillary line.
O ccasionally, patients who present with flank pain are dis- O nce the cyst is exposed from beneath the perinephric fat,
covered to have no other etiology on radiographic evaluation the fluid is aspirated and sent for cytology. A gallbladder nee-
for their complaint either than a large simple cyst, and they dle or O randi-type needle can be used to accomplish the aspi-
may be candidates for therapy. Large parenchymal cysts or ration. The free wall of the cyst is then excised with dissecting
peripelvic/parapelvic cysts can also cause obstruction leading scissors, harmonic scalpel, or hook and sent for pathologic
to pain. Depending on the symptoms, size, site, location, pres- analysis (Fig. 126.2). The wall should be incised as close to
ence of infection, and suspicion of malignancy, the following parenchyma as possible without entering the parenchyma.
renal cystic disorders can be managed laparoscopically: The parenchymal base of the cyst is then examined for evi-
dence of neoplastic change using cup biopsy forceps to per-
1. Renal cystic masses (i.e., Bosniak type IV, cystic renal cell form frozen-section analysis. The edges of the cyst are
carcinoma): laparoscopic nephrectomy or partial cauterized and hemostasis is verified after the pneu-
nephrectomy moretroperitoneum has been lowered to 5 mm H g. The argon
2. Indeterminate cystic masses (i.e., Bosniak type II or III): beam coagulator can be used to quickly paint over any raw
laparoscopic exploration and management bleeding surfaces of parenchyma or cyst wall. If the argon
3. Bosniak type I and II renal cysts, large ( 10 cm) and beam coagulator is used, care should be taken to vent the en-
symptomatic: laparoscopic cystectomy, decortication, or tering argon gas to prevent overpressure and barotrauma.
marsupialization
4. Renal hydatid cysts: same as above
5. Peripelvic or parapelvic cysts: same as above
6. Autosomal dominant polycystic kidney disease (ADPKD):
cyst decortication

Aspiration and injection of sclerosing agents is a safe and
effective solution. This is usually the initial course of manage-
ment for symptomatic renal cysts. Aspiration of cysts may
also prove to be a diagnostic maneuver to examine the effect
on the patient’s symptoms, and if the cyst and pain recur then
the relationship between the two is solidified. Reported suc-
cess rates of cyst aspiration and sclerosis range from 75% to FIGURE 126.1 Port placement for retroperitoneoscopic kidney
97% , with complication rates between 1.3% and 20% (2,3). surgery, such as nephropexy, renal cystectomy, and biopsy.
Re sult s
In most cases, a transperitoneal laparoscopic approach is
used. M ean operative time is 89 to 164 minutes in most se-
ries, with a mean blood loss of 100 mL (5,6). Procedures
performed on peripelvic cysts tend to be more complicated,
with longer operative times and higher blood loss. Length of
stay in the hospital averages 1 to 2 days.
Co mp licat io ns
Bleeding is always a possible complication of laparoscopic
renal cystectomy. H owever, this has not been noted in the sev-
eral reported series. Reaccumulation of cyst fluid is uncom-
mon, ranging from 3% to 4% (5,6). This can occur when the
window fashioned in the cyst wall reapproximates. N ieh and
Bihrle (7) demonstrated that the use of fat was helpful in main-
taining the patency of the marsupialization window. O ther rare
FIGURE 126.2 Renal cyst exposed and ready for excision.
complications include prolonged ileus, delayed hemorrhage,
urinary fistula, and nerve paresthesia.
Fibrin glue with or without oxidized cellulose can be applied

for refractory areas of bleeding. LAPARO SCO PIC KIDNEY BIO PSY
Transp e rit o ne al Ap p ro ach Renal biopsy is an invaluable diagnostic procedure for deter-
The transperitoneal laparoscopic approach is ideal for treat- mining the etiology of renal dysfunction. While percutaneous
ing anterior renal cysts, either simple or multiple. The usual renal biopsy has been proven to be safe and effective, some
technique is laparoscopic marsupialization. This technique clinical circumstances mandate the use of other techniques
has also been reported to treat symptomatic ADPKD (4). for obtaining kidney biopsies.
Under general anesthesia, with the patient in a 45-degree lat-
eral flank position, pneumoperitoneum is established at the
umbilicus. A 10-mm port is placed under laparoscopic visual-
Diag no sis
ization lateral to the umbilicus on the affected side in the
Renal biopsy is most often performed by nephrologists in a
lower quadrant. A third 5-mm trocar is placed in the midline
percutaneous fashion. The indication is usually hematuria,
halfway between the xiphoid process and umbilicus. A fourth
proteinuria, or renal insufficiency, especially when a glomeru-
trocar may be necessary for retraction in some cases and can
lar pathology is suspected.
be placed either in the lower midline or close to the xiphoid in
the midline. The colon is reflected medially and the fascia of
Gerota is incised. The perinephric fat around the cyst is dis- Ind icat io ns fo r Surg e ry
sected cleanly. In cases of polycystic disease, the kidney must
be entirely mobilized inside the fascia of Gerota. O nce again, US-guided percutaneous kidney biopsy is the most common
the cyst fluid can be aspirated with a needle and sent for technique performed. Improved imaging techniques such as
cytology. The cyst can then be unroofed as detailed above and US and CT and smaller-gauge biopsy devices have further re-
its walls and base carefully inspected. Then, a portion of the duced the contraindications to percutaneous (“ blind” ) renal
cyst wall may be attached to the mobilized edge of peri- biopsy. H owever, some clinical circumstances such as severe
toneum with either a clip or suture to ensure communication hypertension, bleeding diathesis, anticoagulation, morbid
with the peritoneal cavity and decrease the likelihood of obesity, and difficult renal anatomy dictate the use of more
recurrence. controlled access and better visualization of the kidney dur-
If the cyst is extremely large, another technique is to fash- ing biopsy. H ence, laparoscopic renal biopsy can be of great
ion a window using dissecting scissors. Retroperitoneal fat or clinical value.
omentum can then be packed into the cyst, thus making it un-
necessary to remove a large amount of cyst wall. If during
any cyst unroofing, excision, or marsupialization there is con- Alt e rnat ive Tre at me nt s
cern that the collecting system has been entered, indigo
carmine can be administered intravenously or a preoperative As mentioned, percutaneous needle biopsy by US or CT guid-
ureteral catheter can be placed in complex cases for retro- ance is the most common method of performing kidney
grade irrigation with methylene blue. N o drains are necessary biopsy. O pen kidney biopsy through a subcostal or dorsal
postoperatively. lumbotomy incision can also be performed.
Co mp licat io ns
O verall, complications related directly to the procedure are
rare because of the direct visualization of the biopsy site for
hemostasis and accurate tissue sampling. The reported inci-
dence of delayed bleeding after laparoscopic renal biopsy is
3% to 4% (8,9). O ther less common complications are re-
lated to visceral injury during access to the retroperitoneum
or inadvertent biopsy of other organs.
LAPARO SCO PIC NEPHRO PEXY

N ephroptosis is a condition of great historical interest. It is
classically defined as descent of the kidney 5 cm (or two
vertebral bodies) when moving to the upright position. The
FIGURE 126.3 Lower pole of kidney exposed with spoon forceps or
condition is much more common in female patients and more
cold-cup biopsy forceps used to take biopsy. commonly affects the right kidney, but it can be bilateral in
up to 20% of cases. M ost patients are thin women.
N ephroptosis may be an incidental finding and should be
treated only when associated with symptoms. Pain is believed
Surg ical Te chniq ue to be a result of acute obstruction and/or renal ischemia upon
standing due to the hypermobile kidney.
Preoperative US, CT, or M RI can help characterize the kidney
and better identify its location to adjacent structures during
surgery. The procedure is ideally performed through a
retroperitoneal approach. Patient preparation and position-
Diag no sis
ing are identical to that described for laparoscopic retroperi- H istorically, the diagnosis of symptomatic nephroptosis was
toneal cystectomy (Fig 126.1). H owever, in many cases only a limited to symptomatology and physical examination.
camera port and single instrument port are necessary. Currently, many diagnostic modalities are available. An intra-
M inimal blunt dissection through the perinephric fat to venous pyelogram with the patient in the supine and standing
expose the lower pole of the kidney is then performed. position is the initial test. The hypermobile kidney will descend
Laparoscopic US may be necessary in some cases to identify in the upright position and might become hydronephrotic.
the lower pole of the kidney. Cold-cup biopsy forceps or Color Doppler ultrasonography with measurement of resistive
spoon forceps are used to obtain several samples of tissue, indices (RI) in the supine and upright position may also be help-
and these are sent to the pathologist for frozen-section analy- ful. A reduction in RI may be seen when moving from the
sis to confirm adequate tissue sampling (Fig. 126.3). A large- supine to upright position, signifying a decrease in renal perfu-
core Tru-cut-type biopsy needle can also be passed through a sion (10). A nuclear renal scan in the sitting position is useful in
trocar or percutaneously to obtain the sample. detecting an obstructive pattern after renal descent, as well as
H emostasis can be achieved with electrocautery or an diminished blood flow to the kidney when the patient is erect.
argon beam coagulator, and if necessary the sites can be packed H owever, some facilities may not have the proper nuclear
with oxidized cellulose (8). The retroperitoneal pressure imaging systems to perform upright scans.
should then be lowered to 5 mm H g and the biopsy sites and
dissected space examined for hemostasis. The port-site fascial
defects can be closed with Vicryl suture or left open since the
procedure is exclusively retroperitoneal. Alt e rnat ive The rap y
M ost patients can be discharged the same day or within 24
hours. H owever, many patients have coexisting medical prob- Laparoscopic nephropexy has become the procedure of
lems that may require longer stays. choice for the correction of nephroptosis. O pen nephropexy
and its variants are also options.
O ut co me s
Adequate tissue samples are obtained in 96% to 100% of pa-
tients in the largest reported series. The mean operative time The surgical management of nephroptosis is controversial
and estimated blood loss is between 90 and 123 minutes and and variable. M any historical options exist, ranging from
25.9 and 67 mL (8,9). The majority of patients are discharged pexy and slings to other organs, ligaments, or the 12th rib.
from the hospital within 24 hours. Current techniques usually employ suture fixation to the
the renal parenchyma to prevent bleeding. In addition, the

genitofemoral nerve running along the psoas fascia should
not be entrapped. Intracorporeal suturing can be simplified
by the use of Lapra-Ty clips (Ethicon Endosurgery, Cincinnati,
O H ) to secure sutures instead of tying knots.
The retroperitoneal laparoscopic approach provides a
direct route to the kidney and may be useful in patients with
prior intra-abdominal surgery. H owever, working space is
sometimes limited, making complete kidney mobilization dif-
ficult. Creation of the retroperitoneal space is performed as
previously described, and nephropexy proceeds as described
above. The procedure can be performed on an outpatient
basis or the patient may be admitted for 24-hour observation.
Follow-up erect and supine radiographic studies are generally
performed in 6 to 12 weeks.
FIGURE 126.4 N onabsorbable sutures placed through renal capsule
and then psoas fascia on upper pole of kidney (medially, superiorly,
and laterally).
O ut co me s
psoas and/or quadratus lumborum fascias. In general, the Success rates are quite high for laparoscopic nephropexy and
techniques require complete mobilization of the kidney inside are comparable to historical open series. Resolution of symp-
the fascia of Gerota down the renal capsule, with sutures toms occurred in 80% to 100% of patients in published
placed directly through the fascia. laparoscopic nephropexy series (11–13). Correlation of reso-
A transperitoneal approach is the most commonly re- lution of symptoms with resolution of renal descent on post-
ported access. The patient is positioned in full flank position, operative imaging appears high. In one series of 31
unless performing bilateral nephropexy, in which the patient retroperitoneoscopic nephropexies, complete symptom reso-
is positioned supine and the bed tilted side to side to access lution was present in 83% of patients and 87% of patients
each kidney. A three-port midline approach is generally used. had no evidence of persistent renal descent on radiographic
The kidney is completely mobilized inside the fascia of studies postoperatively (14).
Gerota and the fascia of the psoas muscle is identified. The
operating table is then moved to a head-down position,
which causes the mobile kidney to be positioned as cephalad Co mp licat io ns
as possible. Beginning at the upper pole, three interrupted
nonabsorbable 3-0 sutures are then placed along the lateral The most feared complication is failure to resolve symptoms.
margin of the kidney (upper, middle, and lower) through the H owever, as noted above, failure is uncommon. O ther com-
renal capsule and then through the psoas fascia (Fig. 126.4). plications include bleeding from the renal parenchyma and
Care should be taken not to place the sutures too deeply into postoperative ileus.
References
1. Kissane JM . The morphology of renal cystic disease. Perspect N ephrol 8. Shetye KR, Kavoussi LR, Ramakumar S, et al. Laparoscopic renal biopsy:
H ypertens 1976;4:31–63. a 9-year experience. BJU Int 2003;91(9):817–820.
2. M organ C Jr, Rader D. Laparoscopic unroofing of a renal cyst. J Urol 9. Gimenez LF, M icali S, Chen RN , et al. Laparoscopic renal biopsy. Kidney
1992;148(6):1835–1836. Int 1998;54(2):525–529.
3. M unch LC, Gill IS, M cRoberts JW. Laparoscopic retroperitoneal renal 10. Strohmeyer DM , Peschel R, Effert P, et al. Changes of renal blood flow in
cystectomy. J Urol 1994;151(1):135–138. nephroptosis: assessment by color Doppler imaging, isotope renography
4. Dunn M D, Portis AJ, N aughton C, et al. Laparoscopic cyst marsupializa- and correlation with clinical outcome after laparoscopic nephropexy. Eur
tion in patients with autosomal dominant polycystic kidney disease. J Urol Urol 2004;45(6):790–793.
2001;165(6 Pt 1):1888–1892. 11. M arcovich R, Wolf JS Jr. Laparoscopy for the treatment of positional re-
5. Atug F, Burgess SV, Ruiz-Deya G, et al. Long-term durability of laparo- nal pain. Urology 1998;52(1):38–43.
scopic decortication of symptomatic renal cysts. Urology 2006;68(2): 12. M cDougall EM , Afane JS, Dunn M D, et al. Laparoscopic nephropexy:
272–275. long-term follow-up, Washington University experience. J Endourol
6. Roberts WW, Bluebond-Langner R, Boyle KE, et al. Laparoscopic ablation 2000;14(3):247–250.
of symptomatic parenchymal and peripelvic renal cysts. Urology 2001; 13. Plas E, Daha K, Riedl CR, et al. Long-term followup after laparoscopic
58(2):165–169. nephropexy for symptomatic nephroptosis. J Urol 2001;166(2):449–452.
7. N ieh PT, Bihrle W 3rd. Laparoscopic marsupialization of massive renal 14. Rassweiler JJ, Frede T, Recker F, et al. Retroperitoneal laparoscopic
cyst. J Urol 1993;150(1):171–173. nephropexy. Urol Clin N orth A m 2001;28(1):137–144.
CHAPTER 127 ■ LAPARO SCO PIC ABLATIO N
O F SMALL RENAL MASSES
ILIA S. ZELTSER AND DAVID E. MCGINNIS
As a result of the widespread use of cross-sectional imaging a high malignant potential when they exhibit coarse calcifica-
techniques, most incidentally discovered renal tumors are tions, thick outer wall, irregular shape, thickened internal sep-
small and locally confined and represent a low-stage renal cell tations, and enhancing mural nodules (Bosniak category III
carcinoma (T1a) (1). Long-term oncologic outcomes of open and IV lesions).
partial nephrectomy have demonstrated that these small tu-
mors ( 4 cm) can be treated with nephron-sparing techniques
with cancer control outcomes that are equivalent to those of INDICATIO NS FO R SURGERY
radical nephrectomy (2). Since the development of laparo-
scopic partial nephrectomy (LPN ) in 1993, several centers of Laparoscopic renal ablation is generally indicated for the
excellence have successfully utilized this technique to treat treatment of suspicious renal masses measuring 4 cm or less in
small renal masses. In fact, recent data of the 5-year outcomes diameter (T1a lesions). Treatment of larger tumors would also
of LPN revealed disease-free survival rates of over 90% , with be considered for patients with solitary kidneys, renal insuffi-
minimal compromise of renal function (3). ciency, inherited renal carcinoma syndromes with multiple
Yet despite the excellent outcomes of nephron-sparing synchronous renal tumors, and bilateral disease.
surgery (N SS), the widespread adoption of this technique by Irreversible coagulopathy is the only absolute contraindica-
the urologic community outside of the centers of excellence tion to laparoscopic RFA and CA. Large tumors, cystic tu-
has been slow. A recent survey of the Surveillance, Epidemiology, mors, and those located in the renal hilum or adjacent to the
and End Results (SEER) registry showed a significant under- pelvis or ureter are relative contraindications. Laparoscopic
utilization of N SS in the treatment of small renal masses. O nly ablation is also relatively contraindicated in patients who are
42% of the tumors 2 cm were treated with N SS in the unable to tolerate abdominal insufflation. A transperitoneal
2000–01 time period, and for the treatment of tumors 2 to laparoscopic approach may be relatively contraindicated in
4 cm, N SS was employed in a mere 20% of cases (4). The sig- patients who have multiple adhesions secondary to previous
nificant technical difficulty of LPN may be responsible for this abdominal surgery or a history of peritonitis, but a retroperi-
trend. Furthermore, as compared to open partial nephrec- toneal approach may be considered in these cases. Both RFA
tomy, LPN is associated with a longer renal ischemia time and and CA can be used to treat exophytic as well as completely
a higher urologic complication rate, even in the most experi- endophytic renal masses. Care should be taken to make sure
enced hands. that endophytic lesions to be treated laparoscopically can be
Thermoablative technologies were introduced to minimize well visualized by ultrasound, since they may not be visible on
the morbidity of partial nephrectomy, particularly in infirm, the surface of the kidney. If an endophytic lesion is not visible
elderly patients with multiple comorbidities. Cryoablation on ultrasound, then it is not a candidate for laparoscopic ab-
(CA) and radiofrequency ablation (RFA) are the two most lation. Selection of the approach (intraperitoneal versus
commonly used energy sources, and both can be applied per- retroperitoneal versus percutaneous) depends on the tumor lo-
cutaneously or laparoscopically. The main limitation of in situ cation, the patient’s health status, and the surgeon’s expertise.
ablation is that the tumor is not excised and therefore the Laparoscopic ablation is generally preferred for anterior and
pathologic confirmation of complete tumor removal is lack- lateral tumors or tumors excessively close to vital structures
ing. Instead, the adequacy of ablation is confirmed by the ab- (e.g., bowel, spleen, major vessels, collecting system), al-
sence of tumor enhancement on follow-up imaging. Despite though even posterior tumors can be treated following ade-
this limitation, excellent midrange oncologic efficacy of both quate mobilization of the kidney or a retroperitoneal
CA and RFA has now been demonstrated. approach.
DIAGNO SIS SURGICAL TECHNIQ UE

Renal malignancy is suspected when a solid renal mass is visu- RFA Me chanism o f Act io n
alized on renal ultrasound, computerized tomography, or mag-
netic resonance imaging. Diagnosis is usually established when RFA utilizes a monopolar alternating electrical current with
a clear enhancement of the lesion is seen during the nephro- the frequency within the radio segment of the electromagnetic
graphic phase following administration of an intravenous con- spectrum. The current flows between the grounding pad and
trast agent. Cystic lesions of the kidney are suspected to have the RFA probe. H eat is generated as a result of ionic agitation
842
Chap t e r 127: Lap aroscop ic Ab lation of Small Re nal Masse s 843
of the tissue around the probe, and cell death is achieved when lateral and posterior lesions when percutaneous RFA is not
the temperature within a tumor and a small rim of the sur- possible or available. Basic laparoscopic techniques are
rounding tissue rises over 60°C. H igh temperatures produce described in Chapter 123.
occlusion of the microvasculature and destruction of the cellu-
lar cytoskeleton, causing tissue ischemia and impaired DN A 1. After antiembolic stockings are placed and general anes-
replication and ultimately resulting in a predictable zone of thesia is induced, the bladder is drained with a Foley
coagulation necrosis around the RF electrode (5). catheter and the patient is positioned in the modified
Based on the type of the feedback loop modulating energy flank position for the transperitoneal approach and in the
delivery to the probe, there are two types of RF generators: standard flank position when retroperitoneal RFA is
impedance-based (Valleylab, Boulder, CO , or Boston Scientific, planned.
N atick, M A) and temperature-based (RITA M edical Systems, 2. For transperitoneal ablation, the abdomen is insufflated
M ountain View, CA). The feedback loops are designed to pre- with a Veress needle or via a H asson technique, and three
vent an overly rapid tissue heating, which would produce transperitoneal laparoscopic trocars are placed in the
charring and increase tissue resistance, thus decreasing the same configuration as for a laparoscopic nephrectomy.
ablation zone. Access to the retroperitoneal space can be obtained using
a visual obturator trocar or an open technique where a
surgeon’s finger is inserted through a 10-mm incision at
Cryo t he rap y Me chanism o f Act io n the tip of the 12th rib and the plane over the psoas muscle
is bluntly developed. The retroperitoneal space can be en-
Cell death secondary to rapid severe freezing occurs by several larged with a dilating balloon or bluntly developed with
mechanisms. Extracellular ice formation results in movement sweeping motions of the laparoscope.
of water out of the cell and leads to changes in intracellular
3. For transperitoneal ablations, the dissection starts with
pH , protein denaturation, and mechanical disruption of the
incising of the white line of Toldt as the colon is reflected
plasma membrane followed by intracellular ice formation.
medially off the fascia of Gerota. O bviously, this step is
Delayed tissue effects are due to the injury to the microvas-
not required during a retroperitoneal approach.
culature resulting in tissue hypoxia, endothelial cell damage,
edema, platelet aggregation, and thrombosis, culminating in co- 4. The fascia of Gerota is opened and the perinephric fat is
agulative necrosis (6). Recently, apoptosis and gene-regulated dissected off the renal capsule to identify the tumor.
cell death were identified as another mechanism of tissue dis- Dissection of the opposite side of the kidney is also per-
ruption following freezing (7). It is generally accepted that a formed to create a space for ultrasonic confirmation of
temperature of 20°C must be achieved to ensure cytotoxic probe placement.
effects of CA. It is not clear whether passive thawing be- 5. Laparoscopic renal ultrasound is then used to define tu-
tween freezing cycles has greater tissue effects than active mor margins. Ultrasound is critical in defining the mar-
rapid thawing. H owever, it is generally accepted that a double gins of partially or completely endophytic renal tumors.
freeze–thaw cycle with ice-ball extension beyond the tumor 6. The location on the abdominal wall allowing the most
margin should be utilized in clinical practice (8). Cryoablation perpendicular path of the probe to the tumor is identi-
probes range from large 5-mm probes to 3.4-mm probes to fied. The probe is inserted through the abdominal wall
currently available 1.47-mm needles (Galil M edical, Yokneam, and the kidney is then manipulated so that the probe en-
Israel, or Endocare, Irvine, CA). Smaller probes were designed ters the lesion at a right angle to the most exophytic point
to allow for a nontraumatic placement through the body of the tumor. The probe is inserted into the tumor and
wall and the renal capsule, more precise tumor targeting, and the tines are deployed to encompass a diameter extending
minimal bleeding following cryoprobe removal. The third- 5 to 10 mm beyond the visualized margin of the tumor.
generation machines utilize argon for freezing and helium for Tine placement is confirmed with laparoscopic ultra-
active thawing. sound (Fig. 127.1).
Routine laboratory studies are obtained and include serum
electrolytes, creatinine, liver function tests, and coagulation
profile. Urine culture is sent, and culture-specific antibiotics
are started in those with positive cultures. A chest radiograph
and an electrocardiogram are performed per the discretion of
the anesthesiologist. Patients taking aspirin, clopidogrel
(Plavix), warfarin (Coumadin), large doses of vitamin E, or
other anticoagulation agents are instructed to discontinue
them 5 to 7 days prior to the intervention, although they may
resume them immediately after RFA or at the surgeon’s discre-
tion after CA. A parenteral antibiotic with good coverage of
skin flora is given within an hour of starting the procedure.
Lap aro sco p ic RFA

A transperitoneal approach is utilized for anterior and upper- FIGURE 127.1 Example of the tines being deployed from the end of
pole tumors. The retroperitoneal approach is reserved for an radiofrequency ablation probe.
TA B LE 1 2 7 . 1
RADIOFREQUEN CY ABLATION PROTOCOL
UTILIZIN G STARBURST XL (RITA) PROBE
Tumor Length of N umber of

Size Treatment Cycle (min) Cycles
1 cm 3 1 or 2
1–2 cm 5 2
2–3 cm 7 2
3–4 cm 8 2
From: O gan K, Jacomides L, Dolmatch BL, et al. Percutaneous

radiofrequency ablation of renal tumors: technique, limitations,
and morbidity. Urology 2002;60(6):954–958.
7. Two cycles of RFA are performed. The duration of each

ablation cycle is determined by the size of the tumor
(Table 127.1).
8. O nce ablation is completed, the probe is removed and FIGURE 127.2 During laparoscopic transperitoneal cryoablation a
biopsies of the tumor with a laparoscopic 5-mm toothed 5-mm diamond flex triangle retractor (Genzyme Surgical) can be used
biopsy forceps are taken. Performing the biopsy following to retract the liver while the ultrasound and laparoscope are used to
rather than before the ablation minimizes bleeding, re- visualize the procedure.
duces the potential for tumor seeding, and provides ade-
quate tissue sample for accurate diagnosis.
9. The biopsy site on the surface of the kidney is examined:
usually no or minimal bleeding results. M ild bleeding can
be controlled by application of FloSeal (gelatin–thrombin larger lesions three 1.47-mm probes are triangulated
matrix, Baxter, Deerfield, IL) hemostatic sealant; how- within the tumor so that the resulting ice balls overlap
ever, occasionally argon beam or electrocautery coagula- and encompass the tumor margins.
tion may be needed. 7. Two freeze–thaw cycles are performed and freezing is con-
10. Colon is replaced in its normal anatomic position and the tinued until the ice ball extends about 5 mm to 1 cm beyond
incised edges of peritoneum are approximated with clips the tumor margin. Extension of the ice ball is monitored
or intracorporeal suturing. The abdomen is desufflated continuously with ultrasound. Temperature monitoring
and the trocars are removed. may be utilized as well to ensure uniform tumor destruc-
11. The postoperative care is the same as for a laparoscopic tion. Eighteen-gauge thermocouples may be placed within
nephrectomy. the tumor or at the tumor margin, and temperatures below
20°C must be registered to ensure uniform cell death.
Patients are followed with contrast-enhanced computerized 8. After the second thaw cycle, the cryoprobes are re-
tomography or magnetic resonance imaging. Successful abla- moved and FloSeal or Endoavitene plug (Davol,
tion is confirmed by the absence of contrast enhancement Cranston, RI) may be applied into the puncture sites to
within the tumor and a narrow rim of normal parenchyma. It help with hemostasis. To avoid tumor cracking, com-
is important to emphasize that the RFA lesion will persist plete thawing of the tumor must be achieved before the
on the follow-up scans, although it may contract slightly. probe is removed.
Endophytic lesions may retract from the renal parenchyma, 9. Colon is replaced in its normal anatomic position and the
with a narrow rim of fat infiltrating the margin. incised edges of peritoneum are approximated with clips
or intracorporeal suturing. The abdomen is desufflated
and the trocars are removed.
10. The postoperative care is the same as for a laparoscopic
Lap aro sco p ic Cryo ab lat io n nephrectomy.
Steps 1 through 5 are identical to those of laparoscopic RFA. Radiographic appearance of successful CA shows lack of
6. O nce the tumor is localized and its margins are defined, gadolinium or intravenous contrast enhancement within the
core needle biopsies or the tumor are taken. The ideal cryolesion, although a small rim of enhancement may be seen
path for the cryoprobe is determined based on the path of on early scans. This rim gradually disappears and is thought
the biopsy needle. The biopsy needle is passed through a to represent reactive changes in the area of sublethal injury
laparoscopic trocar to limit the theoretical risk of tumor and interstitial hemorrhage along the periphery of the cryo-
seeding. For tumors 2 cm or less, a single 4.8-mm probe lesion. Following cryoablation, some cryolesions will dem-
is positioned centrally within the tumor and the proper onstrate gradual reduction in size, with a mean decrease in
location is confirmed with ultrasound (Fig. 127.2). For diameter of 75% at 3 years.
Chap t e r 127: Lap aroscop ic Ab lation of Small Re nal Masse s 845
TA B LE 1 2 7 . 2
SELECTED OUTCOMES OF LAPAROSCOPIC RADIOFREQUEN CY ABLATION (RFA) AN D CRYOABLATION (CA)
Study Modality Access N o. of Tumors Follow-Up (mo) Radiographic Recurrence
Cestari et al., CA Laparoscopy 37 6 0/35

2004 (12)
Stein and Kaouk, 2007 (13) CA Laparoscopy 66 60 3/66
5-year CCS, 98%
Wen and N akada, 2006 (14) CA Laparoscopy 57 12.5 (1–42) 2/57
Park et al., 2006 (10) RFA Laparoscopy 39 26 (12–36) 0/39
H wang et al., 2004 (15) RFA Laparoscopy 15 12 (11–57) 1/24
N ote: CCS, cancer specific survival.
histoplasmosis died following RFA secondary to aspiration

O UTCO MES pneumonia. The death was not attributable to the ablation
technique, but rather to the patient’s overall poor health. In
Excellent midrange oncologic efficacy of both cryoablation the subgroup of 90 laparoscopic procedures, 3.3% of the
and RFA has now been demonstrated. Gill et al. (9) showed a complications were attributable to the laparoscopic tech-
98% cancer-specific survival in 51 patients undergoing nique, 4.4% were attributable to the ablation procedure, and
laparoscopic CA for a unilateral sporadic renal tumor. In a one was iatrogenic.
subset of patients with a median follow-up of 6 years, they Clinical experience with CA has also shown low compli-
demonstrated a 5-year overall survival of 80% . Low tumor cation rates and minimal morbidity. In 56 patients undergo-
recurrence rates have also been shown in multiple other series ing laparoscopic CA, Gill et al. (17) reported two major and
of laparoscopic CA, yet these had shorter follow up (Table two minor complications. The major complications in-
127.2). With a mean follow-up of 25 months, Park et al. (10) cluded a splenic hematoma managed conservatively in one
demonstrated a 98.5% cancer-specific survival and a 92.3% patient and heart failure in another. A pleural effusion and
overall survival in 78 patients (94 renal masses) treated with herpetic esophagitis were the minor complications. CA had a
percutaneous and laparoscopic RFA. Stern et al. (11) com- minimal impact on renal function. The preoperative and
pared the intermediate-term outcomes of patients with clinical postoperative creatinines were comparable in both the en-
T1a renal tumors who were treated with N SS by partial tire study group and the subset of patients with a solitary
nephrectomy or RFA. All patients had at least 2 years of kidney. Even in 13 patients with a pre-existing renal insuffi-
follow-up (the mean [range] follow-up for the partial nephrec- ciency, no significant change in renal function occurred fol-
tomy and RFA groups was 47 [24–93] and 30 [18–42] lowing CA.
months, respectively). The overall actuarial disease-free prob- In a series of 37 patients undergoing laparoscopic CA,
ability for the partial nephrectomy and RFA groups, respec- three patients were found to have bleeding complications sec-
tively, was 95.8% and 93.4% (p 0.67). This initial 3-year ondary to renal fracture (12). Perinephric hematomas were
actuarial analysis showed that RFA for cT1a renal tumors has seen in two patients and gross hematuria developed in one; all
comparable oncologic outcomes to partial nephrectomy; how- three patients were managed conservatively. Interestingly, this
ever, longer-term data are not yet available. It is notable that was the first series to show delayed ureteropelvic junction ob-
tumor seeding in surgical incisions or puncture sites has not struction resulting from CA. This patient was treated success-
occurred in any of the series published to date. fully with a pyeloplasty at 8 months after CA.
Cryoinjury to the pancreas has been reported in a single
patient undergoing retroperitoneal laparoscopic CA (18). The
CO MPLICATIO NS injury was not apparent intraoperatively, and the patient had
a delayed presentation with abdominal pain and guarding.
Current evidence indicates that both renal RFA and CA have Computerized tomography revealed cryoinjury to the pan-
low morbidity and are associated with few complications, creas. Abdominal exploration showed no bowel injury, and
most of which are minor. In a multi-institutional study, drains were placed around the pancreas. The patient recov-
Johnson et al. (16) found a complication rate of 11.1% in ered without further morbidity.
271 patients undergoing renal RFA and CA. Complications Laparoscopic RFA and CA are promising technologies and
occurred after 14.4% of CA cases and 7.6% of RFA cases, can be utilized effectively to treat small renal masses. They
with the most common being paresthesia or pain at the per- require less technical expertise than laparoscopic partial
cutaneous probe insertion site for both modalities. M ajor nephrectomy and appear to have lower morbidity and ade-
complications in the RFA group included ileus, ureteropelvic quate cancer control in the intermediate term. Careful patient
junction obstruction requiring a delayed nephrectomy, and a selection and meticulous technique are critical to achieving
urinary leak. Significant hemorrhage necessitating a transfu- oncologic results comparable to those of partial nephrectomy,
sion and an open conversion were the major complications which remains the gold-standard therapy for small renal
of CA. O ne patient with poor overall health, obstructive masses. Prospective long-term results of ablative therapy for
pulmonary disease, congestive heart failure, and pulmonary renal masses are eagerly awaited.
References
1. Uzzo RG. Renal cell carcinoma: urologists in a new era. J Urol 2005; 10. Park S, Anderson JK, M atsumoto ED, et al. Radiofrequency ablation of
174(5):1723–1724. renal tumors: intermediate-term results. J Endourol 2006;20(8):569–573.
2. Fergany AF, H afez KS, N ovick AC. Long-term results of nephron sparing 11. Stern JM , Svatek R, Park S, et al. Intermediate comparison of partial
surgery for localized renal cell carcinoma: 10-year followup. J Urol 2000; nephrectomy and radiofrequency ablation for clinical T1a renal tumours.
163(2):442–445. BJU Int 2007;100(2):287–290.
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CHAPTER 128 ■ DO NO R NEPHRECTO MY:

