As Cystoscopy equipment,
Urethrotomy tray,
Urethral dialators,
Double giving set,
Sterile water/3ltr Saline,
Guide wire (available)
(f) Urethroscopy/Urethrotomy - A Urethrotome is passed beyond the
Stricture to release and widen the Urethra.
Equipment;
As above (e).
(g) Lithopaxy - Removal of stones in the bladder. Optical Lithotrite is passed
through the Urethra, into the bladder, used to crush stones into small enough
peices to be washed out.
Lithotripsy - is when the stones are blasted by shock waves with a Lithotriter.
Equipment;
Stone punch,
Double bowl,
Ellik evacuator,
Stone forceps tray,
Lithoclast tray,
Air cylinder ( 4 bar),
Lithoclast machine,
Ultrasound Lithotripsy and machine,
Nephroscope (for straight approach for instrumentation),
Cystoscope,
Double giving set,
3 ltr Saline,
Drapes.
(h) Percutaneous Nephroscopy/Nephrolithotomy - removal of stones from the
pelvis of the kidney. A Nephroscope allows the stone to be seen, while forceps
are passed to extract the stone.
Equipment;
Cystoscopy pack,
Cystoscopy tray,
Light lead,
Camera drape,
12 degree Olympus telescope,
Open ended Ureteric catheter,
038 guide wire,
50ml syringe, 3 leur locks, Leur filler,
2ml syringe,
Filter needle,
Methelene blue,
Urografin 150,
16 Urethral catheter,
10ml syringe,
2ltr Urine drainage bag,
Ky Jelly/Instillagel,
Hibidil,
Swabs,
Abo extension set,
Pipe cleaners,
Y Urology giving set,
3 ltr bag Saline,
Nephroscopy tray,
Ky Jelly for Ultrasound,
Nephroscope,
Drapes,
Suction tubing,
15 blade,
Lithoclast tray,
20ml syringe,
2/0 silk,
Betadine prep,
Porges drain 26/28fg and 26 catheter,
Mepore dressing.
Extra's;
Entry needle,
Cook dialators,
Selection of guide wires,
Amplaz trac master,
Encore 26 inflation device,
Biliary manipulation catheter,
Major tray,
Wolfe lithotripsy equipment,
Ureteroscopes (adapter for),
Wolfe metal dialators.
2. Discuss the various patient positions required for the above procedures.
What precautions must be followed to protect the patient.
A-G;
Patient is placed in the half lithotomy position. This is the same as the
lithotomy, except the angle of the legs is lower. Legs must be raised in unison
to prevent dislocation, or muscle/nerve damage. Arms can be folded and placed
on the chest, secured by their gown.
Care must be taken that there is no metal touching the patient, if using
diathermy.
The eyes must be protected, as there can be risk of potential damage of them
drying out, or the lights damaging the retina.
H;
Patient is placed in the Prone position or Prone Oblique, depending on the
surgeon's preference.
It is important that the Thorax and Pelvis are well supported, by placing
pillows underneath, so there is no obstruction to venous return. This will also
ensure the abdomen can move, so patient can breath, or be ventilated. The Ulna
nerves and feet must be protected from undue pressure. Vein boards are used
for the arms.
Again protection for the eyes, and diathermy to consider.
3. (a) What irrigation fluid is used for each of the above procedures and why?
A-C Glycin is used, because diathermy will not work in Saline, to keep a clear
view of the operative site.
D-H Sterile Water or Saline, to keep a clear view of the operative site and to
flush and clean the area.
(b) What is meant by the term continous irrigation?
As long as the surgery is taking place and instruments are being used, the area
is being irrigated to reduce the risk of trauma to tissue and keep a clear view
of the operatie site.
A large bag of saline is connected and pumped through tubing, until the surgeon
is satisfied that the operation is complete. A closed system is used, involving a
Cystoscope and giving set. It reduces clot retention, and discomfort of a
distended bladder, and reduces the risk of the catheter being blocked.
(c)What are the advantages of this whilst using a resectoscope?
Its acts as a coolant to reduce unneccessary burning, and gives the surgeon a
clear view.
4. Telescopes:
(a) Describe the maintenance, cleaning and sterilization of telescopes prior to
use.
Cleaning -Disassemble the instrumentation. Immerse in warm soapy water and
ensure all surfaces are cleaned. A cotton bud may assist to access the distal
lens, objective window and light guide post. If these area's are not thoroughly
cleaned, the resulting image and illumination could be impaired.
Where applicable, remove the eyepeice cap and gently brush the screw threads
to remove any residual fluid or debris. In addition, remove the light guide
adaptors and brush the surfaces and securing threads. Lubricate with grease
prior to disinfection/autoclaving to eliminate sticking/seizing.
Lubricate stopcock - grease
rubber sealing - oil
moving metal parts - oil
Do not get any on the eyepiece lens windows, as this will decrease viewability
and imaging quality.
Regularly lubricate rubber sealings with oil to maintain an optimum level of
sealing effectiveness in the sealings.
