Urological surgery

1. Acute flank pain_Uretric colic or
renal colic
By :Noor Ibrahim Noori
Ayat Ibrahim abdulkareem

2. The commonest urological emergencies,Most often due to the passage of
a stone formed in the kidney, down through the ureter.
Always of renal origin.
♦ Nature of stones are same as that of renal stones.
♦ They are commonly of elongated shape.
♦ They can get impacted at various narrow junctions.
Sites
♦ PUJ.
♦ Where ureter crosses the iliac vessels.
♦ Where ureter crosses vas deferens/broad liga ment.
♦ Where ureter penetrates outer layer of bladder muscle.
♦ In the intramural portion of ureter near the ureteric orifi ce. Stones less
than 5-8 mm size may pass spontaneously.
Renal colic

3. Clinical features:
1. Pain—it is of colicky type and radiates from loin
to groin often to the tip of the genitalia, testis in
males, labia majora in female (referred along the
genito femoral nerve).
It is severe in intensity, increases with
exercise.
It mimics appendicitis, cholecystitis, ovarian or
tubal
pathology.
2. Nausea, vomiting, sweating due to pain and
reflex pylorospasm.
3. Haematuria, dysuria, frequency, strangury.
4. Tenderness in iliac fossa and renal angle (no
rebound tenderness)

4. Differential diagnosis:

5. Work up
• History
•Examination patient want to move around, in an attempt to find a comfortable position
• Investigations in form of:.
♦ Urine—microscopy, C/S.
♦ Plain X-ray, KUB—radio-opaque stones are visible in 90% of cases—in the line of
ureter (near the tips of transverse processes of lumbar vertebrae, sacroiliac joint and
medial to ischial spine). Lateral or oblique films are required to differen tiate from
other opacities which mimic stone.
♦ IVU shows hydronephrosis and hydroureter. Function may be accurately assessed by
isotope renogram.
♦ Blood urea, serum creatinine, serum calcium, uric acid level.
♦ U/S is useful.
♦ CT scan is diagnostic.

6. An intravenous urography showing a calculus
in the upper left ureter

7. Acute management of uretric stones
– Pain relief
• NSAIDs
•Intramuscular or intravenous injection, by mouth, or per rectum
• +/- Opiate analgesics (pethidine or morphine).
–? hydration
– ‘watchful waiting’ with analgesic supplements
95% of stones measuring 5mm or less pas spontaneously

8. Acute management of uretric stones
Indications for Intervention to Relieve Obstruction and/or Remove the
Stone:
–Pain that fails to respond to analgesics.
– Associated fever.
–Renal function is impaired because of the stone (solitary kidney
obstructed by a stone, bilateral ureteric stones, or preexisting renal
impairment )
– Obstruction unrelieved for >4 weeks
– Personal or occupational reasons

9. Treatment of the stones..
Temporary relief of the obstruction:
•Insertion of a JJ stent or percutaneous nephrostomy tube.
•Definitive treatment of a ureteric stone:
• ESWL.
•PCNL
•Ureteroscopy
•Open Surgery: very limited.

10. urinary retention
supervised by :Dr.Thaer
presented by :Hasan Allawi
and Tabark Fadhil

11. Types and pathophysiology
Acute urinary retention: painful inability to void, with relief of pain following drainage of
the Bladder by by catheterization .It is normally associated with more than 500ml of
urine being drained .can classfied either spontaneous or precipitated by event like
infection .
other types
-chronic retention
usually associated with reduced renal function and upper tract dilatation .
-retention with overflow
the patient incontinent with small amount of urine passing from distended bladder .it is
usually follows neglected retention
pathophysiology
-increase urethral resistance
-low bladder pressure (impaired bladder contractilty)
-interruption of sensory or motor innervation of bladder
-central failure of coordination of bladder contraction with external sphincter relaxation.

