The document discusses ureterovaginal fistulas (UVFs), including their causes, risk factors, presentations, diagnostic evaluations, and management approaches. It notes that UVFs are most often caused by gynecologic or obstetric surgeries, with iatrogenic injury occurring in 0.5-2.5% of such procedures. Clinical presentation varies depending on the timing, from abdominal/flank pain immediately post-op to continuous urinary leakage from the vagina in delayed cases. Diagnostic tests include imaging like IVU, CT, MRI, and RGP to identify the fistula. Management involves upper tract drainage via nephrostomy or stenting, with early surgical repair via ureter
The document discusses various types of urinary diversion procedures. It begins with a brief history, noting that the first urinary diversion was performed by Simon in 1852, while the ileal conduit became the gold standard in the 1990s. The main types of diversion discussed are non-continent diversions like ileal conduits, and continent diversions like orthotopic neobladders and heterotopic reservoirs that are catheterized through an abdominal stoma. Key aspects like indications, surgical techniques, and complications are summarized.
This document provides information about percutaneous nephrolithotomy (PNL) from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the moderators of the department, indications and contraindications for PNL, preoperative investigations and consent, renal anatomy considerations, PNL technique, intrarenal access points, and patient positioning for the procedure. The document emphasizes accessing the renal collecting system through a posterior calyx rather than the pelvis or infundibulum. It also highlights important anatomical structures like Brodel's plane to aid safe access during PNL.
Urinary Diversion after cystectomy [Dr.Edmond Wong]Edmond Wong
1. Various gastrointestinal segments can be used for urinary diversion after cystectomy including stomach, ileum, colon and appendix. Each option has advantages and disadvantages related to metabolic complications and risk of infection.
2. The ileal conduit is the most commonly used form of urinary diversion and involves isolating a segment of ileum to create a low pressure urinary reservoir and conduit. Complications include metabolic abnormalities, stomal issues, and ureteral complications.
3. Continent urinary diversions aim to create a reservoir with a continence mechanism but still face challenges with infection risk, metabolic issues and long term complications like malignancy from chronic bacteriuria. Patient factors also influence diversion outcomes.
Prostate carinoma- surgery- Open Radical Retropubic Prostatectomy(rrp)GovtRoyapettahHospit
This document describes the department of urology at a hospital in Chennai, India. It lists the professors and assistant professors in the department. It then provides details on radical retropubic prostatectomy surgery, including its history and the goals of the surgery. It describes the preoperative assessment and surgical procedure, including anatomy, incisions, and key steps like bladder neck reconstruction. It discusses complications, post-operative care, and management of issues like hemorrhage and bladder neck contracture.
This document provides information about retrocaval ureter, including its etiology, diagnosis, and management. Retrocaval ureter is a rare congenital anomaly where the ureter passes behind the inferior vena cava. It occurs due to persistence of the subcardinal veins during embryonic development. Clinical presentations include flank pain, hematuria, urinary tract infections, and urolithiasis. Diagnosis involves imaging tests like intravenous urogram, CT urography, and renography. Surgical management includes open or laparoscopic pyeloplasty to reposition the ureter anterior to the inferior vena cava. Preserving the retrocaval ureter segment may be
This document provides information on the management of non-muscle invasive bladder cancer at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the moderators and professors in the department and provides details on the diagnosis, staging, treatment options including transurethral resection of bladder tumor, adjuvant therapies, and follow-up for non-muscle invasive bladder cancer. It discusses the use of techniques like laser therapy, intravesical chemotherapy and immunotherapy, with a focus on bacillus Calmette-Guérin as options to prevent recurrence of superficial bladder cancer after resection.
1. Midurethral slings are now the gold standard treatment for stress urinary incontinence, replacing pubovaginal slings.
2. Pubovaginal slings are placed at the bladder neck and can be effective for various types of SUI but have higher risks than midurethral slings.
3. Midurethral slings are typically placed at the midurethra using either a retropubic or transobturator approach and have better subjective cure rates than pubovaginal slings.
This document summarizes the surgical anatomy of the prostate gland. It describes the prostate's location and relations to surrounding structures like the bladder, urethra, and rectum. It details the prostate's blood supply from branches of the internal iliac artery, innervation from pelvic splanchic and pudendal nerves, and lymphatic drainage routes. The document also outlines important surgical structures like the prostatic capsule, neurovascular bundle, and surrounding fascial planes important for nerve-sparing prostatectomy.
The document discusses various types of urinary diversion procedures. It begins with a brief history, noting that the first urinary diversion was performed by Simon in 1852, while the ileal conduit became the gold standard in the 1990s. The main types of diversion discussed are non-continent diversions like ileal conduits, and continent diversions like orthotopic neobladders and heterotopic reservoirs that are catheterized through an abdominal stoma. Key aspects like indications, surgical techniques, and complications are summarized.
This document provides information about percutaneous nephrolithotomy (PNL) from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the moderators of the department, indications and contraindications for PNL, preoperative investigations and consent, renal anatomy considerations, PNL technique, intrarenal access points, and patient positioning for the procedure. The document emphasizes accessing the renal collecting system through a posterior calyx rather than the pelvis or infundibulum. It also highlights important anatomical structures like Brodel's plane to aid safe access during PNL.
Urinary Diversion after cystectomy [Dr.Edmond Wong]Edmond Wong
1. Various gastrointestinal segments can be used for urinary diversion after cystectomy including stomach, ileum, colon and appendix. Each option has advantages and disadvantages related to metabolic complications and risk of infection.
2. The ileal conduit is the most commonly used form of urinary diversion and involves isolating a segment of ileum to create a low pressure urinary reservoir and conduit. Complications include metabolic abnormalities, stomal issues, and ureteral complications.
3. Continent urinary diversions aim to create a reservoir with a continence mechanism but still face challenges with infection risk, metabolic issues and long term complications like malignancy from chronic bacteriuria. Patient factors also influence diversion outcomes.
Prostate carinoma- surgery- Open Radical Retropubic Prostatectomy(rrp)GovtRoyapettahHospit
This document describes the department of urology at a hospital in Chennai, India. It lists the professors and assistant professors in the department. It then provides details on radical retropubic prostatectomy surgery, including its history and the goals of the surgery. It describes the preoperative assessment and surgical procedure, including anatomy, incisions, and key steps like bladder neck reconstruction. It discusses complications, post-operative care, and management of issues like hemorrhage and bladder neck contracture.
This document provides information about retrocaval ureter, including its etiology, diagnosis, and management. Retrocaval ureter is a rare congenital anomaly where the ureter passes behind the inferior vena cava. It occurs due to persistence of the subcardinal veins during embryonic development. Clinical presentations include flank pain, hematuria, urinary tract infections, and urolithiasis. Diagnosis involves imaging tests like intravenous urogram, CT urography, and renography. Surgical management includes open or laparoscopic pyeloplasty to reposition the ureter anterior to the inferior vena cava. Preserving the retrocaval ureter segment may be
This document provides information on the management of non-muscle invasive bladder cancer at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the moderators and professors in the department and provides details on the diagnosis, staging, treatment options including transurethral resection of bladder tumor, adjuvant therapies, and follow-up for non-muscle invasive bladder cancer. It discusses the use of techniques like laser therapy, intravesical chemotherapy and immunotherapy, with a focus on bacillus Calmette-Guérin as options to prevent recurrence of superficial bladder cancer after resection.
