Common Surgical Procedures - Urinary tract

Surgical procedures involving urinary stones and tumors of the bladder, ureter, urethra, and kidney are considered in this section. Also discussed are kidney cysts and conditions affecting the adrenal glands which might require surgery.

Urinary Stones

Most stones that occur in the urinary tract are formed in the kidneys, but kidney stones can travel to other areas, such as the ureters, and cause problems there. Various types of stones can develop in the kidneys from several different causes. A common cause is a metabolic disorder involving calcium, proteins, or uric acid. Other causes are infections or obstructions of the urinary tract, the use of certain drugs, such as diuretics, or vitamin deficiency.

Symptoms

Kidney stones seldom cause problems while they are forming, but movement of the stones irritates the urinary tract and can cause severe pain; the irritation of the tissues may cause bleeding that will ultimately show up in the urine. Other symptoms may indicate obstruction of the flow of urine, and infection. In some cases obstruction of a ureter can lead to failure of the kidney. X-ray techniques can usually verify the cause of the patient's symptoms and locate the urinary stone. Most stones cast a shadow on X-ray film, and by injecting special dyes into the urinary system, the degree of obstruction by a stone can be determined.

Ureter Stones

Most stones released by the kidney are small enough to pass through a ureter to the bladder and be excreted while urinating. But if a stone is large enough it can become lodged in a ureter, causing excruciating pain that may be felt both in the back and in the abdomen along the path of the ureter. Ureter stones often can be removed by manipulation, using catheter tubes that are inserted through the bladder. If the stuck stone cannot be manipulated from the ureter, an operation in a hospital is required. However, the surgical procedure is relatively simple and direct. An incision is made over the site of the stuck stone, and the ureter is exposed and opened just far enough to permit removal of the stone. The operation is safe and requires perhaps a week in the hospital.

Kidney Stones

If the urinary stone is lodged in the kidney, the surgical procedure also is a relatively safe one although more complicated and requiring a longer hospital stay. The surgeon must work through skin and muscle layers to reach the kidney, then cut into the kidney if necessary to remove the stone. If the obstruction has been serious enough to impair normal kidney function or if infection has damaged the kidney tissue, the surgeon may elect to remove the affected kidney. Fortunately, the human body can get along fairly well with one good functioning kidney, so a nephrectomy , as the procedure is called, may not be as drastic a maneuver as the patient might imagine. If, on the other hand, the affected kidney has not been seriously damaged, the stone or stones can be removed with instruments or by the surgeon's fingers and the incision in the kidney sewed up so that it can resume its normal functions.

More modern techniques for removing kidney stones include two that hold promise of eliminating nearly all surgical methods. One involves the use of the lithotriptor, a machine that shatters the stones with an electrical shock wave. The wave is focused on the stones with the aid of a reflector and two sophisticated X-ray machines that “aim” the target beam. No surgery is required, and the patient is usually back at work within a week. A second means of attacking kidney stones is a drug, potassium citrate , which keeps the stones from forming. The drug actually corrects the metabolic disorders that cause the formation of kidney stones.

Vesical Stones

Occasionally, urinary stones are found in the neck of the bladder or in the bladder itself. They are called vesical stones and, depending upon their size and other factors, may be removed by several techniques, including use of a cystoscope inserted through the urethra. In some cases the stone can be broken into smaller pieces for removal. If it appears unlikely that the stone can be removed directly or by crushing it, the surgeon can make an incision directly to the bladder in a manner similar to the approach used in removing a stone from the ureter.

Bladder Tumors

About three-fourths of the tumors of the bladder occur in men past the age of 45. Although the specific cause of bladder tumors is unknown, physicians suspect that a cancer-producing chemical is involved. Several studies have found an association between the disease and cigarette smoking or occupations that require contact with organic chemicals used in making dyes. Tumors that appear in the female bladder are less likely to be cancerous than those that occur in the male bladder.