12. causes of acute retention
• The most frequent causes of acute retention:
• Male:
• _Bladder outlet Obstruction (the commonest cause)
• _Urethral stricture
• _Acute urethritis or prostatitis
• _Phimosis
• Female:
• _Retroverted gravid uterus
• _Bladder neck Obstruction(rare)
• Both:
• _Blood clot
• _Urethral calculus
• _Rupture of the urethra
• _Neurogenic(injury or disease of the spinal cord)
• _Smooth muscle cell dysfunction associated with ageing
• _Faecal impaction
• _Anal pain(haemorrhoidectomy)
• _Intensive postoperative _analgesic treatment
• _Some drugs
• _Spinal anaesthesia

13. clinical features and
management
.no urine is pased for several hours
.pain is present
.the bladder is visible ,palpable,tender and dull to percussion.
.potential neurological cause should be excluded by checking reflexes in lower
limb and perinal sensation.
management
History taking
The most important factors to identify when
taking a history from the patient include:
● Symptoms of prostatic enlargement: Frequency, urgency, nocturia,
hesitancy,
poor stream, intermittent flow, terminal dribbling.
● Symptoms of infection: Frequency, urgency, dysuria, visible haematuria.
● Constipation.
● Presence of visible clots and haematuria.
● Recent operative procedures, particularly those involving anasthesia.

14. management
.Symptoms of neurological conditions: Lower limb weakness, saddle anaesthesia,
paraesthesia, faecal incontinence.
● Medications history: Anticholinergics, opiates, anti-histamines, tricyclic
antidepressants.
Examination
-is the patient warm..fever
-abdominal -tender enlarged bladder with dullness to percussion well above
symphysis pubis,often almost to lower level of umbilicus.
-look for phymosis ,mental stenosis and signs of infection in genitalia.
-in female -look for cystoceles ,UV prolapsy ,do vaginal exam and look for pelvic
mass .look for vulval infection and inflamation ,gravid uterus abvoius thing.
-Do DRE/PR examination in males .look for enlarged prostate .
-Do neurological exam to dect neurogenic bladder.

15. mangement
• Investigation
• laboratory studies
• -urinalysis and culture :-for uti ,hematuria ,glycosuria,crystals
• -renal fuction test :-BUN,creatinine ,electroyte .to evaluate renal faiulre .
• -sreum prostate specific antigen:-for prostate cancer if suspected
• -coagulation profile and hemoglobin :-in urinary bladder temponade .
• Imaging
• U/S of kidney ,ureter and bladder :indicate in all patient with urinary retention
• Further investigation
• transrectal U/S
• cystoscopy ,ct urography
• pelvic U/S
• MRI brain or spinal cord

16. management
treatment
-decompression:by suitable catheter by foley’s catheter with three way
irrigating silicone catheter.size from 14 to 18 gauge.it is contraindicated in
patient who have recent urological surgery (radical prostatectomy or
urethral reconstruction).
suprapubic catheter may necessary when obstructive precludes a
urethral catheter and is also prefferred in patient who are require longer
term catheterization.
-medical management :in men with BPH we recommended initiating an
alpha -1 adrenergic antagonist at time of initial catheterization .and we
also suggest ongoing with this treatment to delay recurrence of AUR.
neurogenic bladder related urine retention should be managed with clean
intermittent self cathetrization.
-trial without catheter:for people who is presnted with BPH.
-chronic urinary retention :is directed to renal support ,bladder drainge
slow rate to avoid decompression ,and late treat the cause.

17. RENAL TRAUMA
2 0 2 2
Presented by Dounia khalaf & Hassanien Ahmed

18. INTRODUCTION
Trauma is defined as a physical injury or a wound to living tissue caused by an extrinsic agent.
Renal injuries occur in 1-5% of all trauma cases
• Renal trauma can be life-threatening
• Kidney is the most commonly injured genitourinary organ at all ages, with a male to female ratio of 3:1
• Children are more susceptible to renal trauma than adults
• Renal trauma can be an isolated injury but in 80-95% of cases there are concomitant injuries
mechanism of injury
1-Blunt injury
2-Penetrating injury
Blunt injury Damage caused by impact from an object that doesn't break the skin.
• Causes of blunt injury
i. Rapid deceleration (eg, motor vehicle crash fall from heights))
ii. direct blow to the flank (eg, sports injury)
• More common than penetrating trauma, which
accounts for 80% - 90% of all renal injuries
• Gunshot and stab wounds represent the most common causes of penetrating injuries
• Penetrating injuries tend to be more severe and less predictable and have potential for greater parenchymal
destruction and are most often associated with other organ injuries.

