Verfügbarkeit: Transurethral surgery

Transurethral surgery:

Gespeichert in:

Bibliographische Detailangaben
1. Verfasser:	Mauermayer, Wolfgang (VerfasserIn)
Format:	Buch
Sprache:	English
Veröffentlicht:	Berlin [u.a.] Springer 1983
Online-Zugang:	Inhaltsverzeichnis
Beschreibung:	XXIX, 473 S. Ill.
ISBN:	3540118691 0387118691

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MARC


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100	1		\|a Mauermayer, Wolfgang \|e Verfasser \|4 aut
240	1	0	\|a Transurethrale Operationen
245	1	0	\|a Transurethral surgery \|c W. Mauermayer. With contributions by ... Transl. by A. Fiennes. Foreword by Willard E. Goodwin
264		1	\|a Berlin [u.a.] \|b Springer \|c 1983
300			\|a XXIX, 473 S. \|b Ill.
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Datensatz im Suchindex

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adam_text	CONTENTS CHAPTER A. OPERATING FACILITIES FOR TRANSURETHRAL SURGERY ................................ 1 I. GENERAL CONSIDERATIONS .......................................................................................................... 1 II. THE OPERATING SUITE FOR A TRANSURETHRAL UNIT ................................................................... 1 1. THE OPERATING ROOM FOR TRANSURETHRAL PROCEDURES ....................................................... 1 2. THE ANESTHETIC ROOM ....................................................................................................... 5 3. THE INSTRUMENT ROOM ....................................................................................................... 7 4. ANCILLARY ROOMS ................................................................................................................... 10 5. THE RECOVERY AREA ............................................................................................................... 10 6. THE SITING OF TRANSURETHRAL OPERATING SUITES .................................................................... 10 CHAPTER B. INSTRUMENTS AND THEIR CARE ....................................................................... 11 I. INSTRUMENTS FOR TRANSURETHRAL SURGERY .................................................................................... 11 1. DIAGNOSTIC INSTRUMENTS ............................................................................................................ 11 2. OPERATING CYSTOSCOPES ....................................................................................................... 11 3. WATER CONNECTIONS FOR DIAGNOSTIC AND OPERATING CYSTOSCOPES .......................................... 14 4. ELECTRO-RESECTOSCOPES ............................................................................................................ 15 A) THE RESECTOSCOPE SHEATH ................................................................................................ 16 A) INSULATION-COATED SHEATHS ........................................................................................ 16 P) THE EXTERNAL END OF THE RESECTOSCOPE SHEATH ........................................................ 17 Y) THE OBTURATOR ............................................................................................................ 18 B) THE ELECTROTOME ............................................................................................................... 21 A) LOOP CONTROL MECHANISMS ........................................................................................ 21 P) CUTTING LOOPS AND OTHER WORK PIECES ..................................................................... 22 Y) THE TELESCOPE ............................................................................................................... 26 C) IRRIGATION FLUIDS FOR TRANSURETHRAL SURGERY ................................................................. 26 D) THE FIBER OPTIC LIGHT SOURCE ........................................................................................ 27 E) THE HIGH FREQUENCY DIATHERMY UNIT ............................................................................ 27 F) LUBRICATING AGENTS ........................................................................................................... 27 G) SUNDRIES: LIGHTING CABLE, HIGH FREQUENCY CABLE, IRRIGATION SUPPLY, AND DRAINAGE HOSES ............................................................................................................................... 28 5. LITHOTRITES ............................................................................................................................... 30 A) PRELIMINARY CONSIDERATIONS ............................................................................................ 30 B) THE PUNCH LITHOTRITE ACCORDING TO M AUERMAYER ........................................................ 31 ) THE SHEATH ................................................................................................................... 31 P) THE OPERATING MODULE ............................................................................................... 31 C) THE URAT-I-LITHOTRITE ........................................................................................................ 33 D) THE ULTRASONIC LITHOTRITE ................................................................................................ 33 XVI CONTENTS 6. THE CONTINUOUS IRRIGATION RESECTOSCOPE ............................................................................ 35 7. THE SUPRAPUBIC ASPIRATION TROCAR ........................................................................................ 36 8. THE LASER OPERATING CYSTOSCOPE ............................................................................................ 36 9. THE OPERATING URETHROSCOPE ................................................................................................ 37 II. CLEANING, STERILIZATION AND MAINTENANCE OF ENDOSCOPIC INSTRUMENTS .................................... 38 1. INSTRUMENT CLEANING ............................................................................................................... 38 A) PRELIMINARY DISINFECTION ............................................................................................... 38 B) CLEANING THE SHEATHS AND ACCESSORIES (EXCLUDING TELESCOPES) .................................... 39 C) CLEANING THE TELESCOPES ................................................................................................... 41 D) INSPECTING THE LIGHT CABLES ........................................................................................... 43 2. STERILIZATION AND DECONTAMINATION OF INSTRUMENTS ............................................................ 44 A) THE DECONTAMINATION PROCESS ....................................................................................... 44 B) STERILIZATION ....................................................................................................................... 45 III. HIGH FREQUENCY TECHNOLOGY: APPLICATIONS AND HAZARDS. BY K. F ASTENMEIER AND G. F LACHENECKER ........................................................................................................................... 47 1. CUTTING AND COAGULATING WITH HIGH FREQUENCY CURRENT .................................................... 47 2. THE ELECTRICAL CIRCUIT IN TRANSURETHRAL RESECTION ................................................................ 51 A) CUTTING LOOP AND CONNECTING CABLE ............................................................................ 51 B) INDIFFERENT ELECTRODE ....................................................................................................... 52 C) CURRENT PATHWAYS WITHIN THE PATIENT - EFFECT OF ELECTRICAL PROPERTIES OF INSTRU MENTS AND LUBRICANTS ........................................................................................................ 53 D) INSULATION FAULTS WITHIN THE INSTRUMENT - ELECTRICAL CONDUCTIVITY OF IRRIGATION FLUID ................................................................................................................................... 55 E) CAPACITIVE EFFECTS ............................................................................................................ 57 3. HINTS FOR THE AVOIDANCE OF ELECTRICAL HAZARDS DURING TRANSURETHRAL RESECTION ... 58 CHAPTER C. PREOPERATIVE REQUIREMENTS ....................................................................... 61 I. ASSESSMENT OF THE PATIENT ........................................................................................................... 61 1. THE HISTORY ........................................................................................................................... 61 2. UROLOGICAL ASSESSMENT ........................................................................................................... 62 A) RECTAL EXAMINATION ....................................................................................................... 62 B) RADIOLOGIC INVESTIGATION OF THE URINARY TRACT ............................................................ 62 A) EXCRETION UROGRAM ................................................................................................... 62 /?) CYSTOURETHROGRAM ....................................................................................................... 63 C) INDICATIONS FOR PREOPERATIVE OUTPATIENT CYSTOSCOPY .................................................... 65 II. INDICATIONS FOR SURGERY ................................................................................................................. 66 1. GENERAL CONSIDERATIONS ....................................................................................................... 66 2. GENERAL INDICATIONS FOR PROSTATECTOMY ................................................................................ 67 A) ACUTE RETENTION OF URINE ............................................................................................... 67 B) RECURRENT RETENTION ....................................................................................................... 67 C) INCREASING RESIDUAL VOLUME ........................................................................................... 67 D) CHRONIC RETENTION WITH UPPER TRACT OBSTRUCTION ........................................................ 67 E) RECURRENT INERADICABLE INFECTION .................................................................................... 68 F) HEMORRHAGE FROM PROSTATIC VEINS ......................................................................... 68 G) BLADDER CALCULI ............................................................................................................... 68 H) BLADDER DIVERTICULA ........................................................................................................... 