1. Midurethral slings are now the gold standard treatment for stress urinary incontinence, replacing pubovaginal slings.
2. Pubovaginal slings are placed at the bladder neck and can be effective for various types of SUI but have higher risks than midurethral slings.
3. Midurethral slings are typically placed at the midurethra using either a retropubic or transobturator approach and have better subjective cure rates than pubovaginal slings.
This document summarizes the surgical anatomy of the prostate gland. It describes the prostate's location and relations to surrounding structures like the bladder, urethra, and rectum. It details the prostate's blood supply from branches of the internal iliac artery, innervation from pelvic splanchic and pudendal nerves, and lymphatic drainage routes. The document also outlines important surgical structures like the prostatic capsule, neurovascular bundle, and surrounding fascial planes important for nerve-sparing prostatectomy.
This document discusses the management of non-seminomatous germ cell tumors (NSGCTs). It covers the pathological classification, clinical staging, treatment approaches for different stages, and management of residual or relapsed disease. For stage I disease, options include observation, retroperitoneal lymph node dissection (RPLND), or chemotherapy depending on risk factors. For stage II, nerve-sparing RPLND or chemotherapy is recommended based on tumor burden. Stage III usually receives chemotherapy followed by RPLND if needed. Common regimens include BEP and salvage therapies like TIP are discussed for relapsed or refractory cases. The roles of surgery, chemotherapy, surveillance and newer agents are outlined.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
This document discusses posterior urethral distraction defects (PFUDD) following pelvic fractures. It describes that a hematoma-fibrosis complex forms between the separated urethral ends rather than a simple stricture. Multimodality management including orthopedics may be needed. Imaging like retrograde urethrogram can show a characteristic S-bend deformity. A transpubic approach like the Waterhouse procedure combines perineal and abdominal incisions to allow a tension-free anastomosis but may cause complications like incontinence or impotence.
Megaureter ppt. Types, pathophysiology, evaluation and management.Hussain Shah
- Megaureter (MGU) is defined as a ureteral diameter greater than 7 mm. MGU can be classified based on its cause as refluxing, obstructed, both refluxing and obstructed, or nonrefluxing and nonobstructed.
- MGU is a common finding in neonates referred for urologic evaluation and accounts for up to 23% of cases of urinary tract dilatation seen on prenatal ultrasound.
- Evaluation of MGU involves ultrasound to assess anatomy and severity, VCUG to check for reflux, renal scan to evaluate function, and potentially MRI urography.
- Management depends on etiology but
The document provides information on the surgical anatomy of the kidney and ureter. It discusses the embryology, gross anatomy including orientation and position of the kidneys. It describes the microscopic anatomy including the nephron. It details the coverings of the kidney including the fibrous capsule, perinephric fat, Gerota's fascia and paranephric fat. It outlines the relations of the kidney to surrounding structures like ribs, diaphragm and pleura. It also discusses the blood supply, lymphatic drainage and nerve supply of the kidneys.
This document discusses the management of locally advanced renal cell carcinoma (RCC) at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It covers RCC with involvement of the inferior vena cava (IVC) or invasion of adjacent organs. For IVC involvement, it describes evaluation methods like MRI/CT and surgical techniques for thrombectomy based on the level of thrombus. It also discusses locally invasive non-metastatic RCC and invasion of adjacent organs like liver, duodenum, colon and approaches to management with extended resections when needed.
Percutaneous nephrolithotomy (PCNL) carries risks of several access-related complications. Prevention involves ensuring sterile urine, adequate imaging for access planning, and backup equipment. Initial puncture can lead to hemorrhage, arterial or venous puncture, or injury to surrounding structures. Bleeding is typically controlled with tamponade but may require angioembolization. Delayed hemorrhage can also occur from arteriovenous fistulas or pseudoaneurysms. Careful patient selection, access planning and technique can minimize complication risks.
This document discusses different types of ureteral obstruction and reflux, as well as techniques for ureteral diversion and ureterostomy. It classifies obstructions and reflux as intrinsic or infravesical, primary or secondary. It also describes how to perform a Lembert suture technique for ureteral diversion, where the redundant ureter is folded over a catheter and secured with absorbable sutures.
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
This document discusses pelvic fracture urethral distraction defects (PFUDD). It provides classifications for pelvic fractures and urethral injuries. For urethral injuries, it describes the Colapinto-McCallum and Goldman classifications based on radiological findings. Clinical features, diagnostic evaluations including retrograde urethrography, and management approaches for immediate vs delayed treatment are covered. Goals of treatment include re-establishing urethral continuity while reducing risks of stenosis, incontinence and impotence.
This document summarizes the surgical management of urethral strictures. It discusses investigations like retrograde urethrography and various types of urethroplasty procedures including dilation, internal urethrotomy, lasers, stents, and open reconstruction. Specific procedures covered include anastomotic urethroplasty, substitution urethroplasty using grafts and flaps, and augmented anastomotic urethroplasty. Complications of different procedures like buccal mucosal graft urethroplasty, fasciocutaneous urethroplasty, and anterior and posterior urethroplasty are also summarized.
This document discusses the management of small renal masses (SRMs). It provides an overview of diagnosis and treatment options for SRMs, including:
- SRMs are detected more frequently with improved imaging and account for about 20-25% of renal masses.
- Biopsy and advanced imaging can help differentiate between benign and malignant SRMs and determine tumor aggressiveness.
- Treatment options include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Partial nephrectomy aims to preserve renal function while providing cancer control comparable to radical nephrectomy.
- Factors such as tumor size, location, and patient comorbidities help determine the optimal surgical approach and extent of surgery
This document provides information about upper tract instrumentation and flexible ureteroscopy. It lists the moderators and their departments. It then describes the anatomy of the ureter, its layers, microscopic structure, normal variations in caliber, and significance of narrowings. It discusses the evolution of rigid, semi-rigid and flexible ureteroscopes over time. Properties, uses and complications of different ureteroscopes are summarized. Identification of the ureteral orifice and techniques for ureteral access and flexible ureteroscope introduction are also covered.
This document describes the history and evolution of cystoscopy and endoscopy. It discusses early cystoscopes that used candle light and mirrors, and the development of modern rigid and flexible cystoscopes using electric light, fiber optics, and video imaging. It outlines the key innovators who developed new light sources, lenses, and technologies to improve visualization of the bladder. These advances allowed cystoscopy to become a mainstream urological procedure. The document also provides details on modern cystoscopy techniques and equipment.