Symptoms and Diagnosis

The first symptom of bladder tumor is blood in the urine. The tumor itself may cause no pain, but an early complication could be an infection producing inflammation and discomfort in the region of the bladder. If the tumor blocks the normal flow of urine, the patient may feel pain or discomfort in the area of the kidneys; this condition is most likely to happen if the tumor is located at the opening of a ureter leading from a kidney to the bladder. An early examination of the bladder may fail to locate a small tumor, although X rays might show the growth as a bit of shadow on the film, and obstruction of a ureter could be seen. Nonetheless, examination of the interior of the bladder by a cystoscope is necessary to confirm the presence of the tumor. A biopsy can be made by removing a few tissue cells from the area in a manner quite like the procedure for making a Pap-smear test for possible cancer of the cervix in a female patient.

Treatment

Most early and simple cases of bladder tumor can be corrected by a procedure called saucerization by an instrument that removes the abnormal tissue, leaving a shallow wound that normally will grow over with healthy tissue cells. But a tumor that invades deeply into the wall of the bladder requires more radical therapy, such as surgery to cut away the part of the bladder that is affected by the growth. Radiation also may be employed to control the spread of tumor cells, particularly if laboratory tests indicate that the type of tumor cells involved are sensitive to radiation.

Surgical Procedure

If it is necessary to cut away a part of the bladder, the surgeon simply shapes a new but smaller organ from the remaining tissues. If a total cystectomy is required to save the life of the patient, the entire bladder is removed, along with the prostate if the patient is a man. When the bladder is removed, a new path for the flow of urine is devised by the surgeons, usually to divert the urine into the lower end of the intestinal tract.

Tumors of the Ureter or Urethra

Tumors of the ureter, above the bladder, or of the urethra, below the bladder, may begin with symptoms resembling those of a bladder tumor, although X rays might show the growth as a bit of shadow on the normal flow of urine. Treatment also usually requires removal of the affected tissues with reconstructive surgery as needed to provide for a normal flow of urine from the kidneys.

Kidney Tumors

Wilms' Tumor

Tumors of the kidney generally occur either in children before the age of eight or in adults over the age of 25. The type of tumor that affects children usually is the Wilms' tumor, one of the most common kinds of cancer that can afflict a youngster. The tumor grows rapidly and may be painful even though there may be no obvious signs of urinary tract disorder in the child's urine. The tumor frequently becomes so large that it appears as an abdominal swelling. A Wilms' tumor usually occurs only on one side of the body, but in a small percentage of the cases the disorder can develop in both right and left kidneys. Kidney function may continue normally during growth of the tumor, but cancerous cells from the tumor may be carried by the bloodstream to other parts of the body, by metastasis, causing the problem to spread to the lungs and other vital organs.

Treatment usually requires surgical removal of the affected kidney and radiation therapy; the tumor cells responsible for the growth are sensitive to radiation. The younger the child and the earlier treatment is started, the better are the child's chances for recovery from a Wilms' tumor.

Adult Kidney Tumor

The adult type of kidney tumor, which is more likely to affect men than women, may also appear as an enlarged abdominal mass. But, unlike the Wilms' tumor, the adult kidney tumor presents as an early symptom blood in the urine. Bleeding from the kidney may be painless. X-ray studies may show an enlarged and sometimes distorted kidney. The patient may have symptoms indicating metastasis of the tumor cells to the lungs, bones, or other body systems. Adult kidney tumors are almost always malignant.

Treatment usually requires nephrectomy, or surgical removal of the diseased kidney. Radiation therapy may be provided in addition to the surgery, although the kind of tumor cells involved in the adult type of kidney tumor usually are resistant to radiation. Chemotherapy also may be offered. The chances for complete recovery from a kidney tumor depend upon several factors, such as the location of the tumor in the kidney and the extent of metastasis of the cancerous cells to other organ systems.

Kidney Cysts

A cyst is a small pouch enclosed by a membrane; technically, the urinary bladder and gall bladder are cysts. But the cysts of medical disorders are small pouches or sacs filled with a fluid or viscous substance; they may appear on the skin, in the lungs, or in other body systems, such as the kidneys.

