Inguinal Hernia and Urogenital System

Surgery of groin;
Bladder cancer;
Prostate surgery
Access to lower urinary tract;
2nd June 2016
11:45 – 12:45

Division of Urology
Dept. of Surgery
Prince of Wales Hospital
Anatomy of the Groin
The inguinal canal is about 4 cm
long and passes obliquely through
the flat muscles of the abdominal
wall just above the medial half of
the inguinal ligament. In the male,
the canal conveys the spermatic
cord (comprising the ductus [vas]
deferens and the vessels and
nerves of the testis). In the female,
the canal is narrower and contains
the round ligament of the uterus.
 Anatomy of the Groin

Removal of the skin and subcutaneous tissue reveals both superficial inguinal rings (male
specimen). On one side the external spermatic fascia has been removed to show the margins of
the superficial ring.
 Anatomy of the Groin

Lower fibres of internal oblique and part of the spermatic cord have been excised to reveal the
posterior wall and floor of the canal.
Ilioinguinal nerve does not pass through deep inguinal ring
 Anatomy of the Groin

Superior view of the male pelvis to show structures near the deep inguinal ring.
artery and vein are mislabelled
 Other Surgery of the Groin

Ligation of varicocele
High retroperitoneal ligation of varicocele, also
known as the Palomo technique Past days
very common clinical scenario, usually seen in OPD
Other Surgery of the Groin
Other Surgery of the Groin

groin lymphadenectomy in penis SCC

testicular torsion causing gangrene of scrotum
Proc Natl Acad Sci U S A. 2014 Aug 19;111(33):11932-7

21 13 seconds
1 galloon = 3.7854 L
 Bladder Cancer
transitional cellular carcinoma (> 50% of CA bladder)

(TCC / AdenoCa / SCC )

 Bladder Cancer 10th most common cancer in HK

(TCC / AdenoCa / SCC )

male has higher risk

Age-standardised death rate* of malignant

Age-standardised incidence rate* of
neoplasm of bladder by sex, 2001-2013
malignant neoplasm of bladder by sex,
2001-2012
Age-standardized incidence and death rates of malignant neoplasm of prostate, 1981 - 2014
Anatomy of the Bladder
Peripheral nerve supply
to the lower urinary tract
Neurovasculature related to bladder

since ureter is so close to

vasculature, iatrogenic
ureteric injury is common

right
 Bladder
(Prostate)
& Urethra
Female / Male
Female
Female
Normal looking Laparoscopic View of Female Pelvis
Right ovary and broad
ligament.

The relation of the

very distal ureter to
the surrounding
structures
in the old days PV exam is
conducted to assess possibility of
ureteric colic
Male
Male
Lateral view of the prostate ( Lateral view of the
/ ), left seminal vesicle prostate, RIGHT
neurovascular bundle to
penis
advanced CA rectum can
invade into the ureter and
cause hydronephrosis
 Right vas
Left vas deferens
deferens

Bladder

Right distal
Left distal ureter
ureter
Posterior
surface of Right seminal
prostate vesicle
Cystoscopy View
prostate enlargement

trabeculations in bladder
 Prostate Surgery
Digital Rectal Examination

aaaaaaaaaaaaaaaaaaaaaaaaaaaaa
Anatomy of
Prostate
normal prostate: 15 - 20 cc
Cystoscopy View
Treatment of BPH during longitudinal follow-up up to 6
years ; Olmsted County Study (n=2115; age 40 - 79)
Necessity of therapy for BPH

treatment
received NO
Treatment of BPH 36% treatment
needed
64%

TURP
25%
Medical
therapy
Minimal 64%
invasive
11%

Jacobsen SJ, et al., J Urol 1999; 162(4): 1301 - 1306

Transurethral Laser Prostate Surgery

can be asked in final MB

Laser ablation of prostate:

Green Laser ( KTP ) ( 532nm ) ( for vaporization )
Lithium Triborate ( 532nm ) + MoXyfibre
Diode Laser ( 940 nm, 980 nm, 1318 nm, 1470nm )
Holmium-YAG ( 2140nm ) ( for enucleation )
Thulium ( 2010nm ) ( for resection and vaporization )
 Bipolar
Monopolar
TURP Transurethral TURP