Lubricate moving metal parts in joints or attachment devices.
Disinfection;
Only use solutions that are certified by the manufacturer. Chemical agent
should be capable of deactivating viruses.
Sterilization;
5 minutes at 134 degrees centigrade.
(b) What would the following telescopes be used for?
0' - Direct viewing. Best for Urethroscopy or visual Urethrotomy.
30' - Used with inspecting sheath to examine the Urethra, Prostate, Bladder
neck, Trigone and Posterior wall of the Bladder. Used with crushing forceps,
biopsy forceps, catheter deflecting mechanisms and most Rectoscopes.
70' - To inspect the bladder roof.
12' - Olympus. Same as 30'.
(c) Describe the different cystoscopes used in your department and the
various pieces of equipment that may be used with them.
Cystoscopes are made up of;
An outer sheath,
Inner Obdurator,
Bridge.
They come in three sizes;
21 gauge
22 gauge
22.5 gauge
The younger the man the narrower the gauge.
There is also an Intergrated telescope ( all parts attached already) which is a
17 gauge. This has no outside sheath, and is used for urethral strictures.
Other equipment used;
Telescope,
Light lead,
Button electrode,
Flexible biopsy,
Rigid biopsy,
Grasper,
Guide wires,
Ureteric catheters (to remove stents),
5.List the types of catheters available and state what situation they may be
used.
Ballooned Catheter.
Two way foley;
Called two way because it has two channels. One is for urine drainage and the
other is used to inflate the balloon to keep it in place. Sterile water is used to
inflate the balloon.
Used for emptying the bladder for patients who cannot or may have difficulty
doing so for themselves. Helps keep a measure of their fluid balance.
Three way foley (irrigating catheter)
This has three channels; one for urine drainage, one for inflating the balloon,
and one which opens just below the tip of the catheter for continous irrigation.
Used mainly for endoscopic and open operations on the bladder or prostate,
with a closed drainage system, to prevent clot retention.
Can also be used on an infected bladder for continous irrigation.
Hydrogel catheter which is made of Hydrogel coated latex, can be used for
long term catheterisation.
All the above can be used for removal of blood clots. 3 way ones used often
after prostatic surgery.
There is a silicone catheter for patients with a latex allergy.
Some surgeons like to use a plastic catheter for T.U.R.P. available in
20/22/24 gauges.
6. Why may a patient require a urethral stent?
Mainly for Palliative care.
Put in situ prior to Prostate operations, to relieve discomfort of being unable
to pass urine.
Elderly patients may have benign swelling, so may be used to stretch the
Urethra for their comfort.
7. Give a brief description of the following procedures:
(a) Nephrectomy - Removal of the kidney. Where recurrant infections and
renal scarring has caused severe renal failure.
(b) Partial Nephrectomy - Removal of part of the kidney. Where scarring and
damage is confined to one pole of the kidney, to preserve as many functioning
nephrons as possible.
(c) Radical Nephrectomy - Removal of all perinephric fat and the adrenal
gland, as well as the kidney. To ensure adequate clearance of carcinogenic
tissue, when renal cell carcinoma has occurred. Could also be the result of
trauma.
(d) Uretero-lithotomy - Stone removal from the Ureter. Ureter is exposed and
secured with a tape sling, above the stone. Ureter is opened between stay
sutures over the stone. The stone is removed. Ureteric catheter is passed down
ureter to keep it patent.
(e) Pyelo-lithotomy - Stone removed through incision in the renal pelvis.
(f) Pyeloplasty - Removal of the Renal pelvis. Pelviureteric junction removed
and new one remade which is wide, dependant and spouted, (refashioned for
hydronephrosis).
(g) Cystectomy with ilial conduit - Removal of the bladder, diverting the
ureter's to an iliostomy. In women the Uterus is also removed.
8. Discuss how the patient may be positioned for these procedures.
A,B,C, and F - Patient is placed in a lateral jacknife position to give optimum
access to the kidney for the surgeon. The arm is supported, raised up to
protect the axilliary nerve, and the other arm is placed so it is not being
squased into the side of the patient. Abdomen and lumbar supports are used,
attached to the table, and all area's are padded to protect from diathermy
burns. Towards the end of surgery, the table is straightened at the surgeons
command, to sew up the incision, so the skin is not stretched at this point.
Some surgeons may perform this operation in the supine position, with a
sandbag used to elevate the hips.
D and E - Placed in the lithotomy position. Legs raised together to reduce the
risk of dislocation, muscle and nerve damage. Arms folded and placed on chest.
Pressure points are cushioned where required.
G - Patient placed in Supine Jacknife position to give optimum access to the
bladder. Pelvis is placed in line with an O mark on the table. As with all of the
above padding is used to protect skin from diathermy burns and pressure
points are considered.
9. What methods may be used to minimize heat loss during these procedures-
include TURP.
Fluid warmer
Baer Hugger (warming blanket)
Heated Operating theatre
Warmed fluid (TURP, TURBT)