69 I) SEVERE OUTFLOW DISORDERS WITHOUT RESIDUAL URINE ..................................................... 69 J) BLADDER TUMORS ............................................................................................................... 69 CONTENTS XVII 3. RARE INDICATIONS FOR TRANSURETHRAL SURGERY ........................................................................ 70 A) CHRONIC PROSTATITIS AND PROSTATIC ABSCESS ..................................................................... 70 B) PROSTATIC TUBERCULOSIS ................................................................................................... 70 C) MULTIPLE PROSTATIC CALCULI ............................................................................................... 70 4. INDICATIONS FOR TRANSURETHRAL PROSTATECTOMY ........................................................................ 71 A) PREREQUISITES OF THE SURGEON ........................................................................................... 71 B) EARLY SURGERY ................................................................................................................... 73 C) GENERAL INDICATIONS FOR TRANSURETHRAL RESECTION ........................................................ 73 5. CONTRAINDICATIONS AND LIMITATIONS TO TRANSURETHRAL PROSTATIC ADENOMECTOMY ... 74 A) THE VERY LARGE ADENOMA ............................................................................................... 74 B) THE MARKEDLY PROTUBERANT MOBILE MEDIAN LOBE ........................................................ 74 C) BLADDER CALCULI ............................................................................................................... 75 A) ENDOSCOPIC APPROACH TO CALCULUS AND ADENOMA .................................................... 75 /?) CYSTOTOMY FOR THE CALCULUS AND TRANSURETHRAL RESECTION AT A SUBSEQUENT DATE 75 Y) CYSTOTOMY AND PROSTATECTOMY AS A SINGLE PROCEDURE ............................................ 75 D) BLADDER DIVERTICULUM AND PROSTATIC ADENOMA ............................................................ 75 A) LARGE DIVERTICULUM AND BLADDER NECK FIBROSIS .................................................... 75 /?) MULTIPLE DIVERTICULA ................................................................................................... 76 E) BLADDER DIVERTICULUM, BLADDER CALCULUS AND PROSTATIC ADENOMA ............................ 76 F) URETHRAL STRICTURE ........................................................................................................... 76 G) PARAURETHRAL ABSCESS DURING PRELIMINARY CATHETERIZATION ........................................ 76 H) UNUSUALLY SHORT SUSPENSORY LIGAMENT OF THE PENIS .................................................... 77 I) LARGE, IRREDUCIBLE HERNIAS ............................................................................................... 77 J) EPIDIDYMITIS AND SEVERE URINARY TRACT INFECTION ........................................................ 77 K) ANKYLOSIS OF ONE OR BOTH HIP JOINTS ............................................................................ 77 L) PROSTATIC CARCINOMA AMENABLE TO RADICAL SURGERY .................................................... 77 6. LIMITS OF OPERABILITY ............................................................................................................... 78 A) INITIAL CONSIDERATIONS ....................................................................................................... 78 B) CARDIOVASCULAR DISEASE ................................................................................................... 78 C) PULMONARY DISEASE ........................................................................................................... 79 D) CEREBROVASCULAR DISEASE ................................................................................................ 79 E) RENAL INSUFFICIENCY ........................................................................................................... 80 F) LIVER DAMAGE ................................................................................................................... 80 G) GENERAL DECREPTITUDE ....................................................................................................... 80 H) MENTAL SUBNORMALITY AND PSYCHOSIS ............................................................................ 80 I) INOPERABLE CARCINOMA IN OTHER ORGANS ........................................................................ 81 J) COAGULATION DISORDERS ................................................................................................... 81 K) DIABETES MEILITUS ........................................................................................................... 82 L) OBESITY ............................................................................................................................... 82 M) THROMBOPHLEBITIS, VARICOSE VEINS ................................................................................ 82 III. PREOPERATIVE TREATMENT .............................................................................................................. 82 1. DRAINING THE BLADDER ........................................................................................................... 83 A) INTERMITTENT CATHETERIZATION ............................................................................................ 83 B) PERMANENT DRAINAGE ....................................................................................................... 83 ) THE DYE TEST ............................................................................................................... 83 P) INDWELLING CATHETERS ................................................................................................... 84 Y) SLOW DECOMPRESSION OF THE BLADDER ........................................................................ 84 ) IMMEDIATE DECOMPRESSION OF THE BLADDER ................................................................ 84 E) CYSTOSTOMY ................................................................................................................... 84 2. VASECTOMY ............................................................................................................................... 86 A) INDICATIONS ....................................................................................................................... 86 B) TECHNIQUE ........................................................................................................................... 86 XVIII CONTENTS 3. THE TREATMENT OF URINARY INFECTIONS .................................................................................... 87 4. BALANITIS AND INFLAMMATION OF THE PREPUCE ........................................................................ 87 5. CHANCE FINDING OF UROGENITAL TRACT TUMORS .................................................................... 88 6. STRICTURES OF THE URETHRA ....................................................................................................... 88 7. PREOPERATIVE GENERAL MEDICAL PREPARATION ........................................................................ 88 IV. PREOPERATIVE ENDOSCOPY .......................................................................................................... 89 1. GENERAL CONSIDERATIONS ....................................................................................................... 89 2. INTRODUCING THE INSTRUMENT ................................................................................................... 89 A) SURGICAL ANATOMY ........................................................................................................... 89 B) PHYSIOLOGIC URETHRAL CONSTRICTIONS ................................................................................ 90 A) THE EXTERNAL MEATUS ................................................................................................... 90 P) THE TRANSITION FROM FOSSA NAVICULARIS TO PENILE URETHRA .................................... 91 Y) THE PENILE URETHRA ................................................................................................... 92 8) THE TRANSITION FROM BULBAR TO MEMBRANOUS URETHRA ............................................ 92 C) CURVATURE OF THE URETHRA ............................................................................................... 92 A) CURVATURE AT THE PENOSCROTAL ANGLE ........................................................................ 92 P) CURVATURE IN THE BULB ............................................................................................... 92 Y) VENTRAL CURVATURE OF THE URETHRA DUE TO A MEDIAN LOBE .................................... 93 3. AIDS TO PASSING THE INSTRUMENT ........................................................................................... 94 A) INTERNAL URETHROTOMY WITH THE OTIS URETHROTOME ........................................................ 94 A) PRELIMINARY CONSIDERATIONS ....................................................................................... 94 P) TECHNIQUE OF OTIS URETHROTOMY ................................................................................ 94 Y) THE MODIFIED OTIS URETHROTOME ................................................................................ 95 B) SACHSE URETHROTOMY UNDER DIRECT VISION DURING INSTRUMENTATION .......................... 97 C) INSTRUMENTATION UNDER DIRECT VISION ............................................................................ 97 D) OPTICAL AIDS TO PASSAGE OF THE SHEATH ............................................................................ 98 4. TRAUMA DURING INSTRUMENTATION ........................................................................................... 98 A) PRELIMINARY CONSIDERATIONS ........................................................................................... 98 B) INJURIES BELOW THE EXTERNAL SPHINCTER ............................................................................ 98 C) INJURIES ABOVE THE EXTERNAL SPHINCTER ............................................................................ 99 A) VENTRAL INJURIES ........................................................................................................... 99 P ) DORSAL INJURIES ........................................................................................................... 99 Y) SUBTRIGONAL PERFORATION ........................................................................................... 99 5. ORIENTATION AT THE SITE OF RESECTION .................................................................................... 99 A) TELESCOPES FOR INSPECTION OF THE BLADDER AND BLADDER NECK ........................................ 100 A) THE END VIEWING TELESCOPE ...................................................................................... 