Bladder injuries are rare. But when present in cases of polytrauma they pose both a diagnostic as well as surgical challenge to the attending surgeon. Understanding the mechanisms underlying bladder injuries is pivotal in developing a diagnostic algorithm in order to avoid missing of any urologic injury. Once the extent and site of damage is diagnosed then prompt surgical intervention is the mainstay of treatment. The pathophysiology and management of bladder injuries is discussed in this paper.
This document summarizes retroperitoneal anatomy, collections, and hematomas. It describes the three retroperitoneal compartments and expansive interfascial planes that allow collections to spread. Common causes of retroperitoneal hematomas are discussed. Diagnostic imaging includes CT or angiography. Management depends on stability and source of bleeding, ranging from conservative treatment to angiographic embolization or surgery.
This document discusses pelvic fractures and urethral injuries. It provides classifications for pelvic fractures including the Young-Burgess and Tile classifications. It also describes classifications for posterior urethral injuries, including the Colapinto-McCallum and AAST classifications. Posterior urethral injuries occur in 1.6-9.9% of pelvic fractures and have high mortality. Diagnosis is made through retrograde urethrogram and treatment involves initial suprapubic cystostomy followed later by reconstruction if completely torn. Complications of posterior urethral injuries include stricture, impotence, and incontinence. Anterior urethral injuries are also discussed as well
This document discusses the management of metastatic renal cancer. It notes that approximately 1/3 of newly diagnosed renal cancers are metastatic and 20-40% of localized cancers eventually metastasize. Metastatic renal cancer is usually fatal with 5-year survival rates under 5%. The document outlines treatment approaches including local therapies like cytoreductive nephrectomy and metastasectomy as well as systemic therapies like immunotherapy, targeted therapy and chemotherapy. It provides details on specific immunotherapy agents, targeted therapies including several tyrosine kinase inhibitors, and recommendations on treatment sequencing.
This document discusses ureteral injuries, including their etiology, types, anatomy, risk factors, diagnosis, and management. It notes that ureteral injuries most commonly occur during gynecologic surgeries like hysterectomy. Diagnosis involves imaging like IVU, CT scan, or retrograde ureterography. Management depends on the location and severity of injury, and may include ureteroureterostomy, bowel or bladder flaps, nephrectomy, or autotransplantation. Prevention involves identifying anatomical landmarks and avoiding thermal or electrosurgical injuries during surgery.
This document discusses radiation fistula and malignant fistula. It provides information on:
1) Radiation fistula can occur months to 30 years after radiotherapy for pelvic malignancies and presents as pain. Types include urethrovaginal, vesicovaginal, urethrorectal, and others.
2) Malignant fistula can occur with advanced primary cancers or local recurrence in the pelvis. It may present as a fistula between organs.
3) Evaluation and management depends on the type and complexity of the fistula. Surgical repair often requires interposition flaps or grafts to aid healing in irradiated tissue. Diversion procedures may be used in complex
This document discusses the management of non-seminomatous germ cell tumors (NSGCTs). It covers the pathological classification, clinical staging, treatment approaches for different stages, and management of residual or relapsed disease. For stage I disease, options include observation, retroperitoneal lymph node dissection (RPLND), or chemotherapy depending on risk factors. For stage II, nerve-sparing RPLND or chemotherapy is recommended based on tumor burden. Stage III usually receives chemotherapy followed by RPLND if needed. Common regimens include BEP and salvage therapies like TIP are discussed for relapsed or refractory cases. The roles of surgery, chemotherapy, surveillance and newer agents are outlined.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
This document discusses posterior urethral distraction defects (PFUDD) following pelvic fractures. It describes that a hematoma-fibrosis complex forms between the separated urethral ends rather than a simple stricture. Multimodality management including orthopedics may be needed. Imaging like retrograde urethrogram can show a characteristic S-bend deformity. A transpubic approach like the Waterhouse procedure combines perineal and abdominal incisions to allow a tension-free anastomosis but may cause complications like incontinence or impotence.
Megaureter ppt. Types, pathophysiology, evaluation and management.Hussain Shah
- Megaureter (MGU) is defined as a ureteral diameter greater than 7 mm. MGU can be classified based on its cause as refluxing, obstructed, both refluxing and obstructed, or nonrefluxing and nonobstructed.
- MGU is a common finding in neonates referred for urologic evaluation and accounts for up to 23% of cases of urinary tract dilatation seen on prenatal ultrasound.
- Evaluation of MGU involves ultrasound to assess anatomy and severity, VCUG to check for reflux, renal scan to evaluate function, and potentially MRI urography.
- Management depends on etiology but
The document provides information on the surgical anatomy of the kidney and ureter. It discusses the embryology, gross anatomy including orientation and position of the kidneys. It describes the microscopic anatomy including the nephron. It details the coverings of the kidney including the fibrous capsule, perinephric fat, Gerota's fascia and paranephric fat. It outlines the relations of the kidney to surrounding structures like ribs, diaphragm and pleura. It also discusses the blood supply, lymphatic drainage and nerve supply of the kidneys.
This document discusses the management of locally advanced renal cell carcinoma (RCC) at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It covers RCC with involvement of the inferior vena cava (IVC) or invasion of adjacent organs. For IVC involvement, it describes evaluation methods like MRI/CT and surgical techniques for thrombectomy based on the level of thrombus. It also discusses locally invasive non-metastatic RCC and invasion of adjacent organs like liver, duodenum, colon and approaches to management with extended resections when needed.
Percutaneous nephrolithotomy (PCNL) carries risks of several access-related complications. Prevention involves ensuring sterile urine, adequate imaging for access planning, and backup equipment. Initial puncture can lead to hemorrhage, arterial or venous puncture, or injury to surrounding structures. Bleeding is typically controlled with tamponade but may require angioembolization. Delayed hemorrhage can also occur from arteriovenous fistulas or pseudoaneurysms. Careful patient selection, access planning and technique can minimize complication risks.
This document discusses different types of ureteral obstruction and reflux, as well as techniques for ureteral diversion and ureterostomy. It classifies obstructions and reflux as intrinsic or infravesical, primary or secondary. It also describes how to perform a Lembert suture technique for ureteral diversion, where the redundant ureter is folded over a catheter and secured with absorbable sutures.
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
This document discusses pelvic fracture urethral distraction defects (PFUDD). It provides classifications for pelvic fractures and urethral injuries. For urethral injuries, it describes the Colapinto-McCallum and Goldman classifications based on radiological findings. Clinical features, diagnostic evaluations including retrograde urethrography, and management approaches for immediate vs delayed treatment are covered. Goals of treatment include re-establishing urethral continuity while reducing risks of stenosis, incontinence and impotence.
This document summarizes the surgical management of urethral strictures. It discusses investigations like retrograde urethrography and various types of urethroplasty procedures including dilation, internal urethrotomy, lasers, stents, and open reconstruction. Specific procedures covered include anastomotic urethroplasty, substitution urethroplasty using grafts and flaps, and augmented anastomotic urethroplasty. Complications of different procedures like buccal mucosal graft urethroplasty, fasciocutaneous urethroplasty, and anterior and posterior urethroplasty are also summarized.
