KEY POINTS

1. In the surgical treatment of invasive bladder cancer, a

thorough lymph node dissection is essential.
2. Patients with testicular cancer without radiographic
evidence of metastasis often harbor microscopic deposits
of disease and require either adjuvant treatment or very
close surveillance.
3. Nephrectomy is the mainstay of treatment for localized
renal cell carcinoma, and it also provides a survival benefit
in the setting of metastatic disease.
4. Majority of renal trauma can be treated conservatively,
with early surgical intervention reserved for persistent
bleeding or renal vascular injuries.
5. Distal ureteral injuries should only be treated with
bladder reimplantation because of the high failure rate of
distal ureteroureterostomies.
6. Extraperitoneal bladder ruptures can be treated
conservatively but intraperitoneal ruptures typically
require surgical repair.
7. Nearly all episodes of acute urinary retention can be
treated with conservative measures such as uand
increasing ambulation.
8. Testicular torsion is an emergency where successful
testicular salvage is inversely related to the delay in repair,
so cases with a high degree of clinical suspicion should not
wait for a radiologic diagnosis.
9. Fournier's Gangrene is a potentially lethal condition
that requires aggressive dbridement and close follow-up
due to frequent need for repeat dbridement.
10. Most small ureteral calculi will pass spontaneously, but
Larger Stones (>6 Mm) are better treated with ureteral
stenting and lithotripsy.
ANATOMY
anatomic structures that fall under the purview of
genitourinary surgery are
a) Kidneys
b) Adrenals
c) Ureters
d) Bladder
e) Prostate
f) Seminal Vesicles
g) Urethra
h) Vas Deferens
i) Testes
situated mainly outside the peritoneum
Urologic surgery frequently involves intraperitoneal
approaches to the kidney, bladder, and retroperitoneal
lymph nodes.
Kidney and Adrenal
Kidneys
Paired retroperitoneal organs
Invested in a fibro-fatty layer: Gerota's fascia.

Posterolaterally, the bordered by the quadratus

lumborum
Posteromedially by the psoas muscle
Anteriorly they are confined by the posterior layer of
the peritoneum.
On the left, the spleen lays superolaterally, separated
from the kidney and Gerota's fascia by the
peritoneum.
On the right, the liver is situated superiorly and
anteriorly and also is separated by the peritoneum.
Second portion of the duodenum is in close proximity
to the right renal vessels
During right renal surgery, it must be reflected
anteromedially (Kocherized) to achieve vascular
control
Renal arteries are single vessels extending from the
aorta that branch into several segmental arteries
before entering the renal sinus
a) RIGHT RENAL ARTERY
passes posterior to the Vena Cava
significantly longer than the left renal artery
Occasionally, the kidney is supplied by a
second renal artery, typically to the lower
pole.
Within the kidney, there is essentially no
anastomotic arterial flow, so the kidneys are
prone to infarction when branch vessels are
interrupted
Renal Veins, which course anteriorly to the renal
arteries, drain to the Vena Cava
Left Renal Vein passes anteriorly to the aorta
much longer than the right renal vein
is in continuity with the left Gonadal Vein,
the Left Inferior Adrenal Vein, and a
Lumbar Vein
provide adequate drainage for the left kidney in
the event that drainage to the vena cava is
interrupted
Right Renal Vein has no such collateral venous
drainage.
Collecting system of the kidney is composed of
several major and minor calyces that coalesce into the
renal pelvis.
Renal Pelvis can have either a mainly intrarenal
or extrarenal position
Tapers into the ureteropelvic junction (UPJ)
where it joins with the ureter.

Adrenal Glands
Lie superomedially to the kidneys within Gerota's
fascia. There is a layer of Gerota's fascia between the
adrenal and the kidney

Page 1 of 10

In the presence of a tumor or inflammatory process,

the adrenal can become very adherent to the kidney,
and separation can be difficult
Arterial supply of the adrenals derives from the aorta
and small branches from the Renal Arteries
Venous drainage on the left is mainly through the
Inferior Phrenic Vein and through the Left Renal
Vein via the Inferior Adrenal Vein
On the right, the adrenal is drained by a very
short (<1 cm) vein to the Vena Cava
Can be avulsed by moderate traction and can be
the source of troublesome bleeding.