102 P) DIAGNOSTIC TELESCOPES ............................................................................................. 103 Y) RETROGRADE-VIEWING TELESCOPES .............................................................................. 104 B) DIRECTIONAL FEATURES OF THE BLADDER NECK .................................................................... 105 A) GROUP I FEATURES: DISTAL-PROXIMAL .......................................................................... 105 P) GROUP II FEATURES : CLOCKWISE ROTATION .................................................................. 105 Y) GROUP III FEATURES: LATERAL-MEDIAL, DORSAL-VENTRAL ............................................ 106 6. EXAMINATION OF THE BLADDER NECK ...................................................................................... 107 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 107 B) ASSESSING BLADDER NECK LENGTH .................................................................................. 107 C) DEPTH ASSESSMENT OF THE URETHRAL CLEFT ...................................................................... 108 D) DORSAL TISSUE VOLUME ................................................................................................. 110 E) THE VERUMONTANUM ..................................................................................................... 110 A) FREE-STANDING VERUMONTANUM .............................................................................. 110 P) COVERED VERUMONTANUM ......................................................................................... ILL Y) POORLY VISIBLE VERUMONTANUM .............................................................................. 112 8) AIDS TO SEEKING THE VERUMONTANUM ...................................................................... 112 CONTENTS XIX E) THE TOPOGRAPHIC RELATIONSHIP OF VERUMONTANUM AND DISTAL EXTREMITY OF THE LATERAL LOBE .............................................................................................................. 113 F) THE EXTERNAL SPHINCTER .................................................................................................. 114 A) INITIAL ANATOMICAL CONSIDERATIONS ........................................................................ 114 /?) ENDOSCOPIC APPEARANCE OF THE EXTERNAL SPHINCTER REGION ................................. 115 Y) FURTHER AIDS TO RECOGNITION OF THE SPHINCTER REGION .......................................... 116 J) THE SPHINCTER TEST OF TAMMEN .............................................................................. 116 E ) THE SPHINCTER TEST OF HARTUNG .............................................................................. 117 G) THE INTERNAL URINARY MEATUS ...................................................................................... 117 A) THE INTERNAL MEATUS IN SMALL ADENOMA, BLADDER NECK FIBROSIS, AND TRANSVERSE BAR ............................................................................................................................. 118 0) ENDOURETHRAL HYPERPLASIA ...................................................................................... 118 Y) ENDO VESICAL HYPERPLASIA .......................................................................................... 120 H) THE INTERNAL SPHINCTER .................................................................................................. 123 I) THE BLADDER BASE AND THE RETROPROSTATIC RECESS ...................................................... 124 J) THE URINARY BLADDER ...................................................................................................... 126 A) INCIDENTAL FINDING OF BLADDER DISEASE .................................................................. 126 0) RELATION OF THE BLADDER TO THE OPERATIVE FIELD ...................................................... 127 CHAPTER D. GENERAL RESECTION TECHNIQUE .................................................................. 129 CUTTING METHODS AND TECHNIQUES ...................................................................................................... 129 I. INTRODUCTION ............................................................................................................................ 129 II. HOLDING THE INSTRUMENT ............................................................................................................ 130 1. TWO-HANDED TECHNIQUE ...................................................................................................... 130 2. SINGLE-HANDED TECHNIQUE .................................................................................................. 133 III. IRRIGATION TECHNIQUE ................................................................................................................. 135 1. THE IRRIGATION SUPPLY .......................................................................................................... 135 2. AIR BUBBLES IN THE FIELD ...................................................................................................... 138 3. EVACUATION OF IRRIGATION FLUID AND RESECTION CHIPS ...................................................... 139 A) STANDARD DRAINAGE TECHNIQUE ...................................................................................... 139 B) EVACUATION BY A DRAINAGE PORT ...................................................................................... 141 C) THE COLLECTING SIEVE ...................................................................................................... 142 D) ELLIK BULB IN THE DRAIN HOSE .......................................................................................... 142 E) TECHNIQUE WITH CENTRAL IRRIGATION COCK ...................................................................... 145 F) DRAINAGE BY SPECIALLY DESIGNED INSTRUMENTS OR SUPRAPUBIC TROCAR ....................... 145 A) GENERAL CONSIDERATIONS .......................................................................................... 145 0) THE IGLESIAS IRRIGATING RESECTOSCOP .......................................................................... 147 Y) RESECTION WITH TROCAR DRAINAGE .............................................................................. 148 G) URODYNAMIC ASPECTS OF HIGH AND LOW PRESSURE IRRIGATION DURING TRANSURETHRAL PROSTATIC RESECTION. BY W. S CHUTZ .............................................................................. 150 H) SPECIAL DEVICES FOR EVACUATION OF RESECTION CHIPS .................................................. 153 A) PRELIMINARY CONSIDERATIONS ...................................................................................... 153 0) USE OF THE ELLIK EVACUATOR ...................................................................................... 154 Y) EVACUATION BY METAL PISTON SYRINGE ...................................................................... 155 5) THE EXTRACTION OF OUTSIZE TISSUE FRAGMENTS FROM THE BLADDER ........................... 156 IV. CUTTING TECHNIQUE ..................................................................................................................... 157 1. THE CUT PROPER ..................................................................................................................... 157 A) THE CUT WITH PREDETERMINED END POINT ...................................................................... 157 B) THE CUT WITH PREDETERMINED STARTING POINT .............................................................. 160 XX CONTENTS C) THE EXTENDED CUT ......................................................................................................... 160 D) RETROGRADE CUTTING ......................................................................................................... 166 E) ENTRAPMENT CUTTING ...................................................................................................... 167 2. PRACTICAL ASPECTS OF RESECTION .............................................................................................. 167 A) THE SINGLE CUT ................................................................................................................. 167 B) SERIAL CUTTING ................................................................................................................. 168 C) EXCAVATING THE CAPSULE .................................................................................................. 170 D) CUTTING RATE ................................................................................................................. 171 V. THE RECOGNITION OF INDIVIDUAL TISSUES DURING SURGERY ...................................................... 172 1. PRELIMINARY CONSIDERATIONS .................................................................................................. 172 2. SURGIGAL ANATOMY ................................................................................................................. 173 3. PREREQUISITES FOR THE RECOGNITION OF TISSUE STRUCTURE ...................................................... 174 4. THE APPEARANCE OF INDIVIDUAL TYPES OF TISSUE .................................................................. 174 A) ADENOMA TISSUE ............................................................................................................. 174 B) FIBROMUSCULAR TISSUE ..................................................................................................... 176 C) THE PROSTATIC CAPSULE ...................................................................................................... 176 D) FATTY TISSUE ..................................................................................................................... 177 E) SPHINCTER FIBROSIS TISSUE .............................................................................................. 177 F) BLADDER MUSCLE FIBERS ................................................................................................. 177 G) INFILTRATION BY UROGENITAL TUMORS .............................................................................. 178 H) INFILTRATION BY EXTRINSIC TUMORS .................................................................................. 178 I) EJACULATORY DUCTS ......................................................................................................... 179 J) SEMINAL VESICLES ............................................................................................................. 179 K) BLOOD VESSELS ................................................................................................................. 179 L) PROSTATIC CALCULI ............................................................................................................. 179 M) PROSTATIC ABSCESS ............................................................................................................. 