This document discusses the management of small renal masses (SRMs). It provides an overview of diagnosis and treatment options for SRMs, including:
- SRMs are detected more frequently with improved imaging and account for about 20-25% of renal masses.
- Biopsy and advanced imaging can help differentiate between benign and malignant SRMs and determine tumor aggressiveness.
- Treatment options include radical nephrectomy, partial nephrectomy, thermal ablation, and active surveillance. Partial nephrectomy aims to preserve renal function while providing cancer control comparable to radical nephrectomy.
- Factors such as tumor size, location, and patient comorbidities help determine the optimal surgical approach and extent of surgery
This document provides information about upper tract instrumentation and flexible ureteroscopy. It lists the moderators and their departments. It then describes the anatomy of the ureter, its layers, microscopic structure, normal variations in caliber, and significance of narrowings. It discusses the evolution of rigid, semi-rigid and flexible ureteroscopes over time. Properties, uses and complications of different ureteroscopes are summarized. Identification of the ureteral orifice and techniques for ureteral access and flexible ureteroscope introduction are also covered.
This document describes the history and evolution of cystoscopy and endoscopy. It discusses early cystoscopes that used candle light and mirrors, and the development of modern rigid and flexible cystoscopes using electric light, fiber optics, and video imaging. It outlines the key innovators who developed new light sources, lenses, and technologies to improve visualization of the bladder. These advances allowed cystoscopy to become a mainstream urological procedure. The document also provides details on modern cystoscopy techniques and equipment.
Bladder injuries are rare. But when present in cases of polytrauma they pose both a diagnostic as well as surgical challenge to the attending surgeon. Understanding the mechanisms underlying bladder injuries is pivotal in developing a diagnostic algorithm in order to avoid missing of any urologic injury. Once the extent and site of damage is diagnosed then prompt surgical intervention is the mainstay of treatment. The pathophysiology and management of bladder injuries is discussed in this paper.
This document summarizes retroperitoneal anatomy, collections, and hematomas. It describes the three retroperitoneal compartments and expansive interfascial planes that allow collections to spread. Common causes of retroperitoneal hematomas are discussed. Diagnostic imaging includes CT or angiography. Management depends on stability and source of bleeding, ranging from conservative treatment to angiographic embolization or surgery.
This document discusses pelvic fractures and urethral injuries. It provides classifications for pelvic fractures including the Young-Burgess and Tile classifications. It also describes classifications for posterior urethral injuries, including the Colapinto-McCallum and AAST classifications. Posterior urethral injuries occur in 1.6-9.9% of pelvic fractures and have high mortality. Diagnosis is made through retrograde urethrogram and treatment involves initial suprapubic cystostomy followed later by reconstruction if completely torn. Complications of posterior urethral injuries include stricture, impotence, and incontinence. Anterior urethral injuries are also discussed as well
This document discusses the management of metastatic renal cancer. It notes that approximately 1/3 of newly diagnosed renal cancers are metastatic and 20-40% of localized cancers eventually metastasize. Metastatic renal cancer is usually fatal with 5-year survival rates under 5%. The document outlines treatment approaches including local therapies like cytoreductive nephrectomy and metastasectomy as well as systemic therapies like immunotherapy, targeted therapy and chemotherapy. It provides details on specific immunotherapy agents, targeted therapies including several tyrosine kinase inhibitors, and recommendations on treatment sequencing.
This document discusses ureteral injuries, including their etiology, types, anatomy, risk factors, diagnosis, and management. It notes that ureteral injuries most commonly occur during gynecologic surgeries like hysterectomy. Diagnosis involves imaging like IVU, CT scan, or retrograde ureterography. Management depends on the location and severity of injury, and may include ureteroureterostomy, bowel or bladder flaps, nephrectomy, or autotransplantation. Prevention involves identifying anatomical landmarks and avoiding thermal or electrosurgical injuries during surgery.
This document discusses radiation fistula and malignant fistula. It provides information on:
1) Radiation fistula can occur months to 30 years after radiotherapy for pelvic malignancies and presents as pain. Types include urethrovaginal, vesicovaginal, urethrorectal, and others.
2) Malignant fistula can occur with advanced primary cancers or local recurrence in the pelvis. It may present as a fistula between organs.
3) Evaluation and management depends on the type and complexity of the fistula. Surgical repair often requires interposition flaps or grafts to aid healing in irradiated tissue. Diversion procedures may be used in complex
This document discusses the surgical management of genitourinary tuberculosis (GUTB). It outlines various surgical indications including obstructions, drainages, and reconstructive or ablative procedures. Specific techniques are described for managing infections, strictures, and reconstructing the ureters and bladder. Endoscopic and open surgical options are presented for addressing lesions in the kidneys, ureters and bladder. Reconstructive techniques including psoas hitch, Boari flap, and ileal ureteral substitution are summarized.
This document discusses genitourinary fistulae, specifically vesicovaginal fistula (VVF). It describes the etiology as being mainly obstetric causes in developing countries and iatrogenic, especially surgical, causes in developed countries. The clinical features, evaluation, and management are discussed. Surgical repair is the main treatment and can be done via vaginal or abdominal approaches. The success rate of fistula repair is high at 95% but declines with repeated attempts.
This document discusses urethrovaginal fistula, including its causes such as obstetric trauma and pelvic surgery. It describes the clinical presentation and goals of treatment, which are to restore urethral continuity, ensure continence, and cover the defect with vascularized tissue. Evaluation involves tests like cystoscopy and cystourethrography. Surgical repair principles include multilayer closure and use of tissue flaps. Timing of repair depends on the etiology. Prevention involves careful dissection during anterior colporrhaphy and sling procedures.
This document provides information about urogynecological fistulas from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the different types of genitourinary fistulas including vesicovaginal fistula, their causes such as obstetric injuries or gynecological surgeries. Evaluation methods like cystoscopy and imaging are described. Conservative management and surgical repair techniques for fistulas via vaginal or abdominal approaches are outlined.
This document discusses the anatomy and physiology of the vesicoureteral junction (VUJ) and vesicoureteral reflux (VUR). It provides details on:
- The anatomy of the intravesical and intramural portions of the ureter and factors that allow antegrade urine flow and prevent reflux under normal conditions.
- Grading systems used to classify the degree of reflux seen on voiding cystourethrogram.
- Evaluation methods for VUR including ultrasound, voiding cystourethrogram, radionuclide cystogram, and renal scintigraphy.
- Factors that can cause primary or secondary reflux such as congenital defects or increased
This document summarizes surgical procedures for male infertility performed by the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India. It describes diagnostic tests like testicular biopsy and procedures to improve sperm production such as varicocele repair. It also discusses sperm retrieval techniques and surgical management of ejaculatory duct obstructions. The document provides details on performing various procedures and their indications, techniques, complications, and outcomes.