LAPARO SCO PIC TECHNIQ UES
ERIK P. CASTLE, RAFAEL NUNEZ, CO STAS D. LALLAS, AND PAUL E. ANDREWS
Renal transplantation represents one of the most significant Forum on the care of the live kidney donor set a standard for
developments in surgery. It has had a markedly positive effect the evaluation of potential kidney donors (2,3). This report de-
on the survival of patients with end-stage renal disease. The tails the following variables that are important for donation:
limiting factor has continued to be the number of organs renal function, blood pressure, obesity, dyslipidemia, urine
available for transplantation. Deceased donor donation rates analysis of protein and blood, presence of diabetes, stone dis-
have remained relatively stable, and the waiting list has con- ease, malignancy, urinary tract infections, determination of
tinued to grow—from 47,830 in 2001 to 70,501 in 2006, ac- cardiovascular risk, assessment of pulmonary issues, smoking
cording to the United N etwork of O rgan Sharing Data cessation, and alcohol abstinence. A three-dimensional com-
Registry (2007). puterized tomography (CT) scan is also necessary to evaluate
Living kidney donation stands as an immediate solution to the vascular and collecting system anatomy of the living kid-
the organ deficiency. The disincentives of living renal donation ney donor candidate (1).
can be attributed, in part, to concerns by the donor regarding
the operation, the length of hospitalization, the prolonged re-
cuperation period, morbidity, and mortality. Laparoscopic INDICATIO NS FO R SURGERY
donor nephrectomy (LDN ) offers better cosmesis, decreased
length of stay, and shortened convalescence, decreasing the LDN places healthy individuals at risk of morbidity and mor-
disincentives of living donation. tality to benefit the recipient; however, these risks must be
minimized. This distinct practice raises ethical concerns and
confers a special character to the indications of surgery. The
DIAGNO SIS growth of related and unrelated living kidney donation in-
creases the concerns regarding a variety of issues that are
Individual candidates for living donation are usually between unique to organ donation. Such issues include donor psycho-
18 and 70 years of age, without an absolute upper age limit logical status, motivation, and social aspects (4). Ethical issues
(1). A medical and surgical evaluation is mandatory to accept of emotional and financial rewards must be addressed. In a re-
a living kidney donor (1). The report by the Amsterdam cent study, Rodrigue et al. (5) found that in 132 programs
Chap t e r 128: Donor Ne p hre ctomy: Lap aroscop ic Te chniq ue s 847
across the United States, the presence of financial reward, ac-

tive substance abuse, and active mental health problems pre-
sented complete psychosocial contraindications to donation.
To identify healthy and stable individuals, social and psycho-
logical evaluation of live kidney donors is needed. Guidelines
for such evaluations had been an issue, until recently when
they were standardized by the United N etwork for O rgan
Sharing, the American Society of Transplant Surgeons, and the
American Society of Transplantation (4).
ALTERNATIVE THERAPY
O pen-flank nephrectomy and hand-assisted donor nephrec-
tomy are alternative approaches (6). The procedures are essen-
tially the principles of donor nephrectomy described below,
combined with the early use of the hand port as described for
laparoscopic hand-assisted nephrectomy (Chapter 125). Less
morbid open techniques such as the “ mini-nephrectomy” and
“ mini-incision nephrectomy” use a smaller incision (an aver-
age of 10.5 cm) and can reduce morbidity and hospital length
of stay compared to a more traditional open approach (6–8).
A
Preliminary work has also been performed using single-port
transumbilical access for donor nephrectomy.
SURGICAL TECHNIQ UE
Pat ie nt Pre p arat io n and Po sit io ning
Patients undergo standard workup and clearance by the trans-
plant nephrology team. All donors undergo rigorous medical
and psychological evaluation. In addition to standard laboratory
evaluations, CT is obtained in all patients. Contemporary imag-
ing hardware and software allow for complete evaluation of the
urinary tract within prospective donors. The renal parenchyma,
collecting system, and vascular structures are evaluated in
axial, coronal, and sagittal planes. Three-dimensional recon-
structive applications can also provide 360-degree rotational
views of the vascular and collecting systems.
The kidneys are inspected carefully for nephrolithiasis,
masses, cysts, aberrant vasculature, and variant anatomic for-
mations. Although single arteries, veins, and ureters are desir-
able, it is not uncommon to encounter multiple arteries, early
branching of vessels, circumaortic and preaortic renal veins, B
duplicated collecting systems, and renal calcifications. The
FIGURE 128.1 A: Positioning for a laparoscopic donor nephrectomy
three-dimensional reconstructive CT allows us to determine using a modified flank technique. B: “ Sling position” of the ipsilateral
the optimal kidney for donation. We do not hesitate to utilize arm for a right-sided donor.
the right kidney if there is a contraindication for the left.
M any times the right side offers the transplant surgeons better “ top” leg kept relatively straight. The arm on the contralat-
arterial anatomy. eral, nonoperative side (down side) is placed on an arm board
All patients are given standard preoperative intravenous with standard orientation 90 degrees to the table. An axillary
antibiotics 30 to 60 minutes before incision. Aggressive vol- roll is not used or needed with this modified positioning
ume infusion of normal saline is started in the preoperative as the patient is not in “ full flank” and stress is not placed on
area, with most patients receiving between 3.5 and 4.0 liters the contralateral axillary neurologic or vascular structures. The
of fluids by the time they arrive to the operative suite. Patients patient is secured to the bed with copious use of 3-inch silk
are induced under a general anesthetic with endotracheal intu- tape wrapped around the patient and bed circumferentially at
bation. An orogastric tube and urethral catheter are inserted. the level of the nipples, hips, and knees. This secure taping is
Patients are positioned using a “ modified flank” technique done before the ipsilateral (up side) arm is positioned.
(Fig. 128.1A). A 10-pound sandbag or “ bump” is placed un- The ipsilateral arm is finally positioned on the patient’s
der the mattress on the anticipated operative side. The hips are chest using the “ sling position” (Fig. 128.1B). This is a natural
turned and the “ bottom” leg is bent at the knee, with the ergonomic orientation as one might encounter in patients
wearing slings following clavicular fracture. The elbow is TA B LE 1 2 8 . 1

flexed to 30 degrees, almost as if placing the hand on the pa-
tient’s heart. This allows for the arm to be cephalad to the RECOMMEN DED IN STRUMEN TS FOR
costal margin. The arm is placed on soft foam and taped only LAPAROSCOPIC DON OR N EPHRECTOMY
mildly to prevent movement either into the anesthetic or oper- • H armonic scalpel
ative fields. It is important not to overly adduct the shoulder • Suction irrigator
with this arm as one might see when using an arm board across
• O ne nonlocking atraumatic grasper
the field. Let the upper arm stay in line with the ipsilateral, ax-
• O ne locking atraumatic grasper
illary side of the body. The overadduction may seem optimal
but it actually allows for the arm to end up in a less natural • GelPort
state and can even be intrusive to the surgeon by being a bulky • Laparoscopic articulating endovascular stapler (2.5-mm
structure in the cephalad portion of the operative field. vascular loads)
• Laparoscopic camera and lens (0 and 30 degrees)
• Laparoscopic clip applier (10 mm)
Ge ne ral Te chniq ue • Laparoscopic ports, dilating (12 mm 2, 5 mm 2)
Utilizing a transperitoneal technique, access can be obtained

one of two ways. A Veress needle or H asson technique can be
used. Alternatively, if the kidney is to be removed via an in- employ conventional pure laparoscopic techniques during
fraumbilical incision (midline or Pfannenstiel), then a hand port dissection. The hand port can be placed at the start of the oper-
may be used from the beginning (dashed lines in Figs. 128.2 and ation to obtain the pneumoperitoneum if desired and may al-
128.3). Although we use a GelPort for kidney extraction, we low rapid placement of ports. Instruments can also be passed
through the GelPort as another working site (Table 128.1).
Basic laparoscopic techniques are presented in Chapter 122.
Port positioning for the primary three ports (camera and
two working ports) is similar for both the right (Fig. 128.2)
and left (Fig. 128.3) sides. The two working ports are placed
in a subcostal position in the midclavicular line. The camera
port is placed 5 cm medial to the midclavicular line between
the two working ports. All ports are above the level of the
umbilicus, with medial-to-lateral triangulation. A fourth ac-
cessory port is often used and placement is dependent on
which side is being operated on. O n the right side the acces-
sory port is placed in the epigastric/subxiphoid region as a
standalone liver retractor (Fig. 128.2). O n the left side
(Fig. 128.3), we place the accessory port in a more flank ori-
entation to serve as a bowel retractor and retract the left
colon medially for optimal medial dissection of the renal
vein, adrenal vein, renal artery, and preaortic area. An alter-
native placement of this retraction port is to utilize a trocar
FIGURE 128.2 Port placement for right-sided laparoscopic donor through the GelPort.
nephrectomy. D otted lines represent the extraction incisions.
Me d icat io ns
O ne of the goals during LDN is to maximize diuresis of the
donor renal unit, as volume status and diuresis are generally
felt to be associated with better early function of the trans-
planted kidney. As was discussed above, patients are infused
with large volumes of intravenous fluids to expand the in-
travascular space and maximize renal perfusion. H ealthy
donors should be able to tolerate the 3- to 4-liter volume load
preoperatively and should be diuresing once they arrive to the
operating room. To continue the aggressive filtration and di-
uresis, two separate doses of mannitol are given throughout
the laparoscopic dissection. The first dose of 12.5 g is given
once the pneumoperitoneum is established. The second dose is
given 30 minutes into the dissection. Furosemide is also given
(20 mg) toward the end of the renal dissection. In most cases,
FIGURE 128.3 Port placement for left-sided laparoscopic donor the hope is to achieve a urinary output of 300 to 500 mL per
nephrectomy. D otted lines represent the extraction incisions. hour during surgery.
Although not a part of every transplant protocol, we use hilum. With the gonadal vein retraction, the medial aspect of
heparin prior to extraction. The patient is given a 3,000- the renal vein can be easily identified and lumbar tributaries
unit dose of heparin 5 minutes before anticipated stapling of can be identified. The lumbar vein(s) should be bluntly dis-
the hilum and extraction. O nce the kidney is removed and sected and divided with a single endovascular staple load.
passed off to the receiving transplant team, 30 mg of prota- With the lumbar vein(s) taken, the renal artery can be exposed
mine sulfate can be infused to reverse the anticoagulant ef- and better visualized. Blunt dissection with the suction irriga-
fect of heparin if desired. The use of heparin and protamine tor will expose the takeoff of the left renal artery.
has been part of our protocol for over 500 cases and we The dissection can then be carried to the superior margin
have yet to experience a deleterious effect attributable to of the renal vein. The bowel grasper can be moved more
either drug. cephalad on the left colon, exposing the superior border of the
renal vein and the adrenal gland. If more venous length is de-
sired, the adrenal vein can be bluntly dissected and divided
Le ft -Sid e d Do no r Ne p hre ct o my with another endovascular staple load. Care must be taken to
work in a medial-to-lateral orientation to avoid inadvertent
O nce the pneumoperitoneum is established, the procedure is injury to the superior mesenteric artery, as now the dissection
begun by incising 2 to 3 cm lateral to the left colon. The inci- is being performed cephalad to the renal vein and renal artery.
sion is carried caudal to the pelvic brim, with care taken to Blunt and harmonic scalpel dissection can be used to mobilize
avoid the gonadal vessels and internal ring in male patients. the fascia of Gerota on the superomedial aspect of the kidney.
The cephalad incision is carried toward the ipsilateral shoul- By dissecting the fascia of Gerota medially at this point, the
der lateral to the spleen. Incising lateral to the spleen allows adrenal gland and its attachments should fall medially off the
the splenic flexure of the left colon and spleen to fall medially kidney. The dissection is then carried around the upper pole of
as a unit (Fig. 128.4). This provides excellent exposure of the the kidney.
upper pole. O nce the colon is freed from its lateral attach- O nce the inferior, medial, and upper-pole attachments are
ments, the atraumatic locking retractor is inserted via the dissected free from the kidney, the kidney is attached only by
flank port or GelPort to retract the colon medially. Blunt dis- the renal vasculature, the lateral attachments, and the ureter.
section should be used to identify the gonadal vein and ureter Any remaining dissection of the renal hilum can be performed
as a package and they are retracted anterolaterally. The go- to maximize vascular length. The lateral attachments of the
nadal vein should be retracted along with the ureter, as it ori- kidney are divided within the fascia of Gerota. The dissection
ents the surgeon to the location of the hilum and renal vein. is begun at the inferior margin of the kidney and lateral to the
Utilizing a combination of blunt and careful harmonic scalpel ureter. The periureteral tissue is not violated so as to preserve
dissection, the dissection is carried cephalad toward the renal all vascularity of the gonadal vein and ureteral complex. The
hilum. M ost of the medial attachments, lymphatics, and areo- dissection is carried along the lateral border of the kidney
lar tissue can be divided with the harmonic scalpel. within the fascia of Gerota, resulting in a defatting of the
The dissection should be kept medial along the lateral bor- kidney if possible. The dissection is carried cephalad to the
der of the aorta to allow for medial exposure of the renal incised attachments superiorly. The gonadal vein can then
Left kidney
with Gerota's fascia
Splenorenal
Colonic mesentary divided
ligament
Spleen
FIGURE 128.4 The cephalad incision is carried to

the ipsilateral shoulder. Dividing the colonic mesen-
tery to rotate the colon medially will develop a plane
between the spleen and the fascia of Gerota. The line
of dissection is carried between the two organs to
allow the colon, spleen, and pancreas to fall medially.
Pancreas Left colon The incision of this plane continues cephalad and
mobilized medially medial until the stomach is visualized.
locking retractor should allow for the liver to be maintained in

a cephalad fashion without the need to hold the retractor.
The dissection is begun by incising 3 cm lateral to the right
colon. This dissection is carried caudal to the pelvic brim. Care
is taken to avoid the gonadal vein in men and the possibility of
encountering a retrocecal appendix. The dissection is then
turned cephalad and along the superomedial surface of the kid-
ney. The duodenum will be encountered and can be bluntly dis-
sected in a medial direction. O ften it is easier to “ kocherize”
the duodenum after the ureter is retracted anterolaterally.
The ureter and its surrounding attachments should be re-
tracted anterolaterally. It is very important to identify the go-
nadal vein and dissect it medially away from the ureteral
package so as not to inadvertently avulse it from the vena
cava. With the ureteral retraction, the dissection is carried su-
periorly toward the hilum along the lateral border of the vena
cava. During this portion of the dissection, the duodenum
FIGURE 128.5 A goal of laparoscopic donor nephrectomy is to pro- may need to be bluntly dissected medially and its superior at-
vide a good length of artery and vein on the kidney side. tachments incised with the harmonic scalpel. With the renal
vein identified, the dissection is carried posterior to the vena
cava and renal vein. With careful blunt dissection, the right re-
be dissected and ligated at the pelvic brim. The vein is ligated nal artery should be dissected, and it should be carried as far
with laparoscopic clips and divided. The ureter is also ligated behind the vena cava as possible. If any lumbar veins are en-
and divided, usually at the level of the iliac vessels. The goal countered, they can be clipped and divided to allow for
is to maximize the length of the artery and vein to assist the greater “ rolling” of the vena cava. The dissection is then car-
transplanting surgeon in a successful vascular anastomosis ried along the cephalad border of the renal vein following the
(Fig. 128.5). superolateral margin of the right kidney.
After 3,000 units of heparin have been infused for 3 min- The lateral attachments of the kidney can be divided with
utes, the renal artery is taken with a single endovascular staple the harmonic scalpel starting at the inferolateral margin of
load. The renal vein can then be similarly taken with an en- the lower pole. O nce again, care is taken to preserve all the
dovascular staple load. In cases of a wide vein, a 45-mm-long periureteral tissue. With the kidney completely dissected, the
staple load can be employed. In most cases, optimal retraction ureter can be clipped and divided distally as for the right-
is achieved with pure laparoscopic instruments; in other cases, sided procedure. When taking the renal vessels, the same en-
a hand can be placed in the abdomen through the hand port dovascular stapler can be used. It has been our experience
for retraction. O nce the kidney is extracted and passed off, that adequate venous length can be obtained with articula-
30 mg of protamine sulfate can be infused. The renal fossa tion of the stapler and lateral retraction of the kidney. The
and staple lines are inspected. The adrenal gland should also kidney is extracted and passed off and protamine is given as
be inspected, as in some cases there can be some venous ooze described earlier for the left side. Closure is the same as the
from its lateral edge. H emostatic maneuvers with tissue sealant, left side.
clips, or pressure can be employed if needed.
The ports can be removed under direct vision with the
pneumoperitoneum down to 5 mm H g. The extraction is Ke y Po int s
closed with running suture of the surgeon’s choice. The ports
can be closed with an endoscopic closing device if desired. If 1. It is the authors’ practice to avoid using clips near or
dilating ports are used, these can be left open. In our series, we around the hilum unless necessary. If a vessel cannot be
close the 10-mm and 12-mm dilating ports at the external fas- taken with the harmonic scalpel, then we take it with a sta-
cial level with a 0 Vicryl UR-6 needle and S-retractors, as her- pler. Staples can cross other staple lines. If clips are caught
niation has been reported in the literature. Skin edges can be within a stapler, the results can be disastrous!
closed based on the surgeon’s preference. Wounds can be infil- 2. The gonadal vein should be retracted with the ureter on
trated with a local anesthetic of the surgeon’s choice, typically the left side. It is a “ pathway” to the left renal vein.
lidocaine or bupivacaine. 3. The lumbar veins should be divided on the left side to give ad-
ditional length. These should be taken with a stapler to avoid
problems with clips at the hilum and the use of staplers.
Rig ht -Sid e d Do no r Ne p hre ct o my 4. There is often a tendency to work too lateral and not close
enough to the aorta or vena cava. Staying close to the great
Pneumoperitoneum is established and ports are placed in the vessels allows for maximizing vascular length and facili-
previously described orientation. It is noted that the right tates hilar dissection.
colon is not as intrusive and falls medially much more easily 5. A standard articulating endovascular stapler will suffice
than on the left side. The liver is retracted superiorly by plac- for both sides. Avoiding heroic measures to obtain 2 to 3 mm
ing a locking grasper through the epigastric/subxiphoid port of venous length will prevent complications for an other-
and clamping the underside of the right upper abdomen. The wise healthy patient such as a kidney donor.
6. We recommend attempting to close 12- and 10-mm ports 50 minutes. With our mean operative times down to under
at the fascial level in patients whose body habitus is 90 minutes, we are able to keep the anesthesia time short for
amenable, even if dilating ports are used. our healthy donor patients.
Another concern with LDN is the manner in which the ves-
sels are ligated and divided. There are numerous reports of
O UTCO MES ways to “ maximize” venous and arterial length. We have been
using the laparoscopic articulating endovascular GIA in all
A major point of contention is the comparison of open versus 500 patients (left- and right-sided) without direct technical
laparoscopic donor nephrectomy. In a recent review, Shokeir consequence to our transplant colleagues. We feel that the sta-
(9) evaluated 69 studies referent to LDN and open donor pler is a reliable, safe, and efficient way to manage the artery
nephrectomy (O DN ). Within this comprehensive review, and vein. By eliminating extra steps and tools such as clips
seven reports were randomized controlled trials (RCTs). All and/or directly cutting on a clamp requiring vascular suturing,
RCTs concluded that LDN provides equal graft function at we feel donor safety is preserved. O ne must remember that the
1 year, equal rejection rate, equal urologic complications, and kidney donor patient is an otherwise healthy person, and his
equal patient and graft survival. Analgesic requirements, pain or her well-being and best interests should be of the utmost
data, hospital stay, and time to return normal activities fa- importance.
vored the laparoscopic approach significantly. This report also
compares reported mortalities. A total of 11 deaths in the
LDN cohorts and 10 deaths in the O DN cohorts were re- Co mp licat io ns
ported. A trend toward higher estimated blood loss was found
in the open group. Reports of postoperative complications With an estimated 12% to 14% overall complication rate
were also reviewed. Gastrointestinal problems (bowel injury, and a major complication rate of approximately 1.5% , pa-
bowel obstruction, internal hernia, and pancreatitis) were tients must be fully informed of all possible outcomes. As
more common with LDN , while pulmonary complications with any surgery, there are risks of bleeding, pain, infection,
(atelectasis, pneumothorax, pulmonary congestion, and hy- incisional hernia, deep venous thrombosis, pulmonary em-
poxia) as well as thrombotic complications (deep vein throm- bolus, pneumonia, and cardiac risks. These have the same
bosis, thrombophlebitis, and pulmonary embolism) were incidence as one would expect in any healthy patient under-
more common with O DN . Another aspect to be considered going general anesthesia and laparoscopic renal surgery.
when taking into account outcomes and complications of Table 128.2 outlines the specific risks of laparoscopic donor
LDN is the absence of a uniform system to classify them. In nephrectomy.
order to best address this concern, it is necessary to develop a As with any laparoscopic procedure, there is always the
standardized classification and a nationwide donor registry to possibility of open conversion. The decision to convert most
determine global complications and long-term outcomes often reflects good judgment and in and of itself is not a com-
rather than short reports at single institutions (10). plication. The act of converting should not be considered a
Also important is the report of 15 graft losses directly re- complication, as open surgery is the standard to fall back to
lated to the technical aspect of LDN . It is difficult to say, but and not an adverse approach. The surgeon always has the op-
this may be related to the learning curve of LDN over the tion to convert to open nephrectomy and should have all in-
years, and long-term outcomes will have to be compared. It is struments necessary for open surgery. The incision most often
important to consider that the complications and outcomes in made is a subcostal incision connecting two or more ports if
LDN have a tendency to be experience-dependent. Through possible. In most cases conversion is due to ongoing hemor-
the analysis of the learning curve, different studies have shown rhage or failure to progress secondary to adhesions.
that the incidence of complications tends to diminish as the In addition to open conversion, other potential complica-
surgeon becomes more experienced (9–12). tions inherent to the laparoscopic nature of the operation in-
In our own series of over 500 LDN s, we have carefully fol- clude pneumothorax, port herniation, and trocar injuries.
lowed our early and long-term patient and graft outcomes. We These should be managed in the standard fashion. The pneu-
have previously reported our results after our initial 200 pa- mothorax is often not associated with an air leak, so observa-
tients (13,14). O verall complication rates have ranged be- tion or immediate percutaneous drainage is all that is often
tween 12% and 14% , with only 1.5% of the complications needed. Port herniation should be treated with return to the
being major complications. O ur technique and experience operating room for laparoscopic reduction. Trocar injuries to
have evolved since 1999, when we were doing the dissection underlying structures should be identified and repaired imme-
with conventional laparoscopic technique and placing the diately. In the event of bowel injury during access to the ab-
kidney in a specimen retrieval bag. Since then, we have devel- dominal cavity, the standard of teaching has been to abort the
oped a technique of pure conventional laparoscopic dissec- procedure. Although ileus is rare with laparoscopic surgery, it
tion with kidney extraction through a hand port as described is most often treated with simple bowel rest, ambulation, and
previously. observation.
We have found that having the hand port in place before O ne of the more devastating complications is a vascular
actual extraction has decreased our extraction time to a mean complication within the renal hilum. With the U.S. Food and
of 1.16 minutes. With a short extraction time, the overall Drug Administration having recalled the Weck H em-O -Lok L
warm ischemia time is kept to a minimum. We continue to Polymer Ligating Clips (Weck Closure Systems, Research
do pure laparoscopic dissection as techniques have allowed Triangle Park, N C), it is a contraindication for its use in renal
us to be ready to extract and pass off the specimen in under hilar control. N evertheless, failure of the endovascular stapler
TA B LE 1 2 8 . 2 minimal and most often can be managed with hemostatic ap-

plications of glues, sealants, or even argon beam coagulation.
RISKS SPECIFIC TO LAPAROSCOPIC DON OR Lymphocele is a known complication of donor nephrec-
N EPHRECTOMY tomy. This is often due to the disruption of lymphatic channels
• N eed for open conversion within the hilum as well as injury to the cisterna chyli.
• Pneumothorax
Although rarely seen with donor nephrectomy as it is often
performed transperitoneally, it is still a reported complication.
• Port herniation
If an area walls off and does not communicate with the peri-
• Trocar injuries
toneum, it can result in a lymphocele even in transperitoneal
• Ileus cases. O ften drainage, percutaneous or open, is all that is
• Stapler malfunction resulting in hemorrhage needed. If it results in chylous ascites, then diet modification
• Clip malfunction to medium-chain fatty acids is required. M anagement would
• Injury to the spleen or liver be similar to retroperitoneal lymph node dissection patients
• Lymphocele who suffer this complication.
• Degloving injury to the kidney Degloving injuries to the transplanted renal unit are possi-
• Testicular pain/epididymitis ble. This usually occurs in cases where there is very adherent
perinephric fat and a hand is being used in the dissection. This
can be avoided if direct incision of surrounding attachments,
splenorenal ligaments, and overlying fat is done directly with
is a rare but possible event, as well as with clips. This compli- pure laparoscopic techniques. It is easy to get “ heavy-handed”
cation is usually identified immediately as significant hemor- during manual dissection to expedite an operation. If this de-
rhage will be encountered. Venous bleeding can often be gloving injury does occur, it has little consequence for the
controlled with direct compression (laparoscopic or digital donor but will have to be addressed by the recipient team, as it
through the GelPort), increase of the pneumoperitoneum to 20 can increase the risk of bleeding in the recipient. O ften back-
mm H g, and laparoscopic suturing techniques. Arterial bleed- table repair of stripped renal capsule or intraoperative applica-
ing from the main renal artery due to stapler or clip malfunction of tissue sealants is used.
tion is particularly difficult to control laparoscopically. Simply Finally, in male patients undergoing left LDN , left testicu-
put, if vascular control cannot be obtained with laparoscopic lar pain and/or left epididymitis/orchitis has been reported
maneuvers, one should convert and use standard open tech- postoperatively. This is a consequence of taking the left go-
niques. The same applies to injuries to surrounding structures nadal vein during the procedure. The patients will report an
such as the spleen. Although newer hemostatic glues and “ ache” and fullness in the left hemiscrotum. This is usually
sealants are available, some splenic lacerations and injuries will self-limiting and should be managed with anti-inflammatories
not stop bleeding. If use of hemostatic agents fails, splenec- and scrotal elevation. In cases where an infectious etiology is
tomy may be needed and can be performed laparoscopically or suspected due to urethral catheterization, antibiotic treatment
open, depending on the surgeon. Injuries to the liver are often for 3 to 4 weeks is appropriate.
References
1. M andelbrot DA, Pavlakis M , Danovitch GM , et al. The medical evaluation 8. Kok N F, Alwayn IP, Lind M Y, et al. Donor nephrectomy: mini-incision
of living kidney donors: a survey of US transplant centers. A m J Transplant muscle-splitting open approach versus laparoscopy. Transplantation 2006;
2007;7:2333–2343. 81:881–887.
2. Delmonico F; Council of the Transplantation Society. A report of the 9. Shokeir AA. O pen versus laparoscopic live donor nephrectomy: a focus on
Amsterdam Forum on the care of the live kidney donor: data and medical the safety of donors and the need for a donor registry. J Urol 2007;178:
guidelines. Transplantation 2005;27(79):S53–66. 1860–1866.
3. Delmonico FL, Dew A. Living donor kidney transplantation in a global 10. Kocak B, Koffron AJ, Baker TB, et al. Proposed classification of complica-
environment. Kidney Int 2007;7:608–614. tions after live donor nephrectomy. Urology 2006;67:927–931.
4. Dew M A, Jacobs CL, Jowsey SG, et al.; United N etwork for O rgan Sharing 11. Chin EH , H azzan D, H erron DM , et al. Laparoscopic donor nephrectomy:
(UN O S); American Society of Transplant Surgeons; American Society of intraoperative safety, immediate morbidity, and delayed complications
Transplantation. Guidelines for the psychosocial evaluation of living unre- with 500 cases. Surg Endosc 2007;21:521–526.
lated kidney donors in the United States. A m J Transplant 2007;7: 12. M artin GL, Guise AI, Bernie JE, et al. Laparoscopic donor nephrectomy:
1047–1054. effects of learning curve on surgical outcomes. Transplant Proc 2007;39:
5. Rodrigue JR, Pavlakis M , Danovitch GM , et al. Evaluating living kidney 27–29.
donors: relationship types, psychosocial criteria, and consent processes at 13. Lallas CD, Castle EP, Schlinkert RT, et al. The development of a laparo-
US transplant programs. A m J Transplant 2007;7:2326–2332. scopic donor nephrectomy program in a de novo renal transplant program:
6. M orrissey PE, M onaco AP. Living kidney donation: evolution and techni- evolution of technique and results in over 200 cases. JSL S 2006;10:
cal aspects of donor nephrectomy. Surg Clin N orth A m 2006;86: 135–140.
1219–1235. 14. Lallas CD, Castle EP, Andrews PE. H and port use for extraction during
7. Shenoy S, Lowell JA, Ramachandran V, et al. The ideal living donor laparoscopic donor nephrectomy. Urology 2006;67:706–708.
nephrectomy “mini-nephrectomy” through a posterior transcostal approach.
J A m Coll Surg 2002;194:240–246.
CHAPTER 129 ■ LAPARO SCO PIC AND
RO BO TICALLY ASSISTED PYELO PLASTY
IN ADULTS
KRISTO FER R. WAGNER AND THO MAS W. JARRETT
After the first successful reconstructive procedure was per- morbidity. Direct-vision endopyelotomy via percutaneous ante-
formed by Kuster in 1891, a variety of procedures (open and grade or retrograde approaches yields a lower early success rate
minimally invasive surgeries) have been described for manage- of 66% to 90% when compared to open pyeloplasty and may
ment of the obstructed ureteropelvic junction (UPJ). Laparoscopic have even lower long-term success rates (4–6). We do not use the
pyeloplasty was first described in 1993 by Schuessler et al. (1) fluoroscopic cautery-wire (Acucise, Applied Medical, Rancho
as a less invasive means of reconstructing the UPJ under direct Santa Margarita, CA) technique for UPJ repair.
visualization. This approach preserves the principles of open
pyeloplasty and offers maximal flexibility in reconstruction
without the associated morbidity of a large flank incision. The SURGICAL TECHNIQ UE
learning curve for laparoscopic suturing and prolonged opera-
tive times initially prevented more widespread utilization of The patient is admitted the same day of surgery. After antibi-
the technique. M ore recently, use of robotic technology has otic administration and induction of general anesthesia, an
facilitated the transition for some surgeons and may lead to orogastric tube is inserted and sequential compression devices
decreased operative time. are placed on the lower extremities. The patient is initially po-
sitioned supine (frog-leg position for women and supine for
men). Using a flexible cystoscope, angle-tipped glide wire, and
DIAGNO SIS 5Fr open-ended catheter, a retrograde pyelogram is performed
with C-arm fluoroscopy to confirm the diagnosis and demon-
The diagnosis of UPJ obstruction in general can be made by strate the exact site and nature of the obstruction. A 7Fr
intravenous urogram or diuretic renal scan. Preoperative com- 28-cm (double-pigtail) stent is placed and correct position
puterized tomography may be helpful in identifying patients confirmed with fluoroscopy. A longer-than-usual stent is used
with a crossing vessel who are being considered for an en- to minimize the possibility of stent displacement out of the
dopyelotomy procedure. Retrograde pyelography has an im- bladder during surgical manipulation of the UPJ. In men, the
portant role in confirmation of the diagnosis and for exact glide wire can be resheathed and prepared into the operative
delineation of the obstruction. This can usually be performed field. The stent can then be placed later with the flexible cys-
in conjunction with the procedure. toscope after the back wall of the anastomosis is completed.
This avoids the interference with the proximal stent curl while
suturing the back wall. In women, access to the urethra is
INDICATIO NS FO R SURGERY problematic, and it is preferable to place the stent preopera-
tively. A Foley catheter is inserted before the patient is placed
Laparoscopic pyeloplasty is effective for all types of UPJ ob- in a 45-degree lateral decubitus position. This position mini-
struction but should be strongly considered in instances where mizes potential neuromuscular complications that may occur
a less invasive procedure is less likely to be successful. Such with the 90-degree flank position and is illustrated in previous
situations include severe hydronephrosis, crossing vessels, chapters. A roll is placed under the ipsilateral shoulder and
strictures 2 cm in length, failed previous endoscopic proce- down to the ipsilateral pelvis to keep the operative side ele-
dures, concomitant renal stones, renal ptosis, and poor renal vated and stable. It is not necessary to place an axillary roll,
function. flex the operating table, or elevate the kidney rest. The ipsilat-
eral arm is placed across the chest and the contralateral arm is
placed on an arm board abducted 90 degrees from the table
ALTERNATIVE THERAPY with stacked pillows and folded blankets between the arms.
Care is taken to protect all pressure points with foam. The
Open pyeloplasty has been considered the gold-standard inter- lower knee is bent slightly, and the ipsilateral leg is kept
vention for correcting UPJ obstruction, with a success rate almost straight with pillows or foam placed between them to
exceeding 90% (2,3), but it is associated with significant postop- prevent pressure ulcers and neurologic injury. Foam and wide
erative morbidity related with open flank surgery. Several mini- cloth tape are placed across the upper shoulder and arm and
mally invasive endoscopic procedures for treatment of UPJ across the hip to secure the patient to the operating table. The
obstruction have been developed to minimize the postoperative table is tested tilting maximally to the left and right. The entire
853
abdomen and flank from the xiphoid to the pubis is shaved sweeping motion, further exposing the retroperitoneum. O n
carefully and then scrubbed. the right side, a Kocher maneuver may be necessary to mobi-
lize the duodenum off the medial aspect of the kidney.
The ureter is identified just medial to the lower pole of the
Tro car Place me nt kidney and usually lies lateral and posterior to the gonadal ves-
sels. Gentle palpation of the indwelling stent confirms the
Laparoscopic pyeloplasty is performed by the transperitoneal structure to be the ureter. A plane between the psoas muscle
approach. Pneumoperitoneum is established by inserting a and the ureter is created using gentle sweeping motions and the
Veress needle lateral to the rectus border or into the umbilicus. ureter is dissected cephalad until the UPJ is identified. It is im-
After an insufflation pressure of 15 mm H g is established, portant to dissect the ureter with its adjacent tissue attached to
three midline trocars are placed (Fig. 129.1). The umbilical maximize the blood supply. The ureter should be skeletonized
trocar is 10 mm to allow use of a 10-mm 30-degree laparo- only in the area of the UPJ for delineation of the anatomy.
scope. The remaining trocars are placed two fingerbreadths It is frequently useful to place a 4-0 absorbable suture
above the symphysis pubis and 8 cm above the umbilicus. through the anterior renal pelvis as a stay suture to aid in re-
Trocars are either 5 or 12 mm, depending on surgical side traction and fixation during dissection and repair. This suture
(right or left) and dominant hand of the surgeon. The larger may be passed through the abdominal wall, renal pelvis, and
trocar would be placed in the dominant hand of the surgeon back through the abdominal wall using a Keith needle. It is se-
to allow for passage of the needle driver and/or Endostitch de- cured outside the abdomen using a hemostat to adjust tension
vice during the repair of the UPJ. on the suture. Extra attention should be made for lower-pole
The surgeon operates from the opposite side of the affected crossing vessels, which can be damaged with overzealous dis-
renal unit and uses the supra- and infraumbilical trocars as the section. In the presence of crossing vessels, the renal pelvis and
working ports. The assistant or the robot arm (AESO P) stands ureter are carefully dissected free so that the ureter can be eas-
on the same side of the operating table as the surgeon and ma- ily transposed anteriorly as needed. The ureter and renal pelvis
nipulates the camera by the umbilical port. are then mobilized as needed to allow for a subsequent tension-
The table is rotated with the ipsilateral side up, and the lat- free repair. At this point the surgeon must commit to the type
eral peritoneal reflection overlying the kidney is incised along of repair to be used depending on the nature of the UPJ ob-
the white line of Toldt from the upper pole to approximately struction. Any renal calculi can be removed with a combina-
3 cm below the lower pole. The renocolic ligaments are then tion of direct extraction using forceps through the pyelotomy
divided sharply and the colon is retracted medially with a or with the aid of a flexible cystoscope passed through the
upper trocar.
And e rso n–Hyne s Disme mb e re d

Pye lo p last y
Dismembered pyeloplasty is our preference in most clinical cir-
cumstances (Fig. 129.2). It is especially preferable with cross-
ing vessels and a large redundant renal pelvis. Scissors are used
to transect the UPJ, taking care not to damage the ureteral
stent. The renal pelvis is first incised circumferentially above
the area of stenosis, and the stent is then delivered through this
incision. The initial pyelotomy is made on the medial aspect of
the renal pelvis and cephalad to the UPJ. This results in a “ han-
dle” of tissue that can be used to manipulate the ureter. The
posterior wall is transected, thus completely freeing the ureter
from the renal pelvis. The proximal ureter is spatulated on the
lateral aspect using laparoscopic scissors, with attention not to
spiral the incision. When a crossing vessel is present, the ureter
must be transposed anteriorly to these vascular structures prior
to reanastomosis to the renal pelvis. A reduction pyeloplasty is
performed at this point when necessary.
N ext, 4-0 absorbable stay sutures are placed at the apex
of the spatulated ureter and then through the most depen-
dent portion of the reduced renal pelvis. They are tied using
intracorporeal techniques. This suture is then used in a run-
ning fashion to approximate the posterior portions of the re-
nal pelvis and ureter. Sutures can be placed using the
freehand technique or the Endostitch device (Fig. 129.3) (7).
The medial portion of the proximal ureter used as a handle is
excised. The proximal curl of the stent is placed back into
the renal pelvis or upper pole calyx and the anterior portion
FIGURE 129.1 Trocar placement for transperitoneal laparoscopic of the anastomosis is completed using the same technique.
pyeloplasty. The cephalad portion of the pyelotomy is sutured with
Chap t e r 129: Lap aroscop ic and Rob otically Assiste d Pye lop lasty in Ad ults 855
FIGURE 129.2 Anderson–H ynes dismembered pyeloplasty technique.
continuous 4-0 absorbable sutures using the Endostitch or

freehand technique. Care is taken to avoid incorporating the
stent into the sutures.
Fo le y V–V Pye lo p last y

The Foley Y–V pyeloplasty (Fig. 129.4) may be considered in
the absence of crossing vessels when there is a small renal pelvis
or a high ureteral insertion into the renal pelvis. Using laparo-
scopic scissors, a wide-based V-shaped flap is constructed from
the anterior pelvis. The proximal ureter is spatulated anteriorly.
Using 4-0 absorbable sutures, the apex of the V-flap is sutured
to the apex of the spatulated ureteral incision and tied intracor-
poreally with the Endostitch or freehand techniques. The lower
wall is completed first using the Endostitch to place the sutures, FIGURE 129.3 Endostitch device.
and the anastomosis is completed with sutures that are placed
from the apex out toward the upper pelvis.
to 1 to 2 cm below the UPJ segment. The initial pyelotomy in-
cision, just above the UPJ, can be made with a laparoscopic
Fe ng e r No nd isme mb e re d Pye lo p last y knife or scissors. The longitudinal incision is then closed
(He ine ke –Mikulicz) transversely in a H eineke–M ikulicz fashion over the stent
using one continuous 4-0 absorbable suture.
The Fenger pyeloplasty (Fig. 129.5) may be considered for a
short stenotic segment in the absence of crossing vessels or a
high insertion. The principle of this procedure is a longitudi- Ad d it io nal Salvag e Mane uve rs
nal incision and transverse closure. This technique has the po-
tential advantage of a shorter operative time because fewer Additional maneuvers may be necessary in cases where a long
intracorporeal sutures are needed. A longitudinal incision is ( 2 cm) stricture is present or the anastomosis is under ten-
made with laparoscopic scissors from the renal pelvis distally sion. This is more likely in cases of secondary UPJ obstruction
(Jackson–Pratt) is positioned carefully in the retroperitoneum

to lie adjacent to the newly completed anastomosis but never
in direct contact. The drain is brought out through a small
stab incision in the posterior axillary line and then secured
with a 3-0 nylon suture. All trocars are then removed under
direct vision. The abdominal fasciae of all 10/12-mm port
sites are closed with interrupted 0 absorbable sutures using
the Carter-Thomason closure device. The CO 2 pneumoperi-
toneum is removed to decrease postoperative shoulder irrita-
tion. The drain is connected to bulb suction. The skin
incisions are closed with subcuticular 4-0 polyglactin sutures
and adhesive skin tape.
Transme se nt e ric Ap p ro ach

The transmesenteric approach may offer advantages of de-
creased operative time and ileus in appropriately selected cases.
This approach is primarily useful in left-sided cases because the
splenic flexure lies cephalad to the UPJ (Fig. 129.6A). It is
technically feasible in cases with a laterally displaced colon and
relatively thin mesentery. This anatomic situation is more fre-
quently encountered in pediatric cases or in thin women.
Instead of mobilizing the colon medially, a longitudinal win-
dow is created in the mesentery over the UPJ, taking care to
avoid mesenteric vessels (Fig. 129.6B). A stay suture through
the abdominal wall is most useful to elevate the renal pelvis
and UPJ from the mesenteric window. From this vantage point,
the proximal ureter and renal pelvis are dissected and the re-
FIGURE 129.4 Foley Y–V pyeloplasty technique.
pair of choice is performed as described above.
Ro b o t -Assist e d Lap aro sco p ic Pye lo p last y

The da Vinci robotic surgical system (Intuitive Surgical,
Sunnyvale, CA) offers several advantages over standard
FIGURE 129.5 Fenger nondismembered pyeloplasty (H eineke–

M ikulicz) technique.
or those with previous failed treatment. In these cases, it is

critical to assess the UPJ and stricture length prior to transect-
ing the UPJ. It may be necessary to create a vertical or spiral
flap of renal pelvis to reconstruct the UPJ and gain adequate
length. M obilization of the entire kidney inferiorly may also
provide a few centimeters of additional length. In redo salvage
situations with a very long stricture, a laparoscopic ureterocal-
icostomy or ileal ureter might be necessary.
After the chosen anastomosis is completed, fibrin glue may
be used to help seal the anastomotic site. Then, the pneu-
moperitoneum pressure is dropped to 5 mm H g and the oper-
ative sites are examined for bleeding. After hemostasis is FIGURE 129.6 A: Laterally displaced left colon, suitable for trans-
adequately obtained, a small closed-bulb suction drain mesenteric approach.
Chap t e r 129: Lap aroscop ic and Rob otically Assiste d Pye lop lasty in Ad ults 857
FIGURE 129.6 B: Transmesenteric tech-

nique with stay suture through abdominal
wall.
laparoscopic pyeloplasty. Additional magnification (10 ),

three-dimensional stereoscopic vision, motion scaling, and
tremor filtering provide an increased level of precision in dis-
section and reconstruction. In particular, suturing time may be
decreased with the use of the da Vinci system. The patient is
positioned as described previously for laparoscopic pyelo-
plasty. Trocar placement includes a 10/12-mm trocar at the
umbilicus for the camera and two 8-mm robotic trocars, one in
the midline 8 cm above the umbilicus and one in the lower
quadrant lateral to the rectus border (Fig. 129.7). An addi-
tional 5- or 10-mm port is placed in the lower midline to allow
the assistant to pass suture and provide suction and retraction.
M obilization of the colon and exposure of the UPJ are per-
formed using standard laparoscopic instrumentation as de-
scribed previously. The robot is then docked, with the patient
side cart approaching the patient’s back at a 45-degree angle
from the ipsilateral shoulder toward the umbilicus (Fig. 129.8).
The camera arm and two working arms reach across the pa-
tient’s abdomen and angle back toward the ipsilateral upper
quadrant. The 30-degree down-angled da Vinci scope is con-
nected to the camera arm. The M aryland forceps and Potts
scissors are used to transect the UPJ. The articulating Potts are
particularly useful to precisely spatulate the ureter and tailor
the renal pelvis. The robotic needle drivers are then used to
perform the reconstruction as described previously. Robotic
surgeons should be familiar with standard laparoscopic sutur-
ing techniques to avoid open conversion in the event of a robot FIGURE 129.7 Trocar placement for right-sided robot-assisted
laparoscopic pyeloplasty.
malfunction.
greater than this. Following removal of the Foley, the

