Urologic surgery is the integration of surgical activities for the pelvis—the colon, urogenital, and gynecological organs—primarily for the treatment of obstructions, dysfunction, malignancies, and inflammatory diseases. Common urologic operations include:
Conditions that commonly dictate a need for urologic surgery include neurogenic sources like spinal cord injury; injuries to the pelvic organs; chronic digestive and urinary diseases; as well as prostate infections and inflammations. There are many other common chronic and malignant diseases that can benefit from resection, surgical augmentation, or surgery to clear obstructions. These conditions impact the digestive, renal, and reproductive systems.
Most organs are susceptible to cancer in the form of tumors and invasion of the surrounding tissue. Urologic malignancies are on the rise. Other conditions that are seen more frequently include kidney stones, diseases and infections; pancreatic diseases; ulcerative colitis; penile dysfunction; and infections of the genitourinary tract.
Urologic surgery has been revolutionized by striking advances in urodynamic diagnostic systems. Changes in these areas have been particularly beneficial for urologic surgery: laparascopy, endoscopicexamination for colon cancer, implantation procedures, and imaging techniques. These procedural and imaging advances have brought the field of urology to a highly active and innovative stage, with new surgical options created each year.
Demographics
According to the National Kidney Foundation, kidney and urologic diseases affect at least 5% of the American population, and cause over 260,000 deaths. As the population ages, these conditions are expected to increase, especially among ethnic minorities who have a disproportionate share of urologic diseases. Major urologic surgery includes radical and partial resections for malignant and benign conditions; and implantation and diversion surgeries.
Cancer
Prostate cancer is the most common cancer affecting males in the United States. One in 10 men will have the disease at some time in his life. It is, however, treated successfully with surgery.
According to the Urological Foundation, more than 50,000 new cases of bladder cancer are detected each year. In the United States, bladder cancer is the fourth most common cancer in men and the ninth most common for women.
Kidney cancer occurs in 30,000 patients per year, with about 11,000 deaths. It is the eighth most common cancer in men and the tenth most common cancer in women. Renal cell carcinoma makes up 85% of all kidney tumors. In adults ages 50–70 years, kidney cancer occurs twice as often in men as women. At the time of diagnosis, metastasis is present in 25–30% of patients with renal cell carcinoma.
Other conditions
Enlarged prostate (benign prostate hyperplasia, or BPH) is very common, and often treated with surgery. Interstitial cystitis (bladder infection of unknown origin) often affects women with severe pain and incontinence. The condition, like other forms of severe incontinence, requires surgery.
Incontinence is an increasingly diagnosed problem among the aging population in the United States, and is gaining recognition for its highly debilitating effects both in its fecal and urinary forms. According to the National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), more than 6.5 million Americans have fecal incontinence. Fecal incontinence affects people of all ages; many cases are never reported. Women are five times more likely than men to have fecal incontinence. This is primarily due to obstetric injury, especially with forceps delivery and anal sphincter laceration.
More than 13 million people in the United States experience urinary incontinence. Community based studies reveal that 30% of patients are over the age of 65, and 63% are female. According to one study published in the American Journal of Gastroenterology, only 34% of incontinent patients have ever mentioned their problem to a physician, even though 23% wear absorbent pads, 12% take medications, and 11% lead lives restricted by their incontinence.
Many surgical procedures are now available to correct both fecal and urinary incontinence. They include retropubic slings for urinary incontinence, artificial sphincter implants for urinary and fecal incontinence, and bladder and colon diversion surgeries for restoration of voiding and waste function with an outside appliance called an ostomy. Kidney surgery and transplantation account for a large segment of urologic surgery. Benign conditions include sexual dysfunction, kidney stones, and fertility issues.
Description
Until the late twentieth century, urological operations usually involved open abdominal surgery with full incision, lengthy hospital stays, and long recovery periods. Today, surgery is less traumatic, with shortened hospitalizations. Minimally invasive surgeries are the norm in many cases, with new laparascopic procedures developed each year. Laparascopic surgery is effective for many kidney tumors and kidney removal (nephrectomy), lymph node excision, prostate and ureteral cancers, as well as incontinence, urological reconstruction, kidney stones, and some cases of bladder dysfunction.
Diagnosis/Preparation
Testing is often required to determine if a patient is better suited for open or laparscopic surgery. Blood tests for some cancers, as well as function tests for the affected organs, will be required. Radiographic or ultrasound techniques are helpful in providing images of abnormalities.
Cystoscopy is often used with bladder and urethra surgery. In this procedure, a thin telescope-like instrument is inserted directly into the bladder. Disorders of the colon may be studied with endoscopes, imaging instruments inserted directly into the colon. Urodynamic studies of the bladder and sphincter determine how the bladder fills and empties. Digital rectal exams diagnose prostatic disorders. In this procedure, the physician feels the prostate with a gloved, lubricated finger inserted into the rectum.