19. Grading of Renal Injury

21. Clinical features
• Featuresofshock
• Haematuriamaybemildtoprofusedepending onthetypeofinjury.
• Suddendelayedprofusehemorrhagecausing
• haematuriacanoccurbetween3rddayto3rd weekaftertrauma.
• bruising,swellingandtendernessin theloin.
Management
Whenpossible,obtainafocusedhistory oftheinjuryfromthepatient,prehospitalpersonnel,and
availablebystanders :- (mechanismofinjury,prehospitalcareprovided,andanyprevioushistory
ofgenitourinaryinjuryordisease). Asthegenitourinarytractisseldominjuredinisolation,a
meticulousphysicalexamination iscrucialtoavoidmissingoccultinjuries. Theclinicalcluestoa
potentialrenalinjuryarenonspecific,butinclude:bruising,pain,ortendernesstotheflankor
abdomen;posteriorriborspinefractures;grosshematuria;otherorganinjury;microhematuria,
definedas≥3to5RBCs/HPF;andshock,definedasasystolicbloodpressure≤90mmHg.

22. Theindicationsforradiologicalassessmentare:
● Penetratinginjuries.
● Grosshaematuria.
● Shockincombinationwithmicroscopichaematuria.
● Children:inwhomthekidneysaremuchlower andless wellprotected.
CTscanwithcontrastistheinvestigationofchoice. It
willaccuratelyassesstheextent oftheinjury,showinglaceration,extravasation,surrounding
haemorrhage andvesselinjury. Italsoshowsnon-renalinjuriesandeffectivelystages renalpedicle
injury. Arterialocclusionismanifestasrimenhancementofthenormalrenalcontour.
Treatment
☆ The vast majority of cases of blunt renal trauma can be treated conservatively andinonemajorseries
only2.5%of suchcasesrequiredsurgicalexploration.
☆Most penetrating injuriesfromknifeorgunshotwoundsrequirerenalexploration
☆Ingeneral,minor andlimitedmajorinjuriesaretreated conservatively
☆Unstablemajor injuriesarebesttreatedwith
promptsurgicalexplorationasthislessenstheriskofcontinuedbleeding,sepsisandrenalloss.

23. • Somepatientswhohavenotundergonepriorradiologicalassessmentwillrequirean
immediatelaparotomy and insomepatientsrenaltraumawillbeencountered
unexpectedlyduringlaparotomy.
• Ifthisoccurs,thenanon-tableintravenousurogramisrequired.
• Ifsignificantextravasation,non-function,pooropacificationor caliceal
distortionis foundthen renalexploration isindicated. Anexpandingor pulsatile
retroperitonealhaematomashouldbeexploredbutonlyaftervascularcontrolhasbeen
achieved
• Complications
• Earlycomplications
• Earlycomplications,thosethatoccurwithin1monthofinjury,areurinoma,delayed
bleeding,urinaryfistula,abscess,andhypertension. Prolongedurinaryextravasation
isthemostcommoncomplicationafterrenaltrauma
• Latecomplications
• Latecomplicationsafterrenaltraumaarehydronephrosis,arteriovenousfistula,
pyelonephritis,calculusformation,anddelayedhypertension.