Symptoms

Kidney cysts produce symptoms that resemble the symptoms of cancer of the kidney; in a few cases kidney cysts are associated with tumors that cause bleeding into the cysts. In addition to the troublesome symptoms of flank pain and blood in the urine, untreated cysts can grow until they damage normal kidney tissue and impair the function of the organ's functions. Simple or solitary kidney cysts usually do not occur before the age of 40.

Diagnosis

X-ray techniques are made to determine the exact nature of kidney cyst symptoms, but in some cases exploratory surgery is recommended to differentiate a cyst from a tumor. The cyst is excised, frequently by cutting away the exposed wall of the growth. The chances of the cyst reforming are very slight.

Polycystic Kidney Disease

A different kind of kidney cyst disease, consisting of many small cysts, may be found in younger persons, including small children. The symptoms again may be flank pain and blood in the urine; examination may show some enlargement of the kidney. This form of the disease, sometimes called polycystic kidney disease , can be complicated by uremia and hypertension as the patient grows older. Treatment usually is medical unless the cysts interfere with urine flow by obstructing the upper end of the ureter. If the outlook for recovery through conservative treatment is poor, the surgeon may consider a kidney transplant operation.

Adrenal Glands

The adrenal glands are small hormone-producing organs that are located just above the kidneys. Although the combined weight of the two glands may be only one-fourth of an ounce, the adrenals affect a number of important body functions, including carbohydrate and protein metabolism and fluid balance. Surgery of the adrenal glands may be needed for the correction of various bodily disorders associated with oversecretion of the adrenal hormones; it may also be indicated to help control of cancer of the breast in women and cancer of the prostate in men.

Tumors of the Adrenal Glands

Tumors of the adrenal glands produce a disorder known as primary hyperal-dosteronism , which is marked by symptoms of muscle weakness, hypertension, abnormally large outputs of urine, and excessive thirst. Another kind of tumor invasion of the adrenal glands can produce symptoms of hypertension with headaches, visual blurring, and severe sweating. Still another adrenal-related disorder, called Cushing's syndrome , tends to affect women under the age of 40. The symptoms may range from hypertension and obesity to acne, easy bruising, and amenorrhea (cessation of menstruation). Adrenal tumors may also alter secondary sex characteristics of men and women; they may result in body hair and baldness in women and increased sex drive in men.

Despite the tiny size of the adrenal glands, they are complex organs, and the varied disorders caused by tumors of the glands may depend upon the precise kind of tumor cells involved and the precise area of the glands affected by the tumor, as well as the interactions of the adrenal hormones with hormones from other glands, such as the pituitary, or master gland of the body, located at the base of the brain.

Preoperative Tests

Before adrenal surgery for correction of a disorder is begun, the surgeon may ask for detailed laboratory tests and other diagnostic information. A radioactive scan to help locate and identify the kind of tumor more precisely may be ordered. Women patients who have been using oral contraceptives usually have to discontinue use of “the pill” for two months or more, because the medication can interfere with laboratory studies of hormones in the bloodstream.

Long-Range Effects

Physicians handling the case also must evaluate the long-range effects of an adrenal gland operation because normal metabolism is likely to be disrupted by removal of the glands, if that should be necessary. Hormone medications usually are needed in such cases to replace the hormones normally secreted. An adrenalectomy (removal of an adrenal gland) sometimes is explained as the substitution of a controllable disease for a life-threatening disease that cannot be controlled by medical therapy. If only one of the adrenal glands must be removed, however, the patient may be able to recover and resume a normal life without the need for hormone medications.

Surgical Procedure

The surgical approach to the adrenal glands is similar to that used in kidney operations. The incision may be made through the abdomen or through the flank. The surgery may be primarily exploratory, or the surgeon may excise a part of a gland, an entire gland, or both glands, depending upon the extent of the disease, or upon other factors, such as the need to control cancers in other parts of the body.