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3-Patient Positioning

the etiology of position-related neuropathy is generally secondary to excessive stretch, prolonged compression, or ischemia.

The supine position, used in abdominal, pelvic, and penileprocedures, is generally considered the safest patient position.

However, several specific issues should be considered. Excessive upper extremity abduction (>90 degrees) can lead to tension on the brachial plexus, leading to upper extremity neuropathy.

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One of the most frequent positions used in urology is thelithotomy position .

Improper positioning can lead to transientand occasionally prolonged lower extremity neuropathy

The basic principle of position involvesmanipulation of both lower extremities simultaneouslywith flexion of the hips at 80 to 100 degrees with 30- to

45-degree abduction.

The legs should be padded to avoid excessive compression against the stirrup.

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For most open and laparoscopic upper urothelial tract and renal procedures, the patient is placed in some degree of

lateral decubitus position .

Proper padding of the patient is important withappropriate anterior and posterior support to maintain the

decubitus position .

The most frequent focus of compromise involvespositioning of the arms and potential for brachial plexus injury.

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WOUND CLOSUREAbdominal Incisions

Urologic surgery can encompass a large area of the trunk, and therefore the urologist should be familiar with all type of incisions of the abdomen.

The most commonly used incision in surgery including urology is the midline abdominal incision. This incision can provide access to the entire peritoneum and retroperitoneum.

For procedures focused on particular areas of the abdomen, alternative incisions provide more focused exposure with certain benefits.

A Pfannenstiel incision (transverse lower abdominal incision) can be used for virtually all pelvic procedures and results in improved cosmesis and possibly decreased pain.

For access to the lower third of the ureter, a Gibson incision (i.e., an oblique incision in the lower quadrant) can be used. Using a Gibson incision, entry into the retroperitoneum is gained by splitting the external and internal oblique muscles in the direction of its fibers.

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Access to the upper abdomen and retroperitoneum for renal and adrenal surgery can be gained using various kinds of incisions .

An extraperitoneal approach is best performed via a flank incision over the 11th or 12th rib, with or without partial rib removal .

An extraperitoneal approach avoids the complications of transperitoneal surgery such as bowel injury, postoperative ileus, and adhesion formation .

Transperitoneal access can be obtained via an anterior subcostal incision (two finger breadths below the costal margin).

This incision provides better access to the midline vascular structuresby allowing for complete medial mobilization of the posteriorperitoneum.

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For large or locally advanced (vena cava thrombus) tumors, a thoracoabdominal or chevron incision generally provides the best exposure .

A thoracoabdominal approach is preferred for large upper retroperitoneal tumors or tumors with extension into the thoracic cavity (supradiaphragmatic vena cava tumor thrombus).

On the other hand, a chevron incision is preferred for access to both the right and left abdomen (e.g., bilateral renal tumors) .

In summary, proper choice of incision is often critical to successful surgical outcome, especially for complex operative cases.

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Contemporary OpenSurgery of the Kidney

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Flank Subcostal Useful for surgery on lower renal pole, ureteropelvic

junction, and upper ureter, as well as simple

nephrectomy, nephrostomy tube insertion, and

drainage of perinephric abscess

contamination Extraperitoneal approach prevents peritoneal

Abdominal panniculus falls away from incision

DISADVANTAGES AND POTENTIAL COMPLICATIONS

Poor option for radical or partial

nephrectomy and in patients withsignificant scoliosis or who will nottolerate flank position (e.g., severe

pulmonary comorbidity)Provides poor access to renal hilum and

renal vasculatureExposure possibly hindered by the iliac

crest and subcostal nerveRisks chronic flank pain and bulge and

ischemic injury to a postoperativecontralateral kidney