Ureter
Muscular structures that course anterior to the psoas
muscles from the renal pelvis to the bladder
Blood supply of the proximal ureter derives from the
Aorta and Renal Artery
Comes mainly from the medial direction.
However, once it crosses the iliac vessels at the pelvic
brim near where the iliac vessels bifurcate, it derives
its blood supply laterally from branches from the Iliac
Arteries
Blood supply has implications for managing ureteral
injuries.
Mobilizing the distal ureter for anastomosis
requires releasing its lateral attachments, which
results in ischemia
Distal ureteral injuries are typically managed by
bringing the proximal ureter to the bladder
Course along the pelvic sidewall and pass under the
uterine arteries in women, making them vulnerable to
injury during hysterectomy
Enter the bladder at the lateral aspect of the base
Course through the bladder musculature at an
oblique angle and open into the bladder at the
ureteral orifices that are relatively close to the
bladder outlet.
Bladder and Prostate
Urinary Bladder
Situated in the retropubic space in an extraperitoneal
position
Portion of the bladder dome is adjacent to the
peritoneum, so ruptures at this point can result in
intraperitoneal urine leakage
Anatomic relations of the bladder are dependent on
the degree of filling
Very distended bladder can project above the
umbilicus.
At physiologic volumes (200 to 400 mL), the
bladder projects modestly into the abdomen

Sigmoid colon lies superolaterally and may

become adherent or fistulize to the bladder
secondary to diverticulitis
Rectum lies posterior to the bladder in
males
Vagina and uterus are posterior in females

Prostate
In males, the prostate is in continuity with the bladder
neck, and the urethra courses through it
Has a significant component of smooth muscle
Can provide urinary continence even in the
absence of the external striated sphincter
Puboprostatic Ligaments
Connect the prostate to the pubic symphysis, and
pelvic fractures
Often result in proximal urethral injuries due to
the traction that these ligaments provide.
Between the prostate and the rectum lies
Denonvilliers' Fascia
Main anatomic barrier that prevents prostate
cancer from regularly penetrating into the rectum.
Just beyond the apex of the prostate is the external
(voluntary) sphincter, which is part of the genitourinary
diaphragm.
Penis
Composed of three main bodies, along with fascia,
neurovascular structures, and skin
a) Corpora Cavernosum
Paired, cylinder-like structures that are the
main erectile bodies of the penis.
Proximally, they lie along the medial aspects
of the inferior pubic rami in the perineum.
Distally, they fuse along their medial aspects
and form the pendulous penis.
consist of a tough outer layer called the
Tunica Albuginea, and spongy, sinusoidal
tissue inside that fills with blood to result in
erection
Two corpora cavernosum have numerous
vascular interconnections, so they function
as one compartment
Cavernosal Arteries, which are branches of
the Penile Artery, course through the
center of the corporal sinusoidal tissue.
sinusoidal tissue is innervated by the
Cavernosal Nerves
Autonomic nerves that originate in the
Hypogastric Plexus
Play a critical role in erection.
Page 2 of 10

Before entering the penis, the

Cavernosal nerves travel
immediately adjacent to the
prostate, which explains why they
often are damaged at radical
prostatectomy.
b) On the underside of the penis lies the Corpus
Spongiosum, which surrounds the urethra
Does not have the same tunical layers as
the corpora cavernosum, so it does not
exhibit the same firmness during erection
Tip of the penis, called the Glans, is in
continuity with the corpus spongiosum.
Surrounding all three bodies of the penis are the
Outer Dartos Fascia and the Inner Buck's
Fascia
Dorsal Nerves of the Penis
Provide sensation to the penile skin, derive from
the Pudendal Nerves
Along with the Dorsal Penile Arteries, travel
along the dorsum of the penis within Buck's
fascia
Neurovascular bundle of the penis must be
avoided during surgical exploration of the penis
for injuries or reconstruction.