Resection of
Prostate
Green Light 80 W: ablation / vaporization
( λ = 532 nm )

Green Light 180 W (XPS) ( λ = 532nm ): ablation / vaporization

Diode Laser ( λ = 980 nm ) : ablation / vaporization ? vaporesection

Holmium laser enucleation of Thulium laser vaporesection of
prostate ( HoLEP ) prostate
Lateral view of the prostate ( Lateral view of the
/ ), left seminal vesicle prostate, RIGHT
neurovascular bundle to
penis
 Intra-operative positioning:
Trendelenburg position
1 out of 29 prostate cancer
Endopelvic Fascia
 Endopelvic Fascia
cover more than 60% of prostate surface
 PPL: puboprostatic ligament ; EPF: endopelvic fascia ;
LA: Levator Ani ; P: prostate ; SDV: superficial dorsal vein
 PS: pubic symphysis ; OM: Obturator muscle ;
PPL: puboprostatic ligament ; SDV: Superficial Dorsal Vein
Dorsal Venous Complex
90% of penis venous drainage

derived from EIA

Accessory pudendal artery

Up to 30% in Men
erectile dysfunction if accidentally cut
 Transperitoneal Laparoscopic radical prostatectomy
Dorsal Venous Complex
Robotic

Lap.
The Neurovascular Bundle

cavernosal nerve
free the prostatic fascia from the prostate gland if you want to preserve erectile function in radical prostectomy
 SV: Seminal vesicles ; PC : Prostatic Capsules ; LA : Levator Ani;
R: Rectum ; DF: Denonvillier’s fascia covering medial aspect of neurovascular bundle ;
PP : Prostatic Pedicles ; NVB: Neurovascular bundle ;
PF: Prostatic fascia
Membranous Urethra /

Sphincter Urethra
 DVC: Dorsal Venous Complex ; LA: Levator Ani ;
MU: membranous urethra ; P : Prostate ; SU: Sphincteric Urethra
DVC: Dorsal Venous Complex ; MU: Membranous Urethra ; SU: Sphincteric Urethra ; NVB:
Neurovascular bundle ; P: Prostate ; LA : Levator Ani ; TA: Tendinous Arch of Levator Ani
nerves are
stained
 Clinical Relevance
&
Access to
Lower Urinary Tract
Iatrogenic ureteric injury during hysterectomy /
ureteric obstruction by cervical cancer
Obstruction of ureter by prostate /
rectosigmoid cancer
Acute Urinary Retention / Enlarged prostate
 calcium carbonate

Bladder stones
men uterus
Indwelling catheter
- Urethritis
- Prostatitis
- Bladder stones
- Chronic UTI
- Penile urethral abscess
- Urethral diverticula
- Urethral fistula
- Urethral stricture
- Epididymo-orchitis
- Worsen bladder compliance
Traumatic Insertion of Urethral Foley Catheter
urine gets into peritoneal cavity
 Urological Management
Suprapubic catheterization is considered when
- Urethritis ; Prostatitis ; Penile urethral abscess
- Urethral diverticula ; Urethral fistula ; Urethral stricture ; false passage
- Epididymo-orchitis
- Recurrent urethral catheter obstruction
- Difficulty with urethral catheterization
- Perineal skin breakdown due to urine leakage secondary to urethral incompetence
- Personal preference
 Sequelae Of Long Term
- Urethritis Indwelling
- Prostatitis Urethral Catheterization
- Bladder stones
- Chronic UTI
- Penile urethral abscess
- Urethral diverticula
- Urethral fistula

- Urethral stricture
- Epididymo-orchitis
- Worsen bladder compliance
How do you perform transurethral
sphincterotomy ? do it over 12 o’clock not 6 o’clock
 Urethral Stent

Put the stent across

external urethral
sphincter
Don’t Forget the MCQ
Thank You