Pediatric urology Management Of Antenatal HydroureteronephrosisGovtRoyapettahHospit
This document provides information from the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India. It lists the professors and assistant professors in the department and provides details on fetal development of the urinary tract, grading of antenatal hydronephrosis, causes and evaluation of pediatric hydronephrosis, investigation methods, and management approaches for various prenatal urinary tract abnormalities. Key points covered include risk stratification of urinary tract dilation, indications for fetal intervention, outcomes of fetal cystoscopy versus vesicoamniotic shunting, and guidelines for management of vesicoureteral reflux and megaureter/ureterovesical junction obstruction
This document provides information on bladder injuries, including their classification, mechanisms of injury, symptoms, investigations, and management. It discusses blunt and penetrating trauma as common causes, with extraperitoneal and intraperitoneal ruptures being the main classifications. Symptoms include hematuria, suprapubic pain, and difficulty voiding. Investigations involve cystography, CT cystography, and other imaging. Management depends on the injury type, with simple extraperitoneal leaks sometimes managed conservatively via catheter drainage, while intraperitoneal ruptures typically require surgical repair.
The document discusses urethral injuries, including their classification, causes, clinical features, investigations, and management approaches. It covers injuries to both the posterior urethra from pelvic fractures or trauma, and anterior urethra from straddle injuries or trauma. For posterior injuries, early management includes suprapubic cystostomy while late management involves anastomotic urethroplasty techniques like the Webster or Waterhouse procedure. Anterior injuries are often managed with delayed repair or dilation depending on the severity of stricture formation.
This document discusses the management of ureteral strictures. It provides details on various endourologic and surgical options for treating ureteral strictures, including balloon dilation, ureteroscopic endoureterotomy, ureteral stenting, ureteroureterostomy, and ureteroneocystostomy. The success rates and approaches for different procedures are described. Postoperative care is also outlined.
The document contains information about the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It lists the professors and assistant professors in the department and provides information on grading various types of penile injuries from minor cuts to total penectomy. It also outlines treatments for conditions like penile fractures, foreign objects embedded in the penis, penile amputations, and testicular injuries.
This document discusses the initial management of urethral injuries. It describes the anatomy of the male and female urethra and types of urethral injuries. For anterior urethral injuries, the classic triad of symptoms is outlined and initial investigations and management with suprapubic cystostomy or immediate repair are summarized. Posterior urethral injuries are often associated with pelvic fractures and initial management focuses on hemodynamic stability and associated injuries before addressing the urethra. The document recommends suprapubic cystostomy with possible delayed endoscopic realignment as the standard approach.
This document discusses renal trauma, providing information on evaluation and management. It notes that the kidney is the most commonly injured abdominal organ in trauma cases. Evaluation involves clinical examination looking for hematuria, hypotension, and flank tenderness, as well as imaging like CT or IVU to grade injuries. Most grade I-III injuries can be managed conservatively with bed rest, but higher grade injuries involving the renal parenchyma or vessels often require surgical exploration or angiography. Surgical management principles include debridement, hemostasis and repair of lacerations. Complications of renal trauma include urinoma, abscess, impaired renal function and death in severe cases.
This document provides an overview of genitourinary fistulas, including their causes, types, symptoms, diagnosis, and treatment. It discusses that the most common types of genitourinary fistulas are vesicovaginal, ureterovaginal, and urethrovaginal fistulas. The main causes are gynecological or obstetric surgery and trauma. Symptoms include urinary incontinence and irritation. Diagnosis involves tests like dye tests and imaging. Treatment involves conservative management or complex surgical repair procedures. Post-operative care is important to ensure proper healing. Prevention focuses on avoiding prolonged labor and risky childbirth procedures in developing countries.
This document provides information about the department of urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, including lists of moderators and professors. It then discusses the history, physiology, definition, subtypes, etiology, examination, investigations, and treatment of priapism. The treatment section focuses on approaches for ischemic vs non-ischemic priapism, including aspiration, drug injection, surgical shunting, and arterial embolization. Outcomes and algorithms for treatment are also presented.
This document discusses posterior urethral valves, including their classification, embryology, presentation, diagnosis, and management. It describes Young's classification system for posterior urethral valves, which includes Type I, II, and III valves. Type I valves are the most common, occurring in 95% of cases. The document also outlines the effects of posterior urethral valves on the urinary tract and bladder, as well as the evaluation, treatment, and long-term care of patients with this condition.
This document discusses urinary extravasation, which is when urine leaks out of the urinary tract into other body cavities. It defines two types - superficial and deep extravasation. Superficial extravasation occurs above the perineal membrane and is usually caused by injuries to the penile urethra during instrumentation. Deep extravasation occurs below the perineal membrane due to injuries of the membranous urethra or extraperitoneal bladder from pelvic trauma. Management involves pain relief, antibiotics, suprapubic catheterization, and sometimes surgical exploration and drainage of collections.
This document describes alternatives for urinary diversion after cystectomy from the Department of Urology at GRH and KMC in Chennai. It discusses three main alternatives: abdominal diversion, urethral diversion using gastrointestinal pouches attached to the urethra, and rectosigmoid diversions. For each type, it provides details on procedures, advantages, complications, and postoperative care considerations. The document also discusses continent urinary diversion options that allow intermittent self-catheterization, such as ileocecal sigmoid pouches and the Kock pouch.
This document describes the renogram procedure. It provides details on:
- The radiopharmaceuticals used, including 99mTc-DTPA, 99mTc-MAG3, and 99mTc-DMSA
- How the procedure is performed, including patient preparation, image acquisition, and time-activity curve analysis
- The roles of the radiopharmaceuticals in evaluating renal blood flow, glomerular filtration rate, and renal handling and excretion
- Factors that can affect the procedure such as hydration, medications, and kidney positioning
This document provides information about an X-ray KUB (kidneys, ureters, bladder) exam performed by the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India. It lists the moderators and their qualifications. It then discusses the history of X-rays, how they are produced, standard views, and how to systematically read an X-ray KUB. It describes how to assess technical quality and what to look for, including renal calcifications which are most commonly due to kidney stones. It also discusses mimics of urinary calcifications like gallstones.
This document provides information about a KUB (kidney, ureter, bladder) x-ray performed at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the professors and assistant professors in the department and provides details on the history, physics, techniques, anatomical landmarks, disorders, and interpretations of renal calculi, ureter, bladder, and other findings that can be seen on a KUB x-ray.
This document describes a voiding cystourethrogram (VCUG) conducted by the Department of Urology at GRH and KMC in Chennai, India. It lists the professors and assistant professors moderating the VCUG. The document provides details on the indications, techniques, and pediatric applications of VCUGs, focusing on evaluating conditions like vesicoureteral reflux, posterior urethral valves, bladder diverticula, and ectopic ureters. It compares VCUG to nuclear cystography and voiding sonography as diagnostic tools.
This document provides information about ultrasound use in urology. It discusses the history of ultrasound in urology from 1963 onwards. It then covers basic ultrasound principles including modes, probes, imaging planes and documentation. Applications to the kidney, bladder, prostate and testes are described. Common abnormalities like hydronephrosis, cysts, masses and infections are outlined. In summary, the document is an overview of ultrasound techniques and their use in evaluating the urinary tract and common urologic conditions.