Po st o p e rat ive Care retroperitoneal drain outputs must be monitored for increased
output. If the outputs increase, the Foley should be replaced
The orogastric tube is removed just before extubation. O n the until they drop to acceptable levels. The retroperitoneal drain
ward, vigilant records of outputs must be kept to dictate drain may be removed when the drainage is negligible after the
management. The Foley catheter is removed on postoperative Foley removal, which is usually postoperative day 2. In some
day 1 or 2 if the drain fluid output is consistently 30 to 50 cc cases, patients are sent home with the drains in place if they
per 8 hours. A drain fluid creatinine is obtained if output is have met all other criteria for discharge.
FIGURE 129.8 Room setup for left-sided robot-assisted laparoscopic pyeloplasty.
A clear liquid diet is started on postoperative day 1 and ad- Results have been excellent and are comparable to open
vanced following the passage of flatus. The intravenous antibi- pyeloplasty. In a series of 100 consecutive laparoscopic pyelo-
otics are continued for 24 hours, and then switched to an oral plasty cases from the Johns H opkins H ospital, 96% were suc-
agent. The ureteral stent is removed in the office in 6 weeks. The cessful with a mean radiographic follow-up of 2.2 years (8).
anastomosis is then radiologically re-evaluated with an intra- Fifty-six of 100 patients were found intraoperatively to have
venous urogram or renal nuclear scan 6 weeks after stent re- lower-pole crossing vessels and thus underwent dismembered
moval unless the patient has recurrent symptoms. A follow-up pyeloplasty. In patients with calculi, concomitant laparoscopic
diuretic renal scan is obtained at 6 months postoperatively and pyeloscopy with extraction of the stones was performed. A
compared with the previous study. Thereafter, an intravenous French multicenter study examined 55 retroperitoneal laparo-
urogram or a renal scan is obtained at yearly intervals. scopic pyeloplasty cases and found that 95% of cases were
successfully completed laparoscopically; all patients were
pain-free and radiographically unobstructed by 3 months (9).
O UTCO MES The overall complication rate was 12.7% . Complications in
seven patients included hematoma in three, urinoma in one,
Laparoscopic pyeloplasty retains the benefits of open pyelo- severe pyelonephritis in one, and anastomotic stricture in two,
plasty while minimizing the morbidity of incisional trauma. requiring open pyeloplasty at 3 weeks and delayed balloon in-
This approach should be considered especially in those instances cision at 13 months, respectively.
where endopyelotomy is contraindicated or has compromised The largest comparative series between laparoscopic and
results. Such situations include severe hydronephrosis, renal open pyeloplasties was reported on a retrospective series of
ptosis with renal kinking, poor renal function, strictures longer 42 patients who underwent laparoscopic pyeloplasty and 35
than 2 cm, concomitant nonobstructing renal stones, and who underwent open repair with regard to outcome and com-
crossing lower-pole vessels. The major disadvantage of the plications (10). Follow-up was up to 22 months in the laparo-
laparoscopic approach is the learning curve. The technique scopic group and 58 months in the open series. The
requires not only laparoscopic expertise but also experience complication rate for the laparoscopic group was 12% (five
with intracorporeal suturing and tying. patients) while the open group had 11% (four patients). N o
Chap t e r 130: Lap aroscop ic Ad re nale ctomy 859
significant difference in pain-free rates between both groups the morbidity due to a large flank incision. The increased
was observed (laparoscopic 62% , open 60% ). O bjective suc- availability of laparoscopic training and robot-assisted tech-
cess was based on radiographic findings. Radiologic failure nology has led to acceptable procedure times. M oreover,
was observed in one patient in the laparoscopic group (within longer follow-up has shown durable success rates comparable
24 hours after the stent was removed) and in two patients in to open surgery.
the open group.
Gettman et al. (11) reported the first robot-assisted laparo-
scopic pyeloplasty series in six patients and compared them to Co mp licat io ns
a control group of six standard laparoscopic pyeloplasties.
O perative time and suturing time were significantly decreased All complications of abdominal laparoscopy are possible, and
in the robotic group and the objective success rate was 100% . injury to adjacent organs should be considered when the clini-
A recent multi-institutional series from several hospitals in cal situation is deteriorating. The most common complications
N ew York City included 35 patients, with mean operative are usually due to persistence of urinary leak or urinoma. The
time of 216 minutes and suture time of 63 minutes (12). M ean possibility of urinoma requiring revision of drains can be mini-
hospital stay was 2.9 days, and objective success rates were mized with vigilant placement at the time of surgery. M ost con-
likewise excellent (94% ) with mean follow-up of 7.9 months. trolled urinary leaks can be managed as an outpatient with
Laparoscopic pyeloplasty is a feasible but technically de- continued suction drainage with or without a Foley catheter.
manding procedure. This surgical technique maintains the ad- M ost will close with time. Failure to drain the urine or uri-
vantages of open reconstruction of the UPJ while decreasing noma requires either percutaneous or surgical drainage.
References
1. Schuessler WW, Grune M T, Tecuanhuey LV, et al. Laparoscopic dismem- 8. Jarrett TW, Chan DY, Charambura TC, et al. Laparoscopic pyeloplasty:
bered pyeloplasty. J Urol 1993;150:1795–1799. the first 100 cases. J Urol 2002;167:1253–1256.
2. N otley RG, Beaugie JM . The long-term follow-up of Anderson-H ynes 9. Soulié M , Salomon L, Patard JJ, et al. Extraperitoneal laparoscopic pyelo-
pyeloplasty for hydronephrosis. Br J Urol 1973;45:464–467. plasty: a multicenter study of 55 procedures. J Urol 2001;166:48–50.
3. Persky L, Krause JR, Boltuch RL. Initial complications and late results in 10. Bauer JJ, Bishoff JT, M oore RG, et al. Laparoscopic versus open pyelo-
dismembered pyeloplasty. J Urol 1977;118:162–165. plasty: assessment of objective and subjective outcome. J Urol 1999;
4. Dimarco DS, Gettman M T, M cGee SM , et al. Long-term success of ante- 163:692–695.
grade endopyelotomy compared with pyeloplasty at a single institution. 11. Gettman M , Peschel R, N eururer R, et al. A comparison of laparoscopic
J Endourol 2006;20:707–712. pyeloplasty performed with the da Vinci robotic system versus standard la-
5. M otola JA, Badlani GH , Smith AD. Results of 221 consecutive endopyelo- paroscopic techniques: initial clinical results. Eur Urol 2002;42:453–458.
tomies: an eight-year follow-up. J Urol 1993;149:453–456. 12. Palese M , Stifelman M , M unver R, et al. Robot-assisted laparoscopic dis-
6. N akada SY, Johnson M . Ureteropelvic junction obstruction: retrograde membered pyeloplasty: a combined experience. J Endourol 2005;19(3):
endopyelotomy. Urol Clin N orth A m 2000;27:677–684. 382–386.
7. Adams JB, Schulam PG, M oore RG, et al. N ew laparoscopic suturing
device: initial clinical experience. Urology 1995;46:242–245.
CHAPTER 130 ■ LAPARO SCO PIC ADRENALECTO MY

ARVIN K. GEO RGE AND LO UIS R. KAVO USSI
Since Gagner et al. first described laparoscopic adrenalec- the adrenal gland, has lent itself ideally to the laparoscopic
tomy in 1992, this approach has become the preferred removal of lesions.
technique in the surgical management of most adrenal lesions
(1). Laparoscopic adrenalectomy demonstrates the classical
benefits of minimally invasive surgery, with multiple studies INDICATIO NS
supporting reduction in postoperative pain, analgesia require-
ments, and postoperative morbidity with equivalent func- Laparoscopic adrenalectomy is a definitive surgical treat-
tional outcome when compared with traditional open ment modality for the broad spectrum of adrenal disease.
surgery. Advances in minimally invasive surgical techniques It has been proven safe and effective in the management of
have generated the development of multiple approaches to benign functioning and nonfunctioning adrenal conditions as
adrenalectomy, including transperitoneal, retroperitoneal, well as the majority of malignant neoplasms (Table 130.1).
transthoracic/transdiaphragmatic, and most recently robot- As surgeon experience has increased, the contraindications
assisted surgery. The benign nature of the majority of adrenal to the laparoscopic approach have decreased. In the hands of
disease, combined with the deep retroperitoneal location of a proficient and practiced surgeon, contraindications have
TA B LE 1 3 0 . 1
DIAGNO SIS
IN DICATION S FOR LAPAROSCOPIC
ADREN ALECTOMY Evaluation generally begins with serum and urine chemistry to
distinguish between functioning and nonfunctioning tumors.
Benign Malignant M ore specific investigations, combined with the clinical pre-
Primary aldosteronism Adrenocortical carcinoma sentation, assist in isolation of a specific pathology when pre-
(adenoma/hyperplasia) sent (Table 130.3). Imaging with computerized tomography
Cushing disease or Cushing Solitary adrenal metastases (CT) or magnetic resonance imaging (M RI) is an integral step
adenoma in preoperative assessment, as it provides detailed characteri-
Pheochromocytoma zation of adrenal lesions. The presence of significant retroperi-
Adrenal cyst toneal and periadrenal fat allows for ready identification of
M yelolipoma the gland. CT may help delineate malignant versus benign
Incidentaloma/adenoma lesions based on their attenuation characteristics, with accu-
with 3 cm of growth over racy approaching 90% in suspected adrenal disease. M RI has
time with serial imaging a reported sensitivity and specificity of 89% and 99% , respec-
tively, with adenomas exhibiting a lipid-rich composition in
distinction to the lipid-depleted nature of nonadenomatous le-
sions. Intraoperative ultrasound can elicit detailed informa-
tion regarding internal acoustic appearance, tumor size, extent
TA B LE 1 3 0 . 2 of invasion if present, and adjacent anatomy. Its use is a de-
fined element in adrenal-sparing surgery and can assist in
CON TRAIN DICATION S TO LAPAROSCOPIC cases where it is difficult to distinguish the periadrenal fat
ADREN ALECTOMY from the gland proper. Progress in imaging techniques and
General their interpretation has increased diagnostic accuracy and they
are an essential adjunct in determining diagnosis, operability,
Poor cardiopulmonary
status and surgical approach.
Uncorrected coagulopathy
Specific
R elative contraindications A bsolute contraindications
ALTERNATIVE THERAPY
Tumor size 6 cm Tumor with local invasion
Alternative treatment for adrenal lesions include con-
O besity Tumor with venous ventional open surgery via a transabdominal or retroperi-
Previous abdominal/ thrombus toneal approach, radiofrequency ablation (RFA), and
retroperitoneal surgery Regional nodal cryoablation (2).
involvement RFA provokes local ion agitation and heat, inducing coag-
M alignant/uncontrolled ulative tissue necrosis. In one recent study M ayo-Smith and
pheochromocytoma Dupuy (3) demonstrated the successful treatment of hormon-
ally active tumors and small (5 cm) solitary adrenal metas-
tases/adrenocortical carcinoma. RFA’s use is currently limited
to patients who are not surgical candidates. M unver et al. (4)
become relative, and the advantages of minimally invasive described the first case of cryoablation as an adrenal-sparing
techniques have afforded urologists the opportunity of a procedure for hyperaldosteronism, with subsequent reduction
more aggressive approach in treatment (Table 130.2). in the need of antihypertensives postoperatively. RFA and
TA B LE 1 3 0 . 3
DIAGN OSIS OF ADREN AL LESION S
Primary aldosteronism Plasma aldosterone concentration (PAC) 15 ng/dL

Plasma renin activity (PRA) 1 ng/mL/hr
Aldosterone-to-renin ratio 20–30 (PAC:PRA)
Sodium loading with 24-hour urine aldosterone 12 g/24 hr
Adrenal vein sampling with lateralizing ratio 5
Cushing syndrome 24-hour urine free cortisol
Low-/high-dose dexamethasone suppression with cortisol 5 g/dL
Plasma ACTH level 50 pg/mL is ACTH -dependent
Pheochromocytoma 24 hour serum/urine catecholamines
Plasma fractionated metanephrines
131 I methiodylbenzylguanidine (M IBG)/octreotide scintigraphy
Radiologic imaging with CT/M RI is essential in the diagnosis of all adrenal lesions.
adrenal cryoablation show potential as less invasive surgical preoperative management of pheochromocytomas requires
alternatives for small lesions and adrenal-sparing procedures special consideration, as inadequate blockade of circulating
in patients who are not ideal surgical candidates (4). The cur- catecholamines can trigger hypertensive crises secondary to
rent experience as described in the literature is limited and fur- anesthesia or intraoperative manipulation. Patients should
ther evaluation of such alternative therapies is needed. receive 14 days of blockade with phenoxybenzamine hy-
drochloride titrated to control blood pressure. Additional
blockade may be indicated if arrhythmias persist or prior
treatment proves insufficient.
SURGICAL TECHNIQ UES A mechanical bowel preparation is recommended the night
The transperitoneal approach is preferred by most surgeons prior to surgery. Parenteral intravenous antibiotic prophylaxis
due to the greater working space and familiarity of anatomic is given prior to incision. Invasive monitoring via arterial lines
landmarks. Retroperitoneoscopic adrenalectomy is generally and central venous lines is performed as indicated. A urinary
considered by the more experienced surgeon but may prove Foley catheter allows for bladder decompression and intraop-
useful in patients with adhesions and/or obesity. Thoracoscopic erative urine output assessment. Pneumatic compression
adrenalectomy was described by Gill et al. (5) for the treat- stockings are placed on the lower extremities bilaterally to
ment of select patients with adrenal pathology and significant help prevent deep venous thrombosis.
abdominal and retroperitoneal scarring from previous surgery
through access via the virgin thoracic cavity and transdi-
aphragmatic approach. The introduction of robotic technol- Transp e rit o ne al Lap aro sco p ic
ogy in the minimally invasive arena has proven to be a Ad re nale ct o my
successful alternative to other surgeries with specific benefits.
Robotic systems aid in eliminating surgeon fatigue, tremor The patient is placed in the 45-degree modified flank position
and provide a three-dimensional visualization of the operative and secured with silk tape; all bony pressure points are
field. H owever, they represent a more costly option to the padded prior to the initial incision. The ipsilateral arm can be
healthcare system and additional training by the surgeon. A folded across the chest or placed in an arm rest (Fig. 130.1).
prospective trial of laparoscopic versus robot-assisted adrena- Three or four ports may be used for laparoscopic instru-
lectomies failed to show significant benefit in the latter (6). mentation. Initial access is obtained at the lateral margin of
The study demonstrated that robot-assisted adrenalectomy is the ipsilateral rectus at the level of the umbilicus. A Veress
a feasible alternative to standard laparoscopic surgery with ap- needle is inserted and with CO 2 insufflation, intra-abdominal
propriate robotic experience. Further studies of robotic pressure is increased to 20 mm H g. This is replaced with a
adrenalectomies are needed to show functional advantage or 12-mm laparoscopic port into which a 30-degree lens laparo-
demonstrate cost-effectiveness. Ultimately the choice of surgi- scope is introduced. The remaining trocars are placed under
cal technique is dependent on surgeon experience, the patient’s direct vision at the ipsilateral rectus and costal margin, and
past surgical history, and preoperative findings. anterior axillary line and costal margin. An additional 2-mm
port just below the xiphoid process allows for use of locking
graspers that assist with cephalad retraction of the liver on the
Pre o p e rat ive Co nsid e rat io ns right side (Fig. 130.2). Pneumoperitoneum can be subsequently
reduced to 15 mm H g for the remainder of the operation.
Prior to operative intervention, metabolic abnormalities as-
sociated with hormonally active tumors must be addressed
to optimize the patient for surgery. H ypertension and hy- Transp e rit o ne al Le ft Ad re nale ct o my
pokalemia seen with aldosteronomas are managed with
spironolactone. The patient should be maintained normo- Adrenal exposure begins with incising the line of Toldt with
glycemic with cortisol-secreting adenomas, and stress-dose endoscopic scissors/electrocautery, which allows for medial
steroid administration must occur perioperatively. The mobilization of the splenic flexure and descending colon
FIGURE 130.1 Laparoscopic transperitoneal adrenalectomy. Patient is positioned in the modified or full
flank position for transperitoneal and retroperitoneal approaches respectively. All bony pressure points
are adequately cushioned and the patient is secured in position with silk tape.
5 mm phrenic artery to the adrenal. Larger vessels may be clipped

and transected or coagulated with the harmonic scalpel. The
10/12 mm
adrenal gland is freed from its lateral and inferior attachments
Additional 2 mm
with gentle inferior traction on the kidney, at which point
renal artery branches to the adrenal can been seen and con-
trolled (Fig. 130.6). The adrenal gland and periadrenal fat
are then placed in a laparoscopic retrieval bag and delivered
through the largest port site (Fig. 130.7). The surgical field is
examined at 5 mm H g for adequate hemostasis. Finally, the
fascial layer of the 12-mm port site is repaired with ab-
sorbable suture and laparoscopic exit is completed in stan-
dard fashion.
Transp e rit o ne al Rig ht Ad re nale ct o my

Initial exposure of the adrenal gland begins with cephalad ele-
vation of the liver, which may be completed with a fan retractor
or self-retaining locking graspers. The peritoneum is incised at
the upper pole of the kidney, close to the liver edge, and the
FIGURE 130.2 Laparoscopic transperitoneal adrenalectomy. The pri-
peritoneotomy is extended medially toward the inferior vena
mary port site is located at the lateral margin of the ipsilateral rectus
muscle at the level of the umbilicus. Secondary ports are placed in the cava. At this stage the adrenal gland should be readily visible
anterior axillary line/ipsilateral rectus near the costal margin. An aux- and retracted laterally to expose the renal vein (Fig. 130.8). It is
iliary port may be necessary at the xiphoid for retraction of the liver clipped proximally and distally with two clips on the caval side
on the right side, as illustrated. and divided. Dissection is completed with lateral retraction and
elevation of the adrenal to allow mobilization of its superior,
(Fig. 130.3). The splenocolic and lienorenal ligaments are di- medial, and inferior attachments. Careful control of supplying
vided and the spleen is mobilized medially to expose the vessels is achieved with hemostatic clips or the harmonic
adrenal in the retroperitoneal space (Fig. 130.4). The fascia of scalpel. The free specimen is then placed in a laparoscopic re-
Gerota is opened at the upper pole of the kidney and the peri- trieval bag and delivered through the largest port site. The final
adrenal fat is visualized. Dissection is continued to develop the steps are completed as described with the left side.
plane between the tail of the pancreas and the renal hilum.
The adrenal vein is identified emptying into the renal vein. The
adrenal vein is clipped and divided with a minimum of two Re t ro p e rit o ne al Lap aro sco p ic
clips on the medial aspect (Fig. 130.5). Early ligation prevents Ad re nale ct o my
systemic insult of catecholamines associated with adrenal ma-
nipulation and limits the potential for tumor micrometastases. The patient is positioned in the lateral decubitus position, sta-
Superiorly, care is taken to control contributions of the inferior bilized with an inflatable beanbag, and secured and protected
Line of Toldt
Spleen
FIGURE 130.3 Transperitoneal left

adrenalectomy. Initial exposure be-
Descending colon gins with incising the white line of
Toldt with endoscopic scissors/elec-
trocautery, which allows for gravity-
assisted medial mobilization of the
splenic flexure and descending colon.
Lienocolic
ligaments
Adrenal gland
Spleen
Left kidney
FIGURE 130.4 Transperitoneal left adrenalectomy. The lienocolic and lienorenal ligaments are divided
to expose the adrenal in the retroperitoneal space.
as described for the transperitoneal approach. The table is into the retroperitoneum and inflated to 800 cc. The dilator
flexed to maximize the operative working space. may then be repositioned more cephalad and reinflated to en-
A 12-mm transverse skin incision is made at the tip of the able access/vision between the posterior adrenal outside the
twelfth rib. The flank muscles are split until the thoracolum- fascia of Gerota and the diaphragm (Fig. 130.10). The dilator
bar fascia can be palpated (Fig. 130.9). The fascia is opened is replaced with a balloon-tipped trocar and sealed against the
and a finger is inserted to allow digital dissection and to de- abdominal wall, and CO 2 pneumoretroperitoneum is created
velop the retroperitoneal space. A balloon dilator is introduced to 15 mm H g. Under direct laparoscopic visualization with a
Adrenal gland
Spleen Left kidney
FIGURE 130.5 Transperitoneal left

Adrenal vein adrenalectomy. The left adrenal vein
is ligated with two clips on the side of
the renal vein and sharply divided.
Adrenal gland Liver

Adrenal gland
Spleen
Right kidney
FIGURE 130.6 Transperitoneal left adrenalectomy. The avascular

plane between the adrenal and renal upper pole is developed, and care
is taken to control the arterial contributions from the aorta, renal, and
inferior phrenic arteries.
FIGURE 130.8 Transperitoneal right adrenalectomy. After identifica-
tion of the renal hilum, superior dissection along the inferior vena
cava will demonstrate the short, horizontally lying adrenal vein.
Adrenal gland 30-degree lens laparoscope, an additional port is placed above

the iliac crest in the midaxillary line. The final port is placed
Spleen at the inferior border of the twelfth rib where it meets the
paraspinal musculature. The anatomic landmarks are identified
to ensure localization of the adrenal before mobilization is be-
gun. These include the psoas muscle posteriorly, the fascia of
Gerota anteriorly, and the diaphragm superiorly (Fig. 130.11).
O n the left side the pancreas lies medially, whereas in the right
it is the liver. Pneumoretroperitoneum is subsequently main-
tained at 12 mm H g for the remainder of the operation.
Re t ro p e rit o ne o sco p ic Le ft Ad re nale ct o my

An initial 1.5-cm incision is made transversely along the fascia
FIGURE 130.7 Transperitoneal left adrenalectomy. The freed speci- of Gerota toward the renal upper pole with hook cautery. The
men is placed in a laparoscopic retrieval bag and removed via the pri- perirenal fat is cleaned from the adjacent structures. The plane
mary port site.
between the upper pole and adrenal gland is identified and
developed with superior retraction of the adrenal and inferior
5 mm
10/12 mm
FIGURE 130.9 Laparoscopic retro-

peritoneal adrenalectomy. Primary port
placement is at the tip of the twelfth rib.
Additional ports are placed under direct
laparoscopic vision in the midaxillary
line above the iliac crest and the inferior
border of the twelfth rib, where it meets
the paraspinal musculature.
Dilating balloon
Kidney Iliac crest
A. B.
FIGURE 130.10. Laparoscopic retroperitoneal adrenalectomy. A balloon dilator is inserted into the
retroperitoneum and inflated to 800 cc. It may be repositioned superiorly and reinflated to maximize ex-
posure and working space before creation of CO 2 pneumoretroperitoneum.
Anterior Anterior
Adrenal gland Adrenal gland
Right kidney Left kidney
Psoas muscle Psoas muscle
Right renal vein Right renal artery Left renal vein Left renal artery
Posterior Posterior
FIGURE 130.11. Laparoscopic retroperitoneal adrenalectomy. Prior to incision of the fascia of Gerota,
identification of the anatomic landmarks confirms adequate localization and access to the adrenal. O n
the right the liver lies medially, whereas on the left it is the tail of the pancreas.
retraction of the kidney. Dissection is continued medially toward phrenic vessels, which may obscure the operative field if not
the renal hilum, and exposure of the left renal vein facilitates controlled appropriately. Aortic branches arising medially are
isolation of the adrenal vein arising from the inferomedial controlled in a similar fashion with the harmonic scalpel or
border of the gland. The adrenal vein is clip-ligated with two hemostatic clips. The anterior surface of the adrenal is mobi-
clips on the side of the renal vein and divided. The adrenal is lized from the overlying peritoneum, and the free specimen
dissected free from the psoas posteriorly and the diaphragm can then be placed in a laparoscopic retrieval bag for removal
superiorly with ligation of adrenal branches of the inferior via the primary port site.
There are several clinical benefits of performing laparo-

Re t ro p e rit o ne o sco p ic Rig ht scopic versus open adrenalectomy. Assalia and Gagner (9)
Ad re nale ct o my demonstrated reduced blood loss (154 versus 309 mL), com-
plication rate (10.9% versus 35.8% ), and hospital stay (2.9
Initial access in retroperitoneal right adrenalectomy is similar versus 7.2 days) when comparing laparoscopic and open surg-
to the left side. After incision of the fascia of Gerota and clear- eries. Additionally this study demonstrated that laparoscopic
ance of perirenal fat, the vena cava is readily visualized. surgery utilized less analgesia and had improved cosmesis.
Dissection is continued superiorly along the cava until the These key characteristics translate into increased patient satis-
adrenal vein is encountered. The adrenal vein draining from faction as compared to open surgery. O perative times for la-
the posteromedial portion of the gland is shorter and more paroscopic adrenalectomy are generally longer; this is largely
horizontal than its left-sided counterpart and consequently dependent on surgeon experience and has been shown to equi-
should be approached with caution to avoid tearing. The vein librate with increased number of cases completed (10). The
is ligated and divided as previously described. The adrenal is transperitoneal approach is more often employed by urolo-
then freed from its remaining attachments with meticulous gists due to familiarity with laparoscopic technique and
control of multiple supplying vessels from the aorta, renal anatomic landmarks. A prospective randomized study by
hilum, and inferior phrenic artery. Adrenalectomy is then Rubenstein et al. (11) showed no significant disparity in peri-
completed as described on the left side. operative morbidity or operative time, emphasizing that the
choice of laparoscopic approach lies primarily with the sur-
geon’s comfort with the procedure coupled with the clinical
characteristics of the individual case.
O UTCO MES
N umerous studies have illustrated the dafety and efficacy of Co mp licat io ns
Endoscopic adrenal surgery. Laparoscopic surgery has pro-
duced excellent outcomes in hormonally active lesions. The largest meta-analysis of complications in laparoscopic
Adrenalectomy for aldosteronomas effectively reduces blood and open adrenalectomy, by Brunt (12), reported overall com-
pressure in the majority of patients, with long-term cure in plication rates of 10.9% and 25.2% , respectively. Bleeding was
33% to 60% of patients. Patients with subclinical Cushing the most common complication associated with laparoscopic
syndrome showed improvement in glucose control, blood surgery. O rgan injury, including splenic injury requiring
pressure, and obesity following laparoscopic adrenalectomy. splenectomy and pancreatic, diaphragmatic, and large bowel
Initial concerns regarding laparoscopic treatment of pheo- injury, was also decreased. The greatest reduction in morbidity
chromocytoma and complications which have potential to in- was seen in the incidence of wound (0.6% versus 3.1% ), pul-
crease catecholamine release including pneumoperitoneum monary, and infectious complications. Thromboembolic phe-
have been dismissed; one study even described a reduction in nomena were predominant in obese patients and those with
intraoperative hypertensive events (35% versus 63% ) has prolonged operative times. The mean conversion rate to open
been described (7). Controversy also exists regarding the surgery was 3.6% ; conversion was most often secondary to in-
laparoscopic treatment of adrenal malignancy. The increased traoperative bleeding, although large tumor size, adhesions,
incidence of malignant tumors 6 cm requires careful consid- and malignancy with local invasion were also commonly cited
eration in surgical approach. Small organ-confined lesions reasons. The mean combined mortality rate for laparoscopic
( 6 cm in size) are amenable to laparoscopic excision, but adrenalectomy in an analysis of 2,550 cases was 0.2% , and
case reports in the literature have even described the feasibility though slightly less than open surgery, the difference has not
of radical adrenalectomy with en bloc adrenal vein tumor proven significant. Patients undergoing adrenalectomy for
thrombectomy. The current role of laparoscopic adrenalec- hormonally active tumors must be followed carefully postop-
tomy must be tailored to each individual patient without com- eratively, as contralateral adrenal suppression can result in
promising patient safety and ensuring optimal surgical metabolic derangements requiring replacement of electrolytes,
technique with minimal complications (8). mineralocorticoids, or glucocorticoids.
References
1. Gagner M , Lacroix A, Bolté E. Laparoscopic adrenalectomy in Cushing’s 7. Toniato A, Boschin IM , O pocher G, et al. Is the laparoscopic adrenalectomy
syndrome and pheochromocytoma. N Engl J M ed 1992;327:1033. for pheochromocytoma the best treatment? Surgery 2007;141(6):723–727.
2. M icali M , Peluso G, De Stefani S, et al. Laparascopic adrenal surgery: new 8. Cobb WS, Kercher KW, Sing RF, et al. Laparoscopic adrenalectomy for
frontiers. J Endourol 2005;19(3):272–278. malignancy. A m J Surg 2005;189:405-411.
3. M ayo-Smith WW, Dupuy DE. Adrenal neoplasms: CT-guided radiofre- 9. Assalia A, Gagner M . Laparoscopic adrenalectomy. Br J Surg 2004;91:
quency ablation-preliminary results. R adiology 2004;231(1):225–230. 1259–1274.
4. M unver R, Del Pizzo JJ, Sosa RE. Adrenal-preserving minimally invasive 10. Vargas H I, Kavoussi LR, Bartlett DL, et al. Laparoscopic adrenalectomy: a
surgery: the role of laparascopic partial adrenalectomy, cryosurgery, and ra- new standard of care. Urology 1997;49:673–678.
diofrequency ablation of the adrenal gland. Curr Urol Rep 2003;4:87–92. 11. Rubinstein M , Gill IS, Aron M , et al. Prospective, randomized comparison
5. Gill IS, M eraney AM , Thomas JC, et al. Thoracoscopic transdiaphragmatic of transperitoneal versus retroperitoneal laparoscopic adrenalectomy.
adrenalectomy: the initial experience. J Urol 2001;165:1875–1881. J Urol 2005;174:442–445.
6. M orino M , Beninca G, Giraudo G, et al. Robot-assisted vs. laparoscopic 12. Brunt LM . The positive impact of laparoscopic adrenalectomy on compli-
adrenalectomy. Surg Endosc 2004;18:1742–1746. cations of adrenal surgery. Surg Endosc 2002;16:252–257.
CHAPTER 131 ■ LAPARO SCO PIC AND
RO BO TIC RADICAL PRO STATECTO MY
CO STAS D. LALLAS AND EDO UARD J. TRABULSI
The driving force behind the development of a minimally in-

vasive radical prostatectomy was certainly patient satisfaction DIAGNO SIS
and quality of life. Accordingly, the first laparoscopic radical
prostatectomy (LRP) was performed in 1991 (1). Although Adenocarcinoma of the prostate is typically diagnosed
the benefits to the patient were readily apparent for LRP, the through routine medical screening, which includes a digital
technical challenges and difficult learning curve were also rectal examination and a test for serum prostate specific anti-
broadly recognized, paving the way for a facilitator for this gen (PSA). An abnormal digital rectal examination, elevated PSA
procedure: robotic technology. level, or PSA velocity should prompt a transrectal ultrasound–
Robotically assisted laparoscopic (radical) prostatectomy guided biopsy of the prostate. O nce the diagnosis of cancer is
(RALP) has made an enormous, albeit controversial, impact made, the patient should undergo appropriate staging preop-
on the treatment of prostate cancer. Although different robotic erative counseling, and treatment options should be thor-
platforms have been described in the literature, the da Vinci oughly discussed.
Surgical System (Intuitive Surgical, Sunnydale, CA) has A computerized tomography of the abdomen and pelvis
quickly monopolized the market. Like other robotic surgical and a radioisotope bone scan are traditionally performed on
systems, the da Vinci system operates in a master-slave rela- all patients who are evaluated for prostate cancer. These stud-
tionship with the surgeon, with motions being translated in a ies have been questioned for patients with low-risk features.
filtered, nonparadoxical fashion. The surgeon sits remotely M RI with endorectal coil is performed in some centers for lo-
from the surgical field but does require an assistant at the bed- cal staging but is not widely used.
side for instrument changes, retraction, and suction. The setup
is ergonometric, and unlike with the physically taxing LRP, INDICATIO NS FO R SURGERY
most surgeons can easily accomplish multiple RALPs in a
given day. O ther direct advantages of RALP over LRP include M en with clinically localized prostate cancer who choose sur-
more degrees of freedom of motion, enabled by wristed instru- gical treatment are candidates for this procedure. All patients
ments, as well as nonparadoxical versus paradoxical move- who are evaluated for prostate cancer at our institution
ments and three-dimensional versus planar, two-dimensional are evaluated in a multidisciplinary setting with urologic
visualization. To date, four different generations of the da oncology, radiation oncology, and medical oncology (2).
Vinci system have been released, with the latter three having Preoperative tumor parameters are inputted into the Kattan
four arms (as opposed to three) and the latest model boasting preoperative nomogram to evaluate for risk of extracapsular
telestration, which aids in teaching and proctoring, and high- extension, seminal vesicle invasion, and metastatic disease.
definition visualization. O nce patients have chosen RALP, they are medically cleared if
O pponents to RALP consistently cite the market- and deemed necessary and their bladder outlet and ureteral orifice
patient-driven acceptance of this procedure without any long- location is evaluated by cystoscopy. Patients are excluded if
term follow-up. Additionally, some maintain that the lack of their life expectancy is 10 years or their American Society of
tactile feedback afforded by the minimally invasive prostatec- Anesthesiologists (ASA) score is 4, indicating that they have
tomy is disadvantageous when evaluating for induration, severe comorbidities. M orbid obesity (Body M ass Index 45)
palpable nodules, and delineation of the proximity or involve- is a relative contraindication, as these patients may not be able
ment of the neurovascular bundles by cancer. Finally, several to tolerate Trendelenburg positioning with pneumoperi-
believe that the cost of RALP places it at a distinct disadvan- toneum for an extended period of time. Previous radiotherapy
tage relative to other, more traditional approaches. At our infor pelvic malignancy is a contraindication for RALP or LRP.
stitution, we have completely converted over from LRP, the Prior intra-abdominal surgery is not a contraindication, but
last of which we performed 3 years ago, to RALP, with the rel- patients who have undergone prior pelvic procedures or ex-
ative ease and consistently positive patient outcomes of the tensive intra-abdominal surgery are counseled that their likeli-
latter procedure being the main reasons. Since RALP stands hood of conversion to standard open radical retropubic
firmly on the shoulders of LRP, we describe both procedures, prostatectomy is elevated. N erve-sparing or non–nerve-sparing
with particular focus on our technique and published out- technique is based on the surgeon’s preference, which is based
comes of RALP. on the clinical parameters of the individual patient.
867
ALTERNATIVE THERAPY
Treatment options for clinically localized prostate cancer in-
clude observation, brachytherapy, external beam or proton ra-
diation therapy, cryotherapy, and radical prostatectomy.
Radical prostatectomy includes retropubic, perineal, laparo-
scopic, and robotically assisted laparoscopy.
SURGICAL TECHNIQ UE
The steps involved in the pure laparoscopic and robotically as-
sisted radical prostatectomy employing the more popular
transperitoneal approach are quite similar. O ne of the most
significant differences is the use of robotic instrumentation
versus the use of standard laparoscopic instruments. Critical
to the success of these procedures is a well-trained and coordi-
nated operating room staff with familiarity of the instruments
and devices needed for these complex procedures.
O n the day prior to surgery, patients are placed on a clear
liquid diet and are given a gentle mechanical bowel prepara-
tion with one bottle of oral magnesium citrate as well as a FIGURE 131.2 Port placement for laparoscopic prostatectomy. Five
Fleet enema per rectum. Two large-bore intravenous lines and ports are utilized.
an arterial line, if necessary, are placed. A broad-spectrum
intravenous antibiotic (cephalosporin such as Ancef) is given
1 hour prior to incision, and all patients receive Lovenox 40 mg
subcutaneously prior to surgery for venous thromboembolism
(VTE) prophylaxis. O nce intubated in the operating room, pa-
tients are placed in a low lithotomy position using Allen stir-
rups. The arms are tucked at the patient’s side using 3-in. cloth
tape, and the patient’s shoulders, elbows, wrists, and neck are
padded (Fig. 131.1). An orogastric tube is placed, and the
anesthesia staff are also instructed to limit the intravenous flu-
ids given, to avoid overresuscitation. Typically, we recom-
mend 7 mL per kg intravenous fluids per hour for the entire
case (approximately 500 mL per hour or 1.0 to 1.5 L per case.
Lap aro sco p ic Pro st at e ct o my (LRP)