180 VI. ACCIDENTAL INJURIES ..................................................................................................................... 180 1. INJURIES TO THE PROSTATIC CAPSULE .......................................................................................... 180 A) PRELIMINARY CONSIDERATIONS .......................................................................................... 180 B) THREATENED PERFORATION .................................................................................................. 181 C) COVERED PERFORATION ...................................................................................................... 182 D) FREE PERFORATION ............................................................................................................. 182 E) SUBTRIGONAL PERFORATION .................................................................................................. 184 A) PRELIMINARY CONSIDERATIONS ...................................................................................... 184 /?) SUBTRIGONAL PERFORATION DURING INSTRUMENTATION .................................................. 184 Y) DETACHMENT ............................................................................................................. 186 5) COMPLETE SUBTRIGONAL PERFORATION .......................................................................... 187 2. OTHER TYPES OF ACCIDENTAL INJURY ...................................................................................... 188 A) INJURY TO THE URETERIC ORIFICE ......................................................................................... 188 A) TYPES OF INJURY ......................................................................................................... 188 FI) SEQUELAE ..................................................................................................................... 189 B) INJURIES TO THE EXTERNAL SPHINCTER .................................................................................. 189 A) PRELIMINARY CONSIDERATIONS ...................................................................................... 189 ) APPEARANCE OF THE INJURY .......................................................................................... 189 Y) AFTERCARE ..................................................................................................................... 189 5) GRADING OF INCONTINENCE ACCORDING TO SEVERITY .................................................. 190 ) CONCLUSION ................................................................................................................. 191 C) INTRAPERITONEAL PERFORATION .......................................................................................... 191 D) EXCESSIVE BLOOD LOSS ..................................................................................................... 191 3. CONCLUDING REMARKS ON ACCIDENTAL INJURIES ...................................................................... 192 CONTENTS XXI CHAPTER E. SPECIAL RESECTION TECHNIQUE .................................................................. 193 I. GENERAL CONSIDERATIONS ............................................................................................................ 193 II. BASIC RULES OF RESECTION TECHNIQUE .................................................................................... 194 III. RESECTION OF SMALL ADENOMAS .................................................................................................. 197 1. STEP 1: THE MARKING GROOVE AT 6 O * CLOCK .......................................................................... 197 2. STEP 2: EXTENDING THE GROOVE LATERALLY .............................................................................. 199 3. STEP 3: DEEPENING THE GROOVE DOWN TO THE CAPSULE ...................................................... 199 4. STEP 4: REMOVING THE LATERAL LOBE BASE .......................................................................... 200 5. STEP 5: RESECTING VENTRAL TISSUE .......................................................................................... 201 6. STEP 6: RESECTING THE ROOF OF THE CAVITY .......................................................................... 202 7. STEP 7: RESECTION OF APICAL TISSUE ...................................................................................... 203 A) PRELIMINARY CONSIDERATIONS .......................................................................................... 203 B) STEP 7 A : APICAL RESECTION IN THE IMMEDIATE VICINITY OF THE VERUMONTANUM . . . 204 C) STEP 7B: EXTENDING THE RESECTION FIELD LATERALLY ...................................................... 207 D) STEP 7C: RESECTING THE VENTRAL APEX .......................................................................... 207 8. AIDS TO RESECTION OF APICAL TISSUE ...................................................................................... 208 A) EXAMINING THE NECK OF THE EMPTY BLADDER .................................................................. 209 B) ADVANCING AND WITHDRAWING THE SHEATH (WOBBLE TEST) .......................................... 211 C) RECOGNIZING TISSUES AROUND THE APEX ...................................................................... 211 D) RECTAL PALPATION. AROUND THE PROSTATIC APEX .............................................................. 213 A) ADVANTAGES OF RECTAL SUPPORT .................................................................................. 213 P) DISADVANTAGES OF RECTAL SUPPORT .......................................................................... 214 Y) PRESSING INDICATIONS FOR RECTAL SUPPORT .................................................................. 214 E) FARADIC AND HYDRAULIC STIMULATION OF THE EXTERNAL SPHINCTER .................................. 217 IV. RESECTING LARGE ADENOMAS ...................................................................................................... 217 1. PRELIMINARY CONSIDERATIONS .................................................................................................. 217 2. NESBIT * S METHOD ................................................................................................................. 218 A) STEP 1: FORMATION OF A VENTRAL PLATEAU ....................................................................... 218 B) STEP 2: CUTTING THE TRENCH ............................................................................................ 221 C) STEP 3: TISSUE ABLATION .................................................................................................. 221 D) STEP 4: RESECTION DOWN TO THE PROSTATIC FLOOR ........................................................... 223 E) CONCLUSION ..................................................................................................................... 224 3. EXCAVATING THE CAVITY ......................................................................................................... 225 A) BASIC PRINCIPLES ............................................................................................................. 225 A) SMALL SINGLE CUTS ...................................................................................................... 225 /?) EXTENDED CUTTING ...................................................................................................... 225 B) CONTROL OF INSTRUMENT AND LOOP .................................................................................. 226 A) THE LINEAR CUT ......................................................................................................... 226 P) DEPTH OF TISSUE PENETRATION ...................................................................................... 226 Y) THE EXTENDED CUT: THREE ELEMENTS COMBINED ....................................................... 226 C) DETERMINING THE DEPTH OF CUT ...................................................................................... 228 A) THE TRENCH METHOD (SEGMENTAL METHOD) .............................................................. 229 /?) THE TANGENTIAL METHOD .......................................................................................... 229 4. RESECTING ENDOVESICAL LATERAL LOBES .................................................................................. 230 A) SURGICAL ANATOMY .......................................................................................................... 230 B) RESECTION TECHNIQUE ...................................................................................................... 231 5. RESECTING ENDOVESICAL MEDIAN LOBES .................................................................................. 233 A) SURGICAL ANATOMY ......................................................................................................... 233 B) RESECTION TECHNIQUE ...................................................................................................... 234 XXII CONTENTS 6. BARNES * METHOD ..................................................................................................................... 236 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 236 B) RESECTION ON THE PROSTATIC FLOOR ................................................................................... 236 C) LATERAL LOBE RESECTION ................................................................................................. 237 D) CONCLUSION ..................................................................................................................... 238 7. THE METHOD OF ALCOCK AND FLOCKS ..................................................................................... 238 A) PRELIMINARY CONSIDERATIONS .......................................................................................... 238 B) REMOVING THE MEDIAN LOBE .......................................................................................... 239 C) REMOVING THE LATERAL LOBES .......................................................................................... 239 D) REMOVING THE VENTRAL TISSUE ...................................................................................... 240 E) RESECTING THE PROSTATIC APEX ......................................................................................... 240 F) CONCLUSION ..................................................................................................................... 240 8. FINAL INSPECTION AT THE END OF OPERATION .......................................................................... 241 A) INSPECTION OF THE BLADDER ............................................................................................. 241 A) LOOKING FOR INJURIES ................................................................................................. 