The document provides information about urodynamics testing performed at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the professors and assistant professors who moderate the tests. It then describes the purpose and components of urodynamics testing, which involves a series of tests to evaluate urine storage and evacuation. The key components reviewed include uroflowmetry, measurement of post-void residual urine, cystometrogram, pressure flow studies, and videourodynamics. The document provides details on performing each test and interpreting the results.
This document provides an overview of MRI in urology, with a focus on MRI of the prostate. It discusses the moderators and professors of the department of urology. It then covers the basic principles of MRI, including magnetic field strength, radiofrequency pulses, T1/T2 weighting, and contrast agents. Applications of MRI for prostate imaging and prostate cancer detection are described, including T2-weighted imaging, diffusion-weighted imaging, and magnetic resonance spectroscopy. The PIRADS scoring system and assessment of extracapsular extension on MRI are also summarized.
This document provides information about intravenous urography (IVU), including its definition, history, indications, contraindications, technique, phases, and what is evaluated. Some key points:
- IVU involves injecting iodine contrast intravenously and taking x-ray images as it passes through the kidneys, ureters, and bladder. It was introduced in 1929 by American urologist Moses Swick.
- Indications include evaluating for ureteral obstruction, trauma, congenital anomalies, hematuria, infection, or uncontrolled hypertension. Contraindications include contrast allergy and renal impairment.
- The technique involves injecting contrast as a rapid bolus,
This patient presented with anterior urethral stricture and multiple abnormal connections (fistulas) between the prostate gland/urethra and the skin, resulting in urine leakage to the skin. Treatment will require surgical repair of the strictures and closure of all abnormal connections to restore normal urinary flow and continence.
This document provides information about intravenous urography (IVU), including:
- IVU involves injecting contrast media intravenously and imaging the kidneys, ureters, and bladder.
- It has indications like evaluating suspected obstruction, assessing integrity after trauma, and investigating hematuria or infection.
- Contraindications include contrast allergy and renal failure. Advantages include clearly outlining the urinary system, while disadvantages include need for contrast and radiation exposure.
- The document describes the IVU technique, expected timing of images, and what should be evaluated on the images.
- It also covers normal anatomy, types of contrast media, and abnormal findings that could be
This document provides information about urodynamic evaluation of voiding dysfunction. It discusses the history of urodynamics, aims, equipment used including catheters, flowmeters and EMG equipment. It describes how to conduct urodynamic evaluations including uroflowmetry, cystometrogram, and considerations for filling rate and medium. Key points covered are the indications for urodynamics, preparation of patients, types of equipment and how to interpret uroflow curves and cystometrogram measurements.
This document provides information about various tumor markers used in urology, including prostate-specific antigen (PSA) markers for prostate cancer screening and diagnosis, tumor markers for testicular cancer such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG), and urine-based markers for bladder cancer screening like NMP22 and BTA. It also discusses guidelines for PSA screening and interpretation, as well as clinical applications of different tumor markers for diagnosis, prognosis, monitoring treatment response, and detecting recurrence of urological cancers.
This document discusses transitional urology, which involves the planned movement of adolescents and young adults with chronic urological conditions from pediatric to adult-centered care. It provides an overview of common urological conditions seen in transitional urology, including spina bifida, bladder exstrophy, hypospadias, posterior urethral valves, vesicoureteral reflux, and pediatric genitourinary cancers. It also discusses specific issues in transitional urology like urinary tract infections in neurogenic/reconstructed bladders, troubleshooting continent catheterizable channels, risks of malignancy with augmentation cystoplasty, and presentation of BPH and pelvic organ prolapse in patients with neurogenic
This document provides information about retroperitoneal fibrosis (RPF), including its pathogenesis, clinical presentations, investigations, and management. RPF is characterized by extensive fibrosis in the retroperitoneum that can encase the aorta, vena cava, and ureters. Patients typically present with nonspecific symptoms like back pain, but late presentations can include urinary obstruction and vascular complications. Diagnosis is often made using CT or MRI imaging showing soft tissue surrounding retroperitoneal structures. Treatment involves medications like corticosteroids to reduce inflammation or surgical procedures to decompress the urinary system if obstructed.
The document describes urodynamic evaluation (UDE) performed in the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai. It lists the professors and assistant professors in the department and provides an introduction to UDE. It then describes the various components of UDE including uroflowmetry, cystometry, pressure flow studies and videourodynamics. It outlines the procedure for setting up and performing UDE, and analyzes storage and voiding phases and parameters measured.
This document discusses urinary obstruction, including its pathophysiology, causes, effects on renal physiology and function, histological changes, clinical impact, and renal recovery after relief of obstruction. It provides an overview of how urinary obstruction can lead to permanent kidney damage depending on the severity, chronicity, and baseline kidney condition. Both unilateral and bilateral obstruction are examined, along with the triphasic response and changes in renal blood flow, filtration, and tubular transport that occur.
This document describes uroflowmetry - a noninvasive test used to evaluate urine flow. It discusses the normal and abnormal flow patterns seen in uroflowmetry and their clinical significance. Uroflowmetry provides parameters like maximum flow rate, average flow rate and voided volume. It can detect bladder outlet obstruction, detrusor underactivity or overactivity. However, pressure-flow studies are needed to precisely define lower urinary tract function. Uroflowmetry is useful for screening and monitoring treatment response, though invasive therapy should not be based on uroflowmetry alone per AUA guidelines.
Pathophysiology of pneumoperitoneum and complications of laproscopic surgeryGovtRoyapettahHospit
This document provides information about the Department of Urology at Govt Royapettah Hospital and Kilpauk Medical College in Chennai, India. It lists the professors and assistant professors in the department and provides an introduction to laparoscopy. The rest of the document discusses the history of laparoscopy, choices of insufflation gas, physiological effects of pneumoperitoneum, and potential complications of laparoscopy procedures. It provides details on cardiovascular, respiratory, renal, and other organ system effects of increased abdominal pressure during laparoscopy. The document also outlines potential complications from veress needle placement, trocar insertion, insufflation, and electrosurgery and their management.
This document discusses the history and types of endoscopes used in urology. It describes rigid endoscopes which use a series of lenses to transmit images and how the rod lens system improved image quality. Flexible endoscopes transmit images using fiber optic bundles and have the advantage of being able to flex and access different areas. Newer digital endoscopes replace lenses with CCD chips to provide superior quality images electronically. The document outlines the benefits of different endoscope technologies and future trends including 3D imaging and wireless capabilities.
This document discusses various positioning techniques used in urological procedures. It describes the lithotomy, lateral decubitus, prone, supine, and Trendelenburg positions. For each position, it provides details on how to properly position the patient, including flexion angles, padding of pressure points, and risks of nerve injuries if not performed correctly. It aims to ensure patient safety and provide optimal surgical exposure while avoiding iatrogenic injuries during urological procedures.
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2
3. Urinary leakage following gynaecological or obstetric
surgery is a complication due to the formation of
urogenital fistula.
Significant morbidity, with social and psychological
aspects aggravating the clinical situation.