After a pneumoperitoneum has been established, five trocars
are placed. The first 12-mm trocar is placed at the level of the
A
umbilicus (Fig. 131.2). This can be placed by using an optical
port, employing an open technique, or gently applying pres-
sure to the 12-mm trocar and introducing it into the abdomen.
We use a 0-degree lens throughout the procedure and inspect
the abdominal cavity after placement of our first trocar. O ur
next two 12-mm trocars are placed just lateral to the rectus
on the right-hand and left-hand sides, respectively. These
12-mm trocars are placed 2 to 4 cm inferior to the umbilicus.
Finally, two 5-mm trocars are placed off the anterior iliac
spine on the right-hand and left-hand sides, respectively. Thus
a total of five ports are utilized throughout the procedure
(Fig. 131.1). The patient is now placed into extreme
Trendelenburg position.
If available, the Aesop (Computer M otion, Inc., Goleta,
CA) is placed on the right side of the table and controls the 0-
degree laparoscope and camera through the umbilical port.
O therwise the assistant holds the camera. The assistant stands
B on the right side and the surgeon stands on the left. A fan re-
FIGURE 131.1 A and B: Proper positioning and padding for laparo- tractor is useful in the right 12-mm port to retract the bowel.
scopic or robotically assisted prostatectomy. The cul-de-sac and the vas deferens are identified on both the
Chap t e r 131: Lap aroscop ic and Rob otic Rad ical Prostate ctomy 869
Bladder skeletonized bilaterally down to the seminal vesicles. The vas is

pulled anteriorly with a grasper through the 5-mm right-sided
port (Fig. 131.4), and the assistant uses the irrigator-aspirator
through the 12-mm right-sided port. The seminal vesicles are
dissected using a combination of sharp and blunt dissection to
their tips (Fig. 131.4). With retraction on the seminal vesicles,
the Denonvilliers fascia is incised to create a plane between the
prostate and rectum. The perirectal adipose tissue should be
clearly identified. A rectal bougie can be manipulated to con-
firm the exact location of the rectum.
The bladder is filled with 200 cc of saline, and using the
bipolar cautery and laparoscopic scissors through the left-
sided ports, the lateral aspect of the bladder is dissected off the
anterior abdominal wall by connecting the points between the
incised median and umbilical ligaments and the lateral peri-
toneal reflection (Fig. 131.5). The bladder is emptied and now
has been mobilized. The endopelvic fascia is incised bilater-
ally, the fatty tissue overlying the prostate is dissected with
bipolar cautery, and the superficial dorsal vein is cauterized
Colon using the bipolar forceps (Fig. 131.5). The puboprostatic liga-
ments are sharply divided. The deep dorsal vein complex is
ligated with a CT-1 needle loaded with 0 Vicryl suture. The
needle is slightly straightened before being passed through the
right 12-mm port on a laparoscopic needle driver. A laparo-
scopic grasper is used from the left 12-mm port site. The dor-
FIGURE 131.3 Scoring the peritoneum along the vas deferens into sal vein complex is identified, and a suture is passed around it
the cul-de-sac. with a figure-of-eight suture passed anterior to the urethra
and posterior to this deep venous dorsal complex (Fig. 131.6).
right- and left-hand sides at the level of the internal ring. The The suture is tied intracorporeally, and the dorsal vein com-
peritoneum is scored in a line along the vas deferens down to plex is secured but not divided at this point.
the cul-de-sac (Fig. 131.3). This incision is carried down to the The prostatic base is divided from the bladder neck and is a
second peritoneal fold in the cul-de-sac, and the vas deferens is more challenging part of the procedure. A coagulating scissor
Vas deferens
Seminal
vescicles
Colon
FIGURE 131.4 The vas deferens is lifted anteriorly by the

assistant and the seminal vesicles are dissected free.
Bladder FIGURE 131.5 The bladder is freed off the anterior

abdominal wall by incising the umbilical ligaments and
lateral attachments.
or curved harmonic scalpel can be used. The assistant retracts

the bladder from the right 12-mm port and, using a 5-mm
irrigator-aspirator, outlines the Foley catheter balloon down
toward the level of the prostatic base. The prostatic base is
divided from the bladder neck (Fig. 131.7). The detrusor
fibers are often seen, and bladder is entered and the Foley
identified. The balloon is deflated, and the assistant retracts
the Foley catheter cephalad using a grasper from the right
5-mm port site (Fig. 131.8). The posterior bladder mucosa is
scored and carried through the posterior surface of the
prostate (Fig. 131.9). The seminal vesicles and vas previously
dissected are brought anteriorly and grasped by the assistant
using the laparoscopic 5-mm grasper.
If a nerve-sparing approach is attempted, a right-angled
dissector with sharp dissection as needed can be used through
FIGURE 131.6 The endopelvic fascia is incised and the dorsal vein the right 12-mm port site to free the neurovascular bundle on
complex identified. The deep dorsal vein complex is ligated using a 0 the lateral surface of the prostate prior to dividing the dorsal
Vicryl suture on a CT-1 needle. venous complex. The assistant lifts the seminal vesicle anteriorly,
and the vascular pedicle can be divided with the harmonic
FIGURE 131.7 Division of the anterior bladder neck and

prostatic base using the harmonic scalpel.
FIGURE 131.9 Division of the posterior bladder neck and identifica-

tion of the previously dissected seminal vesicles and vas deferens.
incised, and the prostate can be rolled to both the left- and
right-hand sides to facilitate the exposure. The specimen
FIGURE 131.8 The Foley catheter is grasped and the dissection of the having been placed into the left lower quadrant, the pelvis is
bladder neck continues posteriorly. irrigated and any bleeding controlled.
If there are concerns about the location or injury to the
rectum, a rectal bougie is useful. If necessary, a 20Fr Foley
scalpel or locking clips. Sharp dissection frees the remaining catheter can be placed in the rectum and the pelvis filled with
reflection of endopelvic fascia of the prostate laterally (Fig. saline. Air is injected into the Foley catheter to identify any
131.10). injury.
With a non–nerve-sparing technique, the assistant grasps The bladder neck is identified, and the ureteral orifices are
the seminal vesicle, lifting anteriorly, and the surgeon divides observed for efflux of urine. A urethral sound is placed, and
the entire vascular pedicle and neurovascular bundle with the apical margins may be sent for frozen section if needed. The
harmonic scalpel, working toward the apex of the prostate. urethrovesical anastomosis is begun (Fig. 131.12). Bladder
The prostate is attached posteriorly by the rectourethralis neck reconstruction can be performed anteriorly using a 2-0
muscle and the urethra. The dorsal vein complex is sharply in- Vicryl suture on a UR-6 needle, and the bladder neck can be
cised and the apical notch of the prostate developed. The ante- reconstructed by placing a suture through the anterior portion
rior urethra is now sharply divided, exposing the catheter, of the bladder neck in interrupted fashion.
which is retracted, and the posterior urethra is divided Using a 2-0 Vicryl suture on a UR-6 needle through the
(Fig. 131.11). The assistant provides cephalad retraction by right 12-mm port, the anastomosis is begun by placing a stitch
grasping the base of the prostate in order to allow maximum through the posterior bladder neck from outside the bladder.
exposure of the urethra. The rectourethralis muscle is sharply The needle is grasped, and, using the right 12-mm port, the
FIGURE 131.10 Sharply dissecting the neurovascular

bundle of the lateral aspect of the prostate.
18Fr to 20Fr Foley catheter is placed under direct visualiza-

tion prior to completing the anastomosis, and the final ante-
rior sutures are tied intracorporeally. The bladder is tested by
instilling 60 cc of saline, and if a leak is detected, another su-
ture can be placed. Generally seven to eight sutures are used
for the urethrovesical anastomosis. The right 5-mm port site
incision is extended to accompany a 10-mm Endocatch device
(Auto Suture, N orwalk, CT). After the Endocatch is deployed,
the accompanying needles and prostate with accompanying
seminal vesicles and vas deference are delivered into the bag.
The bag is closed and brought through the right 5-mm port
site. The external oblique fascia and muscle are incised with
electrocautery and the bag removed. This small incision is
closed, the abdomen is reinsufflated, and then a Jackson-Pratt
drain is placed through the left 5-mm port. Ports are closed in
standard fashion and the Foley is left to gravity.
FIGURE 131.11 Division of the anterior urethra. Ro b o t ically Assist e d Lap aro sco p ic
Pro st at e ct o my (RALP)
Pneumoperitoneum is established up to a pressure of 15 mm
H g in a midline supraumbilical location, and a 12-mm trocar
is placed at this site. After blind placement of the midline cam-
era trocar (12 mm), an additional 12-mm, three 8-mm, and
one 5-mm port are placed under direct vision in the patient’s
lower abdomen and pelvis. The initial 12-mm port is always
placed 1 to 2 cm cephalad to the umbilicus. Two 8-mm ro-
botic working ports are placed at the apex of a triangle that is
10 cm lateral to the top of the umbilicus and 15 cm from the
pubic symphysis. The third 8-mm robotic working port is
placed at least 8 cm laterally from the one on the patient’s left-
hand side, and it must be at least two fingerbreadths off of the
anterior superior iliac spine. The 12-mm assistant port is
placed at least 8 cm laterally from the 8-mm robotic working
port on the patient’s right-hand side, and it must be at least
two fingerbreadths off of the anterior superior iliac spine, mir-
roring the 8-mm port on the contralateral side. The 5-mm as-
sistant port is placed 5 to 6 cm directly cephalad to the 8-mm
FIGURE 131.12 Urethral anastomosis beginning with the posterior
sutures. robotic working port (Fig. 131.13). Prior to docking the ro-
bot, the patient is placed in a steep Trendelenburg position.
O nce the robot is docked, instruments are next inserted
posterior stitch on the right side of the urethra is placed. N ext, into the patient and connected to the robot (Fig. 131.14). Both
a second suture is introduced through the left 12-mm port, a monopolar and a bipolar electrocautery instrument are used
and, in similar fashion, the posterior bladder neck is sutured concomitantly, and the fourth arm (if available on the robot)
outside-in followed by the posterior urethra inside-out. Thus is equipped with a grasping forceps. A 0-degree lens is used for
the knots are tied on the outside of the bladder. Alternatively, the entire procedure.
the two-armed suture technique as described for robotic The initial report of LRP described an intraperitoneal ap-
prostatectomy using two 3-0 M onocryl sutures tied together proach, with the surgeon first dissecting the vasa deferentia
can be used (see below). The table is reflexed and the bladder and seminal vesicles through the pouch of Douglas (Fig.
is reapproximated to the urethra. The posterior bladder can 131.15). N ext attention was turned anteriorly, incising the
be grasped from the right side and held in place while the su- urachus and medial umbilical ligaments to enter the space of
tures are tied intracorporeally. Retzius, and proceeding in an antegrade fashion (Fig. 131.16)
The anastomosis is completed. Using the 2-0 Vicryl suture, (1). This intraperitoneal approach was advocated by surgeons
the sutures are placed circumferentially from either the right at the M ontsouris Institute in Paris, who also used an initial
or left 12-mm port as determined by the patient’s anatomy. dissection posterior to the bladder (3). As experience with
O ccasionally, it is necessary to place a back-handed suture LRP grew, the posterior approach was abandoned by some
from the left-sided 12-mm port. The sutures are tied intracor- surgeons who discovered that the vasa and seminal vesicles
poreally. The remaining anterior sutures can be placed. could be adequately dissected once the bladder neck had been
Typically, the left-sided anterior bladder neck and the urethral divided. O nce surgeons were comfortable with dissection of
sutures are placed through the right 12-mm port and vice the vasa and seminal vesicles at this point of the operation,
versa. This allows more effective needle positioning. A new some turned to an extraperitoneal approach.
B
FIGURE 131.14 Port placement for RALP once the robot has been
docked.
B
FIGURE 131.13 A: Port position for RALP: 12-mm ports for camera
and assistant, 8-mm robot port for the three robotic arms; and 5-mm
port for the assistant. B: Ports in position. N ote the line indicating the
pubis and midline for orientation and placement of the ports.
FIGURE 131.15 Posterior dissection. FIGURE 131.16 Beginning intraperitoneal anterior dissection.
The extraperitoneal approach in LRP or RALP places the anatomic merit, given the fact that the endoscopic prostatec-
urologic surgeon who is used to the anatomy of the radical tomy (both LRP and RALP) is an antegrade procedure, and
retropubic prostatectomy (RRP) in familiar territory. In this theoretically the endopelvic fascia, which is intimately
procedure, the preperitoneal space is first bluntly dissected related to the apex of the prostate, does not have to be vio-
with either a finger or a balloon prior to insufflation. By stay- lated until the end of the procedure. Additionally, this
ing out of the peritoneum altogether, theoretical risks such as approach may have positive implications on nerve sparing,
small bowel injury from trocar placement, traction, or elec- given the fact that a healthy amount of tissue is left over the
trocautery are avoided, and the concerns of bowel stasis or neurovascular bundle, limiting the possibility of thermal
ileus due to a urine leak are minimized. Additionally, this ap- spread and traction injury.
proach would have a hypothetical advantage in those patients There are situations, however, when early dissection of the
who have undergone prior intra-abdominal surgery. H ead-to- endopelvic fascia can be beneficial. Especially for the novice,
head comparisons between the two approaches show little after the endopelvic fascia has been divided, the lateral margin
difference with regard to intraoperative and postoperative of the prostate becomes evident. This can be of particular use
parameters, and it is our opinion that the approach ultimately when identifying the margins of the bladder neck, which is one
should be determined by the surgeon. At the Jefferson of the more challenging portions of the RALP. Additionally, in
Kimmel Cancer Center, we use exclusively an intraperitoneal a patient with a large pubic osteophyte or an anteriorly posi-
approach and, as we become more comfortable with the pro- tioned prostate, incision of the endopelvic fascia and the adja-
cedure, have extended our patient selection to include those cent puboprostatic ligaments can drop the prostate into the
individuals who have undergone prior intra-abdominal pro- pelvis, facilitating the apical dissection and the vesicourethral
cedures; these patients currently represent 5% of our overall anastomosis.
experience. We have had no small bowel injuries in these pa-
tients, nor have we had to convert any of these procedures to
an open radical retropubic prostatectomy. Residents and fel- Blad d e r Ne ck Disse ct io n
lows actively participate in the robotic program.
Antegrade division of the bladder neck in LRP and RALP
remains one of the most frustrating parts of this procedure for
Po st e rio r Disse ct io n trainers and trainees alike. At Jefferson, there are several
points that we reinforce with our residents and fellows in or-
The original description of the LRP and subsequent RALP der to guide them through this part of the procedure:
included dissection posterior to the bladder to identify the
vasa deferentia and seminal vesicles prior to dissecting the 1. Use the posterior dissection for those patients in whom
bladder off of the anterior wall (1,3). As noted, this approach the posterior bladder neck may pose a problem (see
has become less popular with RALP as the procedure has above).
evolved. H owever, this initial posterior approach remains an 2. Always incise the endopelvic fascia in order to visualize the
important innovation and can be utilized in patients in whom lateral borders of the prostate as they form the bladder
the posterior dissection of the bladder neck may pose a chal- neck.
lenge. Such patients are those who have had a prior trans- 3. Place the bladder on tension using either the fourth arm or
urethral prostatectomy (TRUP) or other procedure for benign an assistant to see where the bladder drapes over the
disease, those with a very large ( 80 g) or small ( 20 g) prostate (the prostatovesical junction).
prostate, or those with a large median lobe. By dissecting pos- 4. H ave the assistant “ bounce” the Foley balloon on the
terior to the seminal structures and exposing the posterior sur- bladder neck to help identify the area for initial dissection.
face of the prostate, the rectum is released posteriorly, thus 5. Limit the use of electrocautery during dissection so that
minimizing one of the main concerns of this part of the proce- the tissue planes do not become obscured by char.
dure. In fact, we regularly teach this approach to our trainees 6. After incising the anterior bladder neck to reveal the
so that it will be in their armamentarium for a RALP. Foley, deflate the balloon and raise the catheter anteri-
orly with either the fourth arm of the da Vinci or an
assistant.
7. When initially dividing the posterior bladder neck, incise
Incising t he End o p e lvic Fascia full thickness through the detrusor muscle.
Another derivation of the radical retropubic prostatectomy In patients whose biopsy indicates minimal disease at the
that has been incorporated into both the LRP and RALP is prostatic base, a bladder neck–preserving procedure can be
incision of the endopelvic fascia prior to ligating the dorsal performed by peeling the bladder off of the prostate anteriorly
venous complex and dissecting the neurovascular bundle (an anterior peel) (Fig. 131.17). The resulting bladder neck
and apex of the prostate. With regard to this portion of the can be well approximated to the distal urethra for the anasto-
procedure, Stolzenburg et al. (4) have recently reported on mosis. Additionally, this method can be employed to dissect
1,300 cases of a completely extrafascial endoscopic prosta- out a median lobe and still keep the bladder neck diameter
tectomy, with intermediate follow-up showing oncologic adequate for the anastomosis without having to taper it. In
and functional results equivalent to most laparoscopic and contrast, patients at high risk for involvement of the base of
robotic large series. In this technique, the endopelvic fascia the prostate with cancer should have a wide excision of the
is left intact and dissected with the neurovascular bundle. bladder neck with circumferential frozen section biopsies
The dorsal venous complex is taken at the end of the proce- when indicated. In this subset of patients, reconstruction of
dure, prior to dividing the urethra. This method has the bladder neck is necessary (Fig. 131.18).
FIGURE 131.19 Athermal nerve sparing. N V B, neurovascular bundle.
FIGURE 131.17 Demonstration of anterior peel.

prostate. M enon contends that men who undergo the preser-
vation of these nerves, in addition to the traditionally
described N VB, are at a distinct advantage when being evalu-
ated for long-term erectile function after nerve-sparing RALP.
To set up the N VB for dissection, we first incise the poste-
rior Denovilliers fascia to expose perirectal fat and the poste-
rior surface of the prostate. To preserve the N VB, we adhere
to traditional tenets: avoidance of electrocautery and mini-
mization of traction (Fig. 131.19). Vascular pedicles are thus
controlled in an athermal fashion. O ne tool that we have
found useful for this is the robotic H em-O -Lock (Weck,
Research Triangle Park, N C) clip applier. This instrument con-
tains Endowrist technology and therefore can articulate in the
pelvis with 6 degrees of freedom, allowing the surgeon to
place clips at difficult angles and minimizing the importance
of the assistant (Fig. 131.20).
In contrast to nerve-sparing procedures, there has been some
controversy as to the efficacy of minimally invasive prostatec-
FIGURE 131.18 Dissection posterior to the median lobe.
tomy in treating patients with high-risk disease. By stratifying
our patients according to the D’Amico classification (7), we pre-
operatively counsel those patients who are high risk to undergo
Disse ct io n o f t he Vasa a wide prostate dissection, including removing all tissue en-
De fe re nt ia and Se minal Ve sicle s veloped by the lateral prostatic fascia, including bilateral NVB,
and taking a wide bladder neck, as well as an extended lymph
Recent evidence from cadaveric dissections has demonstrated node dissection at the end of the procedure. In such patients,
the intimate proximity of the tips of the seminal vesicles and vascular pedicles are controlled with bipolar electrocautery.
the pelvic plexus ganglions that feed the neurovascular bun-
dles (N VB) (5). This report stated that the N VB may be par-
ticularly vulnerable to thermal, electrical, and/or crush injury
during dissection of these structures. For this reason, we be-
lieve it prudent to avoid excessive traction or gratuitous elec-
trocautery during dissection in this region.
Pro st at ic Pe d icle s and

Ne uro vascular Bund le s
Since the advent of minimally invasive prostatectomy, there
has been a new interest in the anatomy and, more importantly,
the preservation of the N VB. O ne of the more pioneering
of these innovations is the contention by M enon et al. (6) that
the nerves responsible for erections are not only located at the
posterolateral border of the prostate but also course through
the lateral prostatic fascia toward the anterior surface of the FIGURE 131.20 Placing robotic H em-O -Lock clip.
Do rsal Ve no us
Co mp le x and Dist al Ure t hra
We routinely ligate the dorsal venous complex (DVC) at the
end of the procedure, after releasing the N VB and prior to di-
viding the last attachments, the distal urethra and rec-
tourethralis muscle. A 2-0 Vicryl suture on an SH needle is
used to ligate the DVC in either a simple or figure-of-eight
fashion. We changed our timing of ligating the DVC from the
beginning until the end of the procedure for two principal rea-
sons. The first is the fact that RALP is an antegrade, as op-
posed to retrograde, procedure. We believe that one of the
reasons urologists are quick to ligate the DVC early is a
holdover from the retropubic procedure. Since converting to
the end of the case, we have not seen an increase in blood loss
or transfusion rates. O ur most important reason for switch- FIGURE 131.22 Dividing the distal urethra.
ing, however, was that we wanted to change our apical dissec-
tion in the hope of minimizing positive apical margins in our
that we believe has improved our margin rate. Fortunately,
pT2 specimens. After reviewing the margin status of our first
this modification has not compromised continence rates in our
130 cases, we noted a positive margin rate of 14% on pT2
patient population.
specimens (15 out of 109), with the majority of those being
After the remaining attachments are divided, the prostate is
apical (60% ). We analyzed a video of these cases and noted
placed in a laparoscopic entrapment bag and brought to the
that when we ligated the DVC at the beginning of the proce-
extreme lateral aspect of the field.
dure, the apex of the prostate was not completely mobile, and
we frequently placed the suture too proximal and close to the
prostate. When we divided the DVC, at the end of the case, we
were precariously close to the prostatic apex, leading to a pos-
Pe lvic Lymp h No d e Disse ct io n
itive margin. By ligating the DVC at the end of the case, we All patients who undergo a RALP at our institution also re-
have already separated all other attachments, making the ceive a bilateral pelvic lymph node dissection. We feel that
prostate extremely mobile, and we can clearly visualize the this represents a sound oncologic practice with prognostic
DVC in its entirety as we place the suture (Fig. 131.21). and treatment implications that is standard for RRP but has
Additionally, we divide both puboprostatic ligaments, thus been deleted by many robotic surgeons. It adds approxi-
functionally lengthening the DVC so that the suture can be set mately 5 to 10 minutes to the operation, and morbidity is
more distally. With these adjustments, we have realized a sig- minimal. O ur dissection is within the obturator fossa, using
nificant decrease in our overall pT2 positive margin rate and the external iliac vein as our superior landmark with the ob-
our incidence of positive apical margins. turator nerve posterior and the pelvic sidewall lateral. We
After dividing the DVC, the last attachments are the distal routinely take the Cloquet node and leave accessory obtura-
urethra and rectourethralis muscle. We leave a Foley catheter tor vessels intact. For high-risk patients, we extend the supe-
in place when approaching the distal urethra to help identify it rior limit of our dissection to the bifurcation of the common
better. When dividing the urethra, we do so without electro- iliac artery. All vessels are neatly skeletonized. We have found
cautery and enter it approximately 2 to 3 mm distal to the that the exceptional visualization provided by minimally in-
apex of the prostate (Fig. 131.22). This technique prevents us vasive technology clearly identifies the anatomy and lym-
from inadvertently entering the apex, another modification phatic tissue in this area. All lymphatics are secured with
bipolar electrocautery. We have had no symptomatic lympho-
celes and no complications related to this portion of the pro-
cedure. Each lymphatic packet is sent separately to surgical
pathology for permanent analysis.
Ve sico ure t hral Anast o mo sis

The one portion of RALP in which there appears to be relative
uniformity in technique is the vesicourethral anastomosis.
Prior to the anastomosis, the bladder neck is tapered to ap-
proximate the diameter of the urethral aperture using 2-0
Vicryl suture in figure-of-eight knots. We prefer to perform
this anteriorly and posteriorly, administering indigo carmine
intravenously to help identify the ureteral orifices.
Like others, we have adopted the Van Velthoven one-knot,
two-suture method (8). We use two 3-0 M onocryl sutures,
FIGURE 131.21 Placing the dorsal venous complex (DVC) suture. one dyed and one undyed, on SH needles and tie them to one
Re t rie val o f Sp e cime n

and Co mp le t io n o f Surg e ry
A suction drain is placed under direct vision at the end of the
procedure through the fourth arm port. The robot is next un-
docked and the specimen bag delivered through the camera
port, which is opened at the fascial level as needed. This inci-
sion is closed in three layers, and all other incisions are closed
with a subcuticular suture.
Po st o p e rat ive Care and Discharg e

Patients are sent to the recovery room on intravenous fluids,
FIGURE 131.23 Starting the anastomosis at the bladder neck. antibiotics, and pain medication. A 1-L fluid bolus is typically
given intravenously at the end of the procedure because of the
fluid restriction during the case. Patients are encouraged to am-
another, leaving 7 in. of suture length on each. Both sutures bulate the night of surgery and are started on oral liquids the
are started on the bladder neck at 5 o’clock (Fig. 131.23), and first night after surgery. During the first postoperative day, pa-
one is placed to the side while the other is run from urethra to tients receive a clear liquid diet for breakfast and regular food
bladder neck in a counterclockwise direction in an in-to-out, for lunch, and they are aggressively ambulated. The majority
out-to-in fashion, respectively, to provide mucosal apposi- of patients are then discharged after lunch on the first postop-
tion. The assistant slides the catheter along the distal urethra erative day. The catheter is removed the week after surgery
and provides perineal pressure as needed. After three suture (7 to 10 days), depending on the quality of the anastomosis.
throws are placed in the bladder neck, the bladder is para-
chuted down with constant tension on the suture to seat the
posterior plate of the anastomosis. At this point, the catheter O UTCO MES
should be able to passively slide into the bladder. This suture
is then continued in a running fashion to the 12 o’clock posi- Perioperative, oncologic, and functional outcomes of large
tion, and then is held on tension by the fourth arm or by the ( 200 patients) published series of RALP are listed in Tables
assistant. The other suture is next run in a mirror-image fash- 131.1 to 131.4. In each table, the benchmark LRP experience
ion clockwise around the bladder neck. The ultimate bladder of the first 1,000 patients treated at the M ontsouris institute is
neck stitch on both sides is placed in-to-out to end on the out- also included (3,9). (Table 131-4 includes potency data from
side of the bladder. Ten to 11 passes are made in total. Prior this group which were reported in a separate manuscript). The
to tying the two sutures together, a fresh 18Fr Foley catheter major advantage of minimally invasive prostatectomy in the
is placed under direct vision (Fig. 131.24) and 10 cc of sterile perioperative period appears to be a decreased blood loss,
water placed in the balloon. This technique is notably differ- which is directly or indirectly related to most of the parameters
ent from what has been described with the LRP, in which in- listed in Table 131.1. Decreased blood loss to the patient leads
terrupted sutures are typically placed. M any believe that the to fewer transfusions and shorter convalescence, but decreased
colossal challenge and frustration of intracorporeal suturing blood loss to the surgeon means improved visualization in a
and tying deep in the pelvis is the reason that many surgeons relatively dry field, which can have short- and long-term impli-
have converted to RALP. The anastomosis is tested after tying cations on outcomes. Long-term data, however, remain lacking
the sutures using 180 cc saline to ensure its integrity. with regard to this procedure, although early indicators, such
as surgical margin status, are promising. The ultimate role of
RALP in the surgical treatment of prostate cancer and its rela-
tionship to the standard of care remain to be seen, although the
early impact of this technology has been significant.
CO MPLICATIO NS
Reported complications and rates for both LRP and RALP are
similar and range from 1.5% to -20.0% in large series for major
perioperative complications (e.g., hemorrhage, bowel injury,
urine leak, and deep venous thrombosis/pulmonary embolus/
myocardial infarction (DVT/PE/MI)) (9,10). At our institution,
we have found our complication rates to be similar to what has
been reported for RALP in the literature. Of note, of our first
400 pure robotic cases, we have documented 5 cases of hemor-
rhage requiring blood transfusion (1.3% ), 3 bowel injuries
FIGURE 131.24 Visualization of catheter before final completion of (0.8% ), 6 clinical urine leaks (1.5% ), and 3 DVTs (0.8% ), for
urethral anastomosis. an overall major perioperative complication rate of 3.5% .
TA B LE 1 3 1 . 1
PERIOPERATIVE PARAMETERS OF PUBLISHED LAPAROSCOPIC PROSTATECTOMY SERIES
Trans- Conver- Compli- Catheter

# (Type) Or time fusion sion cation In-hospital removal
Author Year of cases (min) EBL (ml) rate (%) rate (%) rate (%) stay (days) (days)
M enon (11) 2003 200 (RALP) 160 153 0 0 8 1.2 7
Patel (12) 2007 500 (RALP) 130 10–130 0 0 1.5 1.0 6.9
Bhandari (13) 2005 300 (RALP) 177 109 0 0 5.7 1.2 6.9
H u (14) 2006 322 (RALP) 186 250 1.6 0.6 17.2 nr nr
Joseph (15) 2006 325 (RALP) 130 196 1 0 9.6 1 nr
M enon (16) 2007 2,652 (RALP) 154 142 0 nr 2.3 1.14 nr
Guillonneau (3) 2000 1,000 (LRP) 239 402 10 5.8 3 nr 6.6
EBL, estimated blood loss; RALP, robotically assisted laparoscopic prostatectomy; LRP, laparoscopic radical prostatectomy; nr, not reported.
Adapted from Ficarra V, et al. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. Eur Urol 2007;51(1):45–55;
discussion 56.
TA B LE 1 3 1 . 2
SURGICAL MARGIN STATUS OF PUBLISHED ROBOTIC LAPAROSCOPIC PROSTATECTOMY SERIES
Pathologic stage (%) PSM Rate (%)

# (Type) Overall
Author Year of cases pT2 pT3a pT3b PSM Rate (%) pT2 pT3a pT3b
M enon (11) 2003 200 (RALP) 86.8 6.8 6.3 6 nr nr nr

Patel (12) 2007 500 (RALP) 88 15 5 9.4 2.5 23 46
Joseph (15) 2006 325(RALP) 81 14 5 13 9.9 37.1 273%
M enon (16) 2007 2,652 (LRP) 77.7 16.9 5.1 13 nr nr nr
Guillonneau (3) 2000 1,000 (RALP) nr nr nr 19.2 15.5 30 32
RALP: robotically assisted laparoscopic prostatectomy; LRP, laparoscopic radical prostatectomy; nr, not reported.
discussion 56.
TA B LE 1 3 1 . 3
CON TIN EN CE DATA OF PUBLISHED LAPAROSCOPIC PROSTATECTOMY SERIES
Continence rates (%)

# (Type) Method of data
Author Year of cases Continence definition collection 3-mo 6-mo 12-mo
M enon (11) 2003 200 (RALP) 0–1 pad (“ safety pad” ) Interview nr 96 nr
Patel (12) 2007 500 (RALP) N o pad Q uestionnaire 89 95 97
Joseph (15) 2006 325 (RALP) N o pad Q uestionnaire 93 96 nr
M enon (16) 2007 2,652 (LRP) 0–1 pad (“ safety pad” ) Interview nr nr 95.2
Guillonneau (3) 2000 1,000 (RALP) 0–1 pad (“ safety pad” ) Interview/ nr nr 88.3
questionaire
PSM , positive surgical margin; RALP, robotically assisted laparoscopic prostatectomy; nr, not reported.
discussion 56.
Chap t e r 132: Lap aroscop ic Manag e me nt of Lymp ho ce le s 879
TA B LE 1 3 1 . 4
POTEN CY DATA OF PUBLISHED LAPAROSCOPIC PROSTATECTOMY SERIES
Potency rates (%)

# (Type) Potency
Author Year of cases definition Data collection 3-mo 6-mo 12-mo
M enon (11) 2003 200 (RALP) Sexual intercourse IIEF-5 25 ( 60 yr) 64 ( 60 yr)
10 ( 60 yr) 38 ( 60 yr)
Patel (12) 2007 200 (RALP) Sexual intercourse IIEF-5 85
Joseph (15) 2006 325 (RALP) IIEF 21 IIEF-5 46
M enon (16) 2007 884 (RALP) Sexual intercourse SH IM 70 a
Guillonneau (17) 2005 550 (LRP) Sexual intercourse 66
a 100% of patients reported to achieve potency at 48 months of follow-up.
RALP, robotically assisted laparoscopic prostatectomy; IIEF, international index of erectile function; SH IM , sexual health inventory for men;
LRP, laparoscopic radical prostatectomy.
Adapted from Ficarra V, et al. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. Eur Urol 2007;51(1):45–55; discussion 56.
References
1. Schuessler WW, et al. Laparoscopic radical prostatectomy: initial short- 9. Trabulsi EJ, Guillonneau B. Laparoscopic radical prostatectomy. J Urol
term experience. Urology 1997;50(6):854–857. 2005;173(4):1072–1079.
2. Valicenti RK, Gomella LG, El-Gabry EA, et al. The multidisciplinary clinic 10. Ficarra V, Cavalleri S, N ovara G, et al. Evidence from robot-assisted la-
approach to prostate cancer counseling and treatment. Sem in Urol O ncol paroscopic radical prostatectomy: a systematic review. Eur Urol 2007;
2000;18(3):188–191. 51(1):45–55; discussion 56.
3. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the 11. M enon M . Robotic radical retropubic prostatectomy. BJU Int 2003;91(3):
M ontsouris experience. J Urol 2000;163(2):418–422. 175–176.
4. Stolzenburg JU, Rabenalt R, Do M , et al. Endoscopic extraperitoneal radi- 12. Patel VR, Thaly R, Shah K. Robotic radical prostatectomy: outcomes of
cal prostatectomy: the University of Leipzig experience of 1,300 cases. 500 cases. BJU Int 2007;99(5):1109–1112.
W orld J Urol 2007; 25(1):45–51. 13. Bhandari A, M cIntire L, Kaul SA, et al. Perioperative complications of ro-
5. Tewari A, Peabody JO , Fischer M , et al. An operative and anatomic study botic radical prostatectomy after the learning curve. J Urol 2005;
to help in nerve sparing during laparoscopic and robotic radical prostatec- 174(3):915–918.
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6. Savera AT, Kaul S, Badani K, et al. Robotic radical prostatectomy with the paroscopic and robotic assisted laparoscopic radical prostatectomy. J Urol
“ Veil of Aphrodite” technique: histologic evidence of enhanced nerve spar- 2006;175(2):541–546; discussion 546.
ing. Eur Urol 2006;49(6):1065–1073; discussion 1073–1074. 15. Joseph JV, Rosenbaum R, M adeb R, et al. Robotic extraperitoneal radical
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Urol 2001;166(6):2185–2188. 16. M enon M , Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy:
8. Van Velthoven RF, Ahlering TE, Peltier A, et al. Technique for laparoscopic contemporary technique and analysis of results. Eur Urol 2007;51(3):648-
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550 procedures. Crit R ev O ncol H em atol 2002; 43:123–133.