241 /?) LOOKING FOR RETAINED RESECTION CHIPS AND COAGULA .......................................... 241 Y) THE LARGE FREE FRAGMENT ..................................................................................... 241 B) INSPECTING THE CAVITY FOR COMPLETE CLEARANCE OF TISSUE .......................................... 243 A) SCANNING THE CAVITY WALL ......................................................................................... 243 /?) INSPECTION OF PARACOLLICULAR TISSUE .......................................................................... 243 V. RESECTING OUTSIZE ADENOMAS ................................................................................................ 244 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 244 2. POINTS OF GENERAL TECHNIQUE ............................................................................................. 245 A) TISSUE VOLUME PER CUTTING RUN ................................................................................. 245 B) RAPID EVACUATION OF IRRIGATING FLUID AND CHIPS ...................................................... 245 3. TROCAR DRAINAGE ................................................................................................................. 245 4. RESECTION ACCORDING TO IGLESIAS ......................................................................................... 245 5. THE * RASP * TECHNIQUE OF REUTER ......................................................................................... 246 6. SUBDIVIDING THE FIELD INTO CUTTING ZONES .......................................................................... 246 7. MARKING TRENCHES ................................................................................................................. 246 8. OPTIMAL HEMOSTASIS ............................................................................................................. 246 9. DETERMINATION OF BLOOD LOSS ............................................................................................. 247 10. ENCUMBRANCE OF THE SURGEON ............................................................................................. 247 11. NESBIT TECHNIQUE ................................................................................................................. 247 12. OUR OWN METHOD ................................................................................................................. 248 A) PHASE 1 ............................................................................................................................. 248 A) STEP 1 ......................................................................................................................... 248 /?) STEP 2 ......................................................................................................................... 249 Y) STEP 3 ......................................................................................................................... 249 D) STEP 4 ......................................................................................................................... 249 B) PHASE 2 ............................................................................................................................. 249 C) PHASE 3 ............................................................................................................................. 250 13. CONCLUSION ............................................................................................................................. 250 CHAPTER F. HEMOSTATIC TECHNIQUE ............................................................................... 251 I. BLOOD LOSS DURING TRANSURETHRAL PROSTATIC SURGERY ............................................................. 251 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 251 2. A METHOD FOR BLOOD LOSS ESTIMATION .............................................................................. 253 3. THE SIGNIFICANCE OF BLOOD LOSS DETERMINATION .................................................................. 253 CONTENTS XXIII II. ARTERIAL BLEEDING ..................................................................................................................... 254 1. GENERAL CONSIDERATIONS ..................................................................................................... 254 2. SURGICAL ANATOMY ................................................................................................................. 254 3. * ANATOMICAL * OPERATIVE TECHNIQUES .................................................................................. 256 A) THE NESBIT TECHNIQUE ................................................................................................. 256 B) THE TECHNIQUE OF ALCOCK AND FLOCKS .......................................................................... 256 C) OTHER TECHNIQUES ......................................................................................................... 257 4. DETECTING HEMORRHAGE ......................................................................................................... 258 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 258 B) INSTRUMENT FACTORS ......................................................................................................... 259 C) THE VALUE OF EXPERIENCE ............................................................................................. 259 5. PREREQUISITES FOR THE DETECTION OF HEMORRHAGE .................................................................. 259 A) A SUITABLE INSTRUMENT (HABITUATION TO A PREFERRED INSTRUMENT) .............................. 259 B) RESECTION TECHNIQUE ..................................................................................................... 260 A) CLEAR VISIBILITY OF THE RESECTION CAVITY .................................................................. 260 A DIVIDING THE OPERATION INTO STAGES .......................................................................... 260 Y) MATCHING THE IRRIGATION RATE .................................................................................. 260 5) POSITION OF INSTRUMENT AND CUTTING LOOP .............................................................. 261 S) IMMEDIATE CLOSURE OF ALL ARTERIES .......................................................................... 262 C) RATIONALE FOR IMMEDIATE HEMOSTASIS .......................................................................... 262 6. GENERAL RULES FOR THE DETECTION OF ARTERIAL BLEEDING ...................................................... 263 A) FINDING ARTERIES DURING RESECTION .............................................................................. 263 B) APPEARANCE OF THE VESSEL STUMP .................................................................................. 264 C) MULTIPLE ARTERIES ............................................................................................................. 265 7. THE TECHNIQUE OF COAGULATING VESSELS .............................................................................. 265 8. SPECIAL PROBLEMS OF HEMOSTASIS .......................................................................................... 266 A) ARTERIES SPURTING INTO THE INSTRUMENT .......................................................................... 267 B) RICOCHET BLEEDING ......................................................................................................... 268 C) BLEEDING FROM BEHIND A TISSUE EMINENCE .................................................................. 268 D) BLEEDING UNDER COAGULA ............................................................................................. 269 E) MASSIVE HEMORRHAGE ..................................................................................................... 270 F) VENTRAL BLEEDS FROM THE VESICOPROSTATIC JUNCTION ...................................................... 271 G) POOR HEMOSTASIS IN PREVIOUSLY COAGULATED TISSUE ...................................................... 272 H) ARTERIAL BLEEDING AT THE MARGIN OF A VENOUS SINUS .................................................. 273 I) PSEUDOHEMOSTASIS ......................................................................................................... 274 J) HEMORRHAGE IN DISTAL AND PROXIMAL EXTREMITIES OF THE FIELD .................................. 276 III. VENOUS BLEEDING ......................................................................................................................... 277 1. GENERAL CONSIDERATIONS ..................................................................................................... 277 2. SURGICAL ANATOMY ................................................................................................................. 277 A) THE SUBMUCOUS SYSTEM ................................................................................................. 277 B) THE DEEP SYSTEM ......................................................................................................... 278 3. DETECTION OF VENOUS BLEEDING DURING SURGERY .................................................................. 278 A) INSPECTION OF IRRIGATION DRAINAGE .................................................................................. 278 B) VISIBLE BLOOD IN THE RESECTION FIELD .......................................................................... 279 C) INSPECTION OF THE RESECTION FIELD .................................................................................. 279 4. CLOSURE OF VENOUS SINUSES ................................................................................................. 280 IV. FINAL INSPECTION OF HEMOSTASIS ............................................................................................. 280 V. SUMMARY .................................................................................................................................... 281 XXIV CONTENTS CHAPTER G. TRANSURETHRAL BLADDER SURGERY .............................................................. 283 I. INTRODUCTION ............................................................................................................................ 283 II. MORBID ANATOMY .................................................................................................................... 284 III. FURTHER ASPECTS OF THE ASSESSMENT AND CLASSIFICATION OF BLADDER TUMORS ...................... 286 1. SITE WITHIN THE BLADDER ..................................................................................................... 286 2. TUMOR MORPHOLOGY ............................................................................................................. 286 A) SURFACE STRUCTURE ............................................................................................................. 