25. INJURIES TO THE URETER
Presented by: Zahraa Naeem & Diana
Abdulameer

26.  Rupture of the ureter
 Injury to one or both ureters during pelvic surgery
- Injury recognised at the time of operation
- Injury not recognised at the time of operation

27. Rupture of the ureter
This is an uncommon result of a hyperextension injury of the spine. The diagnosis is
rarely made until there is swelling in the loin or iliac fossa associated with a reduced
urine output. An IVU or contrast-enhanced CT shows extravasation of contrast.
Injury to one or both ureters during pelvic surgery
This occurs most often during vaginal or abdominal hysterectomy when the ureter is
mistakenly divided, ligated, crushed or excised. Pre-emptive ureteric catheterisation
makes it easier to identify the ureters.
 Injury recognised at the time of operation :
Ureterovesical continuity should be restored by one of the methods for repairing
unless the patient’s condition is poor ; deliberate ligation of the proximal ureter and
temporary percutaneous nephrostomy is then the best course until the patient is well
enough for a repair.

28.  Injury not recognised at the time of operation :
o Unilateral injuries
There are three possibilities:
1 No symptoms. Ligation of a ureter may lead to silent atrophy of the kidney. The injury may be
unsuspected until the patient undergoes urological imaging.
2 Loin pain and fever, possibly with pyonephrosis, occur with infection of the obstructed system.
Loss of function will be permanent unless obstruction is relieved by promptly inserting a percutaneous
nephrostomy.
3 A urinary fistula develops through the abdominal or vaginal wound. The IVU or contrast-
enhanced CT shows extravasation with or without obstruction of one or both ureters.
Nephrostomies may be inserted and repair postponed until oedema and inflammation have subsided,
but delayed repair often leaves the patient incontinent. Early repair is safe if the patient is fit for
surgery.
o Bilateral injury
Ligation of both ureters leads to anuria. Ureteric catheters will not pass and urgent nephrostomy or
immediate surgery is essential.

29. Repair of injured ureter

30. Transureteroureterostomy
ureteroureterostomy

31. Boari operation: a strip of bladder wall is fashioned into
a tube to bridge the gap between the cut ureter and the
bladder.
Psoas hitch of bladder

32. Nephrectomy may be best when the patient’s outlook is poor
and the other kidney is normal. When conservation of all renal
tissue is vital, replacement of the damaged ureter by a segment
of ileum is necessary.

33. Urinary bladder injuries
Urinary bladder injuries
Urinary bladder injuries
Causes:
1. Injuries occur most often from external force(traffic collisions,
industrial trauma, and blows to the lower abdomen) are often
associated with pelvic fractures.
2. Penetrating wound to the lower abdomen.
3. Iatrogenic injury may result from:
a. Emergency C/S
b. inguinal or femoral hernial repairs.
c. excision of the rectum.
d. transurethral operations.(TURBT, TURP)

34. Clinical Findings
Intraperitoneal rupture: the peritoneum overlying the bladder is
breached, allowing urine to escape into the peritoneal cavity.
Therefore may be a cause of acute abdomen.
Extraperitoneal rupture: the peritoneum is intact and urine escapes
into the space around the bladder, but not into the peritoneal cavity.
A. SYMPTOMS & SIGNS
1. Suprapubic pain and tenderness.
2. Difficulty or inability to pass urine (a hematoma may push the bladder
up and affect urination)
3. Hematuria.
4. Abdominal distension.
5. Absent bowel sounds (intraperitoneal rupture).
6. Signs and symptoms of shock in case of associated pelvic fractures.
* These symptoms and signs are an indication for a retrograde
cystogram.

35. C. Investigations:
A plain abdominal film shows pelvic fractures
along with haziness over the lower abdomen from
blood and urine extravasations.
Retrograde cystography.
CT cystography is superior in the identification of
bony fragments in the bladder and bladder neck
injuries as it will show leakage of contrast into intra
or extraperitoneal areas.

36. CT cystography is superior in identifying
bladder injuries as it will show leakage of
contrast into intra or extraperitoneal areas.
Cystoscopy:for detection of intra-
operative bladder injuries.
Ultrasound: Demonstrates intraperitoneal fluid
or an extraperitoneal collection suggests
intraperitoneal or extraperitoneal perforation,
respectively.