Scrotum and Testes

Scrotum
Capacious structure that contains the testes and
epididymis
Because of its dependent position, significant edema
can develop when a patient is fluid overloaded and
bleeding can result in the accumulation of large
hematomas.
Beneath the skin, from superficial to deep, are the
Dartos, External Spermatic, Cremasteric, and
Internal Spermatic Fascias.
These layers are not always distinct. Beneath the
internal fascia are the parietal and visceral layers
of the tunica vaginalis, between which
Hydroceles
Testes
Visceral Layer of the Tunica Vaginalis is adherent to
the testis
Noncompliant to the outer layer is the Tunica
Albuginea.
Inside the tunica are the Seminiferous Tubules.
Blood supply enters the testis at the superior pole by
way of the Spermatic Cord.
In addition to the vas deferens, the cord carries
three separate sources of arterial blood
a) Testicular Artery that branches from the
aorta below the renal artery

b)
c)

Cremasteric Artery
Deferential artery
Interruption of one of the arteries during
Vasectomy or Inguinal Surgery will not result
in ischemia to the testis.
Venous drainage parallels the arterial inflow except
that the Left Gonadal Vein drains into the renal vein
rather than the vena cava.
Dilation of Spermatic Veins is called a
Varicocele
May be palpable when a patient is standing
Not considered pathologic unless they
cause discomfort or affect fertility, which
they sometimes do.

UROLOGIC MALIGNANCIES
BLADDER CANCER
1. Transitional Cell Carcinoma (TCC)
2. Adenocarcinoma
3. Squamous Cell Carcinoma
Categorized
a) Invasive
b) Non-invasive
Most common form of bladder cancer in the United
States is Transitional Cell Carcinoma (TCC).
Tobacco use, followed by occupational exposure
to various carcinogenic materials such as
automobile exhaust or industrial solvents are the
most frequent risk factors, though many with the
disease have no identifiable risks
Other forms of bladder cancer, such as
Adenocarcinoma and Squamous Cell Carcinoma,
occur in distinct patient populations.
Patients with chronic irritation from catheters,
bladder stones, or schistosomiasis infection are
at risk for the Squamous Cell Variant
Those with Urachal Remnants or Bladder
Exstrophy have an increased risk of
Adenocarcinoma.
Categorized into Invasive and Noninvasive Types
Management of TCC varies greatly, depending on the
depth of invasion
Complete transurethral resection of the bladder
tumor, which allows staging of the tumor, is the
first step
Tumor is completely removed, if possible, along
with a sampling of the muscular bladder wall
underlying the tumor, because the large majority
of bladder tumors grow in an exophytic pattern
projecting into the bladder lumen.
In females, a bimanual examination can help
determine if there is fixation of the bladder to adjacent
structures.

Page 3 of 10

Radiologic imaging of most bladder tumors is of

limited benefit in determining the presence or
size/stage of a bladder tumor.
However, in the presence of a known bladder
tumor, unilateral or bilateral hydronephrosis is an
ominous sign of locally advanced disease.
Computed tomography (CT) scans do provide
valuable information regarding metastatic involvement
of pelvic lymph nodes, liver, or lung.
For patients that have disease invading into bladder
muscle (T2), immediate cystectomy with extended
lymph node dissection offers the best chance of
survival, although current long-term cure for those
presenting with clinically localized disease is still only
achieved in 50 to 60% of patients
Addition of Neoadjuvant or Adjuvant Chemotherapy in
those without discernible metastatic spread is
gaining increasing acceptance and does provide an
increase in survival.
Patients with limited lymph node involvement may
be cured with surgery alone, but those with extensive
lymph node involvement have a dismal prognosis.
Patients have multiple reconstructive options,
including
Continent and Noncontinent Urinary
Diversions
Orthotopic Neobladder
Popular urinary diversion for patients
without urethral involvement.
Involves the detubularization of a
segment of bowel, typically distal
ileum, which is then refashioned
into a pouch that is anastomosed
to the proximal urethral.
Detubularization decreases
intrapouch filling pressure, which
improves urinary storage capacity.
External sphincter is still intact,
and voiding is achieved through
sphincteric relaxation and a
Valsalva's maneuver
Most common noncontinent diversion is the
Ileal Conduit, whereby a segment of distal
ileum is isolated with one end brought out
through the abdominal wall as a urostomy.
Preferred for renal insufficiency
because urine is not "stored" and
therefore has less time in contact with
the absorptive surface of the ileal
segment
Also used when the bladder is
unresectable, but urinary diversion is
necessary due to intractable bleeding
or severe voiding pain.