Aftercare
Hospital stays range from one day to one week, depending upon the level of organ involvement and type of urologic surgery (open versus laparoscopic). Major urologic surgeries may require stents (temporary diversion of urine or feces) and catheters that are removed after surgery. Some surgeries are staged in two parts to accommodate the removal of diseased tissue, and the augmentation or reconstruction to replace function. Laparoscopic surgery patients benefit from shorter hospital stays, more rapid recovery, and possibly lower morbidity rates than open surgery procedures. This is increasingly true for prostate cancer surgeries.
Risks
The risks of urologic surgery vary with the type of surgical procedure (open or laparacopic), and the extent of organ involvement. According to one study of 2,407 urologic surgeries in four centers, the overall complication rate was 4.4%, with a mortality rate of 0.08%.
Open surgery poses the standard surgery and anesthetic risks associated with strain on the heart and lungs. Risks of infection at the wound site accompany all surgeries, open and laparoscopic. The risk of injury to adjacent organs is higher in laparoscopic surgery. Kidney removal and transplantation have many risks because of the extent of the surgery, as do surgeries of the colon, bladder, and prostate.
Significant gains have been made in prostate surgery. Urinary control issues following prostate surgery, especially radical prostatectomy, have improved. However, postoperative urinary incontinence remains a significant risk, with 27% of patients in one study reporting the need for some kind of leakage protection. In the same study, only 14.2% of previously potent men reported the ability to achieve and maintain a postoperative erection that is sufficient for sexual intercourse. Urologic surgeons are well versed in the risks and benefits of the surgeries they perform, and they expect to be asked questions related to these issues.
Normal results
The expected surgery result is a topic that the urologic surgeon and patient should address prior to surgery. It is important that the patient understands the issues of recovery, rehabilitation, training or retraining, and the limitations surgery may offer for basic daily functions and enjoyment. Results of urologic surgery are individual, and depend upon the health of the patient and his or her motivation to deal with postoperative recovery issues and changes to organ function brought about by the surgery.
Alternatives
Many urological diseases can be dealt with through diet, weight loss, and lifestyle changes. These modifications are especially significant in preventing and treating conditions of the urinary tract. Obesity and nutrition play a significant role in urologic diseases, and impact many urologic cancers, inflammatory and ulcerative conditions, incontinence, and sexual dysfunction.
Medical interventions are another form of treatment, particularly for infectious and inflammatory urologic conditions. They are particularly useful along with special adjunctive surgical procedures for the treatment of incontinence and painful bladder and kidney conditions. While many cancers must be treated surgically, prostate cancer is often treated with a "wait and see" approach due to its slow rate of growth. There is an increasing trend for men with slow-growing prostate cancers to have regular check-ups instead of immediate treatment.
Walsh, P. Campbell's Urology. 8th ed. Elsevier Science, 2002.
PERIODICALS
Hedican, S.P. "Laparoscopy in Urology." Surgical Clinics of North America 80, no.5 (October 1, 2000): 1465-85.
Leng, W. and E.J. McGuire. "Reconstructive Urology Surgical Craft: Laparoscopic Live Donor Nephrectomy." Urologic Clinics of North America 26, no.1 (February 1999).
Leung, A.K.H., et.al. "Critical Care and the Urologic Patient." Critical Care Clinics 19, no.1 (January 2003).
ORGANIZATIONS
American Society of Nephrology. 1725 Eye Street, NW Suite 510,Washington, DC 20006. (202) 659-0599. Fax: (202) 659-0709.
American Society of Transplantation. 236 Route 38 West, Suite 100, Moorestown, NJ 08057. (856) 608-1104. Fax: (856) 608-1103. <www.a-s-t.org>.
National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health, Information Office. 31 Center Drive, MSC 2560, Building 31, Room 9A-04,Bethesda, MD 20892-2560. (800) 860-8747, (800) 891-5389, (800) 891-5390, (301) 496-3583. Fax: (301) 496-7422. <www.niddk.nih.gov/>.
National Kidney Foundation. Director of Communications, 30 East 33rd Street, New York, NY 10016. (800) 622-9010, (212) 889-2210. Fax: (212) 689-9261. <www.kidney.org>.
OTHER
"Resource Guide: Prostate Cancer." American Foundation for Urologic Diseases. <www.afud.org/>
Nancy McKenzie, Ph.D.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Urologic surgery is performed by surgeons who specialize in the treatment of urologic conditions. Surgery is performed in a general hospital, regional center, or clinic, depending upon the type of procedure.
QUESTIONS TO ASK THE DOCTOR
How many procedures does this physician and hospital perform compared to other facilities?
What are the urination and sexual intercourse risks of this surgery?
Does this condition offer alternatives to surgery without risks of exacerbating the condition?
How often are patients dissatisfied with their outcomes?