287 B) DIRECTION OF GROWTH ..................................................................................................... 289 3. TUMOR SIZE ............................................................................................................................. 290 A) ENDOVESICAL TUMOR BULK ............................................................................................. 290 B) DIAMETER OF THE TUMOR BASE ......................................................................................... 290 4. SOLITARY AND MULTIPLE TUMORS ............................................................................................. 290 5. RECURRENCE RATES ................................................................................................................. 290 IV. ASSESSING THE PATIENT ................................................................................................................. 291 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 291 2. HISTORY ................................................................................................................................. 291 3. RADIOLOGIC INVESTIGATION ..................................................................................................... 292 A) EXCRETION UROGRAM ......................................................................................................... 292 B) CYSTOGRAM ..................................................................................................................... 292 C) CYSTOURETHROGRAM ......................................................................................................... 293 D) PELVIC ANGIOGRAM ......................................................................................................... 293 E) COMPUTER TOMOGRAM ..................................................................................................... 293 F) LYMPHANGIOGRAM ......................................................................................................... 293 4. ULTRASOUND IN DIAGNOSIS ..................................................................................................... 294 5. CYSTOSCOPY ............................................................................................................................. 294 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 294 B) DIAGNOSTIC CYSTOSCOPY ................................................................................................. 294 C) EXAMINATION OF THE INTERNAL MEATUS .......................................................................... 296 D) DYNAMIC CYSTOSCOPY ..................................................................................................... 296 E) EXAMINATION OF THE URETERIC ORIFICES .......................................................................... 297 F) DETERMINING THE SIZE OF THE TUMOR BASE ...................................................................... 298 G) EXAMINATION OF DIVERTICULA ......................................................................................... 300 H) VAGINAL (RECTAL) PALPATION DURING CYSTOSCOPY .......................................................... 301 6. BLADDER BIOPSIES ................................................................................................................. 301 A) BIOPSY BY ENDOSCOPIC FORCEPS ..................................................................................... 301 B) RESECTOSCOPE BIOPSY ..................................................................................................... 301 7. BIMANUAL EXAMINATION UNDER ANESTHESIA ......................................................................... 302 V. OPERATING ON BLADDER TUMORS ................................................................................................ 303 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 303 2. COAGULATION OF BLADDER TUMORS ......................................................................................... 303 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 303 B) TECHNIQUE OF COAGULATION ............................................................................................. 304 C) LOCAL ANESTHESIA FOR COAGULATION AND SMALL RESECTIONS .......................................... 305 D) HEALING AFTER COAGULATION ......................................................................................... 307 3. ELECTRORESECTION OF BLADDER TUMORS ................................................................................. 308 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 308 B) ANESTHESIA FOR THE RESECTION OF BLADDER TUMORS ...................................................... 308 C) METHODS OF AVOIDING OBTURATOR STIMULATION .............................................................. 309 D) HIGH-FREQUENCY CURRENT FOR THE RESECTION OF BLADDER TUMORS .............................. 309 E) INSTRUMENTS FOR RESECTION OF BLADDER TUMORS .......................................................... 309 CONTENTS XXV 4. TECHNIQUE OF BLADDER TUMOR RESECTION .............................................................................. 310 A) HORIZONTAL APPROACH ..................................................................................................... 310 B) VERTICAL APPROACH ......................................................................................................... 310 C) DIVIDING THE STALK ......................................................................................................... 310 D) THE RESECTION OF LARGE EXOPHYTIC GROWTHS .............................................................. 311 E) HEMOSTASIS ..................................................................................................................... 312 5. SPECIAL TYPES OF TUMOR RESECTION ...................................................................................... 314 A) RESECTING TUMORS ON THE POSTERIOR WALL OF THE BLADDER .......................................... 314 B) RESECTING TUMORS ON THE LATERAL WALL OF THE BLADDER .............................................. 317 C) RESECTING TUMORS CLOSE TO THE INTERNAL MEATUS IN THE MALE ................................... 317 D) RESECTING TUMORS CLOSE TO THE INTERNAL MEATUS IN THE FEMALE .............................. 318 E) RESECTING TUMORS ON THE BLADDER VAULT ...................................................................... 320 F) RESECTING TUMORS OF OR AROUND THE URETERIC ORIFICE .................................................. 321 6. TISSUE RECOGNITION DURING RESECTION OF BLADDER TUMORS .............................................. 322 7. SYSTEMATIC TISSUE SAMPLING AS A GUIDE TO COMPLETE RESECTION ...................................... 323 A) SINGLE SAMPLE WITH DIRECTIONAL ORIENTATION .............................................................. 323 B) SAMPLING IN TISSUE LAYERS ............................................................................................. 323 C) BIOPSY TECHNIQUE FOR THE DIAGNOSIS OF CARCINOMA IN SITU AND OTHER EARLY UROTHE LIAL CARCINOMAS ............................................................................................................. 325 8. CONTROLLED PERFORATION ......................................................................................................... 326 A) PRELIMINARY CONSIDERATIONS .......................................................................................... 326 B) THE TECHNIQUE OF CONTROLLED PERFORATION .................................................................. 326 C) IRRIGATION DURING CONTROLLED PERFORATION .................................................................. 327 9. RESECTING THE PERIPHERY OF A TUMOR .................................................................................. 328 10. PALLIATIVE RESECTION ............................................................................................................. 328 VI. ACCIDENTS DURING RESECTION OF BLADDER TUMORS .................................................................. 329 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 329 2. TYPES OF PERFORATION ............................................................................................................. 329 A) INTRAPERITONEAL PERFORATION .......................................................................................... 329 B) EXTRAPERITONEAL PERFORATION .......................................................................................... 330 C) GAS DETONATION ............................................................................................................. 331 VII. CHECK CYSTOSCOPY FOLLOWING TRANSURETHRAL RESECTION OF BLADDER TUMORS ....................... 331 VIII. CONCLUDING REMARKS ON BLADDER TUMOR RESECTION .............................................................. 332 IX. OTHER TRANSURETHRAL BLADDER OPERATIONS ............................................................................. 333 1. INCISING THE NECK OF BLADDER DIVERTICULA .......................................................................... 333 A) PRELIMINARY CONSIDERATIONS AND INDICATIONS .............................................................. 333 B) OPERATIVE TECHNIQUE ...................................................................................................... 333 2. INJECTING DRUGS INTO THE BLADDER .......................................................................................... 335 CHAPTER H. SPECIAL RESECTION PROCEDURES AROUND THE BLADDER NECK .............. 337 I. INTRODUCTION ............................................................................................................................. 337 II. ELECTRORESECTION OF PROSTATIC CARCINOMA .................................................................................. 337 1. PRELIMINARY CONSIDERATIONS AND INDICATIONS ...................................................................... 337 2. OPERATIVE TECHNIQUE ............................................................................................................. 338 A) COMMENCING THE OPERATION .......................................................................................... 338 B) HEMORRHAGE ..................................................................................................................... 338 C) EVACUATION OF CHIPS ...................................................................................................... 338 D) RESECTION OF THE PROSTATIC APEX ................................................................................... 338 XXVI CONTENTS E) HOW MUCH TO RESECT? ................................................................................................. 339 F) RESECTION FOR RECURRENT HEMORRHAGE .......................................................................... 