Each segment of bowel that is used

offers its own advantages and inherent
complications.
Patients with Nonmuscle Invasive TCC (confined to
the bladder mucosa or submucosa) can be managed
with Transurethral Resection alone.
However, patients are at risk for recurrence and
progression to muscle-invasive disease.
Tumor grade is extremely important in assessing the
risk of disease progression
Patients with High-Grade Disease or Recurrent
Tumors can be treated with intravesical agents such
as Bacille Calmette-Gurin or mitomycin C.
Agents decrease risk of progression and
recurrence by induction of an effective
immunologic antitumor response (Bacille
Calmette- Gurin)
Mitomycin C acts through direct cytotoxicity
Those patients at high risk of progression that fail
conservative therapy should be offered
Cystectomy.
As upper tract recurrence is fairly common,
surveillance must be performed with Retrograde
Pyelograms or CT Urograms.

SURGICAL APPROACHES AND COMPLICATIONS

Typical surgical approach for Cystectomy is a lower
midline incision from just above the umbilicus to the
pubic symphysis.
Allows adequate exposure of the pelvic contents,
iliac vessels, and lower abdominal cavity.
Peritoneum between the median umbilical
ligaments (urachal remnant) also is taken with
the specimen.
In men, the prostate is removed with the bladder.
In women, the uterus, ovaries (in postmenopausal
women), and anterior wall of the vagina are removed
with the bladder
Vagina may be spared, depending on the location
and extent of the tumor, but significantly more
operative bleeding results.
Robotic approaches for cystectomy are increasingly
used, but the lymph node dissection and urinary
diversion is still usually finished through an open
incision
Benefit of the robotic portion is decreased blood
loss during the pelvic dissection (due to
pneumoperitoneum), and the shortening of the
time that the abdomen is open.
Complications of bladder cancer surgery involve
perforation during transurethral resection of the
bladder tumor
Requires catheter drainage for several days if
small or open repair
Page 4 of 10

If large and intraperitoneal, which is cystectomy

and urinary diversion may result in ileus, bowel
obstruction, intestinal anastomotic leak, urine
leak, or rectal injury
Urine leak from the ureteroenteric anastomosis is
a common cause of ileus, but may also result in
intra-abdominal urinoma or abscess formation if
drainage is ineffective.
Deep venous thrombosis is common after
Cystectomy due to the advanced age of most
patients, proximity of the iliac veins to the
resection and lymph node dissection, and the
presence of malignancy.

Testicular Cancer
1. Nongerm Cell Tumor
2. Germ Cell Tumor
a) Seminomatous
b) Non-Seminomatous
Most common solid malignancy in men ages 15-35 y/o
Most men are diagnosed with an asymptomatic
enlarging mass
Major risk for the development of testicular cancer is
Cryptorchidism
Early surgical intervention to bring an
undescended testis into the scrotum alters the
future risk of cancer
Allows much easier monitoring for the
development of a testicular mass.
Most neoplasms arise from the germ cells, though
non-germ cell tumors arise from Leydig's or Sertoli's
cells
NONGERM CELL TUMORS are rare
Generally follow a more benign course.
GERM CELL CANCERS are categorically
divided into Seminomatous and NonSeminomatous forms that follow different
treatment algorithms.
All solid testicular masses observed on physical
examination and documented on ultrasound are
malignant until proven otherwise, because the vast
majorities are cancerous.
Initial studies must include tumor markers, including fetoprotein and human chorionic gonadotrophin.
Elevated tumor markers are found almost
exclusively in Non-seminomatous Germ Cell
Tumor, though occasionally seminomas will
cause a modest rise in beta human chorionic
gonadotrophin.
Chest and abdominal imaging must be performed to
evaluate for evidence of metastasis