Ureterovaginal fistula -most serious of the urinary
fistulas because of its potential to cause incontinence,
sepsis, and renal loss.
Dept Of Urology, KMC and GRH, Chennai 3
4. Ureteral fistulae to the genital tract in the female most
often connect with the vagina .
fallopian tube , Uterus -Very rare
Iatrogenic Ureteric injuries - 52-82% during Gynaec Sx.
Iatrogenic ureteral injury leading to UVF - 0.5% to 2.5%
Up to 10% patients- Concomittant VVF.
Dept Of Urology, KMC and GRH, Chennai 4
5. Etiology
Gynecologic Surgery
Abdominal hysterectomy
1.3-2.2%
Lap hysterectomy 1.3 %
Vaginal hysterectomy
0.03%
Radical hysterectomy
Caesarian section
Anterior colporrhaphy
(cystocele repair)
transvaginal oocyte
retrieval.
Other Pelvic Surgical
Procedures
Vascular surgery
Urologic surgery including
retro pubic bladder neck
suspensions
Colon surgery
Other
Locally advanced
malignancy
Radiation therapy
Pelvic trauma
Chronic inflammatory
diseases: actinomycosis,
etc.
Dept Of Urology, KMC and GRH, Chennai 5
6. Risk factors
Anatomical Pathological Technical
1. Ureter attached
peritoneum
1. Congenital anomalies
of ureter/ kidney
1. Massive intraoperative
hemorrhage 2
2. Close to female genital
Tract
2. Ureteric displacement:
(uterus size ≥12 weeks,
prolapse, Tumors
(ovarian),cervical or
broad ligament swelling.
2. Coexisting bladder
injury
3. Ureter has variable
course
3. Adhesions (previous
pelvic surgery,
Endometriosis, PID)
3. Technical difficulties
4. Not easily seen or
palpated
4. Distorted pelvic
anatomy
4. Inexperienced surgeon
Half of ureteric injuries has no identifiable risk factors
Dept Of Urology, KMC and GRH, Chennai 6
7. Gynaecology procedure –Injury risk
During control of
active bleeding /
clamping large segments
of the tissues.
Lower third of the
ureter
- lateral edge of the
uterosacral ligament,
-ventral to the uterine
artery
- just lateral to the cervix
and fornix of the vagina.
Dept Of Urology, KMC and GRH, Chennai 7
8. Obstetric procedure –Injury risk
Pelvic adhesions due to
repeated caesarean
section,
Markedly enlarged
uterus
Massive bleeding
obscuring the operative
field
Dept Of Urology, KMC and GRH, Chennai 8
9. Pathogenesis
• Urinary extravasation , urinoma formation,
• Subsequent extension along Non anatomic
planes created during surgery.
• Eventual drainage through the vaginal
incision / an ischemic area of vaginal cuff.
Dept Of Urology, KMC and GRH, Chennai 9
11. Intra op Ureteric injuries
1. Ligation (suture)
2. Crushing injury (clamp)
3. Transection ( partial, complete)
4. Angulation
5. Ischemia (ureteral stripping, Electrocoagulation)
6. Resection of ureteral segment.
Electrical , thermal , or laser energy, or from linear stapler
during laparoscopy
Dept Of Urology, KMC and GRH, Chennai 11
12. Risk factors for Postoperative fistulae
Dept Of Urology, KMC and GRH, Chennai 12
13. Prevention
Pre operative Intra operative
1. To identify ureteral
abnormalities - IVP
1. Adequate exposure
2. Preoperative stenting 2. Stay outside the vascular
sheath zone of thermal injury
3. Lighted ureteric stents are
popular in laparoscopy
3. Ureteric dissection and direct
visualization
4. Incise the peritoneal
reflection between the uterus
and bladder
5. the bladder is reflected
inferiorly with sharp dissection
Vaginal Surgery / anterior colporrhaphy - sutures should not be inserted too
deeply while plicating the bladder
Vaginal hysterectomy – adequate vesico-uterine space before clamping
Dept Of Urology, KMC and GRH, Chennai 13
14. The venial sin is injury to the ureter
the moral sin is failure of recognition -
Higgins
Almost ½ of ureteric injuries can be prevented ,
out of these ½ can be detected Intraoperativly.
Dept Of Urology, KMC and GRH, Chennai 14
15. Identification –Intra Op
Dye test - intravenous pyridium or methylene blue
Urinary extravasation within 3-5 mts.
Cystoscopy- detects only obstructive injuries
non obstructive ,partially obstructive ,late
injuries secondary to ischaemia and avascular necrosis
Perioperative laparoscopic ultrasound probe
-ureteric diameter exceeds 3.0mm
- no peristaltic activity during 5 min of follow-up
Dept Of Urology, KMC and GRH, Chennai 15
16. Clinical Presentation
Presentation of a patient with a UVF usually varies
- in relation to timing after surgery.
Immediate postoperative period - abdominal or
flank pain, abdominal fullness, fever, or any
combination of the above.
Dept Of Urology, KMC and GRH, Chennai 16
17. Delayed presentation :
days or weeks postoperatively,
C/o Continuous urinary leakage, which the patient may
or may not be able to discern is from the vagina.
Volume of leakage may vary .
Continuous urinary incontinence -large fistulas
Watery discharge - small fistulas.
Patients typically void normally.
Dept Of Urology, KMC and GRH, Chennai 17
18. Clinical examination
Abdominal examination :- nonspecific generalized
tenderness, and costo vertebral tenderness may be
present.
Vaginal examination :- a mass or erythema of the
vaginal wall may be visible.
Dept Of Urology, KMC and GRH, Chennai 18
19. Diagnostic Evaluation
Imaging studies :
USG
CT urogram,
MRU
intravenous urography (IVU), and
retrograde pyelography
Double dye test
Dept Of Urology, KMC and GRH, Chennai 19
20. DOUBLE DYE or TAMPOON TEST
For diagnosing vesicovaginal or ureterovaginal fistulae.
oral phenazopyridine (Pyridium)
methylene blue is filled in to the empty bladder via a
urethral catheter.
A tampoon is placed into the vagina.
blue- vesicovaginal fistula
orange- ureterovaginal fistula is suspected.
Dept Of Urology, KMC and GRH, Chennai 20
22. IVU-Findings
Extravasation outside the ureter,
Drainage of contrast media into vagina (Fistula track )
Hydronephrosis and hydroureter
Delayed function /Non excretion
High oblique or lateral film - to differentiate the
contrast in the bladder from that in the vagina.
Sensitivity of excretory urography in detecting
ureterovaginal fistula is about 33%
Dept Of Urology, KMC and GRH, Chennai 22
23. IVU
Left HUN with a distal tapering of
the ureter
Opacification of the vagina
Dept Of Urology, KMC and GRH, Chennai 23
24. IVU
Left Ureter entering the vagina Rt HUN with contrast in vagina
Dept Of Urology, KMC and GRH, Chennai 24
28. RGP
Outlines the ureter and fistula well,
an abrupt termination of the ureter 2 to 4 cm from
the ureteral orifice.