MANAGEMENT O F LYMPHO CELES
SEAN P. HEDICAN AND STEPHEN Y. NAKADA
Lymphoceles are localized encapsulated collections of lym- Disruption of the lymphatics in the closed space of the pelvis
phatic fluid created by disruption of lymphatic vessels that can following limited extraperitoneal pelvic lymph node dissections
occur following renal transplantation or other procedures has also led to localized lymphoceles in patients being treated
during which lymphatic channels are transected in the pelvis for prostate cancer, with a reported incidence of 0.5 to 10%
or retroperitoneum. The incidence of asymptomatic lympho- (2,4,5). Significant contributing factors to the formation of the
celes following renal transplantation or combined kidney pan- lymphoceles include the administration of low-dose heparin (6),
creas transplantation has been reported to be as high as 20% prior radiation, presence of metastases, surgical technique, and
(1). Contributing factors in transplant patients include episodes the extent of the dissection (5). The majority of these pelvic
of rejection, cytomegalovirus infections, and post-transplanta- lymphoceles remain clinically asymptomatic. Lymphoceles have
tion reoperations (2,3). also been described following retroperitoneal procedures such
as nephrectomy, retroperitoneal lymph node dissections for

testis cancer, or aortic surgery.
DIAGNO SIS
Asymptomatic lymphoceles are usually discovered inciden-
tally at the time of renal allograft ultrasound (Fig. 132.1) or
computerized tomographic (CT) imaging of the abdomen and
pelvis (Fig. 132.2) performed for unrelated indications. They
appear as a single or septated chamber with H ounsfield unit
characteristics and echotexture consistent with fluid located in
the region of the renal allograft or adjacent to the iliac vessels.
These structures can be difficult to differentiate from a uri-
noma unless an ongoing urine leak can be documented via
contrast or radionuclide imaging. In the case of a urinoma, as-
piration and analysis of the fluid will demonstrate a creatinine
value elevated above corresponding serum values (7). The
creatinine value on the fluid aspirated from a lymphocele
will be equivalent to serum. H ematomas and abscesses usu- B
ally contain fluid with a higher echogenicity on ultrasound
FIGURE 132.1. Ultrasound images of a large lymphocele containing C

low echogenic fluid extending below and medial to the transplant
kidney. FIGURE 132.2. Computerized tomographic images demonstrating
the transplant kidney in the right lower quadrant and the inferior
and medial location of lymphocele A: N ote the close proximity of
the adjacent iliac vessels containing calcified atherosclerotic plaque.
B: Extension of the lymphocele at its greatest dimension and the
cephalad extent of the bladder appearing medially. C: Compression
of the lateral wall of the bladder by the medial extent of the
lymphocele.
examination, with an increased nonenhanced density on CT

imaging (8). The presence of signs and symptoms of an infec-
tion in association with a high-density fluid collection, often
with mild enhancement of thickened walls or surrounding tis-
sue stranding, usually denotes an abscess. The diagnosis is
confirmed and therapeutic intervention often begins with per-
cutaneous drainage or aspiration of purulent material (2).
The primary indication for a lymphocelectomy (surgical un-
roofing or marsupialization of a lymphocele) is symptoms re-
lated to its mass effect. The reported incidence of symptomatic
A lymphoceles following renal transplantation ranges from 3%
to 7% (9,10). Symptomatic lymphoceles after pelvic lym- the fascia. This approach was felt to be especially applicable
phadenectomy following radical retropubic prostatectomy are for lymphoceles in locations not readily accessible to
rare, and the majority remain asymptomatic and resolve spon- transperitoneal window creation. The catheters were removed
taneously. Symptoms necessitating surgical drainage and 6 months later, with no signs of recurrence after removal in
unroofing include labial, scrotal, or lower extremity swelling, two patients with at least 1 year of follow-up.
deep venous thrombosis with or without pulmonary em-
bolism, a sensation of pelvic fullness, and irritative voiding
complaints due to compressive effects on the bladder or rec- SURGICAL TECHNIQ UE
tum (5). Renal transplant dysfunction secondary to ureteral
obstruction with associated hydronephrosis versus direct com- Pre o p e rat ive Pre p arat io n
pressive effects on the allograft has also been reported. A re-
view of indications for surgery in transplant recipients Patients are placed on a clear liquid diet beginning at noon the
demonstrated that 69% were performed for local symptoms, day prior to their procedure and are also instructed to drink a
14% for graft dysfunction, and 17% for both (9). Ureteral bottle of magnesium citrate in an effort to cleanse the bowel.
obstruction following pelvic lymphadenectomy for prostate Decompression of the bowel aids in visualization during the
cancer is extremely rare (5). operation and improves the speed of bowel recovery. On call to
the operating room, the patient is administered a single dose of
an appropriate intravenous broad-spectrum antibiotic. Patients
ALTERNATIVE THERAPY on long-term steroid immunosuppressive therapy may require
supplemental stress dosing per the anesthesia team. Compressive
Prior to the first reported case of laparoscopic lymphocelec- knee or thigh-high stockings (TED hose) and sequential com-
tomy in 1991 by M cCullough et al. (11), the treatment of pression devices are applied to the lower extremities to reduce
choice for a symptomatic lymphocele was open transperi- the risk of deep venous thrombosis formation. Hair is removed
toneal marsupialization, with a reported complication rate of from the area of the operative field, including the pubic region
4% and a recurrence rate of 15% on review of 129 patients and lower abdomen, using an electric shear.
undergoing open lymphocelectomy (10). This method is still
utilized for complex lymphoceles that are multiseptated and
lying in a difficult-to-access lateroposterior or lateroinferior Pat ie nt Po sit io ning
position relative to the allograft. Lymphoceles located in these
locations have also been shown to be associated with a higher The operating table should be equipped with a kidney rest and
incidence of conversion from a laparoscopic to open surgery allow flexion/deflection and full Trendelenburg positioning. A
as a result (12). Infected lymphoceles requiring extensive evac- 3-inch foam pad mattress is placed on the operating table, fol-
uation and washout of purulent debris, excision of all septa- lowed by a full-size gel pad to aid in securing the patient. Prior
tions, and drain placement also support the use of an open to transferring the patient from the transport bed to the oper-
extraperitoneal approach (2,3). ating table, 70% isopropyl alcohol can be used to cleanse the
Similar to symptomatic renal cysts, aspiration of lymph back to remove body oils and debris to establish secure trac-
fluid alone via a percutaneous approach is associated with a tion between the patient and the gel pad without the use of
75% to 100% incidence of lymphocele recurrence. These re- shoulder bars, chest tape, or straps. Alternatively, any of the
sults are not significantly improved by insertion of a percuta- other aforementioned securing methods can be utilized.
neous drain. The use of sclerosing agents instilled into the Following intubation of the patient, an orogastric tube is in-
lymphocele cavity has been reported to increase the likelihood serted to decompress the stomach, and nitrous oxide should
of successful ablation to approximately 85% to 90% (3). be avoided to prevent bowel distention and to reduce the risk
Sclerosing agents vary depending upon the series, but the use of creating a combustible environment when electrocautery is
of alcohol, tetra- or doxycycline, povidone-iodine, and fibrin being utilized. The patient should be positioned with the um-
sealant have all been reported (3,13). It should be noted that bilicus at the region of the kidney rest to allow flexion of the
this treatment usually requires multiple instillations that can table with slight kidney rest elevation to increase the distance
last as long as 45 days (3). The use of this approach is con- between the umbilicus and the pubic symphysis, assisting in
traindicated for complex multiseptated lymphoceles due to in- spacing of the trocars.
complete drainage and inability to introduce sclerotic agent The Foley catheter should be inserted on the operative field
into all chambers (13). Sclerotic agents are also best avoided after preparing and draping to allow access for filling and de-
when the ureter contacts one of the walls of the lymphocele compressing the bladder, which may assist in localization of
due to the concern that the inflammatory response induced the lymphocele. M ale patients are placed supine on the oper-
could result in periureteral fibrosis and ultimate transplant ating table. Female patients should be positioned in low litho-
ureteral obstruction. Infected lymphoceles likewise should not tomy using Allen stirrups to allow adequate access to the
be treated with aspiration and sclerosis even when utilizing urethral meatus. Alternatively, slight frog-leg positioning can
antibiotic agents, as this can lead to persistence and even ag- be utilized in nonobese female patients. If the legs are not se-
gravation of the infection. cured in stirrups, tape can be placed across the upper thighs
Adani et al. (14) utilized an outpatient technique for drain- and a strap across the lower legs to secure them in position.
ing persistent lymphoceles into the peritoneal cavity in seven The arms are protected in eggcrate foam and tucked at the
patients via intraperitoneal placement of a two-cuff Tenckhoff sides using either a split draw sheet or Plexiglas arm sleds. When
dialysis catheter with the fenestrated end in the peritoneum arm sleds are utilized, care must be taken to avoid disruption
and the other end in the lymphocele cavity, with the body of of the securing Velcro on their insertion, as this holds the
the catheter tunneled subcutaneously with the cuff secured to 3-inch foam mattress in place and can lead to its dislodgement
and inadvertent patient movement on deep Trendelenburg po-

sitioning. Although it is rarely required, the security of the pa-
tient’s position should be tested in full Trendelenburg tilt prior
to preparation and draping. A wide surgical skin preparation
should be performed to include the genitals for sterile Foley
catheter insertion and adequate exposure to allow adequate
trocar spacing and conversion to an open operation if neces-
sary. A standard wide-aperture laparoscopic drape can be uti-
lized when patients are not placed in stirrups; otherwise,
standard cystoscopy legging and aperture drapes are utilized
after four-towel draping of the abdominoperineal region. The
aperture can be enlarged to give adequate exposure to the
lower abdomen.
Est ab lishing Pe rit o ne al Acce ss

and Tro car Co nfig urat io n
FIGURE 132.3. Recommended port configuration for right laparo-
Access to the peritoneum can be obtained utilizing a closed scopic lymphocelectomy. X , 10/12-mm port; O , 5-mm port; , alter-
native 5-mm port.
needle (Veress) puncture technique or an open direct vision
(i.e., H asson cannula) method. A 1-cm supraumbilical incision
is made through the skin and the underlying dermis using a
combination of scalpel and electrocautery incision for insertion The surgeon stands on the side opposite the lymphocele
of the initial port. If the lymphocele is extremely large, extend- and the assistant and scrub personnel stand on the ipsilateral
ing to or above the level of the umbilicus, this centrally located side across from the primary surgeon. The monitor and tower
port can be moved in a cephalad direction to ensure that the or boom arm containing the insufflation unit, light, and cam-
port enters approximately a hands-breadth above the upper era source are positioned at the foot of the patient. The patient
extent of the lymphocele. Transabdominal ultrasound can be is placed in Trendelenburg positioning to the extent necessary
used to assist in port placement or the extent of the lymphocele to liberate the bowel off the area of dissection, and the table is
estimated by counting CT scan slices above and below the um- airplaned slightly toward the operating surgeon.
bilicus to predict its location. The underlying soft tissues are
bluntly dissected down to fascia using a sharp clamp.
Initial pneumoperitoneum is created as described in Id e nt ificat io n o f t he Lymp ho ce le
Chapter 123. The insufflation pressure set point should be
placed at 15 mm H g, and once this pressure level is obtained, After release of any overlying bowel or omental adhesions to
a visual introducing trocar (e.g., O ptiview, Ethicon Endo- the lower quadrant of interest, the lymphocele can be identi-
Surgery, Cincinnati, O H ) is used to insert a 10/12-mm port via fied as a bluish-black pelvic structure if thin-walled. The over-
the previously made periumbilical incision. The 0-degree 10- all appearance can vary significantly, and when the wall is
mm laparoscope is inserted into the O ptiview and can be used thickened, differentiation from the bladder can be difficult
to visualize each layer of the abdominal wall as it is traversed (Fig. 132.4A). Depending upon its location, other surrounding
using a back-and-forth twisting motion until full entry into vital structures, such as the transplant or native ureter or iliac
the peritoneal cavity is confirmed. O nce the visual introducing vessels, can also be incorporated into one or more of the walls
port has been inserted, the 0-degree lens is exchanged for a 30- of the lymphocele. M ethods to assist in identification and dif-
degree lens to allow a greater range of visualization angles. ferentiation from the bladder have been described, including
Two additional working ports are then placed, adjusting distention followed by decompression of the bladder with
their position depending upon the location of the lymphocele. sterile saline. The bladder can also be filled with indigo
In general, a 5-mm working port is inserted a hands-breadth carmine or methylene blue–stained saline and a laparoscopic
down from the supraumbilical port just lateral to the midline aspirating needle can be inserted into the identified structure
on the side contralateral to the lymphocele. If the distance be- presumed to be the lymphocele (Fig. 132.4B). This is con-
tween the umbilicus and the pubic symphysis is sufficient to firmed to be the lymphocele if the aspirated fluid does not
allow placement of two ports separated by a hands-breadth contain blue-tinged fluid (15).
without entry into the bladder, the third port (5 mm) can be A similar but opposite method to assist in the identification
placed below the second port in the midline. This also requires of the lymphocele has also been described. This involves out-
that the lymphocele is not exceptionally large and that the pa- lining the lymphocele using transabdominal ultrasound and
tient is not morbidly obese (Body M ass Index 35). In gen- percutaneous needle puncture with aspiration followed by in-
eral, placement of this port a hands-breadth lateral to the jection of the lymphocele with dilute methylene blue–tinged
midline just below the level of the umbilicus on the side ipsi- saline. This results in staining of the walls of the lymphocele,
lateral to the lymphocele is preferred. In the standard trocar allowing confirmation of the structure prior to unroofing by
arrangement, a 10-mm port can be utilized to allow lateral laparoscopic needle aspiration with return of blue–tinged fluid
camera positioning if desired during the case (Fig. 132.3). (2,15). O nce the lymphocele is entered, the blue staining of the
Alternatively, a 5-mm port can be utilized if a 5-mm laparo- chamber assists in identification of its extent and the amount
scope is available. of unroofing required.
A C
B D
FIGURE 132.4. Laparoscopic view of right lower quadrant lymphocele adjacent to a renal transplant.
A: Thick-walled appearance making differentiation between the indigo carmine–containing bladder and
lymphocele difficult. B: Laparoscopic aspiration needle inserted into the lymphocele, yielding clear fluid.
C: Lymphocele unroofing begins utilizing an electrocautery hook. D: Final appearance of wide-mouthed
peritoneal aperture created in the lymphocele.
Excisio n o f t he Lymp ho ce le laparoscopic surgery, yet no ureteral injuries occurred (3). The
wall of the lymphocele can then be excised from the central in-
O nce the lymphocele is identified, cold or cautery shears, a cision to the edge of the thin region of the wall using the la-
cautery hook (Fig. 132.4C), or a harmonic scalpel can be utilized paroscopic instruments to ballot the area to help judge its
to unroof the lymphocele, incising through the area of the wall thickness and the likely involvement of surrounding structures.
that appears to be the thinnest portion of the structure in a di- The excision is then carried out circumferentially until the en-
rection parallel to the presumed course of the transplant ureter. tire exposed region of the lymphocele is excised (Fig. 132.4D).
After the initial incision, care should be taken to inspect the wall O nce the segments are excised, they can be removed via the
to make sure that structures such as the renal allograft ureter or 10/12-mm port or cut into strips prior to removal if they are too
pelvis, native ureter, or bladder are not injured in the process. In large to fit through the port. The specimen is visually inspected,
general, only the portion of the wall in contact with the peri- and if any concerning elements are identified, such as portions
toneum is excised, and any of the contained loculations are dis- of ureter, these can be confirmed via frozen section analysis, al-
rupted bluntly and the walls excised. Although stenting of the lowing intraoperative management. If the excised region of the
transplant ureter can be performed to help in its identification, lymphocele is small ( 4 cm) due to the presence of surrounding
this can be technically challenging. In a large multi-institutional vital structures, and this results in a deep-chambered cavity
retrospective study, 81 patients underwent laparoscopic marsu- with a narrow aperture, then consideration should be given for
pialization, and none of the ureters were stented prior to the placement of an omental wick.
(BUN ) and creatinine (Cr) testing are performed the morning

Place me nt o f O me nt al Wick following the operation. If significant lower extremity edema
or transplant ureteral obstruction occurred preoperatively due
H su et al. (3), in their large multi-institutional review of la-
to the lymphocele, then more careful postoperative electrolyte
paroscopic lymphocelectomy, reported that omental interposi-
and fluid management may be required.
tion was utilized in only 14% of the 81 reported cases and
Discharge criteria include toleration of a regular diet, pas-
“ was not considered to be an essential pre-requisite for long-
sage of flatus, and pain adequately controlled on oral analgesics.
term success.” It was the reported practice of the lead author
Typically patients are ready for discharge within 24 hours of the
of the study to utilize an omental tag only if it could be “ read-
procedure; however, the mean hospital stay in a large reported
ily transposed and affixed to the lymphocele window.” In the-
review series was 1.5 days (3).
ory, use of native vascularized tissues to maintain patency of
the unroofed portion of the lymphocele will facilitate contin-
ued patency and peritoneal drainage of the lymphatic fluids. O UTCO MES
The omental interposition graft is usually established using
the most distal tip of the omentum, which is isolated; if neces- In a multi-institutional study of 81 patients, H su et al. (3) noted
sary the omentum can be divided in a craniocaudad direction to a lymphocele recurrence rate of 6% over an average of 27
facilitate mobilization. M ajor vasculature should be left in months of follow-up after laparoscopic marsupialization. This
place, and typically extensive dissection to the margin of the compares favorably to the 0% to 15% recurrence rate follow-
stomach is not required. O nce the omentum can be readily af- ing open lymphocelectomy reported in the literature (10,15). In
fixed to one of the internal walls of the fenestrated lymphocele, a comparison of a group of patients treated with laparoscopic
several sutures on a small (e.g., RB-1) needle or tacking tita- lymphocelectomy to a contemporary group of patients treated
nium clips are placed to secure the tip of the mobilized omen- via an open approach, Gill et al. (2) reported a statistically sig-
tum near the base of the lymphocele. N eedles for laparoscopic nificant reduction in blood loss (34.6 versus 117.3 mL), more
suturing should be introduced and removed via one of the rapid resumption of oral intake (0.9 versus 2.5 days), shorter
10/12-mm trocars to prevent their entrapment in the valve hospital stay (2 versus 6.1 days), and more rapid convalescence
mechanism of the port. If the camera port is the only 10/12-mm (2.2 versus 6.9 weeks), respectively. A $7,400 reduction in total
trocar being utilized for the procedure, this may require switch- hospital costs has also been reported for laparoscopic versus
ing to a 5-mm laparoscope to use via one of the working ports open lymphocelectomy, largely due to the significant reduction
to allow needles to be introduced into the peritoneal cavity. in hospital stay (12). It is important to note that more contem-
In more complex cases of difficult-to-reach lymphoceles, porary case series would likely reflect trends toward shorter
where an omental wick may not be expected to maintain hospital stays for both of these approaches.
durable patency, laparoscopic marsupialization with place-
ment of peritoneal dialysis catheters cabled together has been
utilized to maintain continued lymphoperitoneal flow (16). Co mp licat io ns
The reported incidence of complications in one of the largest
Po st o p e rat ive Care series of laparoscopic lymphocelectomy was 5% intraopera-
tively and 4% postoperatively (3). This compares favorably to
The patient’s postoperative diet is advanced as tolerated and the 0% to 12% complication rate reported following open
the Foley catheter is removed once the patient is able to ambu- lymphocelectomy (2,12,15). O ne of the most frequently oc-
late. In male patients with a history of voiding dysfunction, curring intraoperative complications noted by M elvin et al.
the Foley catheter is left indwelling until the first postopera- (15) was division of the transplanted ureter, which occurred in
tive day, and several scanned postvoid residual volumes are 7% of their cases. Several methods have been employed to
evaluated following its removal to ensure adequate bladder prevent this complication, including ureteral stent placement
emptying. Intravenous pain medication is transitioned rapidly and insertion of a lighted fiberoptic stent.
to oral analgesics once the patient is tolerating clear liquids. The reported incidence of open conversion was shown to be
Laboratory studies are kept to a minimum and individualized 0% to 36% (12,15). Risk factors for conversion of a laparo-
depending upon the patient’s clinical condition. In general, he- scopic to an open approach include prior operations, multiple
moglobin/hematocrit levels as well as a blood urea nitrogen fluid collections, and unfavorable location of the lymphocele.
References
1. Doehn C, Fornara P, Fricke L, et al. Laparoscopic fenestration of post- 6. Catalona WJ, Kadmon D, Crane DB. Effects of mini-dose heparin on lym-
transplant lymphoceles. Surg Endosc 2002;16:690–695. phocele formation following extraperitoneal pelvic lymphadencectomy.
2. Gill IS, H odge EE, M unch LC, et al. Transperitoneal marsupialization of J Urol 1980;123:890–892.
lymphoceles: a comparison of laparoscopic and open techniques. J Urol 7. H amza A, Fischer K, Koch E, et al. Diagnostics and therapy of lymphoce-
1995;153:706–711. les after kidney transplantation. Transplant Proc 2006;38:701–706.
3. H su TH S, Gill IS, Grune M T, et al. Laparoscopic lymphocelectomy: a 8. Gazelle GS, M ueller PR. Abdominal abscess. Imaging and intervention.
multi-institutional analysis. J Urol 2000;163:1096–1099. R adiol Clin N orth A m 1994;32:913–932.
4. M cCullough DL, M cLaughlin AP, Gittes RF. M orbidity of pelvic lym- 9. Bailey SH , M one M C, H olman JM , et al. Laparoscopic treatment of post
phadenectomy and radical prostatectomy for prostate cancer. J Urol 1977; renal transplant lymphoceles. Surg Endosc 2003;17:1896–1899.
117:206–207. 10. Fuller TF, Kang SM , H irose R, et al. M anagement of lymphoceles after re-
5. Patel A. Complications of lymphadenectomy. In: Taneja SS, Smith RB, nal transplantation: laparoscopic versus open drainage. J Urol 2003;169:
Ehrlich RM , eds. Com plications of Urologic Surgery: Prevention and 2022–2025.
M anagem ent. 3rd ed. Philadelphia: WB Saunders, 2001:370–386.
Chap t e r 133: Lap aroscop ic Blad d e r Proce d ure s: Rad ical Cyste ctomy, Partial Cyste ctomy, Urachal Excision, Dive rticule ctomy 885
11. M cCullough CS, Soper N J, Clayman RV, et al. Laparoscopic drainage of a 14. Adani GL, Baccarani U, Risaliti A, et al. Treatment of recurrent sympto-
posttransplant lymphocele. Transplantation 1991;51:725–727. matic lymphocele after kidney transplantation with intraperitoneal
12. Gruessner RWG, Fasola C, Benedetti E, et al. Laparoscopic drainage of Tenckhoff catheter. Urology 2007;70:659–661.
lymphoceles after kidney transplantation: indications and limitations. 15. M elvin WS, Bumgardner GL, Davies EA, et al. The laparoscopic manage-
Surgery 1995;117:288–295. ment of post-transplant lymphocele. A critical review. Surg Endosc 1997;
13. Chin AI, Ragavendra N , H ilorne L, et al. Fibrin sealant sclerotherapy for 11:245–248.
treatment of lymphoceles following renal transplantation. J Urol 2003; 16. M atin SF, Gill IS. Laparoscopic marsupialization of the difficult lymphocele
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CHAPTER 133 ■ LAPARO SCO PIC BLADDER

PRO CEDURES: RADICAL CYSTECTO MY, PARTIAL
CYSTECTO MY, URACHAL EXCISIO N,
DIVERTICULECTO MY
SEBASTIEN CRO UZET, GEO RGES-PASCAL HABER, AND INDERBIR S. GILL
inflammatory pathology, fixation of the bladder to surround-

LAPARO SCO PIC RADICAL ing structures and pelvic wall on bimanual palpation, and
CYSTECTO MY uncorrected bleeding diathesis. M orbid obesity and previous
pelvic radiation can significantly complicate the technical per-
Radical cystectomy is the treatment of choice for high-risk, formance of LRC. Previous aortoiliac vascular surgery and
recurrent, superficial, and invasive cancer of the urinary blad- endovascular stenting can make the ureteric dissection
der. This procedure is traditionally performed through an challenging.
open midline incision. Radical cystectomy is curative for most
patients who have localized disease, with 5- and 10-year
recurrence-free survival rates approaching 70% (1,2). Alt e rnat ive The rap y
Laparoscopic radical cystectomy (LRC) is an attractive
minimally invasive alternative to conventional open radical Bladder-preserving protocols utilizing external beam and
cystectomy, as it faithfully duplicates technical aspects of open chemotherapy are available for those who may not be consid-
surgery yet is associated with decreased blood loss (3,4). In ered for radical cystectomy.
reconstructing the ileal conduit or neobladder, an open-
assisted approach is preferable to a purely intracorporeal
technique for the following reasons: the operating time is Surg ical Te chniq ue
shorter than a pure laparoscopic approach, bowel-related
complications are fewer, and the advantages of a laparoscopic Pat ie nt Pre p arat io n
approach to cystectomy are preserved and it is technically
A thorough preoperative evaluation is necessary, including
simpler to perform (5,6).
cardiac and medical clearance. Antiplatelet agents should be
discontinued at least 1 week before surgery. Anticoagulant
discontinuation may necessitate bridging to heparin perioper-
Diag no sis
atively. M echanical bowel preparation includes a clear liquid
The diagnosis and staging of muscle-invasive bladder cancer diet and 4 L of polyethylene glycol on the afternoon before
are addressed elsewhere in this book. surgery. A stoma site is marked before LRC for all patients by
a stoma therapist. Broad-spectrum intravenous antibiotics
(usually a third-generation cephalosporin and metronidazole)
Ind icat io ns are administered at induction. As such, the patient prepara-
tion is the same as for open surgery.
Patients with organ-confined high-risk superficial or invasive
bladder cancer are candidates for LRC. O ur current con- Pro ce d ure
traindications include computerized tomographic evidence The patient is secured on the operating table in the low litho-
of bulky primary tumors, extravesical spread, or gross lym- tomy position, with both arms adducted and secured to the
phadenopathy, frozen pelvis due to previous surgery or table, thus allowing access to the patient’s perineal area and
rectum. All pressure points are meticulously padded. These allow precise orientation during the procedure and
Sequential compressing stockings are applied. The operating expeditious dissection.
table is placed in a steep Trendelenburg position and the pa-
tient is prepared from the nipples down to the midthighs, in- Mo b ilizat io n and Divisio n o f t he Ure t e rs
cluding the genitalia. A warming blanket covers the upper We first identify the peristaltic right ureter as it crosses the il-
chest and shoulders. The patient is draped in a sterile fashion iac vessels at the pelvic brim. Using J-hook electrocautery, the
using leggings and a special laparoscopy drape. An 18Fr Foley peritoneum is incised along the anterior aspect of the ureter
catheter is inserted from the operative field after sterile prepa- and dissected linearly and distally to the visible peritoneal fold
ration and draping of the patient. overlying the ureter as it enters the bladder. When circumfer-
The surgeon stands on the left side of the patient, while the entially mobilizing the ureter from the pelvic brim down to the
first assistant stands opposite the surgeon on the right side of vesicoureteric junction, it is important to maintain an ade-
the patient. The scrub nurse/technician stands between the quate cover of periureteric fatty tissue. Close to the vesi-
legs of the patient and has the instrument table behind him or coureteric junction, the superior vesical artery and the vas
her. If necessary, a second assistant stands to the left of the sur- deferens are visualized crossing the ureter. These are mobilized
geon. Two camera monitors are positioned 20 to 30 cm above away from the ureteric surface to obtain maximum ureteric
each outstretched foot of the patient, in direct line of sight of length and do not routinely need division at this point. If ante-
the surgeon and the first assistant. O ther laparoscopic essen- grade ureteric dissection proves difficult, the peritoneum of
tials such as the insufflator, light source, camera console, the ureteric fold can be incised closer to the bladder and
recording equipment, and electrocautery are located on a the incision continued in a cephalad direction up to the
ceiling-mounted boom that is situated behind and to the left of pelvic brim.
the first assistant. A suction unit is placed just below the The right ureter is clipped with H em-O -Lok clips at the
boom. An ultrasonic scalpel and bipolar electrocautery unit is vesicoureteric junction and divided such that there are two
placed behind the second assistant. clips on the bladder side and one on the distal ureter. The
A 1.5-cm vertical incision is made in the midline about 2.5 cm two clips on the bladder side of the transected ureter serve as
above the umbilicus; this incision will later be incorporated critical landmarks during the subsequent dissection, as they
into the midline incision for the open bowel work. A 2-mm provide a readily identifiable visual clue during transection of
M iniport (Autosuture, N orwalk, CT) is inserted into the the lateral pedicles. The single clip on the cut end of the
abdomen through this incision and CO 2 pneumoperitoneum proximal ureter allows its hydrodistention, which facilitates
is created to 15 mm H g. We prefer to use a 2-mm M iniport to later ureteroenteric anastomosis. A terminal ureteric biopsy is
obtain initial access rather than a Veress needle, as it allows a sent for frozen section analysis. The left ureter is mobilized
higher gas flow rate and occasional direct inspection of the similarly. Some patients have significant sigmoid adhesions,
peritoneal cavity with a 2-mm laparoscope in case of doubt. which might require lysis to allow identification of the left
A 12-mm primary port is placed through the supraumbili- ureter.
cal incision, and a 10-mm 0-degree laparoscope is introduced.
Four secondary ports are inserted under vision. A 12-mm Re t ro ve sical Disse ct io n
right upper port is placed at the previously marked stoma site
The retrovesical space is now dissected. To achieve this, it is
and is inserted through the belly of the right rectus muscle,
essential to tautly retract the sigmoid colon proximally out of
carefully avoiding the right inferior epigastric vessels under
the pelvis to facilitate visualization of the cul-de-sac. We use a
clear visualization. For ileal conduit diversion, the stoma will
2-0 polypropylene suture on a straight Keith needle inserted
be constructed at this site during the “ open” part of the oper-
into the abdomen directly through the skin in the left
ation. Three other secondary ports are placed: a 5-mm left up-
hypochondrium. This suture is anchored through two selected
per port at the lateral edge of the left rectus muscle just below
appendices epiploicae of the most prominent part of the sig-
the level of the umbilicus, and a 5-mm port placed 2.5 cm me-
moid colon and brought back out through the abdominal
dial and cephalad to each anterior superior iliac spine.
wall in the left hypochondrium, where it is held taut with a he-
The surgeon typically uses the right-hand 12-mm port and
mostat. This simple maneuver efficiently and tautly retracts
the left pararectal 5-mm port. The first assistant drives the
the sigmoid colon out of the pelvis, obviates the need for an
camera through the midline 12-mm port and simultaneously
assistant to do so, and provides an excellent view of the oper-
uses the 5-mm right lateral port for suction and/or retraction.
ative field.
If a patient has had previous abdominal surgery, we prefer
The ureters have already been mobilized and transected,
initial access through the spatially most distant quadrant, of-
and the lateral peritoneum of the rectovesical pouch is already
ten the left upper quadrant, as most patients with previous
divided. The two lateral peritoneotomies are now joined
surgery have scars either in the midline or in the right half of
across the midline. It is important that the peritoneotomy
the abdomen.
across the cul-de-sac be created quite distally, such that it is
Upon initial inspection the surgeon must identify five im-
only 1 to 2 cm anterior to the surface of the rectum. O ften
portant landmarks:
there is a subtle transverse peritoneal fold at this location (we
1. The medial umbilical ligaments refer to it as the “ second peritoneal fold” ). This plane is now
2. The peritoneal folds overlying the ureters close to the developed between the vasa and seminal vesicles anteriorly,
bladder and the anterior surface of the rectum posteriorly. The ves-
3. The vasa on each side sels supplying the seminal vesicles are controlled, and bilat-
4. The posterior cul-de-sac of the rectovesical pouch eral vasa and vesicles are maintained en bloc with the
5. The iliac vessels bladder. Continued dissection brings the posterior layer of the
Denonvilliers fascia into view, which is incised with cold divided just caudal to the umbilicus. The bladder is released
Endo-shears to reveal the yellow prerectal fat posterior to the from the anterior abdominal wall; care is taken to protect the
prostate. This is an important landmark guiding the posterior inferior epigastric vessels as they course up from the external
dissection, the plane of which must remain between the iliac vessels to enter the posterior rectus sheath.
prostate anteriorly and the prerectal fat posteriorly to mini- The space of Retzius is developed behind the pubic bone.
mize chances of rectal injury. Areolar tissue is dissected away to expose the anterior surface
of the prostate and the endopelvic fascia on each side. The
Lat e ral Disse ct io n and Co nt ro l o f endopelvic fascia is incised down to the region of the dorsal
Vascular Pe d icle s venous complex. The superficial dorsal vein is coagulated and
The parietal peritoneum lateral to the medial umbilical liga- divided with the bipolar forceps. Fat overlying the anterior
ments is incised from the vas deferens as it crosses the pelvic surface of the prostate is cleared off with the bipolar forceps.
brim toward the peritoneotomy across the rectovesical cul-de- The puboprostatic ligaments are divided with cold Endo-
sac. The vasa are clipped and divided at the pelvic brim. The shears.
space between the bladder and the lateral pelvic wall is now
developed bluntly, retracting the bladder medially away from Transe ct io n o f Do rsal Ve in Co mp le x and
the iliac vessels and the obturator nerve. As the bladder is still Me mb rano us Ure t hra, Sp e cime n Ent rap me nt
anteriorly attached to the abdominal wall, this allows the lat- The dorsal venous complex (DVC) is now transected with a
eral pedicles to be clearly identified bilaterally. The lateral laparoscopic stapler. O ften an additional suture of 2-0
pedicles are now divided with a laparoscopic stapler. O nce polyglactin on a CT-1 needle is necessary to secure complete
again, the two clips on the bladder end of the transected jux- hemostasis of the DVC. The membranous urethra is tran-
tavesical ureters serve as critical landmarks for the anterome- sected with cold Endo-shears, the catheter is removed, and the
dial limit of resection; the laparoscopic stapler is deployed just urethra at the prostate apex is immediately occluded with a 2-0
posterolateral to these clips. Usually two or three cartridge polyglactin suture on a CT-1 needle to prevent local spillage of
firings are necessary on each side to control the entire width of urine. The remaining posterior pedicles are clipped and di-
the lateral pedicles down to the endopelvic fascia on either vided. The remaining posterior attachments of the prostate
side. apex are divided and the freed specimen is entrapped in an
The posterior pedicles are now visualized coursing from Endocatch II bag. The mouth of the bag is transiently retrieved
just lateral to the rectum toward the urinary bladder (Fig. 133.1). outside a port site, double-ligated to prevent any spillage, and
These are controlled with the stapler or divided between se- returned into the abdomen.
quentially applied H em-O -Lok clips. Usually only the cepha-
lad part of the posterior pedicles can be controlled at this Mo d ificat io ns fo r Cyst e ct o my in Wo me n
stage; their caudal aspect is addressed after releasing the bladder O nce the ureters are clipped and divided, the uterus is ante-
from the anterior abdominal wall and completing the anterior verted by the RUM I uterine manipulator (Cooper Surgical,
dissection. At this point the dissection is close to the anterolat- Trumbull, CT) and the sigmoid is retracted as described above
eral surface of the rectum. An assistant’s finger in the rectum (Figs. 133.2 and 133.3). The infundibulopelvic ligaments are
can provide guidance in avoiding rectal injury. transected with a laparoscopic stapler. With the uterus still an-
teverted and the adnexa retracted anteriorly, the peritoneum
Ant e rio r Disse ct io n over the apex of the posterior fornix is scored transversely
A liberal inverted-U incision is made with the J-hook electro- with the laparoscopic J-hook. The cervical cup aids in identi-
cautery, starting lateral to each medial umbilical ligament, fying the posterior fornix. The remaining posterior dissection
with the limbs of the U joined anteriorly across the midline at and the vaginal incision are made after preparing the DVC.
the umbilicus. The urachus and medial umbilical ligaments are
FIGURE 133.1 Stapling of the bladder pedicles. FIGURE 133.2 M odification for cystectomy in the female patient.
blood flow in the neurovascular bundles during and after the

procedure (8).
Mo d ificat io ns fo r Re p ro d uct ive O rg an–Sp aring

Cyst e ct o my in Wo me n
In carefully selected, sexually active young women with low-
grade organ-confined disease, a more limited approach can be
used. Precise dissection of the bladder away from the uterus
and vagina is critically important. The uterus is retroverted,
the bladder is identified, and the peritoneum on the anterior
surface of the uterus is incised transversely using a J-hook.
With the bladder now retracted anteriorly, dissection is per-
formed along and close to the anterior surface of the uterus,
developing this avascular plane. Typically dissection proceeds
smoothly until the cervix is reached, where adhesions are
often dense. At this point extreme care is taken not to thin
the vaginal wall or the bladder. This dissection is carried
FIGURE 133.3 M odification for cystectomy in the female. distally down to the bladder neck, which is the end point of
posterior dissection. Anterior dissection is now performed and
the lateral pedicles are divided with a stapler. The urethra is
The lateral pedicles are transected with laparoscopic staplers prepared in the usual fashion. As the vagina is not opened, the
and the bladder is dropped in the usual fashion. The DVC is specimen is entrapped in an Endocatch II bag.
suture-ligated with a 2-0 polyglactin suture on a CT-1 needle.
Attention is now returned to the posterior dissection. With Ext e nd e d and Hig h-Ext e nd e d
the uterus anteverted, a transverse incision of the posterior Lymp had e ne ct o my
vaginal fornix is completed at the previously scored site. The We perform pelvic lymph node dissection after the LRC. The
vaginal incision is extended distally on either side of the ure- lateral limit of the dissection is the genitofemoral nerve and
thra, excising a narrow central strip of vagina en bloc with the the medial limit is the obturator nerve. The distal limit is the
bladder specimen. inguinal ligament and the proximal limit is the aortic bifurca-
Using a perineal approach, the external meatus and distal tion. The technique mimics the “ split-and-roll” technique
urethra are circumferentially cored out using electrocautery. used during open surgery. Right lymphadenectomy is per-
After removing the RUM I manipulator, the distal urethra and formed first. The fibroareolar tissue lateral to the gen-
an underlying strip of anterior vaginal wall are dissected free itofemoral nerve is divided, exposing the iliopsoas muscle.
by the transvaginal approach. The specimen is delivered en The tissue packet is dissected en bloc off the surface of the
bloc through the vagina. The vagina is reconstructed by com- iliopsoas muscle and swept medially, dissecting behind the il-
bined perineal and laparoscopic suturing before proceeding iac vessels down to the obturator nerve. Tissue anterior to the
with urinary diversion (7). external iliac artery and vein is then individually split longitu-
dinally using the J-hook, skeletonizing the vessels circum-
Mo d ificat io ns fo r Ne rve -Sp aring ferentially. The external iliac vein typically appears flat at
Cyst e ct o my in Me n standard pneumoperitoneum pressures. O ccasionally, pneu-
O nce the ureters are divided and posterior dissection com- moperitoneum pressure might need to be decreased to 5 mm
mences, care is taken to stay closely along the surface of the H g to facilitate identification of the external iliac vein.
seminal vesicles, as the neurovascular bundles run lateral to Cephalad dissection along the common iliac artery is facil-
the apical tip of the vesicles distally toward the prostatovesic- itated by the fact that the transected ureter has already been
ular junction. Thermal energy is avoided in the vicinity of the mobilized away during the LRC procedure. The circumferen-
bundles. The plane of dissection is closer to the bladder and tially mobilized common iliac artery is retracted with a vessel
further from the rectum. The bundle on either side is dis- loop to retrieve the posterior fibrofatty lymphatic tissue distal
sected away with cold Endo-shears, and hemostasis is se- to the aortic bifurcation. The internal iliac artery is carefully
cured with H em-O -Lok clips. This is in contrast to the mobilized, taking care to avoid injury to the internal iliac vein.
non–nerve-sparing technique, in which a laparoscopic stapler The released tissue packet is rolled medially posterior to the
is used for en masse transection of the lateral pedicle more mobilized iliac vessels, delivering it into the pelvis. Dissection
posterolaterally, closer to the rectum, and at a considerable along the medial aspect of the packet separates it from the pre-
distance from the bladder. During the anterior dissection, viously identified obturator nerve. Distally, the tissue packet is
the endopelvic fascia is maintained intact, and the lateral clipped and transected at the inguinal ligament (Fig. 133.4).
pelvic fascia is incised high on the prostate to drop the bundles M ore recently, we have performed a high-extended pelvic
posteriorly. The DVC is divided with a laparoscopic stapler, lymph node dissection by dissecting the anterior surface of the
exposing the membranous urethra. The bundles on either aorta and vena cava up to the inferior mesenteric artery; the
side are released from the prostate apex using cold Endo- para-aortic, preaortic, interaortocaval, precaval, and pericaval
shears, and the urethra is divided. The remainder of the oper- lymphatic fatty tissue is excised. The aortic bifurcation and
ation proceeds in the usual fashion. Intraoperative real-time the presacral area are also dissected.
transrectal ultrasound guidance is of help during nerve- Care must be taken to avoid cutting into any enlarged
sparing cystectomy, as it can confirm the location of and lymph nodes to minimize the risk of tumor spillage. The
placed in the pelvis through the left and right lateral 5-mm
port sites. The ureteric stents are brought out through the left
pararectal 5-mm port site. The suprapubic tube draining the
pouch is brought out through the right 12-mm port site. The
abdominal cavity is extensively irrigated before closure, and
this can be done efficiently using this combined approach.
Pure Lap aro sco p ic Ile al Co nd uit and