Most common site of spread is the

retroperitoneal lymph nodes extending from the
common iliac vessels to the renal vessels, and
abdominal imaging should be performed in all
patients.
No role for percutaneous biopsy of testicular masses
due to the risk of seeding the scrotal wall and
changing the natural retroperitoneal lymphatic
drainage of the testicle, because the testes have a
remarkably predictable pattern of lymphatic drainage.
In cases where metastatic disease to the testicle is
suspected, an Open Testicular Biopsy by delivery of
the testicle through the inguinal canal is
recommended.
Lymphoma may involve one or both testes, but
evidence of the disease usually is present elsewhere
in the body, although relapses may be isolated to the
testes.
Even in the absence of enlarged lymph nodes (stage
I), micrometastatic disease is often present, so
Adjuvant Surgery or Chemotherapy is offered.
Retroperitoneal Lymph Node Dissection (RPLND)
Potentially curative in the setting of limited lymph
node involvement
Preferred adjuvant treatment of those with stage
I disease; some advocate its use in stage IIa
and IIb disease.
Pure Seminoma is exquisitely radiosensitive
Stage I, IIa, and IIb disease can be treated with
External Beam Radiation to the retroperitoneal
nodes.
Both forms of germ cell tumors with disseminated
disease or large bulky lymph nodes are best treated
with Chemotherapy
Teratoma frequently is a component of retroperitoneal
lymph node metastasis
It is not responsive to chemotherapy or radiation
Demonstrate aggressive malignant degeneration.
Post-chemotherapy RPLND for residual masses
Large bulky metastases may encase the great
vessels
Vascular Graft Placement after resection
occasionally is required.

SURGICAL APPROACH AND COMPLICATIONS

ORCHIECTOMY
An inguinal incision is made over the external
ring and carried laterally over the position of the
internal ring.
It is important to not violate the scrotal skin due
to the concern, mostly theoretical, of altering the
lymphatic drainage of the testis.
RPLND

Page 5 of 10

A midline incision usually is made from the

xiphoid process to the pubic symphysis
Some use a thoracoabdominal approach
Laparoscopic approaches are used with
increasing regularity.
Complications of testicular cancer surgery include
Scrotal Hematoma formation, which can be
prevented by meticulous hemostasis.
Complications after RPLND include bowel
obstruction; excessive bleeding, particularly from
Retrocaval Lumber Veins; and chylous ascites.
Patients who undergo a full, bilateral
RPLND often suffer from anejaculation due
to the interruption of the Descending
Postganglionic Sympathetic Nerve Fibers
that are involved in seminal emission.
For this reason, right and left templates
have been developed that limit
dissection and preserve some of these
nerves with a low risk of leaving
residual microscopic cancer
Kidney Cancer
Renal cell carcinoma (RCC)
Malignancy of the renal epithelium that can arise from
any component of the nephron
Histologic subtypes include
a) Clear-Cell
b) Papillary (Types I And Ii)
c) Chromophobe
d) Collecting Duct
e) Unclassified Forms
Collecting Duct and Unclassified Forms have
dismal prognosis and very little response to systemic
therapy.
Benign lesions which are more commonly found when
small tumors are removed
Include Oncocytomas and Angiomyolipomas.
Renal tumors are usually solid, but they also can be
cystic.
Simple Cysts are very common and are not
malignant, but more Complex Cysts may be
malignant
Bosniak Classification System
Based on septations, calcifications, and
enhancement
Used to assess the likelihood of malignancy