37. Treatment
A. EMERGENCY MEASURES
Shock and hemorrhage should be treated.
Catheterization usually is required in patients with pelvic trauma but is
contraindicated in case of:
1. Blood at the urethral meatus.
2. Scrotal hematoma or swelling.
3. High riding prostate on PR examination.
4. Patient desires to void but is unable to.

38. B. SURGICAL MEASURES
1.Extraperitoneal bladder rupture
Bladder drainage with a urethral catheter for 2 weeks followed by a
cystogram to confirm the perforation has healed. If leaks keep the
catheter for additional 2 weeks.
Indications for surgical repair:
1- If you have opened the bladder to place a suprapubic catheter for a
urethral injury.
2- A bone spike protruding into the bladder on CT.
3- Associated rectal or vaginal perforation.
Where the patient is undergoing open fixation of a pelvic fracture, the
bladder can be simultaneously repaired.
Intraperitoneal
Usually repaired surgically to prevent complications from leakage of
urine into the peritoneal cavity

39. Urethral injury
Presented by : Mustafa Saleem &Fatima Raheem
Supervised by:- Dr.Thaer Al-Omary

40. Anatomy
Posterior urethra:
Prostatic urethra.
Membranous urethra.
Anterior urethra:
Bulbar urethra.
Penile urethra.

41. RUPTURE OF MEMBRANOUS URETHRA AND/ OR
PROSTATIC URETHRA (Posterior Urethra)
Cause :
road traffic accidents.
Injury can also occur during instrumentation.
Calculus passage and catheterisation.
In prolonged labour, due to longstanding pressure on the urethra by foetal head.
Based on ascending urethrogram ,posterior urethral injury is classified as (McCallum-colapinto classification)
Type I: Elongation of posterior urethra, but intact .
Type II: Prostate "plucked off" membranous urethra with extravasation of urine above sphincter only-Floating prostate-
Vermooten's sign .
Type Ill: Total disruption of urethra with extravasation of urine both above and below the sphincter.
Urethral injury

42. Clinical Features
Blood in external meatus.
Failure or difficulty in passing urine.
Extravasation of urine to scrotum , perineum and abdominal wall.
Shock with pallor, tachycardia, hypotension.
On per rectal (PR) examination, prostate may be felt high or may not be palpable at all signifies floating prostate
Investigators :
X-ray pelvis to see for fracture.
Ultrasound abdomen to see pelvis and other injuries .
Urethrogram is done to see the site and type of tear (often reserved to do at later stage).
Treatment :
The shock and associated injuries are treated.
Antibiotics, blood , fluid replacement, treatment of other injuries.
If there is floating prostate should treated

43. RUPTURE OF BULBOUS URETHRA (Anterior Urethra)
Mechanisms:
The majority a result of a straddle injury in boys or men.
Direct injuries to the penis
Penile fractures
Inflating a catheter balloon in the anterior urethra
Penetrating injuries by gunshot wounds.
Symptoms and signs:
Blood at the end of the penis
Difficulty in passing urine
Frank hematuria
Hematoma may around the site of the rupture
Penile swelling

44. Diagnosis:
Retrograde urethrography:
Contusion: no extravasation of contrast.
Partial rupture : extravasation of contrast, with contrast also present in the bladder:.
Complete disruption: no filling of the posterior urethra or bladder .
Treatment
Patient should be told not to try to pass urine, if passed , then extravasation of urine occurs. In operation
theatre, one attempt of urethral catheterisation is tried gently. If able to pass a catheter, then it is left in
place. Often perinea! haematoma which occurs, has to be drained . Antibiotics shou ld be given to
prevent sepsis. If catheter fails to pass, then under general anaesthesia, in lithotomy position, SPC is
done. Bulbous urethra is exposed through perinea! midline incision and tear is sutured with an indwelling
Foley's catheter. Drain is then placed into the perineum. If suturing is not possible (sometimes), then
perinea/ urethrostomy is done and at later stages continuity is maintained (usually after 3 months).