O rt ho t o p ic Ne o b lad d e r
The technique for the pure laparoscopic ileal conduit repli-
cates the open procedure with a few minor modifications (6).
A 15-cm segment of ileum is isolated using two applications of
an Endo-GIA stapler, and the mesentery is also divided with
this stapler. The isolated segment is dropped posteriorly.
Ileoileal continuity is restored intracorporeally using an appli-
cation of the Endo-GIA stapler, followed by another applica-
tion of the Endo-GIA stapler to close the defect. The proximal
end of the conduit is imbricated using a running absorbable
suture and the mesenteric window is closed with interrupted
FIGURE 133.4 Extended node dissection. suture. The stoma is then fashioned, allowing the conduit to
be stretched by gravity, thereby improving exposure of the
proximal end in preparation for anastomotic suturing. The
lymphadenectomy specimen is immediately entrapped in an left ureter has been brought through a mesenteric defect to
Endocatch bag, avoiding contact with adjacent tissues. the right side of the retroperitoneum. The distal ends of the
Lymphadenectomy is then performed on the left side in similar ureters are spatulated and two separate “ Bricker” anasto-
fashion (9). moses are performed using interrupted sutures.
Urinary Dive rsio n Briefly, 55 to 65 cm of ileum is isolated and ileoileal conti-
nuity is restored intracorporeally as described above. The ex-
As mentioned previously, our current preference is to perform cluded segment is irrigated and detubularized along its
this part of the procedure through a 6- to 8-cm midline inci- antimesenteric border, keeping the proximal 10 cm intact as
sion. The three specimens (bladder and two lymphadenectomy an isoperistaltic afferent limb. The posterior neobladder plate
specimens) in their separate bags are removed through this in- is created by continuous intracorporeal suturing and the apex
cision. The pelvis is carefully inspected to confirm good hemo- of the posterior neobladder plate is circumferentially sutured
stasis. An ileal conduit or ileal neobladder is fashioned in the to the posterior urethra to complete the urethroileal anasto-
usual manner, essentially at or near skin level. mosis. The anterior neobladder wall is then closed and a 22Fr
If an ileal conduit is made, the stoma is fashioned at the site Foley catheter is placed. Finally, the ureters are implanted into
of the right-sided 12-mm port. This port site is further ex- the afferent segment using a technique identical to that for the
panded and a stoma is fashioned in the usual manner. A 10-mm ileal conduit anastomoses (Fig. 133.5).
Jackson–Pratt drain is placed in the pelvis and a 24Fr Foley
catheter is placed in the pelvis through the urethra. The bal- Po st o p e rat ive Care
loon of this catheter is inflated to 50 mL and placed on trac-
tion for 24 to 48 hours. The abdominal incision is then closed The neobladder is gently irrigated with 50 mL of saline every
in layers using looped polydioxanone sutures for the fascial 4 hours to prevent mucous plugging of the catheters.
layer and 4-0 subcuticular polyglactin for the skin. The 5-mm Intravenous fluids and antibiotics are continued until bowel
port sites are closed with 4-0 subcuticular polyglactin. function is regained. Diet is gradually advanced and antibi-
For the ileal neobladder, the pouch is completed and otics are switched to the oral route. The ileoureteric stents are
closed, and the most dependant aspect is defined and a small removed in 1 week after a negative intravenous urogram. The
enterotomy made. This site is tagged with a polyglactin suture Jackson–Pratt drains are removed sequentially, as per the de-
and later used for the urethral anastomosis. The ureteric stents crease in their output. The urethral Foley catheter and supra-
and suprapubic tube are brought through separate openings in pubic catheter are removed at 10 to 12 days after a normal
the anterior wall of the pouch and secured with chromic gut cystogram.
pursestring sutures. The pouch is irrigated to confirm water-
tight integrity. It is then dropped into the pelvis, one port O ut co me s
is reinserted under direct vision, and the abdominal wall In the past consecutive 50 LRC procedures (38 men, 12
is closed in layers as described above. The pneumoperitoneum women) with a urinary diversion performed extracorporeally
is then re-established and the other laparoscopic ports are through a 5- to 6-cm minilaparotomy at our center, the
reinserted. The urethroneovesical anastomosis is completed mean operative time was 6.3 hours and mean blood loss was
laparoscopically using a running preknotted double-arm su- 363 mL. Twelve percent of patients required blood trans-
ture of 2-0 poliglecaprone 25 and 2-0 polyglytone 6211 on a fusion, time for first oral intake was 3.4 days, and time to
UR-6 needle over a 22Fr Foley catheter, akin to the technique ambulation was 3.0 days (Table 133.1).
used for urethrovesical anastomosis during laparoscopic radi- This group was compared to a contemporary cohort of
cal prostatectomy. Two 10-mm Jackson–Pratt drains are 50 open radical cystectomy procedures (34 men, 16 women)
FIGURE 133.5 Pure laparoscopic orthotropic

neobladder.
with urinary diversion. There were no significant differences accounts for 0.5% to 2% of all bladder tumors and approx-
between the groups with respect to mean patient age (66 ver- imately 40% of vesical adenocarcinomas.
sus 67; p 0.61), Body M ass Index (27 versus 26; p 0.50), Patients with resectable tumors traditionally underwent en
comorbidities, history of prior abdominal surgery and opera- bloc cystoprostatectomy and wide excision of the urachus and
tive indications. Tumor was organ-confined ( pT2N 0), non– umbilicus. Extended partial cystectomy and umbilectomy pro-
organ-confined (pT3-4N 0), and lymph node positive vide survival rates comparable to those of radical cystectomy
(pTanyN ) in 66% , 28% , and 6% of the LRC patients (13). The surgical approach has leaned more toward bladder
and 62% , 20% , and 18% of the open surgery patients, re- sparing because published reports have not shown an advan-
spectively, with no significant differences between the groups tage compared to radical surgery (14).
(p 0.15) (see Table 133.1) (10,11).
Surg ical Te chniq ue s

PARTIAL CYSTECTO MY,
URACHAL EXCISIO N Urachal Ad e no carcino ma
Patient preparation, positioning, and port placement are simi-
The urachus is a vestigial fibrous cord derived from involution lar to those previously described for LRC. The only variation
of the allantois that extends from the bladder apex to the um- is the placement of the camera port 3 cm above the umbilicus.
bilicus and forms the median umbilical ligament. Urachal rem- The peritoneal and preperitoneal tissue between the medial
nant is a rare congenital anomaly, with an incidence of umbilical ligaments is dissected free of the transversalis fascia.
2:300,000 in infants and 1:5,000 in adults. Traditional surgi- The dissection must include an extensive resection of the peri-
cal management of benign urachal disease involves the radical toneum lateral to the two medial umbilical ligaments, which
excision of all anomalous tissue with or without a cuff of defined the lateral limits, the posterior sheath of the rectus
bladder tissue via the open approach (12). Urachal carcinoma muscle of the abdomen to the arcuate line and the muscle
TA B LE 1 3 3 . 1
CLEVELAN D CLIN IC EXPERIEN CE WITH LAPAROSCOPIC RADICAL CYSTECTOMY
Laparoscopic Open radical

radical cystectomy cystectomy p
O perative time (hr) 6.3 0.26 5.3 0.28 0.01

Blood loss (cc) 363 259 801 684 0.0004
Transfusion 12% 40% 0.001
Ileus 18% 28% 0.21
O ral intake (days) 3.4 1.1 4.2 2.1 0.05
M inor postop complications 18% 22% 0.62
M ajor postop complications 8% 6% 0.69
Ambulation (days) 3.0 1.6 3.4 3.3 0.63
H ospital stay (days) 8.0 3.2 8.7 2.9 0.27
Lymph nodes on final pathology (n) 14.8 7.0 15.8 7.1 0.58
Positive surgical margins 2% 6% 0.29
fibers of the rectus muscle below it, the extraperitoneal fat in bladder diverticulum classically consists of diverticular abla-
the space of Retzius as the anterior limit, the urachus up to the tion by open surgery and relief of the prostatic obstacle (16).
umbilicus superiorly, sparing the umbilical skin. An endolaparoscopic approach combining laparoscopic diver-
The bladder is distended with 200 mL normal saline to fa- ticulectomy with transurethral resection of the prostate
cilitate the mobilization and dissection. The junction of the (TURP) is statistically superior to open surgery in terms of
solid tumor with the bladder is determined on the anterior as- blood loss, postoperative hospital stay, and analgesic require-
pect by inflating and deflating the bladder, and a cystotomy is ment.
made. The excision of the bladder dome is performed with a
2-cm margin of normal mucosa. The specimen is enclosed
within the Endocatch bag and placed in the right iliac fossa. Surg ical Te chniq ue
The bladder is closed in two layers using absorbable sutures.
Bilateral extended pelvic lymphadenectomy is performed The patient is first placed in the lithotomy position and a stan-
as described in the laparoscopic cystectomy section. The three dard TURP is performed with meticulous hemostasis. A
specimens (the resected tumor and two lymphadenectomy holmium laser TURP is preferred because of its hemostatic
specimens) are removed in separate bags through the properties. A ureteral catheter is inserted if the diverticulum
supraumbilical port. is close to the ureter. A 10Fr Foley catheter is placed in the
diverticulum and the balloon is inflated with 20 to 25 mL
Urachal Re mnant s normal saline. The neck of the diverticulum is occluded with
The patient is placed in a supine position and a Foley catheter a gentle traction. Another 14Fr irrigation catheter is placed in
is inserted in the bladder. Three trocars are generally used: the the bladder. The patient is moved into the supine position with
12-mm camera port is placed in the midline above the umbili- 15-degree Trendelenburg. A 10-mm supraumbilical midline
cus and two trocars (5 and 12 mm) are placed on either side, incision is made for the camera port. An extraperitoneal space
lateral to the rectus muscle. There are several other possible is created by using an atraumatic laparoscopic balloon. The
trocar placements as well (15). preperitoneal space is inflated up to 12 mm H g. Two 5-mm
The medial umbilical ligaments are clipped and divided. working ports are inserted in both iliac fossae and a 12-mm
The peritoneal and preperitoneal tissue between the medial port is placed in the suprapubic area. The bladder is mobilized
umbilical ligaments is dissected free of the transversalis fascia. anterolaterally, and the diverticulum is identified after inflat-
Dissection is carried along the preperitoneal plane toward the ing it selectively with normal saline through a Foley catheter.
umbilicus, surrounding the cyst. The cephalic side of the le- The diverticulum is then circumferentially dissected until its
sion is ligated at the umbilicus and divided. The umbilicus is neck is identified. Sharp transection of the diverticulum di-
usually not excised. The bladder is filled via the urethral rectly at its neck is performed over the Foley catheter. The
catheter and the cuff is removed. The specimen is placed in a neck is then closed in two layers with 3-0 absorbable running
laparoscopic bag and removed by the 12-mm port site. The sutures, and a watertightness test is performed with bladder
bladder defect is closed with laparoscopic suturing using 4-0 irrigation. The resected diverticulum is removed through the
and 3-0 suture. 10-mm port. A 14Fr suction catheter is placed in the perivesi-
cal space through the 5-mm port.
The laparoscopic procedure can also be carried out via a
BLADDER DIVERTICULECTO MY transperitoneal approach. The drain is removed postopera-
tively after 48 hours of dryness. The bladder catheter is re-
A bladder diverticulum is a herniation of the bladder mucosa moved on the 10th postoperative day after confirmation of
as a result of bladder outlet obstruction. The surgical treatment watertight healing with a negative cystogram.
of benign prostatic hyperplasia associated with a symptomatic
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structed ileal conduit after porcine cystoprostatectomy. J Urol 2001;166: Update Series 1998;17:298–303.
285–288. 14. Ashley RA, Inman BA, Sebo TJ, et al. Urachal carcinoma: clinicopathologic
6. H aber GP, Campbell SC, Colombo JR Jr, et al. Perioperative outcomes with features and long–term outcomes of an aggressive malignancy. Cancer
laparoscopic radical cystectomy: “ pure laparoscopic” and “ open-assisted 2006;107:712–720.
laparoscopic” approaches. Urology 200770(5):910–915. 15. O kegawa T, O dagane A, N utahara K, et al. Laparoscopic management of
7. Kaouk JH , Gill IS, Desai M M , et al. Laparoscopic orthotopic ileal neo- urachal remnants in adulthood. Int J Urol 2006;13(12):1466–1469.
bladder. J Endourol 2001;15:131–142. 16. Champault G, Riskalla H , Rizk N , et al. Laparoscopic resection of a blad-
8. M oinzadeh A, Gill IS, Desai M , et al. Laparoscopic radical cystectomy in der diverticulum. Prog Urol 1997;7:643–646.
the female. J Urol 2005;173(6):1912–1917.
CHAPTER 134 ■ LAPARO SCO PIC BLADDER
NECK SUSPENSIO N
RICHARD W. GRAHAM
The first modern advance in the surgical treatment of female incontinence (cystocele, rectocele, other forms of vaginal pro-
urinary incontinence was described by Dr. Victor M arshall lapse) and whether the patient is obese or has other risk fac-
along with his colleagues Drs. M archetti and Krantz (1). The tors for surgery, including chronic bronchitis, prior radiation,
M arshall-M archetti-Kranz procedure was based on the con- extensive varicose veins (we have seen large venous plexi in
cept that the loss of the angle of bladder neck juncture com- the space of Retzius), neurologic issues, or diabetes.
bined with the bladder neck protruding through the pelvic The physical examination should be detailed. O ften associ-
floor muscles was the cause of stress urinary incontinence ated with SUI are vaginal defect issues that need to be repaired
(SUI). H is idea was to place stitches next to the bladder neck at the time of surgery. Is there good estrogenation of the
and sew these stitches to the periosteum. This would elevate vagina and perivaginal areas? What is the status of her uterus?
the bladder neck and might provide a permanent solution for We perform the M arshall test. (We have patients cough with
the incontinence from the scar formation. The initial results a full bladder and then watch their urinary leakage. N ext we
were excellent, though complications included osteitis pubis apply digital pressure to the periurethral tissue to watch the
and some patients with permanent retention. M ost of Dr. leakage stop; if it does not, then we re-evaluate the situation.)
M arshall’s patients did not void for weeks; he often stated that We check the rectal tone as well.
if the patient voided before 6 weeks that the procedure would Cystoscopy is performed in all patients to assess the ure-
not last (private communication). Subsequent procedures and thra and bladder. It is important to note urethral length and
modifications have been tried, none with perfect results. angulation of the bladder, urethra, and possible cystocele. (We
In the early 1990s we started to investigate laparoscopic have noted that releasing the veins at the midline of the blad-
surgery as a minimally invasive technique in urology. The ini- der neck may increase the length of the urethra by a small por-
tial strategy was to copy open techniques, improving them by tion without a laparoscopic bladder neck suspension [LBN S],
using higher magnification with more light and CO 2 insuffla- as Dr. M arshall noted in his experience with open proce-
tion to lift the abdominal wall and compress the bowel at the dures.) Additionally, the estrogenation of the urethra provides
same time. us clues to proper treatment. The cotton-tipped swab test may
O ur initial experience was very encouraging, and later ex- be of some benefit here as well.
perience of over 600 cases seems to echo this success (2). In a Finally, we feel that urodynamics can be a major help in
head-to-head trial with open sling procedures at our institu- ascertaining the patient’s overall incontinence picture and pro-
tion, the laparoscopic procedure showed superior outcomes file. H er leak point pressures, volume capacity, and other mea-
and fewer adverse outcomes. sures help guide our decisions to her care. Videourodynamics
are now part of our evaluation as well in helping determine
the three-dimensional anatomy and function of the patient.
DIAGNO SIS
The evaluation and selection of patients for any type of treat- INDICATIO NS FO R SURGERY
ment for stress urinary incontinence is key to the outcome.
The group of patients we want to focus on are the female pa- The indication for surgery for us is based on a paradigm of
tients with hypermobility of the bladder neck who have good clinical evaluations and is based on what we feel will work
sphincter control. best for the individual. We like to begin with medical therapy.
The patient’s history is one of the most important parts of We start with local estradiol therapy if the patient can tolerate
the preoperative and diagnostic evaluation, which should it and there are no contraindications. O ur experience has
assess the duration of the problem, time of onset, and cofac- shown us that a poorly estrogenized patient can have excellent
tors such as whether the problem occurred after pregnancy responses to the cream alone. We tend to limit the local treat-
or at the beginning of menopausal symptoms. In the latter ment to 4 g a week (one fingertip of cream). O ther noninva-
group medical management is usually tried first, and watch- sive treatments will include biofeedback, begun a month after
ful waiting may be appropriate. O ther important factors in- starting local estrogen. Failure to respond to noninvasive man-
clude whether the woman is sexually active, whether the agement in a patient with diagnosed SUI is the primary indica-
incontinence is mixed, how many pads she is wearing, what tion for surgery.
induces the leakage, and whether there are signs of intrinsic We have found that prior pelvic surgery may restrict the
sphincter deficiency. In considering surgery, it is important to available space for suturing retropubically, so we may perform
know if there are other pelvic problems associated with the an LBN S using a ProTac (Tyco H ealthcare Group, N orwalk,
892
Chap t e r 134: Lap aroscop ic Blad d e r Ne ck Susp e nsion 893
CT) and polypropylene mesh system to achieve our goal of

suspension as opposed to using permanent Gore-Tex (WL SURGICAL TECHNIQ UE
Gore and Associates, Flagstaff, AZ ) sutures. If other proce-
dures are necessary at the same time, and these are open pro- The patient is prepared and draped in the lithotomy position,
cedures (total abdominal hysterectomy), then we will opt for arms by her side, with the vagina prepared as well. N eeded
open techniques, often using a ProTac and mesh again. materials are listed in Table 134.1. A 16Fr Foley catheter is
If the patient has morbid obesity, a previous kidney trans- placed in the bladder after the patient is draped, and 30 cc of
plant, history of radiation, significant bronchitis, or requires water is placed in the balloon. The surgeon stands at the pa-
vaginal surgery at the same time, we may decide to use a trans- tient’s side, on the left side if the surgeon is right-handed. A
obturator sling instead of an LBN S, as this patient may re- 1.0- to 1.5-cm incision is made lateral to the umbilicus. With a
quire more support. We have had fairly good experience with pair of M etzenbaum scissors, the fat is split down to the exter-
this procedure as well as with the TVT and feel most comfort- nal oblique fascia. Using 1-cm “ S” retractors, the fat is held
able with this direction. We have seen two erosions with the back and the fascia grasped with a Kocher clamp, and a 1.0-
TVT, and the chance of urinary retention or the need of later to 1.5-cm cut is made in the external oblique fascia superior to
urethrolysis may be higher with a sling, but that is the balance the clamp. This cut is in a medial/lateral direction. Using a 0
we use (3). Vicryl UR-6 needle, the stitch is placed on the inferior edge of
the fascia and the clamp removed. N ext the muscle fibers are
split in a longitudinal direction and the “ S” retractors placed
deeper into the wound to hold back the muscle fibers. The
ALTERNATIVE THERAPY posterior sheath is exposed. N ext a Tyco/US Surgical PDB
There have been many operations described for SUI. The ante- 1000 dissecting balloon is lubricated and placed into the space
rior colporrhaphy by H . A. Kelly was felt to be a significant (Tyco H ealthcare, N orwalk, CT). The balloon is gently slid to
achievement in its day for SUI and was subsequently improved the posterior sheath, and the retractors are then removed.
upon by others. The initial success rate quoted of 92% was Using a zero-degree 10-mm laparoscope inside the dissec-
not able to be reproduced over time, and subsequent years tor, the apparatus is carefully slid into the space of Retzius
showed a reduction in success rates. This seems to be the trend (Fig. 134.1). O ne should see muscle above the balloon and
in many operations for the treatment of SUI. fascia below. If bowel is seen, then the peritoneum has been vi-
Each technique has its own inherent advantages and disad- olated and there is no need to expand the balloon. If all is in-
vantages. There are many studies quoted as alternative surgi- tact, the balloon is slowly expanded with about 45 pumps
cal techniques with superior success rates, often with small with the hand pump (Fig. 134.2). The apparatus is removed
numbers of patients with fewer than 5 years’ experience (4). after all the air in the balloon has been released.
M any of the larger series of composite studies are with numer- Then a Tycos blunt port is placed into the wound (Fig. 134.3).
ous surgeons at multiple institutions with variable skills and The tip is gently placed such that it abuts the posterior fascia.
experience. So sorting out what is the best technique and al- Then 25 cc is placed in the balloon port and the foam cuff
ternatives can be a challenge in itself. The standard operations brought down to the skin. The retroperitoneal space is then
through the years have been primarily retropubic procedures
with excellent results initially that tend to have a percentage of
failing over time. Additionally, suburethral slings of variable TA B LE 1 3 4 . 1
materials seem to be mentioned throughout the literature at MATERIALS N EEDED FOR LAPAROSCOPIC BLADDER
this time, first described by Goebel in 1910 using a piece of N ECK SUSPEN SION
pyramidalis muscle. N ow various ways of placement are being
used, and the way these materials are now attached appears to • 16Fr Foley catheter
be the latest trend. • Two 1-cm “ S” retractors
N onsurgical options include adult diapers, which are more • O ne Kocher clamp
popular worldwide than surgery. The cost is enormous, and • M etzenbaum scissors
the satisfaction with this alternative is dependent upon the • O ne 0 Vicryl suture UR-6
user. • AutoSuture PDB 1000 dissecting balloon
Biofeedback and behavioral modification have had great
• AutoSuture 10-mm blunt/balloon port
success in some series as well. O ne can never rule this ap-
• AutoSuture ProTac 5 mm
proach out as a primary option in the patient’s health care.
It does require constant attention even after the initial ther- • 5-mm laparoscopic port/10-mm laparoscopic port
apy has been taught, as the muscles will atrophy if not stimu- • O ne dissector 5 mm
lated and the problem will return (5). In a similar physical • Polypropylene fine woven mesh—need two pieces cut
therapy realm, electrical stimulation of the nerves and mus- 1 cm by 10 cm
cles, both directly through vaginal devices and indirectly • 30 cc sterile water to fill balloon
through nerve stimulation products, has been used with mixed • 4-0 M onocryl suture
results (6). • O ne ampule of Dermabond
Sometimes the best alternative is the placement of a perma- • 5-mm clip applier on standby
nent Foley catheter to keep the bladder empty. There are a sig- • Suction irrigator on standby
nificant group of patients with macerated skin who are not • Preoperative antibiotics; we usually use Ancef
candidates for corrective repairs of their condition, either be- • Z ero-degree 10-mm laparoscope
cause surgery won’t help or for other reasons.
FIGURE 134.1 From the periumbilical incision, the balloon dissector

is passed into the space of retzius over the posterior fascia.
FIGURE 134.4 The clip applier is introduced to clip the vesssels

above the anterior bladder neck. This allows some lengthening of the
bladder neck once these vessels are cut, and helps to better identify
the bladder neck urethral junction.
below the pubic hair line, midline into the space of Retzius.
Since the bladder has been decompressed, this should enter
into the space easily. If there has been prior surgery, the port
can be placed laterally to midline, being careful not to hit the
subumbilical artery just below the lateral rectus muscle.
FIGURE 134.2 The balloon dissector is insuflated with the pump for Using the surgeon’s dissector of choice through the 5-mm
45 compressions in order to create the space for CO 2 infusion. port, the fat must be dissected off the bladder neck, the
Cooper ligament, and the fascia lateral to the bladder neck.
O nce the fat has been removed, it is critical that the bladder
neck be exposed. If there is a small vessel midline above the
bladder neck extending from the anterior wall toward the
bladder, it should be clipped with a small clip so the bladder
neck is truly exposed (Fig. 134.4). With 30 cc in the balloon,
one can see where the bladder neck joins the urethra.
The surgeon’s left hand is placed into the vagina (right
hand if the surgeon is left-handed), and the balloon is palpated.
Under the scope one ought to be able to see the fascia lift up
where the surgeon’s finger is. Then using a piece of polypropy-
lene fine woven mesh, a 10-cm by 1-cm strip is attached to a
dissector (Fig. 134.5). The camera is removed and cleaned
while the piece of mesh is gently placed down the camera port
into the space of Retzius. N ote: one has to aim somewhat an-
teriorly so as not to perforate the posterior fascia.
The camera is placed back in the trochar. A dissector is
placed in the 5-mm port. The mesh is identified, and one end
FIGURE 134.3 The blunt port is placed in the periumbilical incision, of the rectangular piece is laid down on the fascia lateral to the
above the posterior fascia when the balloon dissector is removed. The left bladder neck, where the surgeon’s finger is waiting. The
space of Retzius is then insufflated to a pressure of 15 mmhg. dissector is removed and a ProTac is placed in the 5-mm port.
Five tacs are used to secure the mesh to the fascia (Fig. 134.6).
The ProTac is removed and a dissector placed in the 5-mm
inflated with CO 2 to a pressure of 15 cm. The 10-mm scope is port. The mesh is pulled toward the left Cooper ligament, the
placed in the port. O ne uses the scope to follow the posterior ProTac is reintroduced, and while the mesh is held under some
fascia to the space of Retzius. Sometimes one needs to point tension the ProTac fires 5 tacs, attaching the mesh to the
the end of the scope up to go over the posterior sheath. Cooper ligament. The procedure is repeated on the right side,
O nce into the space, the surgeon looks for signs of bleed- such that there is a piece of mesh on either side of the bladder
ing, injuries, and so forth. If all is clear, a 5-mm port is placed neck attached to the sides of the pelvis (Fig. 134.7).
Chap t e r 134: Lap aroscop ic Blad d e r Ne ck Susp e nsion 895
FIGURE 134.8 A bladder neck suspension here with Gortex suture

FIGURE 134.5 While the index finger is placed at the bladder neck, being sewn into the periurethral fascia at the level of the bladder
the pro tac is used to fire 5 tacs on top of the mesh toward the under- neck.
lying finger engaging the periurethral fascia. Then the other end of the
mesh is placed on Coopers ligament where 3 tacs are fired through the
mesh into Cooper’s ligament, securing the suspension.
FIGURE 134.9 The gortex suture is first placed in the bladder neck
then sewn to Cooper’s ligament.
FIGURE 134.6 The mesh is then placed on Cooper’s ligament and

attached with 3–5 protacs.
If there is no bleeding or any complications, the gas is emp-
tied out of the pelvis after the 5-mm port is removed under
direct vision. N ext, the blunt port is removed after deflating
its balloon. The fascia is closed with the 0 Vicryl and the
wound infiltrated with 0.5% M arcaine without epinephrine.
The skin edges are closed with 4-0 M onocryl, and Dermabond
is placed over the two small incisions. The Foley balloon is de-
flated and then refilled with 5 cc of sterile water.
The alternative to using the ProTac system is to use Gore-
Tex sutures (Figs. 134.8 and 134.9). M ultiple sutures are placed
in the same location as the tackers and mesh (Fig. 134.10). The
advantage of the Gore-Tex suture is that there is no postneu-
ralgia syndrome from the tacs (in over 600 procedures, we
have had 4 cases in which we replaced the mesh and tacs with
suture).
The patient is usually discharged the same day or 23 hours
postoperatively. The Foley catheter is left in for 2 days. The
FIGURE 134.7 H ere mesh has been attached on both sides with patient is advised against vaginal intercourse or heavy lifting
stabilization of bladder neck. for 6 weeks.
FIGURE 134.10 Usually multiple gortex sutures are used on both FIGURE 134.11 After the bladder neck is suspended, one can exam-
sides. ine the bladder with a flexible cystoscope to inspect the work.
TA B LE 1 3 4 . 2
O UTCO MES
RESPON SE TO QUESTION “DO YOU LEAK WHEN
YOU COUGH, LAUGH, OR SN EEZE?”
Co mp licat io ns
Follow-Up Laparoscopic
Intraoperative complications happen in a very small percent- Interval Bladder N eck Raz
age of people in our experience and in other series (9). The
most obvious would be bleeding from the dissection balloon, 1 M onth 140/158 (89% ) 70/83 (84% )
which has never been an issue for us. 6 M onths 121/144 (84% ) 41/66 (62% )
O ver 40% of our patients have had previous surgery in the 12 M onths 104/129 (81% ) 40/67 (60% )
area, and the bladder is encased in significant scar. O ur experi- 24 M onths 47/69 (68% ) 22/43 (51% )
ence is that sometimes the dome of the bladder is densely ad- 36 M onths 23/34 (68% ) 4/17 (24% )
hered to the symphysis pubica, and in the process of freeing up 48 M onths 4/6 (67% ) 1/5 (20% )
the bladder neck, the bladder can be opened. The key for repair
of such an opening is to free up the entire area prior to repairing
the hole. We place a 2-0 Vicryl suture at each lateral edge of the
wound and alternate working the sutures to the middle. This is some may have prolonged overactivity and should be treated
especially helpful when there is a lot of adipose tissue on the medically.
bladder as well. We leave the Foley catheter in for 5 days.
With this technique our experience has been that postopera-
tive retention is rare ( 1% ). O ur Foley catheters are left in for Re sult s
48 hours to be sure that the patients do not have to return in the
middle of the night with urinary retention. If the retention con- O ur initial success rate for the surgery was 93% to 94% as as-
tinues, we instruct the patient on intermittent catheterization till sessed by patient questionnaires. Long-term follow-up ( 2 to
the problem resolves. Urethrolysis is a very rare occurrence, and 4 years) shows stabilization in the 68% range. We performed
in the few people we explored we found that the mesh was not a prospective head-to-head study comparing 330 LBN Ss ver-
attached to the sidewall at all. Interestingly, the scar reaction sus 200 open sling procedures and found a significant superi-
was around the bladder neck. The bladder neck was elevated ority in success and complication rate with the LBN S in a
and suspended by the scar itself (Fig. 134.11). So we lysed the 4-year period.
scar, not the mesh. The LBN S appears to be a viable alternative in the quest
We have had one erosion of the sidewall mesh into the for continence control in women with SUI. There are other
bladder, which happened several years after the surgery. This procedures available, each with its advantages and disadvan-
was removed laparoscopically and the bladder closed without tages. With the very low complication risk, extremely low
sequelae. sling erosion rate, and minimal bladder hyperactivity and mis-
We expect that some of the patients will develop some uri- ery rate of the LBN S in our hands, we have returned to it and
nary frequency, which usually resolves in a few weeks, though turned away from suburethral slings.
Chap t e r 135: Misce llane ous Lap aroscop ic Urolog ic Proce d ure s: Calculus, Varicoce le , Ure te rolysis 897
References
1. Kaufman JM . O perative management of . . . Surg G ynecol O bstet 7. Scarpero H , Dmochowski R, N itti V. Repeat urethrolysis after failed ure-
1949;88: 509. 2. throlysis for iatrogenic obstruction. J Urol 169(3):1013–1016.
2. Yang SC, Park DS, Lee JM , et al. Laparoscopic extraperitoneal bladder 8. Schultheiss D, Brödel M , Kelly H A. Urogynecology and the birth of mod-
neck suspension (LEBN S) for stress urinary incontinence. J Korean M ed Sci ern medical illustration. Eur J O bstet G ynecol R eprod Biol 86(1):113–115.
1995;10(6):426–430. 9. M cDougall E, H eidorn C, Portis A, et al. Laparoscopic bladder neck sus-
3. Burch JC. Cooper’s ligament urethrovesical suspension for stress . . . pension fails the test of time. J Urol 162(6):2078–2081.
G ynecology 1961;81:281–290. 10. Z tsch F. Goebel-Stoeckel sling operation. In: M attingly RF, Thompson JD,
4. M itrani A, Sharp M , Z ilberman A, et al. Urethral length in urinary stress eds. Telinde’s operative gynecology... G ynak U Urol 1910;2:187.
incontinence. BJO G : Int J O bstet G ynaecol 78(7):664–666. 11. Luber K, Wolde-Tsadik G. Efficacy of functional electrical stimulation in
5. The Q -tip test correlation with urethroscopic findings in urinary stress in- treating genuine stress incontinence: a randomized clinical trial. J Urol
continence. BJO G : Int J O bstet G ynaecol 78(7):664–666. 160(6):2305–2305.
6. Stein M , Discippio W, Davia M , et al. Biofeedback for the treatment of
stress and urge incontinence. J Urol 153(3):641–643.
CHAPTER 135 ■ MISCELLANEO US

LAPARO SCO PIC URO LO GIC PRO CEDURES:
CALCULUS, VARICO CELE, URETERO LYSIS
GO RDO N L. FIFER AND RAJU THO MAS
therapy. Yet infrequent cases exist in which endoscopic or

CALCULUS DISEASE ESWL treatment either has failed or has low expectations for
success, and in such cases surgical stone removal remains a
O ne can duplicate the traditional open surgical approaches in viable option.
appropriately selected patients using laparoscopic techniques. Since the introduction of laparoscopic surgery in the early
O ne should, however, gain experience with the common la- 1990s, urologists have recreated virtually every open stone
paroscopic procedures and be comfortable with these prior to surgical procedure using laparoscopic techniques. Appro-
tackling these less common or unusual procedures. priate patient selection is crucial to ensure that a given patient
The advent of endourology in the late 1970s has trans- is amenable to laparoscopic management of such calculi.
formed the practice of urology. U.S. Food and Drug Adminis- The presence of a large impacted stone is one indication for a
tration approval of extracorporeal shock wave lithotripsy laparoscopic approach (3). Although laparoscopy is infre-
(ESWL) in 1984 marked a significant paradigm shift in the quently utilized for management of urolithiasis, this tech-
treatment of urinary tract calculus disease, moving away from nique is invaluable when really indicated, providing a
open surgery to less invasive techniques. In modern urologic minimally invasive approach to managing select cases of
practice, open stone surgery now accounts for 5% of all urolithiasis (2,4,5).
procedures performed to treat urolithiasis (1,2).

Diag no sis
As noted, ESWL, ureteroscopic, or percutaneous techniques
Imaging with computerized tomography (CT) is the standard are the preferred standard for the management of urolithiasis.
today for the identification of urolithiasis. Less commonly, ex- O pen ureterolithotomy is another alternative to the laparo-
cretory urography, retrograde pyelography, or ureteroscopy is scopic approach.
the diagnostic method.

Ind icat io ns
The precise location of the stone must certainly be identified
Technologic advances in the design of endourologic instru- with preoperative imaging. H elical CT scanning provides de-
ments, including ureteroscopes, nephroscopes, baskets, and tailed anatomic information. The planned approach for ap-
lithotriptors, including the holmium laser, have all con- propriate trocar placement will depend on the location of the
tributed to the great success of minimally invasive stone stone and can be categorized as either upper, which includes
FIGURE 135.2 Patient positioned for right laparoscopic ureterolitho-

tomy. The camera is placed in the umbilical trocar. This configuration
can also be used for laparoscopic right ureterolysis, also described in
FIGURE 135.1 X-ray shows a very large calculus (arrow ) impacted this chapter.
in the upper portion of the right ureter.
calculi in the renal pelvis and the upper ureter (above the The colon is reflected along the white line of Toldt and is
pelvic brim) (Fig. 135.1), or low er, for calculi in the ureter dis- allowed to fall medially, aided by airplane rolling the bed, if
tal to the pelvic brim. needed. The ureter is identified and traced to the renal pelvis
Placement of a ureteral stent is often required to manage or until the stone is encountered. For a ureteral stone, since
large or impacted stones. To facilitate intraoperative place- the proximal ureter is usually dilated or tortuous, placement
ment of a ureteral stent, cystoscopy with ureteral catheteriza- of vascular tape or a vessel loop around the ureter proximal
tion should be performed at the onset of the case. If a guide to the stone can help prevent proximal stone migration. The
wire can be manipulated past the stone, this will aid the stent ureter or renal pelvis is opened with either shears or a la-
placement; if a wire cannot bypass the stone, an open-ended paroscopic scalpel handle (Aesculap, Center Valley, PA). The
ureteral catheter is advanced up to the level of the stone. This stone should be removed in one piece when possible and
provides a conduit for passing a wire after the stone is re- may have to be extracted with the use of an Endocatch bag
moved and may help identify the ureter during the laparo- at the end of the procedure. A guide wire can be placed ret-
scopic dissection portion of the procedure. A urethral Foley rograde through the preplaced ureteral 5Fr open-ended
catheter is placed to drain the bladder and a suture used to se- catheter, followed by placement of a double-pigtail ureteral
cure the ureteral catheter, both of which are prepared into the stent. The incision in the ureter or pelvis is closed laparo-
operative field during laparoscopy. scopically with a 4-0 polyglactin suture (continuous or inter-
rupted) and a closed suction drain is left in place until
Fo r Up p e r St o ne s output subsides.
The patient is placed in a modified lateral recumbent position
with the ipsilateral side elevated with a bean bag or kidney Fo r Lo w e r St o ne s
rest. The patient is secured to the operating room table with For stones in the lower portions of the ureter, the patient may
3-inch silk tape across the chest, waist, and legs. A test air- be left in a supine position. The peritoneum is again entered at
plane roll of the table is performed to ensure the patient is the choice of the surgeon with the camera port placed at the
adequately secured. The abdomen is entered with either the umbilicus. The axis between the camera trocar and the stone
Veress needle or the H asson method, at the surgeon’s discre- is marked, and the two operating ports are then placed under
tion. Port placement is similar to that used for pyeloplasty, direct vision on either side of the body just lateral to the rectus
with the camera port placed at the umbilicus. The two operat- muscles. The surgeon stands on the contralateral side of the
ing ports can be placed either in the midline, superior and inpatient and begins the dissection at the level of the bifurcation
ferior to the umbilical port, or lateral to the midline and 45 of the common iliac vessels. The ureter is followed proximally
degrees to either side of a “ line” from the camera port toward or distally until the stone is located. The surgical procedure
the renal pelvis or ureteral stone location (1). The axis of bal- proceeds in a similar fashion as described above. For stones
ance is a line joining the camera trocar to the location of the located in the midureter, the colon may need to be mobilized
calculus. The accessory or working trocars are placed with for exposure, which may be assisted by a gentle airplaning of
this axis in mind (Fig. 135.2). the table to the contralateral side.
Po st o p e rat ive Manag e me nt

The Foley catheter is left in place for 48 hours to maintain a
low-pressure drainage of the urinary tract. This will expedite
removal of the peri-incisional drain. The ureteral stent can be
removed with the use of a cystoscope in 2 to 4 weeks.
O ut co me s
This procedure is not commonly performed and is practiced
more commonly outside the United States. Success rates of
over 94% are reported (6).
Co mp licat io ns
All standard laparoscopic surgical complications are possible,
including infection, bleeding, and conversion to an open surgi-
cal procedure. Prolonged urinary leakage and urinary stricture
are possible.
FIGURE 135.3 Appropriate position of trocars for varix ligation. The

LAPARO SCO PIC VARICO CELE array of trocars is used in either left or bilateral varix ligation. The sub-
umbilical trocar is either a H asson cannula for open laparoscopy or a
LIGATIO N standard trocar inserted following Veress needle insufflation. The oper-
ating trocars are 5.5 mm when a 5-mm clip applier is available or
Dilation of the pampiniform plexus of veins draining from the 10 mm when one must rely upon a 10.5-mm hemoclip applier.
testicles is encountered in up to 15% of the general male pop-
ulation and in 40% to 70% of men undergoing evaluation for
Two separate trocar templates exist. The first places one
infertility. Laparoscopic varicocele ligation closely resembles
port just inferior to the umbilicus and lateral to the rectus
the retroperitoneal approach first described by Palomo in
muscle on the ipsilateral side, with the second port infraumbil-
1948 (7).
ical in the midline. The second template places both operative
trocars just lateral to either edge of the rectus muscle and
slightly inferior to the umbilicus. The latter allows for bilat-
Ind icat io ns fo r Surg e ry eral procedures to be performed if necessary (Fig. 135.3).
O nce the ports are placed, attention is turned to the inter-
Indications for surgical correction include infertility with
nal inguinal ring, and the nearby iliac vessels, vas deferens,
poor-quality semen, decrease in testicular size, and chronic
and medial umbilical ligament are all identified (Fig. 135.4). If
pain or discomfort from a large varicocele. A failed previous
the colon obscures the internal ring, it should be mobilized by
attempt at retroperitoneal repair is a contraindication to la-
incising the line of Toldt or placing the patient in slight
paroscopic varicocele ligation. The ultimate choice of varico-
cele ligation method is determined by surgeon preference and Trendelenburg position. The magnification afforded by the la-
experience as well as patient-specific factors. paroscope aids in the visualization of the spermatic vessels
running beneath the peritoneum.
The peritoneum is incised lateral to the spermatic cord
Alt e rnat ive The rap y (Fig. 135.4) and the testicular artery and veins are dissected
free. If identified, the testicular artery should be preserved. Use
Several different surgical techniques have been described with of electrocautery should be restricted so as not to cause thermal
inguinal (Ivanissevitch), subinguinal microscopic (M armar– injury to the artery. The use of papaverine liquid over the ves-
Goldstein), and open retroperitoneal or high ligation tech- sels will assist in dilation of the artery, subsequent pulsations,
niques (Palomo) approaches. M icroscopic techniques are be- and easier identification of the artery. The intraoperative la-
coming more commonly used to reap the benefits of a less paroscopic Doppler probe is helpful to identify the artery.
invasive procedure and reduced incidence of hydrocele. Arterial preservation is not a requirement. The cremasteric and
Embolization of the dilated veins is sometimes utilized. deferential collateral circulations are not jeopardized by the la-
paroscopic approach and are usually sufficient to maintain the
viability of the testicle. The dissection and ligation is described
Surg ical Te chniq ue in Figures 135.5 to 135.7. The vessels may be ligated with tita-
nium clips, the endovascular stapler, or intracorporeal knot ty-
M ost surgeons utilize the transperitoneal approach, with some ing. After ligation, they are transected, completing the procedure.
reports of successful laparoscopic extraperitoneal varix liga- Alternatively, a bulk ligation of the cord with a 2-0 silk or sta-
tion. The patient is placed in a supine position and the peri- pler can be performed without regard to preserving the artery.
toneum entered at the umbilicus with either the Veress needle It may be useful to divide the cord into smaller packets without
or H asson technique. After creation of pneumoperitoneum, regard to the spermatic artery preservation.
the table is rotated, and the additional operative trocars are If scrotal emphysema is present, we eliminate it with brief
placed under direct vision. compression before final port removal. Standard laparoscopic
FIGURE 135.4 A 3- to 5-cm incision through the peritoneum is made

lateral to the spermatic vascular bundle; it extends cephalad from a
point 3 to 5 cm above the internal ring.
closure techniques are followed. Patients are discharged on the and artery-sparing procedures will last 45 to 60 minutes. A
day of surgery without restrictions in physical activity. randomized trial comparing open to laparoscopic varix liga-
tion revealed similar outcomes in terms of efficacy and
complications, but advantages in terms of pain and recovery
O ut co me s time (8). Results indicate that spermatic arterial ligation did
not influence response and did not result in testicular
O perative times vary based upon extent of operation (uni- atrophy.
lateral or bilateral), complexity of repair (artery sparing
takes longer than artery sacrifice), and laparoscopic experi- Co mp licat io ns
ence (novice takes longer than expert). With experience, Due to the age group involved, perioperative complications
non–artery-sparing procedures will last 15 to 30 minutes are very rare. Potential complications include bleeding, a need
lower extremity edema, hypertension, or hematuria may also

occur. O n the other hand, ureteral strictures may be asympto-
matic and can present with painless hydronephrosis (6,9,10).
Diag no sis
Preoperative imaging may consist of intravenous pyelography
or CT scans, typically demonstrating hydronephrosis and me-
dial deviation of the course of the ureter, either unilaterally or
bilaterally. Retrograde pyelograms performed just prior to
ureterolysis may provide updated information regarding the
course of the ureter and help identify the extent (length) of
ureteral entrapment.