Most cases are sporadic

Frequently involve a germline mutation in a tumorsuppressor gene.
Von Hippel-Lindau Disease
associated with multiple tumors including Clear
Cell RCC involved gene: VHL
frequently is mutated or hypermethylated in
sporadic RCC
rare forms include
Birt-Hogg-Dub Syndrome
patients get Oncocytomas or Chromophobe
Tumors.
Hereditary papillary RCC and hereditary
Leiomyomatosis develop papillary RCC.
Most common sites of metastasis: retroperitoneal
lymph nodes and lungs
Common sites of spread: liver, bone, and brain
20-30% of patients present with metastatic disease
Surgical Debulking can improve survival
Patients with all but the smallest renal masses should
undergo testing for the presence of metastatic disease
including chest CT, bone scan, and liver function tests.
Patients with localized disease may be cured with
either Partial or Radical Nephrectomy
Oncologic efficacy of Partial Nephrectomy
(nephron sparing) similar to that of radical
nephrectomy
Patients with larger tumors or with a more central
tumor location may be at increased risk for surgical
complications.
Nephron-Sparing Surgery
Should be considered in all patients
Those patients undergoing a Radical Nephrectomy
are at risk for future chronic kidney disease
Risk of contralateral RCC is 2-3% i
Partial Nephrectomy may prevent the future need for
dialysis in case of a contralateral kidney tumor.

Minimally Invasive Techniques

Laparoscopic Radical Nephrectomy
Allows more rapid convalescence
Decreased narcotic requirements
Laparoscopic Partial Nephrectomy
Page 6 of 10

Challenging and is performed only in

experienced hands due to its associated high
rate of complications
Ablative Techniques
Cryoablation
Radiofrequency Ablation
Observation also may be a viable option for small
renal masses
Most are low grade with a slow growth rate
Patients very rarely progress to metastatic
disease after limited follow-up of 2 to 3 years
10% of RCC invades the lumen of the renal vein or
vena cava
Degree of venous extension directly impacts the
surgical approach
Patients with thrombus below the level of the
liver managed with cross-clamping above and
below the thrombus
Extraction from a Cavotomy at the insertion
of the renal vein
Usually, the thrombus is not adherent to the
vessel wall
Cross-Clamping the vena cava above the
hepatic veins can drastically reduce cardiac
preload, and therefore, bypass techniques often
are necessary
Multidisciplinary approach with either
Venovenous or Cardiopulmonary Bypass
is necessary
Invasion of the wall of the vena cava or atrium
Deep hypothermic circulatory arrest may
be used to give a completely bloodless field.
Tumor thrombus embolization to the pulmonary
artery
Rare but known complication during these
cases
Associated with a high mortality
Extensive Tumor Thrombus
Intraoperative Transesophageal
Echocardiography should be considered for
monitoring and assessment of possible
thrombus embolization.
If a thrombus embolization occurs
Sternotomy/ Cardiopulmonary Bypass with
extraction of the thrombus may be
lifesaving.
Patients undergoing resection of localized renal
masses are at substantial risk of future recurrence
Most widely accepted prognostic findings are tumor
stage, grade, and size
Each exerts an independent effect on recurrence
Surveillance strategies after nephrectomy typically
involve

Abdominal and chest imaging at 6- to 12-month

intervals for 5 to 10 years, depending on the level
of risk as determined by the original lesion.
Isolated solitary recurrences, either local or distant
Can be resected with long-term disease-free
rates approaching 50%