339 G) RESECTION OF NECROTIC, INFECTED TUMORS ...................................................................... 340 H) RESECTING TUMOR INFILTRATING THE BLADDER .................................................................. 340 III. RESECTION FOR BLADDER NECK FIBROSIS ...................................................................................... 340 IV. RESECTION FOR OUTFLOW OBSTRUCTION IN THE FEMALE BLADDER .................................................. 341 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 341 2. SYMPTOMS OF FEMALE BLADDER OUTFLOW OBSTRUCTION .......................................................... 342 3. DIAGNOSIS OF THE DISORDER ................................................................................................. 343 A) CYSTOSCOPY ..................................................................................................................... 343 B) URODYNAMIC INVESTIGATIONS ......................................................................................... 343 C) DIFFERENTIAL DIAGNOSTIC CONSIDERATIONS ...................................................................... 344 4. MORBID ANATOMICAL CHANGE AND OUTFLOW DISORDERS OF THE FEMALE BLADDER .... 345 5. TREATMENT OF BLADDER OUTFLOW DISORDERS .......................................................................... 345 A) TRANSURETHRAL RESECTION ................................................................................................. 345 B) POSTOPERATIVE TREATMENT ............................................................................................. 346 6. ASSESSING THE OPERATIVE SUCCESS RATE ................................................................................. 346 V. RESECTION AND PROSTATIC CALCULI ............................................................................................ 346 VI. RESECTION AND PROSTATIC ABSCESS ............................................................................................. 347 VII. RESECTION AND CHRONIC PROSTATITIS ......................................................................................... 348 VIII. RESECTION AND PROSTATIC TUBERCULOSIS ..................................................................................... 349 IX. PALLIATIVE RESECTION ................................................................................................................ 349 X. ELECTRORESECTION IN PATIENTS WITH CARDIAC PACEMAKERS, ARTIFICIAL HEART VALVES OR VASCULAR PROSTHESES. BY W. S CHUTZ ......................................................................................................... 350 XI. RESECTION FOR IMPAIRED MICTURITION FOLLOWING RECTAL SURGERY ......................................... 353 XII. RESECTING PAPILLARY TUMORS OF THE PROSTATIC URETHRA ......................................................... 354 XIII. RESECTION OF BLADDER DIVERTICULA ............................................................................................. 354 XIV. RESECTION AND BLADDER CALCULI ................................................................................................. 355 XV. RESECTION OF BLEEDING ADENOMAS ............................................................................................. 355 XVI. RESECTION IN THE PRESENCE OF BLADDER TUMOR .......................................................................... 356 XVII. RESECTION FOLLOWING OPEN ADENOMECTOMY .......................................................................... 356 CHAPTER I. LITHOLAPAXY ................................................................................................. 359 I. PRELIMINARY CONSIDERATIONS .................................................................................................... 359 II. PRELIMINARY ASSESSMENT OF THE PATIENT .................................................................................. 359 III. INDICATIONS ................................................................................................................................. 360 IV. THE TECHNIQUE OF LITHOLAPAXY ................................................................................................. 360 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 360 2. ULTRASOUND LITHOLAPAXY ..................................................................................................... 361 A) THE * AACHEN * ULTRASOUND LITHOTNTE ........................................................................... 361 B) TECHNIQUE WITH THE ULTRASOUND LITHOTRITE .................................................................. 362 3. URAT-I LITHOLAPAXY ............................................................................................................. 363 A) APPARATUS ..................................................................................................................... 363 B) THE PROBE ..................................................................................................................... 363 CONTENTS XXVII C) HAZARDS OF THE TECHNIQUE .............................................................................................. 363 D) ANESTHESIA FOR PRESSURE WAVE LITHOLAPAXY .................................................................. 363 E) INSTRUMENTS FOR PRESSURE WAVE LITHOLAPAXY .............................................................. 364 F) THE TECHNIQUE OF ELECTROHYDRAULIC LITHOLAPAXY ...................................................... 364 4. THE PUNCH LITHOTRITE ......................................................................................................... 365 5. TECHNIQUE OF EVACUATION ..................................................................................................... 366 6. DIFFICULT LITHOLAPAXY DUE TO ANATOMICAL FACTORS .......................................................... 367 7. POSTOPERATIVE CARE ............................................................................................................. 367 CHAPTER K. THE ZEISS LOOP AND THE PLACEMENT OF INDWELLING URETERIC CATHETERS 369 I. EXTRACTING URETERIC CALCULI WITH ENDOSCOPIC INSTRUMENTS .................................................. 369 1. PRELIMINARY CONSIDERATIONS .................................................................................................. 369 2. INDICATIONS FOR USING THE ZEISS LOOP .................................................................................. 370 3. DESCRIPTION OF THE ZEISS LOOP .............................................................................................. 370 4. INTRODUCING THE ZEISS LOOP .................................................................................................. 372 A) THE STANDARD LOOP ...................................................................................................... 372 B) THE TILTING LOOP ............................................................................................................. 375 C) CHECKING LOOP POSITION .................................................................................................. 375 5. TECHNIQUES OF CALCULUS EXTRACTION ...................................................................................... 375 A) TRACTION TECHNIQUE ......................................................................................................... 376 B) THE INDWELLING LOOP ..................................................................................................... 376 6. HAZARDS ................................................................................................................................. 377 II. PLACEMENT OF INDWELLING URETERIC CATHETERS .......................................................................... 378 1. PASSING PLAIN CATHETERS ......................................................................................................... 378 2. INDWELLING URETERIC CATHETERS .............................................................................................. 379 3. INDICATIONS FOR INDWELLING URETERIC CATHETERIZATION .......................................................... 379 4. THE DOUBLE-! CATHETER AND ITS PROPERTIES .......................................................................... 380 A) TECHNIQUE OF CATHETERIZATION ...................................................................................... 380 B) DIFFICULTIES DURING CATHETERIZATION .............................................................................. 381 5. SIDE EFFECTS ............................................................................................................................. 381 CHAPTER L. ENDOSCOPIC PROCEDURES IN THE URETHRA. BY R. HARTUNG ................. 383 I. INTRODUCTION ............................................................................................................................. 383 II. INTERNAL URETHROTOMY UNDER DIRECT VISION .......................................................................... 384 1. HISTORY OF THE PROCEDURE ..................................................................................................... 384 2. DIAGNOSIS OF URETHRAL STRICTURE IN THE MALE ...................................................................... 384 3. INDICATIONS FOR URETHROTOMY UNDER VISION ...................................................................... 384 4. UNDERTAKING SURGERY ............................................................................................................. 385 A) INSTRUMENTS ..................................................................................................................... 385 B) PREOPERATIVE PREPARATION OF THE PATIENT ...................................................................... 386 C) OPERATIVE TECHNIQUE ...................................................................................................... 386 D) OPERATIVE DIFFICULTIES ...................................................................................................... 387 E) OPERATIVE COMPLICATIONS .............................................................................................. 387 5. POSTOPERATIVE TREATMENT FOLLOWING VIEWING URETHROTOMY .............................................. 388 III. ENDOSCOPIC LASER SURGERY TO URETHRAL STRICTURES .................................................................. 388 XXVIII CONTENTS IV. ENDOSCOPIC SURGERY FOR URETHRAL TUMORS .............................................................................. 389 1. THE PROBLEM ......................................................................................................................... 389 2. TECHNIQUE OF HIGH-FREQUENCY SURGERY .............................................................................. 