Ureteral continuity cofirmed - an attempt at
stenting is warranted.
Dept Of Urology, KMC and GRH, Chennai 28
29. RGP
abrupt termination of the distal
ureter.
extravasation of
contrast in the distal ureter.
Dept Of Urology, KMC and GRH, Chennai 29
31. Goals of Therapy
Expeditious resolution of urinary leakage
Avoidance of Urosepsis
Preservation of renal function
Preservation of fertility
Exclude associated VVF
Dept Of Urology, KMC and GRH, Chennai 31
32. Management
Upper tract diversion
Timing of the repair
Surgical technique
Dept Of Urology, KMC and GRH, Chennai 32
33. Conservative Non operative
Spontaneous fistula closure in patients with
ureteral continuity and a normal-appearing
ureter beyond the fistula , although this is
unusual.
with varying success, in 5–15%
Labasky et al
Dept Of Urology, KMC and GRH, Chennai 33
34. Upper tract diversion
Prompt drainage of upper urinary tract - partial
ureteral obstruction is often present
An attempt at RGP & ureteral stenting or
percutaneous nephrostomy tube
as soon as possible if direct open surgical repair
is not immediately considered.
Dept Of Urology, KMC and GRH, Chennai 34
36. Endoscopic Management
Presentation within 3 weeks of injury,
<2 cm length of injury,
with remaining ureteral continuity.
a retrograde ureteral stent,
percutaneous nephrostomy, and
antegrade ureteral stent .
Dept Of Urology, KMC and GRH, Chennai 36
38. Retrograde ureteral stent
If a point of obstruction is unable to be traversed, rigid
ureteroscopy may be helpful.
Low flow irrigation should be used, Guidewire is passed
under direct vision.
Inflamed, edematous ureters may tear
Guidewire does not pass easily - aborted.
Dept Of Urology, KMC and GRH, Chennai 38
39. Following successful stent placement, CBD should be
maintained for a minimum of 2 Weeks to prevent
extravasation secondary to vesicoureteral reflux up the
stent.
Followup IVP should also be performed prior to
discontinuation of the ureteral stent and 3–6 months later to
document patency of the ureter.
Dept Of Urology, KMC and GRH, Chennai 39
40. PCN +/- antegrade stent placement
Nephrostomy alone may allow spontaneous
healing of a small fistula.
If a wire cannot be passed through a point of
obstruction, the attempt should be discontinued, and
the nephrostomy is left in place.
Persistent attempts - tearing of the ureter
,submucosal dissection and edema.
Dept Of Urology, KMC and GRH, Chennai 40
41. Memokath 051 stent
Thermo expandable nickel-titanium alloy
content and the closed tight spiral structure.
Wide calibre of the strictured segment,
provides adequate urinary drainage, and
prevents the escape of urine to a coexisting UVF
Minimal risk of crystal deposition, urothelial
in-growth, ischaemic damage or corrosion of the
ureteric wall.
Neither hinders ureteric peristalsis nor
causes VUR.
Stent migration- remote chance only
Dept Of Urology, KMC and GRH, Chennai 41
42. If ureteral stenting is Unsuccessful due to
Complete ureteral occlusion or prolonged leakage
Persists , formal surgical repair is indicated …
Dept Of Urology, KMC and GRH, Chennai 42
43. Timing of the repair
Timing of the repair of ureterovaginal fistulae is controversial.
Some authors advocate early repair
While others recommend a delay of 4 to 8 weeks
More recent literature suggests that early repair is preferred and
is not associated with an increase in morbidity or higher failure
rates. (Payne, 1996).
Dept Of Urology, KMC and GRH, Chennai 43
44. Timing of surgical intervention :
Extent of the causative operation
Condition for which it was performed
Type and time of ureteric injury
Condition of the pelvic tissues
General condition of the patient
Mandal AK,Sharma SK,Vaidyanathan S,Goswami AK.,Ureterovaginal fistula:
summary of 18 years' experience . Br J Urol. 1990 May;65(5):453-6.
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45. Surgical technique
1. URETERIC REIMPLANTATION
Open surgical repair most commonly involves
URETERONEOCYSTOSTOMY.
Ureteroneocystostomy is performed with / without a
psoas hitch.
Occasionally, a Boari flap may be necessary due to
extensive ureteral injury.
Dept Of Urology, KMC and GRH, Chennai 45
46. Principles
Meticulus dissection, preserving ureteral sheath
Tension free anastomosis ( ureteral mobilization)
Water tight closure , absorbable suture.
Peritonium or omentum to surround the anastomosis
Drain ( closed, suction) to prevent urine collection
Stenting the anastomotic site
Consider proximal diversion with PCN
Dept Of Urology, KMC and GRH, Chennai 46
47. Ureteroneocystostomy
Transperitoneal /Extraperitoneal approach
Ureteral mobilisation – Prox healthy ureter
- Pathological site
Bladder mobilisation – Sup vesicle pedicle
Fistula localisation
Division of ureter & closure of stump
Vaginal defect closure- Not always
Dept Of Urology, KMC and GRH, Chennai 47
48. Ureteral Lenghtening
Technique Lengthening ( in Cms )
Ureteroneocystostomy 4-5
Psoas Hitch 6-10
Boari Flap 12-15
Renal Descensus 5-8
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54. 2.OTHER PROCEDURES : rarely indicated are
Transureteroureterostomy,
Ileal substitution of the ureter,
Renal autotransplantation
3.IPSILATERAL NEPHRECTOMY – Very rare
Extensive renal damage due to obstruction or infection.
Dept Of Urology, KMC and GRH, Chennai 54
58. Complications
Urine leak
Injury to opposite ureter
Bladder spasm
Stenosis at anastomosis site
VUR – due to inadequate tunneling
Dept Of Urology, KMC and GRH, Chennai 58
59. VVF associated with UVF
If the Associated VVF overlooked , urinary leakage
will persist post operatovely.
Combination closure of VVF with reimplantation of
the ureter into the bladder and interposition of
omentum or a peritoneal patch between the bladder and
vagina.
Dept Of Urology, KMC and GRH, Chennai 59
60. Management of Ureterovaginal Fistula
Confirm diagnosis (IVP +/- RPG/CT)
Successful placement
Exclude VVF (Cystoscopy +/- VCUG, double dye test)
Unsuccessful
Attempt stent placement
Suspect Ureterovaginal Fistula
Surgical repair
(ureteroneocystostomy)
Remove stent in 4-6 wks
Repeat imaging
Persistent fistula Resolution of fistula
Wein, Alan J. et al., Campbell-Walsh Urology, 10th Ed., Vol 3, 2012
60
61. SUMMARY
All patients with suspected uretrovaginal fistula should
undergo upper tract evaluation ( IVP and/or CT urogram )
Cystoscopy - essential to rule out the associated
vesicovaginal fistula.
Minimal invasive approach should be the first choice of
treatment. At least 6 weeks of stenting is allowed for healing.
In the case of failure, an open surgical repair is
necessary.
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