SURGICAL APPROACH AND COMPLICATIONS

Nephrectomy, either Partial or Radical, can be
performed through a number of surgical approaches.
Flank incisions over the 11th or 12th ribs
From the anterior axillary line to the lateral border
of the rectus muscle provide access to the kidney
without entering the peritoneum
If small, the Pleurotomy usually can be closed
without need for a chest tube
Anterior subcostal approach also is used for
nephrectomy.
No risk for pleural entry incision is transperitoneal
Ileus is somewhat more likely.
Laparoscopic nephrectomy is now common place
Laparoscopic Partial Nephrectomy is used
less frequently.
For large tumors (Right side) where the liver makes
exposure of the tumor
More difficult, a Thoracoabdominal Approach is
very helpful.
Flank incision is made over the 10th ribs and
carried further posterior and anterior than a
typical flank incision
Chest and abdominal cavities are intentionally
entered for maximum exposure
Diaphragm is partially divided in a circumferential
fashion which allows cephalad retraction of the
liver
Chest tube is used postoperatively
Adrenal gland is no longer routinely removed
unless the tumor is adherent to it.
Complications of radical nephrectomy include
Bleeding
Pneumothorax
Splenic Injury
Liver Injury
Pancreatic Tail Injury
Partial Nephrectomy has the added risks of
delayed bleeding and urine leak.
Ileus is not common place when the peritoneal
cavity is not entered.
Prostate Cancer
Most common non-skin malignancy in men
Incidence: 250,000-300,000 per year.

Page 7 of 10

Yearly screening consisting of digital rectal exam and

Serum Prostate-Specific Antigen (PSA) Testing
starting at age 50 years old is recommended
Patients of African American descent or those with a
family history of prostate cancer should be considered
for screening starting at 45 years of age.
Men with abnormal digital rectal exams or PSA
elevation have an indication for prostate biopsy to
determine the presence of the disease
Majority of patients with prostate cancer will not die of
the disease by 10-15 years, whether it is treated at
diagnosis or not
Undergoing initial treatment have improved
cancer-specific survival
Graded according to the Gleason Scoring System
Primary and secondary score are assigned
based on the most common and second most
common histologic pattern
Grades run from 1 for the most differentiated to 5
for the least
Added to give the Gleason score
In current practice, scores below 6 are almost
never assigned.
Gleason score, preoperative PSA level, and digital
rectal exam are used to estimate the likelihood of
whether the cancer is localized, locally advanced, or
metastatic
High Gleason scores (8 to 10) or a high PSA
level (>20) is much more likely to have spread
Often at a micrometastatic level
After definitive treatment, an increasing PSA is
indicative of recurrent cancer.
Most common site of spread: pelvic lymph nodes and
bone
Patients with intermediate or high-risk disease based
on clinical stage, grade on biopsy, and PSA level,
staging includes bone scan and CT imaging to
evaluate the pelvic lymph nodes.
Multiple treatment options are available for men with
localized disease, including
Radical prostatectomy (retropubic, perineal, or
robotic/laparoscopic approaches)
Brachytherapy
External Beam Radiation Therapy.
For low-risk disease, the efficacy of each treatment
modality is thought to be similar
Radical Prostatectomy can be performed with
Unilateral or Bilateral Cavernosal NerveSparing to limit postoperative erectile
dysfunction (ED).
For high-risk disease
Either NonNerve-Sparing Surgery or External
Beam Radiation Therapy plus Androgen
Deprivation may be performed

Irritative voiding and bowel symptoms are common

after radiation therapy, with ED being a late side
effect.
Radical prostatectomy is associated with early
incontinence and ED (depending on nerve-sparing).
Incontinence improves significantly with time,
with <1% of men in experienced hands suffering
severe long-term problems with urinary control.
ED improves with time
large majority of younger men (<55 years of age)
regain erectile function, often with the aid of oral
medications
If both cavernosal nerves were spared
Older men or those with 0 or 1 nerve spared
have lower rates of erectile function.
Expectant management may be useful strategy in
men with anticipated survival of <10 years, low
Gleason cores ( 6), early stage disease (cT1c) and
small volume (biopsy)
Patients should be watched closely by digital rectal
exam, PSA testing and repeat biopsy at 1 year to
assess the possible progression of disease
Once prostate cancer has spread, it is no longer
curable.
Medications that lower serum testosterone or that
block the androgen receptor are able to control
the disease, often for years, but the cancer
inevitably becomes resistant to this treatment
Can live many years, and a large number
die of causes other than prostate cancer.