45. Testicular torsion
Mohammed Ali
Fatima kareem

46. Testicular torsion
is a twist of the spermatic cord, resulting in strangulation of th
—Most frequently between the ages of 10 and 30 (peak incide
If left
untreated, the blood flow to the testicle ceases and the testicle
dies. The earlier the surgery to untwist the testis can be undertaken the bette
per cent if the testicle can be untwisted within 6 hours of the
torsion taking place compared with an approximate 20 per cent
salvage rate if the surgery is delayed for 24 hours.

47. Predisposing causes:
1.An abnormally high attachment of the tunica vaginalis predispose to tors
2.Separation of the testis from the epididymis- torsion about the pedicle be
3-• Inversion of the testis is the most common predisposing cause.
The testis is rotated so that it lies transversely or upside down.
Straining on stool, lifting of a heavy weight and coitus
are all possible precipitating factors. Alternatively, torsion may
develop spontaneously during sleep.

48. Clinical Features
1. Is most common between 10-25 years of age although a few cases
occur in infancy.
2. Symptoms vary with degree of torsion most commonly there is sudden
agonizing pain in the groin and lower abdomen.
3. Nausea and may be vomiting
4. O/E: the testis seems high and the tender twisted cord can be palpated
above it.
5. Elevation of testis worsing pain.Prehn’s sign describes the (relief of pain
with elevationof the testicle and) was once to be touted as a method to
distinguish epididymitis from torsion since the pain associated with torsion
is usually not relieved with elevation of the testicle (ie, positive Prehn’s =
epididymitis). However, this sign is not reliable in differentiating these two
entities.
6. Several studies have found loss of the cremasteric reflex to be the most
accurate sign of testicular torsion. This reflex is elicited by stroking the
ipsilateral thigh which leads to reflex elevation of the ipsilateral testicle by
greater than 0.5cm.

49. Diagnosis
1.History & physical examination
2.Doppler U/S scan will confirm absence of blood supply to affected
testis. 63.6-100% sensitivity and 97-100% specificity.
High-resolution US (HRUS) for direct visualisation of the spermatic cord
twist with a sensitivity of 97.3% and specificity of 99%.
3.Scintigraphy and, more recently,
4.Dynamic contrast-enhanced subtraction MRI of the scrotum also
provide a comparable sensitivity and specificity to US

50. History and examination
1-There is a sudden onset of severe pain in the hemiscrotum.
2-It is often associated with nausea.
3-There is sometimes a history of minor trauma to the testis.
4-Some patients report previous episodes with spontaneous resolution of th
5-The torted testis is usually moderately swollen and very tender to the touc
6-It may be high riding compared to the contralateral testis and may lie in a h
7-Thecremasteric reflex is nearly always absent.

51. Differential diagnosis
1-Epididymo-orchitis.
2-Torsion of a testicular appendage.
3- strangulated inguinal hernia compressing the cord
and causing compression of the pampiniform plexus.
4-mumps orchitis
5-Idiopathic scrotal oedema

52. Surgical management
1-Scrotal exploration should be undertaken as a matter of urgency
since delay in relieving the twisted testis results in permanent
ischemic damage to the testis, causing atrophy, loss of hormone and
sperm production, and, as the testis undergoes necrosis and the
blood–testis barrier breaks down, an autoimmune reaction against
the contralateral testis (sympathetic orchidopathy).
2-Bilateral testicular fixation should always be performed since the
bellclapper abnormality that predisposes to torsion often occurs
bilaterally
fixation with non-absorbable sutures between the tunica vaginalis
and the tunicaalbuginea.
The other testis should also be fixed because the anatomical
predisposition is likely to be bilateral
3-Manual detorsion may be attempted in the emergency room while
awaiting surgery. Occasionally, the induction of anesthesia will
reduce spasm and promote spontaneous detorsion—in both of these
instances,Bilateral orchiopexy should still be performed to prevent
recurrence.