Ureterolysis can be both diagnostic, allowing for biopsy of the
retroperitoneal mass, and therapeutic, allowing release of the
ureters.

FIGURE 135.5 The entire spermatic vascular bundle is mobilized
from the underlying psoas muscle. A combination of sharp and blunt
Traditionally, ureterolysis is performed by the open surgical
dissection facilitates separation of the spermatic vessels from sur- approach. M any centers will attempt a trial of steroids empir-
rounding tissues. O ne should avoid deep dissection in order to spare ically before surgical correction. M alignant RPF can some-
the underlying genitofemoral nerve crossing anterior to the psoas times be managed primarily by chemotherapy without the
muscle. need for ureterolysis (6,9).
to convert to an open procedure, infection, testis atrophy or

loss, and failure to correct the varicocele. Even with successful
correction of the varicocele (i.e., absence of a palpable varix at
Ure t e ro lysis
6 months following surgery), signs and/or symptoms that
prompted the operation (orchalgia, oligoasthenospermia) may Laparoscopic ureterolysis begins with cystoscopy and retro-
persist. grade placement of either a double-pigtail stent or a ureteral
catheter to aid in identification of the ureter during la-
paroscopy. Either a regular 5Fr open-ended or lighted catheter
LAPARO SCO PIC URETERO LYSIS may be used. To further aid ureteral delineation from the sur-
rounding dense fibrotic tissue, a super-stiff guide wire may
Ureteral stenosis or strictures can be caused by a variety of in- also be placed inside a ureteral catheter (10). Similar to la-
trinsic as well as extrinsic causes. Thus, ureteral strictures can paroscopic pyeloplasty positioning, the patient is placed in a
be caused iatrogenically, such as post-ureteroscopy or follow- lateral decubitus position with the ipsilateral side elevated to
ing other surgical procedures in close proximity to the ureter. allow gravity retraction of the bowels. If a bilateral ureteroly-
Stenosis may also be secondary to conditions such as sis (6,9,10) is planned, the patient may either be left supine or
retroperitoneal fibrosis (RPF) or extrinsic tumors. The clinical repositioned (this is recommended) after completion of the
features include flank pain, abdominal pain, renal failure, first side.
as well as signs and symptoms of urinary tract obstruction, The template for port placement will vary depending on
bacteremia, etc. the extent of fibrosis and the levels of the ureter involved. A
RPF is an inflammatory process involving the retroperi- standard pyeloplasty template (see earlier under calculus man-
toneum that results in excessive fibrosis and often causes agement) may be sufficient for isolated upper ureteral involve-
ureteral entrapment, compression, and obstruction leading to ment, but additional ports may be necessary to free the entire
hydronephrosis. The primary, idiopathic etiology accounts for ureter.
70% of the cases, with the remainder of cases occurring sec- After creating pneumoperitoneum and rotating the patient,
ondarily in response to numerous conditions, including vascu- the colon is mobilized along the white line of Toldt and al-
lar aneurysm with or without grafting; radiation exposure; lowed to fall medially. When necessary, this incision is ex-
inflammatory bowel disease; malignancy; or drug exposure, tended over the iliac vessels to allow exposure of the full
including use of beta-adrenergic blockers or ergot alkaloids. course of the ureter. Depending on the extent of RPF, the
The most common presentation is colicky flank pain from ureters are often retracted medially and may be overlying the
ureteral obstruction; however, the fibrosis may be so extreme great vessels entrapped in dense fibrous scars, making local-
as to entrap the great vessels or renal vasculature, so that ization difficult.
FIGURE 135.6 A: When performing an artery-sparing varix ligation, the vascular bundle that does not
contain the spermatic artery is ligated and then divided. For small venous aggregates or single spermatic
veins, the 5-mm reusable clip or suture ligature is utilized based on surgeon preference. A 5- to 10-cm lig-
ature is passed into the abdominal cavity. O ne end is passed from right to left under the vessels to be lig-
ated, extending only 1 cm beyond the vessels. The other end is long to facilitate instrument tie. B. The
long end is grasped by the left-hand instrument, allowing sufficient slack to permit easy wrapping around
the tip of the right-hand instrument. The instrument tie can be accomplished with two curved dissectors
with tips rotated up. Alternatively, instruments specifically designed for laparoscopic suture and ligation
may be used. C: The nonarterial vascular bundle is ligated. D: The spermatic veins are divided between
ligatures.
as the underlying cause of the fibrosis, and multiple biopsies

are taken from periureteral tissues and sent for both frozen
and permanent analysis.
Laparoscopic ureterolysis is also amenable to hand-assisted
laparoscopic approaches and has also been reported using
robotic techniques. The principles of ureterolysis can be fol-
lowed with the use of the intra-abdominal hand to assist in
identification and dissection of the ureter (9).
Manag e me nt o f Ure t e ral St rict ure s

For benign, iatrogenic or idiopathic ureteral strictures, the
strictured ureteral segment is excised. Caution should be exer-
cised around the iliac vessels and the inferior vena cava so as
to prevent vascular injury. The ureteral ends are then spatu-
lated. The posterior walls of the ureteral ends are anasto-
mosed using 4-0 polyglactin sutures. A ureteral stent is then
placed in a retrograde fashion utilizing the 5Fr open-ended
ureteral catheter, which is removed after a guide wire is placed
through it. The anterior end-to-end anastomosis of the
ureteral ends is now completed. A closed-suction drain is
placed. A Foley catheter drains the bladder postoperatively to
maintain a low-pressure urinary drainage system.
If the ureteral stricture is long, and if the anastomosis is
under tension, then the management strategy may involve
further laparoscopic ureterolysis to ensure a tension-free
anastomosis. Rarely, one may have to utilize procedures such
as nephropexy to enable a tension-free end-to-end ureter-
oureterostomy.
FIGURE 135.7 Upon completion of the procedure, all spermatic
veins have been ligated and divided by either clip or suture. O nly the
spermatic artery or arteries remain, and arterial patency is docu- Po st o p e rat ive Manag e me nt
mented by Doppler.
The Foley catheter is usually left indwelling for 48 hours. The
drain is kept in place for another day or two, then removed.
If a ureteral catheter was placed, gentle manipulation may The indwelling stent is removed using a flexible cystoscope
help locate the ureter. Alternatively, the distal ureter may be 4 to 6 weeks postoperatively. Postoperative imaging is recom-
encountered medial to the medial umbilical ligament and mended to evaluate for any residual or silent recurrence of the
traced proximally, or the proximal ureter may be isolated at hydronephrosis.
the ureteropelvic junction and dissected distally. O nce posi-
tively identified, a window is created around the ureter and
vascular tape or a vessel loop is placed around to allow retrac- O ut co me s
tion without undue manipulation of the ureter. Combinations
of blunt, sharp, and electrocautery dissection are necessary to A recent multicenter review indicated overall success rates of
liberate the ureter from surrounding fibrosis, although the lat- 83% per renal unit (6). This was confirmed by follow-up
ter should be used sparingly to avoid vascular compromise. imaging in these cases. O ther institutional series are also fa-
For patients with RPF, after the ureter is mobilized, it should vorable (6,9,11).
be intraperitonealized, and after this is accomplished, the pos-
terior peritoneum is closed with clips or preferably with su- Co mp licat io ns
tures. If a ureteral catheter was placed at the onset, it should Any complication that can be associated with laparoscopy, in-
be exchanged for an indwelling self-retaining ureteral stent at cluding conversion to an open procedure, has been reported.
this time. Special efforts must be made to rule out malignancy O ne series reported a conversion rate to open of 17.6% (11).
References
1. M atlaga BR, Assimos DG. Changing indications of open stone surgery. 5. M icali S, M oore RG, Averch TD, et al. The role of laparoscopy in the man-
Urology 2002;59:490–493. agement of renal and ureteral calculi. J Urol 1997;157:463–466.
2. Paik M L, Wainstein M A, Spirnak JP, et al. Current indications for open 6. Duchene DA, Winfield H N , Cadeddu JA, et al. M ulti-institutional survey
stone surgery in the treatment of renal and ureteral calculi. J Urol 1998; of laparoscopic ureterolysis for retroperitoneal fibrosis. Urology 2007;
159:374–379. 69(6):1017–1021.
3. Gaur DD. Retroperitoneal laparoscopic ureterolithotomy. W orld J Urol 7. Palomo A. Radical cure of varicocele by a new technique: preliminary re-
1993;11:175–177. port. J Urol 1948;61:604–607.
4. Goel A, H amal AK. Upper and mid-ureteric stones: a prospective unran- 8. Podkamenev VV, Stalmakhovich VN , Urkov PS, et al. Laparoscopic
domized comparison of retroperitoneoscopic and open ureterolithotomy. surgery for pediatric varicoceles: randomized controlled trial. J Pediatr
BJU Int 2001;88:679–682. Surg 2002;37:727–729.
9. Brown JA, Garlitz CJ, H ubosky SG, et al. H and-assisted laparoscopic 14. Elashry O M , N akada SY, Wolf JS Jr, et al. Ureterolysis for extrinisic ureter
ureterolysis to treat ureteral obstruction secondary to idiopathic retroperi- obstruction: a comparison of laparoscopic and open surgical techniques. J
toneal fibrosis: assessment of a novel technique and initial series. Urology Urol 1996;156(4):1403–1410.
2006;68(1):46–49. 15. Fugita O E, Jarrett TW, Kavoussi P, et al. Laparoscopic treatment of
10. Kavoussi LR, Clayman RV, Brunt LM , et al. Laparoscopic ureterolysis. retroperitoneal fibrosis. J Endourol 2002;16:571–574.
J Urol 1992;147:426–429. 16. Gad El-M oula M , Abdallah A, El-Anany F, et al. Laparoscopic
11. Srinivasan AK, Richstone L, Permpongkosol S, et al. Comparison of la- ureterolithotomy: our experience with 74 cases. Int J Urol 2008;15(7):
paroscopic with open approach for ureterolysis in patients with retroperi- 593–597.
toneal fibrosis. J Urol 2008;179(5):1875–1878. 17. Puppo B, Carmiginani G, Gallucci M , et al. Bilateral laparoscopic ureterol-
12. Atug F, Woods M , Burgess S, et al. Robotic pyeloplasty in children. J Urol ysis. Eur Urol 1994;25(1):82–84.
2005;174:1440–1442. 18. Soper M J, Barteau JA, Clayman RV, et al. Comparison of early postopera-
13. Clayman RV, Kavoussi LR, Soper M J, et al. Laparoscopic nephrectomy. tive results for laparoscopic versus standard open cholecystectomy. Surg
Initial case report. J Urol 1991;146:278–282. G ynecol O bstet 1992;174:114–118.
SECTIO N X ■ NEW FRO NTIERS
THO MAS W. JARRETT
CHAPTER 136 ■ TISSUE-ENGINEERING STRATEGIES

FO R URO GENITAL REPAIR
ANTHO NY ATALA
Congenital disorders, cancer, trauma, infection, inflammation, tissues in the body. They may serve as simple cell carriers, or
iatrogenic injuries, or other conditions of the genitourinary they can provide structural support for tissue formation.
system can lead to organ damage or complete loss of function. Biomaterials can be fabricated from synthetic materials, natu-
M ost of these situations require eventual reconstructive proce- rally derived substances, or both combined, and they can be
dures. These procedures can be performed with native configured into liquid, gel, or solid forms depending on the
nonurologic tissues (skin, gastrointestinal segments, or mu- specific needs. These substances facilitate the localization and
cosa), homologous tissues from a donor (cadaver or living delivery of cells to desired sites in the body as well as define a
donor kidney), heterologous tissues or substances (bovine col- three-dimensional space for the formation of new tissues with
lagen), or artificial materials (silicone, polyurethane, Teflon). appropriate structure. They also serve as a guide for the devel-
H owever, these materials often lead to complications after re- opment of new tissues with appropriate function (32,33).
construction. The implanted tissue is sometimes rejected, and Direct injection of cell suspensions without a biomaterial car-
often the inherently different functional aspects of the differ- rier has been attempted, but without this specialized scaffold
ent tissues or materials used in the reconstruction cause a mis- function, it is difficult to control the localization of trans-
match in the system. As an example, current methods of planted cells (13,55). Furthermore, bioactive signals, such as
replacing bladder tissue with gastrointestinal segments can be cell-adhesion peptides and growth factors, can be incorpo-
problematic due to the opposite ways in which these two tis- rated along with cells to help regulate cellular function (33).
sues handle solutes; urologic tissue normally excretes materi- Cell behavior in the newly formed tissue can be regulated by
als, but gastrointestinal tissue generally absorbs the same multiple interactions of the cells with their microenvironment,
materials, and this type of mismatch can lead to metabolic including interactions with cell-adhesion ligands and with sol-
complications as well as infection. The replacement of lost or uble growth factors (29). Some materials are designed to carry
deficient urologic tissues with functionally equivalent ones these factors into the body and release them at a specified rate
would improve the outcome of reconstructive surgery in the to assist the cells in the organizational process.
genitourinary system. This may soon be possible with novel The ideal biomaterial should be biocompatible, promote
tissue-engineering techniques. cellular interaction and tissue development, and possess similar
mechanical and physical properties to the tissue to be generated
so that the nascent tissue will be able to withstand in vivo
TISSUE-ENGINEERING BASICS forces. Generally, three classes of biomaterials have been used
for the engineering of genitourinary tissues: naturally derived
Tissue engineering uses the principles of cell transplantation, materials, such as collagen and alginate; acellular tissue matri-
materials science, and biomedical engineering to develop bio- ces, such as bladder submucosa and small intestinal submu-
logical substitutes that can restore and maintain the normal cosa; and synthetic polymers, such as polyglycolic acid (PGA),
function of damaged or lost tissues and organs. It can involve polylactic acid (PLA), and polylactic (PLGA). While synthetic
injection of functional cells into a nonfunctional site to stimu- polymers can be produced reproducibly on a large scale
late regeneration, or it may involve the use of biomaterials. with controlled properties of strength, degradation rate, and
These are natural or synthetic matrices, often termed scaf- microstructure, naturally derived materials and acellular tissue
folds, that encourage the body’s natural ability to repair itself matrices have the potential advantage of biologic recognition,
and assist in determination of the orientation and direction of which can lessen host-versus-graft reactions.
new tissue growth. O ften, tissue engineering uses a combina-
tion of both of these techniques. For example, biomaterial ma-
trices seeded with cells can be implanted into the body to Ce lls fo r Uro g e nit al Tissue -Eng ine e ring
encourage the growth or regeneration of functional tissue. Ap p licat io ns
O ften, when cells are used for tissue engineering, donor tissue
Bio mat e rials Use d in Ge nit o urinary is removed and dissociated into individual cells, which are ei-
Tissue Co nst ruct io n ther implanted directly into the host or expanded in culture,
attached to a support matrix, and then implanted. The im-
Biomaterials in genitourinary tissue engineering function as an planted tissue can be heterologous, allogeneic, or autologous.
artificial extracellular matrix (ECM ) and are used to replace Ideally, this approach allows lost tissue function to be restored
biologic and mechanical functions of native ECM found in or replaced in toto with limited complications (1–4,6,7).
905
906 Se ct io n X: Ne w Frontie rs
Autologous cells are the ideal choice, as their use circum- cells have been maintained in the undifferentiated state for at
vents many of the inflammatory and rejection issues associ- least 80 passages when grown using current published proto-
ated with a nonself donor. H owever, one limitation of cols (69). In addition, many protocols for differentiation into
cell-based tissue-engineering techniques has been the difficulty specific cell types in culture have been published. H owever,
of growing specific cell types in large quantities. Even when many uses of these cells have been controversial in the United
certain organs, such as the liver, have a high regenerative ca- States due to the ethical dilemmas that are associated with the
pacity in vivo, in vitro expansion of cells derived from these manipulation of embryos in culture.
organs has proved to be difficult. H owever, the discovery of Adult stem cells have the advantage of avoiding some of
privileged sites for committed precursor cells in specific organs the ethical issues associated with embryonic cells, and, unlike
and extensive study of the conditions that promote precursor embryonic cells, they do not transdifferentiate into a malig-
cell maintenance and differentiation within these sites have be- nant phenotype, so there is a diminished risk of teratoma for-
gun to overcome some of the limitations associated with cell mation should the cells be implanted in vivo. H owever, adult
expansion in vitro. Urothelial cells that are present in the blad- stem cells are limited for clinical use because expansion to the
der, for instance, have been grown in culture in the past, but large quantities needed for tissue engineering is difficult.
only with limited success. H owever, several novel culture pro- Fetal stem cells derived from amniotic fluid and placentas
tocols have been developed over the past two decades that al- have recently been described and represent a novel source of
low the maintenance of urothelial precursor cells in an stem cells (19,20). The cells express markers consistent with
undifferentiated state. As these cells can remain in the growth human ES cells, such as octamer-4 (O CT4) and stage-specific
phase, the ability to expand urothelial cultures is vastly im- embryonic antigen-4 (SSEA-4), but they do not form teratomas.
proved (18,42,58,62). These studies suggest that it may be The cells are multipotent and are able to differentiate into cells
possible to collect autologous urothelial cells from human from all three germ layers. In addition, the cells have a high
bladders, expand them in culture, and return them to the replicative potential and could be stored for future use, without
donor in sufficient quantities for reconstructive purposes the risks of rejection and without ethical concerns.
(18,23,42,43,48,58). In addition to urothelial cells, methods N uclear transfer, or cloning, can serve as another source of
to induce the in vitro expansion of a variety of primary human pluripotent “ stem” cells that could possibly be used for regen-
cells have been developed, making the use of autologous cells erative medicine therapies. Two types of cloning procedures ex-
for clinical applications a real possibility, though there are still ist: reproductive cloning and therapeutic cloning. Banned in
hurdles to overcome. most countries for human applications, reproductive cloning is
Another major concern has been that, in cases where cells used to generate an embryo that has identical genetic material
must be expanded from a diseased organ, there may no longer as its cell source. This embryo is then implanted into the uterus
be enough normal cells present in that organ to begin the of a pseudopregnant female to give rise to an infant that is a
process. Recent research suggests that this may not be the clone of the donor. While therapeutic cloning also produces an
case, however. For example, one study has shown that cul- embryo that is genetically identical to the donor nucleus, this
tured neuropathic bladder smooth muscle cells possess and process is used to generate blastocysts that are explanted and
maintain different characteristics than normal smooth muscle grown in culture, rather than in utero, to produce ES cell lines.
cells in vitro, as demonstrated by growth assays, contractility, These autologous stem cells have the potential to become
and adherence tests in vitro (44). Despite these differences, almost any type of cell in the adult body, and thus would be
when neuropathic smooth muscle cells were cultured in vitro useful in tissue and organ replacement applications (25).
and then seeded onto matrices and implanted in vivo, the Therefore, therapeutic cloning, which has also been called so-
tissue-engineered constructs showed the same properties as matic cell nuclear transfer, may provide an alternative source of
the constructs engineered with normal cells (37). It is now transplantable cells that are identical to the patient’s own cells.
known that genetically normal progenitor cells, which are the Recently, exciting reports have been published of the suc-
reservoirs for new cell formation, are present even in diseased cessful transformation of adult cells into pluripotent stem cells
tissue. These normal progenitors are programmed to give rise through a type of genetic “ reprogramming.” Reprogramming
to normal tissue, regardless of whether they reside in a normal is a technique that involves dedifferentiation of adult somatic
or diseased environment. Therefore, the stem cell niche and cells to produce patient-specific pluripotent stem cells, without
its role in normal tissue regeneration remains a fertile area of the use of embryos. Cells generated by reprogramming would
ongoing investigation. be genetically identical to the somatic cells (and thus, the pa-
tient who donated these cells) and would not be rejected.
St e m Ce lls and O t he r Plurip o t e nt Ce ll Typ e s Takahashi and Yamanka were the first to discover that mouse
M ost current strategies for tissue engineering depend upon a embryonic fibroblasts (M EFs) and adult mouse fibroblasts
sample of autologous cells from the diseased organ of the could be reprogrammed into an “ induced pluripotent state
host. In some instances, primary autologous human cells can- (iPS)” (67). Takahashi and Yamanaka were the first to discover
not be expanded from a particular organ, such as the pan- 24 genes that were thought to be important for ES cells and
creas. In these situations, pluripotent human stem cells are identified 4 key genes that were required to bestow ES cell–like
envisioned to be an ideal source of cells, as they can differenti- properties on fibroblasts: O ct3/4, Sox2, c-M yc, and Klf4.
ate into nearly any replacement tissue in the body. M ouse embryonic fibroblasts and adult fibroblasts were co-
Embryonic stem (ES) cells exhibit two remarkable proper- transduced with retroviral vectors, each carrying one of the
ties: the ability to proliferate in an undifferentiated but still 4 genes, and transduced cells were selected via drug resistance.
pluripotent state (self-renewal), and the ability to differentiate The resultant iPS cells possessed the immortal growth charac-
into a large number of specialized cell types (14). They can be teristics of self-renewing ES cells, expressed genes specific for
isolated from the inner cell mass of the embryo during the ES cells, and generated embryoid bodies in vitro and teratomas
blastocyst stage, which occurs 5 days after fertilization. These in vivo. When iPS cells were injected into mouse blastocysts,
Chap t e r 136: Tissue -Eng ine e ring Strate g ie s for Urog e nital Re p air 907
they contributed to a variety of cell types. H owever, although Although this is an exciting phenomenon, it is unclear why
iPS cells selected in this way were pluripotent, they were not reprogramming of adult fibroblasts and reprogramming of
identical to ES cells. Unlike ES cells, chimeras made from iPS mesenchymal stromal cells have similar efficiencies (67). It
cells did not result in full-term pregnancies. Gene expression would seem that cells that are already multipotent could be re-
profiles of the iPS cells showed that they possessed a distinct programmed with greater efficiency, since the more undiffer-
gene expression signature that was different from that of ES entiated the donor nucleus, the better somatic cell nuclear
cells. In addition, the epigenetic state of the iPS cells was some- transfer (SN CT) performs (12). This further emphasizes our
where between that found in somatic cells and that found in ES limited understanding of the mechanism of reprogramming,
cells, suggesting that the reprogramming was incomplete. yet the potential for this area of study is exciting.
These results were improved significantly by Wernig and
Jaenisch in July 2007 (70). Fibroblasts were infected with
retroviral vectors and selected for the activation of endoge- APPLICATIO N O F TISSUE
nous O ct4 or N anog genes. Results from this study showed ENGINEERING TO SPECIFIC
that DN A methylation, gene expression profiles, and the chro-
matin state of the reprogrammed cells were similar to those of
URO LO GICAL PRO BLEMS
ES cells. Teratomas induced by these cells contained differenti-
ated cell types representing all three embryonic germ layers. Inje ct ab le (Ce ll) The rap ie s
M ost importantly, the reprogrammed cells from this experi-
ment were able to form viable chimeras and contribute to the Inje ct ab le Cho nd ro cyt e s
germ line like ES cells, suggesting that these iPS cells were Vesicoureteral reflux (VUR) and stress urinary incontinence
completely reprogrammed. Wernig et al. (70) observed that (SUI) are two urologic conditions that can result from dys-
the number of reprogrammed colonies increased when drug function of a specific sphincter muscle. When severe, these
selection was initiated later (day 20 rather than day 3 post- conditions are repaired surgically. H owever, cell-based thera-
transduction). This suggests that reprogramming is a slow and pies for both VUR and incontinence would be an important
gradual process and may explain why previous attempts re- alternative to surgical repair of these conditions. Ideally, such
sulted in incomplete reprogramming. a therapy would be easily administered by injection and well
It has recently been shown that reprogramming of human tolerated by the patient. Currently, the injection of bulking
cells is possible (66,78). Takahashi and Yamanaka (67) agents such as Teflon paste is used clinically to treat VUR in
showed that retrovirus-mediated transfection of O ct3/4, Sox2, particular, but the biocompatibility of synthetic bulking agents
Klf4 and c-M YC generates human iPS cells that are similar to over the long term is a concern. The ideal substance for endo-
human embryonic stem (hES) cells in terms of morphology, scopic treatment of reflux and incontinence should be in-
proliferation, gene expression, surface markers, and teratoma jectable, nonantigenic, nonmigratory, volume-stable, and safe
formation. Thomson’s group (78) showed that retroviral for human use.
transduction of O ct4, Sox2, N anog, and LIN 28 could gener- Toward this goal, long-term studies were conducted to de-
ate pluripotent stem cells without introducing any oncogenes termine the effects of injectable chondrocytes for the treat-
(c-M YC). Both studies showed that human iPS cells were sim- ment of VUR in vivo (3). Chondrocytes were chosen because
ilar but not identical to hES cells. the use of autologous cartilage for the treatment of VUR in
Another concern is that these iPS cells contain three to six humans would satisfy all of the requirements for an ideal in-
retroviral integrations (one for each factor), which may injectable cell-based therapy. Chondrocytes derived from an ear
crease the risk of tumorigenesis. O kita et al. (52) studied the biopsy can be readily grown and expanded in culture.
tumor formation in chimeric mice generated from N anog-iPS N eocartilage formation can be achieved in vitro and in vivo
cells and found that 20% of the offspring developed tumors using chondrocytes cultured on synthetic biodegradable poly-
due to the retroviral expression of c-myc. An alternative ap- mers. In the VUR experiments, chondrocytes were suspended
proach would be to use a transient expression method, such as in an alginate matrix and injected around the vesicoureteral
adenovirus-mediated system, since both Jaenisch and sphincter. In time, normal cartilage replaced the alginate as the
Yamanaka showed strong silencing of the viral-controlled alginate slowly degraded. This system was then adapted for
transcripts in iPS cells (47,52). This indicates that these viral the treatment of VUR in a porcine model (6). These studies
genes are only required for the induction, not the mainte- show that chondrocytes can be easily harvested and combined
nance, of pluripotency. with alginate in vitro, that the suspension can be easily injected
Another concern is the use of transgenic donor cells for re- cystoscopically, and that the elastic cartilage tissue formed is
programmed cells in the mouse studies. In both mouse studies, able to correct VUR without any evidence of obstruction.
iPS cells were isolated by selecting for the activation of a drug- Two multicenter clinical trials were conducted using this
resistant gene inserted into endogenous Fbx15, O ct3/4, or engineered chondrocyte technology. First, patients with VUR
N anog. The use of genetically modified donors hinders its clini- were treated at ten centers throughout the United States. The
cal applicability for humans. To assess whether iPS cells can be patients had a similar success rate as with other injectable
derived from genetically unmodified donor cells, murine embry- substances in terms of cure. Cartilage formation was not
onic fibroblast (M EF) and adult skin cells were retrovirally noted in patients with treatment failure. Patients who were
transduced with O ct3/4, Sox2, c-M yc, and Klf4 and ES–like cured probably had a biocompatible region of engineered au-
colonies were isolated by morphology, without the use of drug tologous tissue present (22). Secondly, patients with urinary
selection for O ct4 or N anog (47). iPS cells from unmodified incontinence were treated endoscopically with injected chon-
donor cells formed teratomas and generated live chimeras. drocytes at three different medical centers. Phase 1 trials
This study suggests that genetically modified donor cells are not showed an approximate success rate of 80% at 3 and 12
necessary to generate iPS cells. months postoperatively (9).
Inje ct ab le Muscle Ce lls testicular dysfunction consists of periodic intramuscular injec-

The potential use of injectable, cultured myoblasts for the tions of chemically modified testosterone or application of a
treatment of SUI has been investigated (15,73). In one study, transdermal testosterone patch. H owever, long-term nonpul-
labeled myoblasts were directly injected into the proximal ure- satile testosterone therapy is not optimal and can cause multi-
thra and lateral bladder walls with a microsyringe in an open ple problems, including erythropoiesis and bone density
surgical procedure. Tissue harvested up to 35 days postinjec- changes.
tion contained the labeled myoblasts, as well as evidence of A system was designed wherein Leydig cells were microen-
differentiation into regenerative myofibers. This study shows capsulated for controlled testosterone replacement. Purified
that a significant portion of the injected myoblast population Leydig cells were isolated and encapsulated in an alginate-
survived and remained in vivo. Similar techniques of sphincter- poly-L-lysine solution. The encapsulated Leydig cells were in-
derived muscle cells have been used for the treatment of uri- jected into castrated animals, and serum testosterone was
nary incontinence in a pig model (64). The fact that cultured measured serially; the animals were able to maintain testos-
myoblasts survive after injection and mature into muscle tis- terone levels in the long term (45). These studies suggest that
sue supports the feasibility of using culture-expanded cells of microencapsulated Leydig cells may be able to replace or sup-
muscular origin as an injectable bioimplant. plement testosterone in situations where anorchia or testicular
The use of injectable muscle precursor cells has also been in- failure is present.
vestigated for use in the treatment of urinary incontinence due
to irreversible urethral sphincter injury or developmental de-
fects. M uscle precursor cells are the quiescent satellite cells
found in each myofiber that can proliferate to form myoblasts Tissue The rap y: Eng ine e ring Co mp le t e
and eventually myotubes and new muscle tissue. Intrinsic mus- St ruct ure s in t he Ge nit o urinary Tract
cle precursor cells have previously been shown to play an active
role in the regeneration of injured striated urethral sphincter
(71). In a subsequent study, autologous muscle precursor cells Ure t hra
were injected into a rat model of urethral sphincter injury, and Various strategies have been proposed over the years for the
both replacement of mature myotubes and restoration of func- regeneration of urethral tissue. Woven meshes of PGA
tional motor units were noted in the regenerating sphincter (Dexon) have been used to reconstruct urethras in dogs
muscle tissue (72). This is the first demonstration of the re- (53). Also, PGA has been used as a cell transplantation vehicle
placement of both sphincter muscle tissue and its innervation to engineer tubular urothelium in vivo (7). Small intestinal
by the injection of muscle precursor cells. This suggests the pos- submucosa (SIS) without cells was used as an onlay patch
sibility that muscle precursor cells may be a minimally invasive graft for urethroplasty in rabbits (35). Finally, a homologous
solution for urinary incontinence in patients with irreversible graft of acellular urethral matrix was also used in a rabbit
urinary sphincter muscle insufficiency. model (63).
In addition, injectable muscle-based gene therapy and tis- Bladder-derived acellular collagen matrix has proven to be
sue engineering were combined to improve detrusor function a suitable graft for repair of urethral defects in rabbits. In the
in a bladder injury model, and this may be a novel treatment rabbit model, the neourethras created with these matrices
option for urinary incontinence (26). demonstrated a normal urothelial luminal lining and orga-
nized muscle bundles shortly after repair (35,63). These re-
sults were confirmed clinically in a series of patients with a
Inje ct ab le Le yd ig Ce lls history of failed hypospadias reconstruction, wherein the
Patients with testicular dysfunction require androgen replace- urethral defects were repaired with human bladder acellular
ment for somatic development. Conventional treatment for collagen matrices (Fig. 136.1) (5,16). O ne of the advantages
FIGURE 136.1 Tissue engineering of the urethra using a

collagen matrix. A: Representative case of a patient with
a bulbar stricture. B: Urethral repair. The strictured tissue is
excised, preserving the urethral plate (left), and the matrix is
anastomosed to the urethral plate in an onlay fashion on the
right. C: Urethrogram 6 months after repair. D: Cystoscopic
view of urethra before surgery (left) and 4 months after
repair (right).
of this material over nongenital tissue grafts currently used for the urinary tract (11,24). An example of this strategy is the
urethroplasty (e.g., buccal mucosa) is that the material is “ off combination of the techniques of autoaugmentation with
the shelf.” This eliminates the necessity of additional surgical those of enterocystoplasty. An autoaugmentation is performed
procedures for graft harvesting, which may decrease operative and the diverticulum is covered with a demucosalized gastric
time, as well as the potential morbidity due to the harvest or intestinal segment.
procedure.
The previous techniques, using nonseeded acellular matri-
Matrices for Bladder Regeneration. N onseeded allogeneic
ces, were successfully applied experimentally and clinically for
acellular matrices have served as scaffolds for the ingrowth of
onlay urethral repairs. H owever, when tubularized urethral re-
host bladder wall components. The matrices are prepared by
pairs were attempted experimentally, adequate urethral tissue
mechanically and chemically removing all cellular compo-
regeneration was not achieved and complications ensued, such
nents from bladder tissue (54,57,65,75). The matrices serve as
as graft contracture and stricture formation (41). Tubularized
vehicles for partial bladder regeneration, and relevant anti-
collagen matrices seeded with cells have performed better in
genicity is not evident. O ne example is SIS, a biodegradable,
animal studies. In a rabbit model, entire urethral segments
acellular, xenogeneic collagen-based tissue matrix. SIS was
were resected and urethroplasties were performed with tubu-
first used in the early 1980s as an acellular matrix for tissue
larized collagen matrices either seeded with autologous cells
replacement in the vascular field. It has been shown to pro-
or without cells. The tubularized collagen matrices seeded
mote regeneration of a variety of host tissues, including blood
with autologous cells formed new tissue that was histologi-
vessels and ligaments (8). Animal studies have shown that the
cally similar to native urethral tissue (59). The tubularized col-
nonseeded SIS matrix used for bladder augmentation is able to
lagen matrices without cells led to poor tissue development,
regenerate in vivo (34,36).
fibrosis, and stricture formation.
In multiple studies using various materials as nonseeded
grafts for cystoplasty, the urothelial layer was able to regener-
Blad d e r ate normally, but the muscle layer, although present, was not
fully developed (36,57,65,75). O ften the grafts contracted to
Currently, gastrointestinal segments are commonly used for
60% to 70% of their original size with little increase in bladder
bladder replacement or repair. H owever, gastrointestinal tis-
capacity or compliance (39,56). Studies involving acellular ma-
sues are designed to absorb solutes that urinary tissue ex-
trices that may provide the necessary environment to promote
cretes, and due to this difference in function, multiple
cell migration, growth, and differentiation are being con-
complications may ensue, such as infection, metabolic distur-
ducted. Recently, bladder regeneration has been shown to be
bances, urolithiasis, perforation, increased mucus production,
more reliable when the SIS was derived from the distal ileum
and malignancy (30,31,46). Because of the problems encoun-
(34). With continued research in this area, these matrices may
tered with the use of gastrointestinal segments, numerous in-
have a clinical role in bladder replacement in the future.
vestigators have attempted alternative reconstructive
procedures for bladder replacement or repair. The use of tissue
expansion, seromuscular grafts, matrices for tissue regenera- Bladder Replacement Using Tissue Engineering. Cell-seeded
tion, and tissue engineering with cell transplantation has been allogeneic acellular bladder matrices have been used for blad-
investigated. der augmentation in dogs. A group of experimental dogs un-
derwent a trigone-sparing cystectomy and were randomly
assigned to one of three groups. O ne group underwent closure
Tissue Expansion for Bladder Augmentation. A system of
of the trigone without a reconstructive procedure, another un-
progressive dilation for ureters and bladders has been pro-
derwent reconstruction with a nonseeded bladder-shaped
posed as a method of bladder augmentation but has not yet
biodegradable scaffold, and the last underwent reconstruc-
been attempted clinically. Augmentation cystoplasty per-
tion using a bladder-shaped biodegradable scaffold that
formed with dilated ureteral segments in animals has resulted
was seeded with autologous urothelial and smooth muscle
in an increased bladder capacity ranging from 190% to 380%
cells (50).
(38,61). A system for the progressive expansion of native
The cystectomy-only and nonseeded controls maintained
bladder tissue has also been used for augmenting bladder
average capacities of 22% and 46% of preoperative values,
volumes in animals. Within 30 days after progressive dilation,
respectively. H owever, an average bladder capacity of 95% of
the neoreservoir volume was expanded at least tenfold.
the original precystectomy volume was achieved in the cell-
Urodynamic studies showed normal compliance in all ani-
seeded tissue-engineered bladder replacements (Fig. 136.2).
mals, and microscopic examination of the expanded neoreser-
The subtotal cystectomy reservoirs that were not recon-
voir tissue showed a normal histology. A series of
structed and the polymer-only reconstructed bladders showed
immunocytochemical studies demonstrated that the dilated
a marked decrease in bladder compliance (10% and 42% to-
bladder tissue maintained normal phenotypic characteris-
tal compliance, respectively). The compliance of the cell-
tics (61).
seeded tissue-engineered bladders was almost no different
from preoperative values (106% ). H istologically, the non-
Seromuscular Grafts and De-epithelialized Bowel Segments. seeded scaffold bladders presented a pattern of normal urothe-
Seromuscular grafts and deepithelialized bowel segments, either lial cells with a thickened fibrotic submucosa and a thin layer
alone or over a native urothelium, have also been attempted of muscle fibers. The retrieved tissue-engineered bladders
(10,11,17,24,51,60). Keeping the urothelium intact avoids the showed a normal cellular organization consisting of a trilayer
complications associated with use of bowel in continuity with of urothelium, submucosa, and muscle (50).
FIGURE 136.2 Gross specimens and cystograms at 11 months