389 3. TECHNIQUE OF LASER COAGULATION ......................................................................................... 389 V. ENDOSCOPIC CORRECTION OF CICATRICIAL BLADDER NECK STENOSIS .............................................. 389 1. INTRODUCTION ......................................................................................................................... 389 2. DIAGNOSIS ............................................................................................................................. 390 3. INDICATIONS FOR SURGERY ......................................................................................................... 390 4. OPERATIVE TECHNIQUE ............................................................................................................. 390 VI. ENDOSCOPIC SUBMUCOUS BLADDER NECK INFILTRATION WITH TEFLON IN THE TREATMENT OF URI NARY INCONTINENCE ..................................................................................................................... 391 1. INTRODUCTION ......................................................................................................................... 391 2. OPERATIVE TECHNIQUE IN THE MALE ...................................................................................... 392 3. OPERATIVE TECHNIQUE IN THE FEMALE .................................................................................. 392 CHAPTER M. URETHRAL DILATATION ................................................................................... 393 I. PRELIMINARY CONSIDERATIONS .................................................................................................... 393 II. BOUGIES AND DILATORS ................................................................................................................ 393 III. PATIENT ASSESSMENT ..................................................................................................................... 393 IV. DILATING THE URETHRA ................................................................................................................. 394 1. BLIND DILATATION ..................................................................................................................... 394 2. DILATATION UNDER DIRECT VISION ......................................................................................... 395 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 395 B) TECHNIQUE ......................................................................................................................... 396 3. REPEATED DILATATION AS DEFINITIVE TREATMENT .................................................................. 397 4. GOLDEN RULES OF DILATATION ................................................................................................. 397 CHAPTER N. POSTOPERATIVE MANAGEMENT ..................................................................... 399 I. MANAGEMENT FOLLOWING NORMAL CONCLUSION OF SURGERY ...................................................... 399 1. PASSING THE INDWELLING CATHETER ......................................................................................... 399 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 399 B) CATHETERIZATION AFTER SATISFACTORY HEMOSTASIS ........................................................... 399 C) CATHETERIZATION IN THE PRESENCE OF VENOUS HEMORRHAGE (VENOUS SINUSES) .... 402 2. IRRIGATING THE BLADDER ......................................................................................................... 405 3. EVACUATING CLOTS FROM THE BLADDER ..................................................................................... 405 4. VIGOROUS REACTIONARY HEMORRHAGE ON THE DAY OF OPERATION ....................................... 405 5. POSTOPERATIVE FLUID INTAKE (MANAGEMENT OF IRRIGATING FLUID OVERLOAD) ...................... 406 6. MANAGEMENT OF URINARY INFECTION ..................................................................................... 406 A) PRELIMINARY CONSIDERATIONS ......................................................................................... 406 B) PARAURETHRAL ABSCESS ..................................................................................................... 407 C) SEVERE URETHRITIS ............................................................................................................. 407 D) CAVERNITIS ......................................................................................................................... 407 E) EPIDIDYMITIS ..................................................................................................................... 408 7. POSTOPERATIVE MOBILIZATION ................................................................................................. 408 8. REMOVING THE CATHETER ......................................................................................................... 408 CONTENTSXXIX 9. ASSESSING THE RESULT ............................................................................................................. 409 10. RECATHETERIZATION ................................................................................................................. 409 11. POSTOPERATIVE MEDICATION ..................................................................................................... 410 12. REPEAT RESECTION FOR POOR STREAM ..................................................................................... 410 II. POSTOPERATIVE MANAGEMENT OF OPERATIVE COMPLICATIONS ...................................................... 411 1. POSTOPERATIVE MANAGEMENT OF PERFORATION ...................................................................... 411 A) POSTOPERATIVE MANAGEMENT OF EXTRAPERITONEAL PERFORATION ...................................... 411 B) POSTOPERATIVE MANAGEMENT OF INTRAPERITONEAL PERFORATION ...................................... 411 2. POSTOPERATIVE MANAGEMENT OF URETERIC ORIFICE TRAUMA ................................................. 412 3. POSTOPERATIVE MANAGEMENT OF EXTERNAL SPHINCTER INJURIES ............................................. 412 4. POSTOPERATIVE MANAGEMENT OF THE TUR SYNDROME ......................................................... 412 III. POSTOPERATIVE COMPLICATIONS ................................................................................................. 413 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 413 2. PERSISTENT OOZING ................................................................................................................. 414 3. MODERATE HEMORRHAGE ......................................................................................................... 414 4. MILD HEMORRHAGE ................................................................................................................. 414 5. MICROSCOPIC HEMATURIA ..................................................................................................... 415 6. INFECTIVE PROBLEMS ................................................................................................................. 415 7. CATHETER-INDUCED BLADDER SPASM ...................................................................................... 415 A) REGULATING CATHETER POSITION ...................................................................................... 415 B) DRUG THERAPY ................................................................................................................. 415 8. URGE INCONTINENCE ................................................................................................................. 416 IV. LATE COMPLICATIONS AFTER TRANSURETHRAL SURGERY .................................................................. 416 1. PRELIMINARY CONSIDERATIONS ................................................................................................. 416 2. URETHRAL STRICTURE ................................................................................................................. 416 3. INTERNAL MEATAL STENOSIS ..................................................................................................... 417 A) PRELIMINARY CONSIDERATIONS .......................................................................................... 417 B) TREATMENT ..................................................................................................................... 417 A) RETROGRADE INCISION WITH THE RESECTOSCOPE LOOP .................................................. 417 /?) INCISION BY WIRE PROBE ............................................................................................. 417 Y) * COLD * INCISION WITH THE SACHSE KNIFE .................................................................. 418 4. RECURRENCE OF URINARY SYMPTOMS ..................................................................................... 418 5. UNYIELDING URINARY INFECTION ............................................................................................. 419 CHAPTER O. LEARNING AND TEACHING TRANSURETHRAL OPERATIVE TECHNIQUE ... 421 COLOR PLATES ...................................................................................................................... 427 REFERENCES .......................................................................................................................... 457 SUBJECT INDEX .................................................................................................................. 465
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spelling	Mauermayer, Wolfgang Verfasser aut Transurethrale Operationen Transurethral surgery W. Mauermayer. With contributions by ... Transl. by A. Fiennes. Foreword by Willard E. Goodwin Berlin [u.a.] Springer 1983 XXIX, 473 S. Ill. txt rdacontent n rdamedia nc rdacarrier DNB Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=024173245&sequence=000001&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis
spellingShingle	Mauermayer, Wolfgang Transurethral surgery
title	Transurethral surgery
title_alt	Transurethrale Operationen
title_auth	Transurethral surgery
title_exact_search	Transurethral surgery
title_full	Transurethral surgery W. Mauermayer. With contributions by ... Transl. by A. Fiennes. Foreword by Willard E. Goodwin
title_fullStr	Transurethral surgery W. Mauermayer. With contributions by ... Transl. by A. Fiennes. Foreword by Willard E. Goodwin
title_full_unstemmed	Transurethral surgery W. Mauermayer. With contributions by ... Transl. by A. Fiennes. Foreword by Willard E. Goodwin
title_short	Transurethral surgery
title_sort	transurethral surgery
url	http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=024173245&sequence=000001&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA
work_keys_str_mv	AT mauermayerwolfgang transurethraleoperationen AT mauermayerwolfgang transurethralsurgery

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