SURGICAL APPROACH AND COMPLICATIONS

Retropubic Prostatectomy
Uses a lower midline incision from the pubic
symphysis to approximately 5 cm below the
umbilicus
Peritoneum is not entered
Lymph nodes are removed between the external
iliac and obturator vessels bilaterally
May be omitted in cases where the
probability of involvement is very low.
Some regularly perform a wider dissection that
may improve staging, although any therapeutic
benefit is uncertain
Cavernosal nerves lay immediately posterolateral
to the prostatic capsule
May be spared if the cancer is not likely to
penetrate the capsule on that side, which is
a function of preoperative parameters such
as biopsy results, PSA, and clinical
examination.
Perineal Prostatectomy
Involves a transverse incision between the
scrotum and anus.
Page 8 of 10

Benefits include
Reduced blood loss and faster
convalescence
Does not allow lymph node dissection
Nerve-sparing is more difficult.
Robotic Prostatectomy
Superseded Laparoscopic Prostatectomy due to
the lower learning curve and increased agility.
Benefits are lower blood loss and faster
convalescence.
Complications of prostatectomy depend on approach.
Retropubic approaches may result in urine leaks,
lymphocele, and very rarely, rectal or ureteral
injury
Perineal approach has a higher rate of rectal
injury
Robotic prostatectomy uses a transperitoneal
approach that can occasionally result in ileus,
particularly in cases of a urine leak from the
vesicourethral anastomosis.
All approaches carry a small risk of urinary
incontinence and a more substantial risk of ED.

TRAUMA
Kidney
Renal injuries are more common during blunt trauma
Accounting for 90% of injuries to the kidney
Any patient with a major deceleration injury, shock,
or gross hematuria should undergo radiographic
imaging of the kidneys.
All patients with penetrating injuries to the flank or
abdomen must undergo imaging unless unstable and
requiring immediate exploration.
Renal injuries are classified by extent of damage
Blunt Traumatic Injuries usually can be
managed conservatively
Penetrating Renal Injuries usually require
exploration.
Urinary extravasation alone does not require
exploration, but reimaging is necessary and,
if persistent leakage is present, a stent or
nephrostomy tube is indicated.
Renal Injury Scale

All Grade V Vascular Injuries should be

considered for immediate exploration
Delay of several hours greatly decreases
the risk of renal salvage.
High-grade renal injuries are associated with
significant bleeding
Patients who are stable and without a
pulsatile or expanding hematoma can be
observed.
Even in expert hands, the risk of renal loss at surgery
is significant
Must be considered before opening the
retroperitoneum
Most grade IV injuries can be managed
nonoperatively
Patients typically are placed on restricted activity
until hematuria resolves

If immediate operative exploration for other injuries is

required, renal injury staging can be performed while in the
operating
room. If concern exists over renal injury or the presence of
a retroperitoneal hematoma, a single-shot, 10-minute
delayed IV
pyelogram (IVP) (2 mL/kg contrast) is useful at assessing
the presence of two functional kidneys and extent of injury.
If the
IVP is abnormal or the hematoma is pulsatile, renal
exploration should be performed.
Renal exploration should begin once the renal hilum is
controlled. Although rarely necessary, temporary control of
the renal
hilum may decrease the need for nephrectomy when a
significant injury is found on exploration. Complete
exposure is
necessary to evaluate the extent of injury. All nonviable
tissue should be dbrided and segmental and intralobar
arteries
ligated with 4-0 chromic or polydioxanone sutures. If the
collecting system is injured, it should be repaired at this
time. A
stent and percutaneous drain should be considered to
prevent urinoma formation. A partial vascular injury to the
renal vein
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or artery can be repaired with 5-0 or 6-0 Prolene sutures. A

complete injury may require dbridement, and if an end-toend

anastomosis cannot be performed, a vascular graft may be

required

Page 10 of 10