of the cystectomy-only, nonseeded controls, and cell-seeded
tissue-engineered bladder replacements in dogs. The cystec-
tomy-only bladder had a capacity of 22% of the preoperative
value and a decrease in bladder compliance to 10% of the pre-
operative value. The nonseeded controls showed significant
scarring with a capacity of 46% of the preoperative value and a
decrease in bladder compliance to 42% of the preoperative
value. An average bladder capacity of 95% of the original
precystectomy volume was achieved in the cell-seeded tissue-
engineered bladder replacements, and the compliance showed
almost no difference from preoperative values that were mea-
sured when the native bladder was present (106% ).
A clinical experience involving engineered bladder tissue Ex Vivo Functioning Renal Units. Dialysis is currently the
for cystoplasty reconstruction was conducted starting in 1999. most common form of renal replacement therapy. H owever,
A small pilot study of seven patients was reported, using a the relatively high morbidity and mortality resulting from
collagen scaffold seeded with cells either with or without this process have spurred investigators to seek alternative
omentum coverage, or a combined PGA-collagen scaffold solutions. In an attempt to assess the viability and physiologic
seeded with cells and omental coverage (Fig. 136.3). The pa- functionality of a cell-seeded device to replace the filtration,
tients reconstructed with the engineered bladder tissue created transport, metabolic, and endocrinologic functions of the
with the PGA-collagen cell-seeded scaffolds showed increased kidney, a synthetic hemofiltration device and a device that
compliance, decreased end-filling pressures, increased capaci- contained tissue-engineered porcine renal tubules were incor-
ties, and longer dry periods (2). Although the experience is porated into an extracorporeal perfusion circuit, and this was
promising in terms of showing that engineered tissues can be introduced into acutely uremic dogs. Levels of potassium and
implanted safely, it is just a start in terms of accomplishing the blood urea nitrogen (BUN ) were controlled during treatment
goal of engineering fully functional bladders. Further experi- with the device. The fractional reabsorption of sodium and
mental and clinical work is being conducted. water was possible. Active transport of potassium, bicarbon-
ate, and glucose, as well as a gradual ability to excrete ammo-
nia, was observed. These results demonstrated the feasibility
Kid ne y of an extracorporeal assist device that is reinforced by the use
The kidney is the most challenging organ in the genitouri- of proximal tubular cells (27).
nary system to reconstruct because of its extremely complex Using similar techniques, the development of a tissue-
structure and function. Concepts for a bioartificial kidney engineered bioartificial kidney consisting of a conventional
are currently being explored. Some investigators are pursu- hemofiltration cartridge in series with a renal tubule assist
ing the replacement of isolated kidney function parameters device containing human renal proximal tubule cells was used
using extracorporeal units, while others are aiming to rein patients with acute renal failure in the intensive care unit.
place total renal function with tissue-engineered bioartificial The initial clinical experience with this bioartificial kidney
renal structures. suggests that renal tubule cell therapy may provide a dynamic
FIGURE 136.3 Construction of an engineered human blad-

der. A: The engineered bladder anastomosed to native bladder
tissue with running 4-0 polyglycolic sutures. B: Implanted
bladder covered with fibrin glue and omentum.
FIGURE 136.4 Combining therapeutic cloning and tissue engi-

neering to produce kidney tissue. A: Illustration of the tissue-
engineered renal unit. B: Renal unit seeded with cloned cells, 3
months after implantation, showing the accumulation of urine-
like fluid. C: There was a clear unidirectional continuity between
the mature glomeruli, their tubules, and the polycarbonate mem-
brane. D: Elispot analyses of the frequencies of T cells that
secrete IFN -gamma after primary and secondary stimulation
with allogeneic renal cells, cloned renal cells, or nuclear donor
fibroblasts.
and individualized treatment program as assessed by acute period. H owever, mating activity in the animals with the cell-
physiologic and biochemical indices (28). seeded corpora appeared normal by 1 month after implanta-
tion. The presence of sperm was confirmed during mating,
Creation of Functional Renal Structures in Vivo. Another ap- and sperm was present in all rabbits with the engineered
proach to improve renal function involves the augmentation corpora. The female rabbits that mated with the animals
of renal tissue with kidney cells expanded in vitro and used for implanted with engineered corpora conceived and delivered
subsequent autologous transplantation. M ost recently, an at- healthy pups. Animals implanted with the matrix alone were
tempt was made to reconstitute renal epithelial cells for the unable to demonstrate normal mating activity and failed to
generation of functional nephron units. Renal cells were har- ejaculate into the vagina (74,76).
vested and expanded in culture. The cells were seeded onto a
tubular device constructed from a polycarbonate membrane, Engineered Penile Prostheses. Although silicone is an ac-
which was connected at one end to a Silastic catheter that ter- cepted biomaterial for penile prostheses, biocompatibility is a
minated in a reservoir. The device was implanted in athymic concern (49,68). Use of a natural prosthesis composed of au-
mice. H istologic examination of the implanted devices over tologous cells may be advantageous. In a recent study, the fea-
time revealed extensive vascularization with formation of sibility of applying engineered cartilage rods in situ was
glomeruli and highly organized tubulelike structures. investigated (77). Autologous chondrocytes were harvested
Immunocytochemical staining confirmed the renal phenotype. from rabbit ear and expanded in culture. The cells were
Additionally, yellow fluid was collected from inside the im- seeded onto biodegradable poly-L-lactic acid–coated polygly-
plant, and its creatinine and uric acid concentrations were colic acid polymer rods and then implanted into the corporal
consistent with the makeup of dilute urine. Further studies spaces of rabbits. Examination at retrieval showed the pres-
have shown the formation of renal structures in cows using ence of well-formed, milky-white cartilage structures within
nuclear transfer techniques (Fig. 136.4) (40). The expansion the corpora at 1 month, and the polymer scaffolding had de-
of this system to larger, three-dimensional structures is the graded by 2 months. There was no evidence of erosion or in-
next challenge awaiting researchers in the urogenital tissue- fection in any of the implantation sites. Subsequent studies
engineering field. were performed to assess the long-term functionality of the
cartilage penile rods in vivo. To date, the animals have done
Pe nis well and can copulate and impregnate their female partners
without problems.
Reconstruction of Corporal Smooth Muscle. O ne of the ma-
jor components of the phallus is corporal smooth muscle. The
creation of autologous functional and structural corporal tis- Fe male Ge nit al Tissue s
sue de novo would be beneficial in cases of congenital abnor- Congenital malformations of the uterus may have profound
mality of the genitals and in other situations where implications clinically. Patients with cloacal exstrophy and in-
reconstruction is functionally and aesthetically necessary. In tersex disorders may not have sufficient uterine tissue present
order to look at the functional parameters of engineered cor- for future reproduction. We investigated the possibility of en-
pora, acellular corporal collagen matrices were obtained from gineering functional uterine tissue using autologous cells.
donor rabbit penile tissue, and autologous corpus cavernosal Autologous rabbit uterine smooth muscle and epithelial cells
smooth muscle and endothelial cells were harvested, ex- were harvested and expanded in culture. These cells were
panded, and seeded on the matrices. The entire rabbit corpora seeded onto preconfigured uterine-shaped biodegradable
was removed and replaced with the engineered structures. The polymer scaffolds, and these were used for subtotal uterine tis-
experimental corporal bodies demonstrated intact structural sue replacement in the corresponding autologous animals.
integrity by cavernosography and showed similar intracorpo- Upon retrieval 6 months after implantation, histological, im-
ral pressures by cavernosometry when compared to the nor- munocytochemical, and Western blot analyses confirmed the
mal controls. Rabbits that received scaffolds without cells presence of normal uterine tissue components. Biomechanical
failed to achieve normal erectile function throughout the study analyses and organ bath studies showed that the functional
characteristics of these tissues were similar to those of normal

uterine tissue. Breeding studies using these engineered uteri are SUMMARY
currently being performed.
Similarly, several pathologic conditions, including congeni- Tissue-engineering efforts are currently being undertaken for
tal malformations and malignancy, can adversely affect nor- every type of tissue and organ within the urinary system.
mal vaginal development or anatomy. To investigate M ost of the effort expended to engineer genitourinary tis-
tissue-engineering methods of generating vaginal tissue for use sues has occurred within the last decade. While some tissue-
in these situations, vaginal epithelial and smooth muscle cells engineering applications are beginning to enter clinical
of female rabbits were harvested, grown, and expanded in cul- practice, many of the new tissue-engineering techniques de-
ture. These cells were seeded onto biodegradable polymer scribed must be studied further before they can be applied to
scaffolds, and the cell-seeded constructs were then implanted human disorders. H owever, recent progress suggests that en-
into nude mice for up to 6 weeks. Immunocytochemical, his- gineered urologic tissues and cell therapy may have clinical
tological, and Western blot analyses confirmed the presence of applicability, particularly in reconstruction of this system in
vaginal tissue phenotypes. Electrical field stimulation studies children.
in the tissue-engineered constructs showed similar functional
properties to those of normal vaginal tissue. When these con-
structs were used for autologous total vaginal replacement, ACKNO WLEDGMENTS
patent vaginal structures were noted in the tissue-engineered
specimens, while the non–cell-seeded structures were noted to The author would like to thank Dr. Jennifer O lson for editor-
be stenotic (21). ial assistance with this manuscript.
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2000;164:1405–1411.
CHAPTER 137 ■ IMAGE-GUIDED THERAPY:

CURRENT PRACTICE AND FUTURE
DIRECTIO NS
PETER PINTO AND HAL B. HO O PER
The use of imaging technology to guide urologic therapy has for superficial bladder cancer. Although other techniques may
traditionally found itself limited to one of three modalities: be employed, none have yet gained wide acceptance.
direct visualization, ultrasound, and fluoroscopy. For many The declining cost and ever-increasing resolution of
urologic conditions these technologies form the bedrock of advanced imaging devices such as computerized tomography
detection and therapy. For instance, cystoscopy remains the (CT) and magnetic resonance imaging (M RI) scanners has led
gold standard in the detection, surveillance of, and treatment to their increased availability. Whereas such devices were once
quite limited in the quality of the data they could provide and use of imaging technologies for the diagnosis of routine com-
were available sporadically at best, their increasing use as a plaints ensures that this trend will continue.
first-line diagnostic tool, along with current medicolegal M any of these masses will be 4 cm in diameter at the time
requirements, has revolutionized a wide variety of diagnostic of detection (7), and thus their management choices are var-
algorithms across the field of medicine. ied. Treatment has recently focused on sparing as much renal
The above factors, combined with the increasing interest of parenchyma as possible. N ephron-sparing procedures are
both patient and practitioner in reducing the potential mor- also essential in the management of the cohort of patients
bidity associated with highly invasive interventions, has fueled with heritable kidney cancers such as von H ippel-Lindau
the investigation of a wide variety of less invasive techniques (VH L) disease, Birt-H ogg-Dube (BH D) syndrome, and heredi-
for the treatment of a variety of urologic diseases. In addition, tary papillary renal cell carcinoma (H PRCC). M any of these
circumstances beyond the realm of control of the practitioner, patients will require multiple interventions for their renal
both fiscal and patient-driven, incentivize reducing the num- tumors.
ber of hospital days for the therapy of a given condition. The development of minimally invasive surgical (M IS)
These conditions have given rise to the nascent field of image- techniques utilizing image guidance is often an excellent
guided therapy. option for both subsets of patients. Several of the more widely
We will discuss image-guided therapy in the broadest sense, available options, including their relative benefits and risks,
including ultrasound, endoscopy, and fluoroscopy, as well as are discussed below.
therapeutic techniques guided in real time by CT and M RI
scanners.
Lap aro sco p ic Part ial Ne p hre ct o my w it h

URINARY TRACT ENDO SCO PY Int rao p e rat ive Ult raso und
Endoscopy, primarily the management of urinary calculi, Although the reported complication rate of laparoscopic
represents the historical forefront of image-guided therapy in partial nephrectomy (LPN ) varies widely and is highly
the field of urology. operator-dependent, recent literature reviews suggest these
Bozzini of Frankfort is credited with the first endoscopic in- rates to be comparable with those of open partial nephrec-
vestigations, popularly dated to 1805 (1). Fisher and Segalas tomy (O PN ). A recent review of the available published se-
also described the construction and use of cystoscopic appara- ries undertaken by Porpiglia et al. (8) suggests that while
tuses for urethral visualization in the 1820s (2). These early the overall rate of hemorrhage is slightly higher in LPN se-
efforts were quickly abandoned, however, as reflected candle- ries than in O PN series (mean of 5% versus 3.2% , respec-
light was insufficient to adequately illuminate the urinary tract tively), the overall rate of surgical complications with LPN
sufficient to facilitate adequate examination or manipulation. is roughly equivalent (4.1% to 38.6% in O PN versus 9%
It was left to Desmoreaux in 1853 to claim the mantle of to 33% in reviewed LPN series). Furthermore, recently
“ Father of Cystoscopy” and to describe the urethral and vesic- published data indicate that increased experience with LPN
ular mucosa of a living patient. With the aid of petroleum- will reduce complication rates to that of O PN (9). Finally,
fired lamps, reflecting mirrors, and a refinement of Bozzini’s LPN potentially offers shorter length of stay (5.7 versus
design of two nested metal tubes, he was able to overcome the 2.9 days) and reduced cost when compared with the open
technical challenges that had stymied his forebears and to per- approach, making this option attractive to provider and
form detailed examination of the lower urinary tract (3). patient alike (10).
Technology has, of course, propelled the management of Although preoperative imaging is essential for operative
urinary calculi, urothelial tumors, and other urinary tract planning and choice of port location, tumor location and
pathology beyond the imagination of the earliest investiga- nature (endophytic versus exophytic) often make definitive
tors. A series of technologic evolutions—the use of fiberoptics laparoscopic lesion identification and determination of
for light and image transmission, wire-guided flexible metal margin difficult. Intraoperative ultrasound is thus often em-
instruments, laser lithotripsy, and high-definition closed- ployed to assist in tumor location and adequate resection
circuit television picture reproduction—has produced the while minimizing the amount of normal parenchyma re-
ability to perform any number of manipulations for a wide moved. Additionally, the relationship of the tumor to struc-
variety of conditions. The indications for and details of these tures deeper within the renal sinus may be more readily
therapies are discussed elsewhere in this text, but endoscopy appreciated. In situations where the presence of venocaval
of the urinary system bears mention as the forebear of all thrombus is equivocal by preoperative imaging, intraoperative
other image-guided therapies in the field of urology. ultrasound will assist in definitive diagnosis and in-field man-
agement and extirpation (11).
In a N ational Cancer Institute (N CI) published series of
patients with hereditary renal carcinoma, intraoperative
IMAGE-GUIDED THERAPY IN THE ultrasound identified tumors that were undetectable by the
MANAGEMENT O F RENAL surgeon in 25% of cases, some as large as 4 cm, of which 50%
TUMO RS were pathologically proven renal cell carcinoma (RCC) (12).
Campbell et al. (13) report that although the use of intraoper-
Although there is wide variability between reported series as to ative ultrasound is no more accurate in the detection of tu-
the percentage of incidentally detected renal masses (25% to mors than the combination of preoperative CT imaging and
84% in a review of several recent series [4–6]), the widespread direct inspection for multifocal disease, the detection of small
endophytic tumors and of the intrarenal extent of deep tumors measured from 1.0 to 4.6 cm and were located centrally and
was enhanced by its use. peripherally. Two major complications were noted (one 1-unit
transfusion and one abscess due to involvement of an adjacent
bowel loop). Ice-ball formation was tracked by serial M RIs,
Cryo t he rap y and a 5-mm overlap was considered sufficient through two
freeze-thaw cycles. Twenty-four of 26 tumors were considered
Cryotherapy has emerged as a viable and widely accepted ablated by the first treatment on serial follow-up M RI (mean
alternative to surgical management of small renal tumors. In follow-up of 14 months). A subsequent report by this same
most commercially available systems, tissue cooling is created group noted that external manual compression of adjacent
via a heat-sink effect due to the vaporization of a cryogenic bowel loops was safe and efficacious at displacing the inter-
liquid, typically liquid nitrogen or argon, between an inner ested organ from the treatment field in 14 patients, further
and outer probe lumen. This rapid cooling is alternated with improving the safety profile of this intervention (17).
either a rapid thawing mediated by a separate cryogenic liquid The most commonly reported complications of the percu-
or passive thawing. This process is repeated at least twice in taneous approach are operative site pain and parasthesias,
most described techniques, although some groups advocate although more serious complications, such as renal fracture,
additional cycles (14). Direct tissue destruction by ice crystal ureterocalyceal injury, hemorrhage, and bowel injury, are
formation, local vascular disruption, induction of apoptotic certainly possible and have been reported.
signals, and immunologically mediated destruction of cells As with any percutaneous ablative interventions, the lack
within the ablated area that survive the initial freeze-thaw of histologic confirmation of complete tumor destruction
cycles provide for a highly effective ablative modality (7). remains problematic (15). M any centers make use of follow-
Adequacy of treatment has been shown in a porcine model up imaging with either contrast-enhanced CT or M RI imaging
to require cooling cells to 19.4°C, though clinical practice and an interval of 1 to 6 months from treatment to the initial
commonly chills tissue to 40°C to ensure adequate tissue scan. Contrast enhancement in the bed of ablation is most of-
destruction. This equates to a roughly 0.5- to 1.0-cm exten- ten cited as sufficient evidence of local recurrence and should
sion of the ice-ball beyond the tumor margin (15). Although recommend expeditious biopsy to rule out local recurrence.
widely investigated as a laparoscopic ablative technology, Shingleton and Sewell (18) report no radiographic evidence
several examples in the available literature support the effi- of local tumor recurrence in their M RI-guided PCA cohort of
cacy and safety of percutaneous cryotherapeutic ablation four patients with a median follow-up of 14 months; only one
(PCA) as an image-guided technique (14,16–20). patient required retreatment. Although data from the
As mentioned above, PCA techniques vary widely depend- Cleveland Clinic (22) indicate an excellent short-term correla-
ing upon the chosen imaging modality. The importance of tion between radiographic imaging and pathological analysis
proper probe placement, lesion location and thus accessibility, with laparoscopic cryoablation, poor correlation was seen in
and the use of an adequate number of probes to generate a their percutaneous radiofrequency ablation cohort (six pa-
sufficient ablative margin must be considered in preoperative tients with a positive posttreatment biopsy and no enhance-
planning. Serial imaging throughout treatment to monitor ment on M RI or CT).
ice-ball margin and its proximity to adjacent structures is es-
sential for both safety and efficacy. The choice of general anes-
thesia versus sedation varies, with most M RI-based techniques Rad io fre q ue ncy Ab lat io n (RFA)
opting for a general approach due to procedure length and the
ability to more tightly regulate diaphragmatic excursion. All FDA approved in the treatment of soft tissue lesions and long
protocols, however, must take into account the location of used for the treatment of bone and liver tumors, RFA gen-
adjacent organs and structures, especially in the treatment of erates direct tissue damage by the controlled delivery of
anterior renal lesions. Patient positioning, external compres- alternating current. H yperthermic protein denaturation and
sion, and needle-based methods such as “ hydrodissection” membrane destruction result in coagulative necrosis with
(the introduction of sterile saline between adjacent viscera extensive local tissue destruction. Energy delivery from the
and the lesion to be ablated), have all been described as safe generator is controlled by measuring temperature or local
and effective methods of reducing collateral damage during tissue impedance at the probe tip, with temperatures in excess
ice-ball formation (17,19,21). of 70°C for 1 minute often considered adequate, although
Gupta et al. (16) describe a series of 27 enhancing tumors many protocols have been published that differ by institution
treated in 20 patients by a CT-guided, percutaneous approach (4– 6,21,23,24). The infusion of hypertonic saline at the probe
under conscious sedation. Tumors were located both centrally tip is often employed to decrease impedance, resulting in
and peripherally and ranged in size from 1.0 to 4.6 cm. Ice- larger RFA lesions, referred to as “ wet” RFA (15).
ball formation was tracked by intermittent, intraprocedural O f particular concern in RFA is the presence of nearby
CT, with a margin of over 1.2 cm obtained in all cases through major vascular structures or tumors more centrally located.
two freeze-thaw cycles and only one major complication (two- H ighly vascularized areas suffer from a “ heat-sink” effect that
unit transfusion) reported. O nly one lesion demonstrated en- will produce temperature variations within the supposed field
hancement on follow-up CT, with a mean follow-up interval of ablation. Although long used for focal ablation of the liver,
of 5.9 months. the kidney’s high vascular flux, containing 5 times as much
An M RI-guided percutaneous approach in 23 patients is blood per gram as the liver, presents special challenges for
described by Silverman et al. (19). A special procedure room successful RFA (25). Such features may prevent tissues from
was required due to the presence of a high-field magnet and reaching the requisite temperature, preventing adequate
the choice of general anesthesia. Tumors in this series also tumor destruction. Although this phenomenon has become
less pronounced with the introduction of higher-powered follow-up imaging does not definitively indicate recurrence,
generators, medullary and corticomedullary lesions demon- as granulomatous reactions or infection in the ablated bed
strate persistently higher failure rates than exophytic cortical may also enhance, and absence of enhancement also does not
lesions (26). Some authors recommend renal artery occlusion signify complete tumor ablation. Salvage treatment should
to circumvent this effect and have described the execution of therefore proceed with deliberation and only after definitive
such in the laparoscopic literature, although a percutaneous rebiopsy (4,13).
approach would prohibit this precaution (15,27).
RFA also proves challenging when trying to monitor the
zone of ablation achieved. Unlike cryotherapy, which gener- O t he r Ab lat ive Te chno lo g ie s
ates a clearly demarcated barrier between the involved and
spared tissues, RFA generates a lesion that resists easy imme- Although PCA and RFA have both garnered FDA approval
diate characterization. As ablated tissues fail to enhance with for the treatment of small renal lesions, multiple other image-
intravascular contrast, intraprocedural contrast-enhanced guided ablative modalities are under investigation. Although
imaging may help estimate the amount of cellular destruction few of these methods have been evaluated to date beyond
achieved. For patients with deranged renal function, however, modest initial clinical trials, preliminary investigation in
this may prove problematic, particularly with CT-guided animal models and with selected patients continues apace.
modalities. M ost promising among these emerging technologies is that
A series by Fotiadis et al. (23) has been published in which of high-intensity focused ultrasound (H IFU). By combining a
the ablative properties of ethanol, long used in the treatment parabolic reflector with a piezoceramic element within an
of hepatic lesions, was combined with CT-guided percuta- external transducer, highly focused ultrasound waves can be
neous RFA in the ablation of small renal lesions (mean dia- delivered precisely to lesions of interest, quickly ( 1 second)
meter 3 cm, range 0.8 to 6.0 cm). Animal studies suggest raising tissue temperatures in a sharply circumscribed area
that this approach may cause extensive local thrombosis, and producing focal coagulative necrosis via thermal effects
thereby diminishing the “ heat-sink” effect described above. and mechanical disruption of membranes via microbubble
The amount of ethanol administered centrally within the cavitation (32). Although this phenomenon was realized in the
tumors was quite small, 1.7 mL on average, but the need for 1940s, advances in technology have decreased the size and
reablation was small, with only 6 of 28 patients requiring power demands of H IFU transducers, thus reviving interest in
additional treatment as a result of follow-up imaging, some- their use.
what below the rate of 27.5% cited elsewhere (7,23). H acker et al. (33) performed transcutaneous H IFU on 19
An excellent review of the available literature on percuta- patients and 24 dogs under general anesthesia prior to radical
neous RFA was recently conducted by Park and Cadeddu nephrectomy using in-line ultrasound guidance and a hand-
(28). They reviewed series performed under ultrasound, CT, held transducer. Although the technique was generally safe,
and M RI guidance using all widely available commercial elec- two grade III skin burns were reported in the human arm at
trode systems. Lesion size both in this review and within indi- higher power settings. The quality of ablation was variable
vidual series was noted to be an independent predictor for and did not seem to correlate with increases in delivered
single-session failure, with 3 cm commonly noted as the energy (from 200 to 1,600 W) or pulse duration (1 to 5 sec-
breakpoint for retreatment (5,15). They noted a combined onds). Indeed, some hyperechoic areas visualized during abla-
minor/major complication rate of 5% to 10% , with pyeloca- tion showed no histologic evidence of necrosis, although
lyceal injuries (stricture and urinoma) and hemorrhage delayed nephrectomy specimens in the canine arm of the study
requiring surgical intervention the most common major com- showed more reliable tissue ablation. Furthermore, the use of
plications (28). Although the risk of injury to adjacent viscera in-line ultrasound for intraprocedural guidance was noted as a
is low, techniques to further minimize these undesired out- major limitation. Backscatter during sonication caused by
comes have also been successfully explored in light of previ- microbubble formation prevented real-time visualization of
ous experience with RFA of hepatic lesions, including the lesion formation, impairing consistent energy delivery.
interposition of carbon dioxide gas or sterile fluid (21). This Tumor heterogeneity, respiratory motion, and the absorp-
review also notes that deliberate RFA of tumors located im- tive and reflective properties of intervening tissues may all
mediately adjacent to the collecting system should be discour- contribute to reduce the power applied to the tissue of interest
aged due to the high risk of stricture creation and persistent from that generated at the transducer. The transducer has
urine leak. been mounted on a mechanical arm to minimize potential
Cancer-specific survival was noted to be excellent, with an operator error, and the employment of M RI has been hypoth-
aggregate cancer-specific survival of around 95% at a mean esized as a technique for improving guidance (34–36). M ajor
follow-up of 19.5 months across series. Salvage nephrectomy technical hurdles still exist to the successful and widespread
or partial nephrectomy was performed in only 1.1% of cases. deployment of H IFU for the ablation of small renal tumors,
H owever, definitive histologic demonstration of complete tu- but investigation continues at many centers.
mor ablation is lacking in this percutaneous technique. There are also several other potential techniques. The use
Although previously published reports of skip lesions and in- of laparoscopic microwave antennas to induce coagulative
complete tumor ablation after RFA exist, contrary work indi- necrosis has been successfully tested in a rabbit model and
cates that oncologic control with RFA may well be adequate may be adaptable to an image-guided probe-based technique
(29,30). Radiologic demonstration of lack of tumor growth in the future (37). M R-guided laser interstitial therapy, involv-
or enhancement on CT or M RI at follow-up is typically ing the placement of laser fibers directly into malignant tissue,
deemed adequate, with initial scans typically performed at has been investigated under M R guidance, although no pub-
1 month. Unfortunately, the presence of enhancement on lished human trials exist at this time (15). Similarly, a number
of catheter-based techniques for the delivery of ablative agents improve the yield of ultrasound-guided transrectal prostate
have been reported, but none have yet gained widespread biopsy in a cohort of men at increased risk for PCa. Through
acceptance. a proprietary arrangement with Phillips USA they have devel-
oped a system for the registration of previously acquired M RI
images with real-time TRUS onto a single platform. Although
Imag e -Guid e d The rap y in t he their initial reported clinical data do not indicate a statistically
Manag e me nt o f Pro st at e Cance r (PCa) significant increase in cancer yields, they acknowledge that
a number of improvements in their platform have yet to be
Asymptomatically elevated PSA levels drive many to choose realized.
biopsy, with the detection of small amounts of low-risk dis- A subsequent report by the N CI/Phillips group (43) details
ease often being the result. Although early, definitive, whole- the development of a motion-compensation system via the use
gland therapy for these patients offers them a high likelihood of closed-loop magnetic tracking for the above-mentioned
of disease-free survival, the potential morbidities involved with image fusion platform. Ex vivo phantom studies indicate that
the currently available options are significant. Impotence, uri- an accuracy of 2 to 3 mm can be achieved with this refinement
nary incontinence, proctitis, and, for those who choose surgi- in place. O ngoing investigation will determine if this increased
cal excision, perioperative complications such as deep venous accuracy can equate to increased biopsy yield.
thromboses and injury to adjacent organs are reported risks of
whole-gland therapy. Pe rmane nt Pro st at e Se e d Imp lant at io n
Although it is likely that many men with low-risk disease Brachyt he rap y (PPI)
will die with, rather than of, their PCa, which individuals fall Available data for the use of intraprostatic radionucleotide-
into which category cannot currently be determined prospec- containing seeds (I-125 or Pd-103) in the treatment of PCa
tively. The impact of whole-gland therapeutic morbidities may suggests a durable oncologic outcome as measured by
potentially produce a profound diminishment in quality of biochemical relapse, whether this treatment modality is used
life. M any groups have initiated the investigation of novel as monotherapy for low-risk disease or is used in combination
focal therapies or the modification of existing treatment with external beam radiation therapy (EBRT) for intermediate-
modalities in the treatment of PCa to minimize potential inter- and high-risk patients (44).
vention-related adverse outcomes. Treatment planning to ensure that the low-energy photons
used in brachytherapy sufficiently cover the prostate volume
Imag e -Guid e d Pro st at e Bio p sy while minimizing the dose to adjacent structures, particularly
As prostate biopsy remains the gold standard for cancer diag- the urethra and rectum, is critical. Planning has traditionally
nosis, increased screening has predictably increased the annual consisted of preoperative imaging of the prostate in contigu-
number of biopsies performed. Biopsy is typically performed ous segments using a TRUS probe and correlation of these
with TRUS guidance in a sextant fashion, and the yield of the images with biopsy results. This evaluative study is subject to
most optimistic reported extended biopsy schema (performed the vagaries of patient positioning, probe angle and attitude,
exclusively based on elevated PSA) was only 44% (39). For in- and change in anatomic relationships in the conscious versus
dividuals undergoing repeat biopsy, this rate can be expected the anesthetized patient. The above factors may conspire to
to fall, with rates as low as 4% to 12% on the fourth attempt produce either “ hot” or “ cold” spots, adversely affecting either
and a higher attendant complication rate (40). M any image- oncologic efficacy or toxicity profiles (44).
guided techniques have been reported that seek to address the Several groups have reported their experience with the use
shortcoming with this extant biopsy paradigm. of M RI guidance in both the planning and execution of PPI to
Investigations into the use of M RI, in particular endorectal improve dosimetric coverage. Researchers have reported on
coil M RI (erM RI), for the detection of prostate cancer has the use of a real-time interventional 0.5-T open-configuration
become increasingly widespread. The use of an endorectal coil M RI system for preoperative dosimetric planning, probe
to reduce the signal-to-noise ratio increases image resolution, tracking, and “ on the fly” plan modification based on seed
particularly of T-2 weighted images, and reduces the amount deployment as measured by T-2 weighted imaging (45). They
of time needed to perform spectroscopic and contrast- used a specially designed M RI-compatible perineal template
enhanced studies. Signal-to-noise is also reduced by the use of for the introduction of I-125 sources with the patient in the
higher field magnets, and 3-tesla (3-T) devices are increasingly lithotomy position under general anesthesia. All the required
available. Although published results for specificity and sensi- probes and other equipment were also M RI-compatible. In a
tivity vary widely across studies and between the widely used series of ten patients, they report median seed misplacement at
modalities, M RI remains the most sensitive available imaging 3 mm, which corresponded to underdosing of 1% to 13% .
technique for the detection of prostate cancer (41). With the use of online M RI guidance, they were able to
Anastasiadis et al. (42) report on their experience with an recover as much as 12% of this lost coverage with the addi-
in-gantry biopsy system guided by erM RI. Twenty-seven men tion of a median of eight seeds (46).
with one prior negative biopsy were sampled in a 1.5-T A collaborative group from Johns H opkins University
closed-bore magnet under local anesthetic using an M RI- and the N CI/N IH (47) describe the use of a closed-bore 1.5-T
compatible template, needle guide, and biopsy needles based system for the guided transperineal delivery of high-dose-rate
on T-2 weighted images. The reported yield of 55% was well Ir-192 sources in four patients. They constructed an M RI-
above that reported in the literature for biopsies performed compatible device combining the endorectal coil and perineal
with TRUS guidance alone. template and placed the patient in the lateral decubitus posi-
The N CI group (41) have reported their initial experience tion for improved access. Three-dimensional reconstructions
with the use of both 1.5- and 3.0-T M RI instruments to indicate that this approach delivered the desired radiation
dose to over 90% of the gland, averaging approximately 2- and aggressive investigation of subtotal therapeutic modalities
mm needle placement accuracy, with 5% urethral toxicity. for the treatment of PCa (50). M any image-guided focal abla-
Total required time for imaging and therapy was an average of tion methods are under investigation, including focal
6 hours. brachytherapy, laser interstitial ablation, cryotherapy, H IFU,
M untener et al. (48) have developed a pneumatically actu- and gamma-knife. H owever, oncologic outcomes data remain
ated, M RI-compatible, fully automated robot for the delivery sparse at this time for most of these platforms, with the excep-
of PPI. By eliminating the use of electrical circuitry in this tion of H IFU and cryotherapy. Yet even in these cases, studies
device, they report successful use of the device in magnets up involving their use in concert with sophisticated image guid-
to 7 T with no evidence of field perturbation. Furthermore, ance are currently quite limited.
the device is highly accurate, with a step size of 0.05 mm. Use Regardless of the modality chosen, the decision of who
of this device for the placement of PPI implants in a tissue should receive focal therapy continues to be elusive. Clearly
mockup suggest submillimeter accuracy, with a mean error of these patients should have organ-confined disease, although
0.72 mm reported in the automated placement of a group of there the consensus ends. Despite the fact that PCa is a multi-
125 seeds. Although no clinical results are, as yet, reported in focal disease, data suggest that for clinically relevant tumors,
this series, continued research is planned. the index lesion, that is to say, the largest focus of PCa found
at resection, is of the most interest. Published retrospective
Imag e -Guid e d Fo cal Ab lat io n in t he data indicate that the overall Gleason score, risk of extracap-
Manag e me nt o f PCa sular extension, and disease-free survival as a function of
The downward stage migration of PCa in the PSA era has tumor volume can be determined with the index lesion in
created a situation in which many men may be receiving 90% of cases (49).
overtreatment for their disease. As fewer than a third of men Though PSA screening and the aforementioned stage
diagnosed in this country chose to defer therapy for their migration have consistently reduced the size of this index le-
disease, according to the N CI SEER database from 1995 to sion over the past two decades, the mean size of 2.4 cc is well
1999, the evidence suggests that almost 50% of men treated above the detection limits reported in the literature for erM RI.
with whole-gland extirpation or irradiation may have died Reports exist in the literature citing 85% sensitivity for the
with, rather than of, their disease (49). detection of lesions 1 cm by T-2 weighted eM RI combined
This discrepancy, combined with recently published data with spectroscopy (49,51). Despite these preliminary suc-
regarding favorable oncologic-specific survival results with iso- cesses, M RI remains to be validated as a stand-alone method
lated treatment of PCa index lesions, has promoted a widespread for the detection and staging of PCa.
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SE V E N T H E D I T I O N

GLEN N ’S URO LO GIC

Library of Congress Cataloging-in-Publication Data

SECTIO N I ■ ADREN AL, REN AL, URETER, PELVIS 1

Chapter 2 Partial N ephrectomy 6

Chapter 3 Radical N ephrectomy 14

Chapter 4 Intracaval Tumors 23

Chapter 5 Transplant N ephrectomy 32

Chapter 6 Renovascular Disease 36

Chapter 7 Anatrophic N ephrolithotomy 45

Chapter 8 Renal and Retroperitoneal Abscesses 51

Chapter 10 Renal Allotransplantation 65

Chapter 11 Ureteral Complications Following Renal Transplantation 71

Chapter 12 Renal Autotransplantation 76

Chapter 14 Simple and Partial Cystectomy 92

Chapter 15 Radical Cystectomy in Men 97

Chapter 16 Radical Cystectomy in Women 104

Chapter 17 Bladder Diverticulectomy 113

Chapter 18 Bladder Augmentation 118

Chapter 19 Management of the Distal Ureter for N ephroureterectomy 125

Chapter 20 Vesicovaginal Fistula 130

Chapter 21 Enterovesical and Rectourethral Fistulas 137

Chapter 22 Vesical Trauma and Hemorrhage 143

Chapter 23 Interstitial Cystitis/ Painful Bladder Syndrome 150

SECTIO N III ■ PRO STATE 163

Chapter 25 Surgery for Benign Prostatic Hypertrophy 166

Chapter 26 Prostatic Imaging and Biopsy 175

Chapter 27 Pelvic Lymphadenectomy 179

Chapter 28 Open Radical Retropubic Prostatectomy 186

Chapter 29 Radical Perineal Prostatectomy 194

Chapter 30 Brachytherapy for Localized Prostate Cancer 202

SECTIO N IV ■ URETH RA 211

Chapter 32 Female Urethral Diverticulum 214

Chapter 33 Reconstruction of the Female Urethra 220

Chapter 34 Surgical Management of the Incompetent Bladder Outlet

Chapter 35 Surgery for Urethral Stricture Disease 236

SECTIO N V ■ VAS DEFEREN S, SEM IN AL VESICLE, TESTIS 355

Chapter 54 Seminal Vesicle and Ejaculatory Duct Surgery 361

Chapter 55 Vasectomy 372

Chapter 56 Vasoepididymostomy 379

Chapter 57 Vasovasostomy 387

Chapter 58 Microsurgical Varicocelectomy 397

Chapter 59 Testis Biopsy and Testicular Sperm Extraction (TESE) 401

Chapter 60A Epididymal Sperm Aspiration 407

Chapter 60B Epididymectomy 410

Chapter 61 Ejaculation Induction Procedures: Penile Vibratory

Chapter 62 Anatomy of the Testis 419

Chapter 63 Simple Orchiectomy 428

Chapter 64 Inguinal Orchiectomy 433

Chapter 65 Organ-Preserving Surgery in Testicular Tumors 438

Chapter 66 Retroperitoneal Lymphadenectomy 442

Chapter 67 Torsion of the Testicle 448

Chapter 68 Scrotal Trauma and Reconstruction 453

SECTIO N VI ■ PEN IS AN D SCRO TUM 465

Chapter 70 Partial and Total Penectomy in the Management of

Chapter 71 Inguinal Lymphadenectomy for Penile Carcinoma 473

Chapter 72 Surgical Treatment of Peyronie Disease 481

Chapter 73 Priapism 487

Chapter 74 Penile Prosthesis Implantation 492