Surgery Genitourinary

7/27/2019 Surgery Genitourinary

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GENITOURINARY

Hernia:Abnormal protrusion of a viscus or part of a viscus through a defect either inthe containing wall or within the cavity of the viscus. Involves anterior & posterior muscle

layers of the abdomen, diaphragm, and walls of the pelvis. Can be external or internal.

External Hernia:Common, present as abnormal lump. (Inguinal most common in

males, femoral more common in females)

Richters Hernia:Part of the circumference of bowel trapped within hernial sac (Doesnot result in intestinal obstruction due to non-occlusion of lumen of bowel)

Littres Hernia: A small bulge in the small intestine present at birth (Meckels

diverticulum) lies within hernia sac, most common in femoral or inguinal hernia.

Maydls Hernia:Hernial sac contains two loops of intestine that may become

obstructed or strangulated. Not recognized unless hernia contents are inspected.

Predisposing Factors:Congenital (i.e. present at birth)AcquiredIncreased Intra-abdominal pressure (Coughing/vomiting/ascites)

Complications:

Irreducibility (least serious):

Adhesions between sac and its contents Fibrosis leading to narrowing of neck of the sac Sudden increase in IAP that causes permanent displacement of the sac

Obstruction:

Neck is sufficiently narrow to occlude the lumen of the intestine Nearly always irreducible and may become strangulated Urgent Presents with intestinal obstruction (abdominal colic, vomiting, constipation, abdominal

distension)

Strangulation (most serious):

Compression at the hernial orifice cuts off blood supply Lymphatic and venous obstructed, leading to oedema and venous congestion Serious complication if intestine is involved Erythema of the overlying skin is a late sign Immediate operation needed


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Reducible Hernia: Easy come, easy go Irreducible Hernia: Hard to be reduced Incarcerated Hernia: Retented and confined hernia Strangulated Hernia: Causes enteric necrosisInguinal Hernia:Most common hernia, frequent in men.Etiology:

Inguinal canalpasses through the abdominal wallbetween the deep (internal) andsuperficial (external) inguinal rings

The canal is a site of weakness and thereforepotential herniationIndirect Inguinal Hernia:

The neck of the sac is situated lateral to the inferior epigastric artery Sac accompanies the spermatic cord along the inguinal canal towards the scrotum Sac lies in front of the cord, enclosed by the coverings of the cord

Causes:

Failure of the processus vaginalis to form the ligamentum vaginale Loss of integrity of the inguinal canalDirect Inguinal Hernia:Rare in females, doesnt occur in children,more common on right side after appendicectomy. Protrudes directly through posterior

wall of inguinal canal, medial to the inferior epigastric artery.

Causes: Main reason is weakness of the inguinal canal Herniation occurs atHesselbachs triangle Neck of a DIH is usually larger than the body and so strangulation is rare Rarely reaches a large size or approaches the scrotum

Features:

Inguinal discomfort Pain

Severe pain suggests obstruction or strangulation. Lump usually obvious, often precipitated by increasing IAP, reduce completely with rest and

lying down.

The patient initially is examined standing to demonstrate the lump and possible coughimpulse

Then lying down to allow the hernia to be reduced


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Difference between IIH & DIH:

IIHprotrudes along the line of the inguinal canal towards the scrotum or labia DIHappears as a diffuse bulge at the medial end of the inguinal canal IIHis prevented from appearing by applying pressure over the deep inguinal ring (which

lies just above the midpoint of the inguinal ligament)

DIHprotrudes through the posterior wall of the inguinal canal medial to the deep ring. IIHis controlled by pressure in the deep ring DIHappears medialto the examiners two fingers Accurate distinction may be impossible because of variation of the deep inguinal ring IIHare more likely to develop complications If the pulse lies laterally, it is indirect inguinal hernia. If the pulse lies medially, it is considered as direct inguinal hernia.

Treatment:

Inguinal hernias are best treated surgically May under general, regional or local infiltration anaesthesia

Principles of Operation: Any correctable aggravating factors be identified and treated In infants and young adults, repair usually be limited to high ligation Eliminate the hernia sac, reconstruct the inguinal floor Bilateral repair usually discouraged; Laparoscopic repair can be done with low risk

Traditional Repair (Herniorrhaphy):

Repair posterior wall of the inguinal canal

Repair the external oblique aponeurosis Strong non-absorbable sutures are used

IMPORTANT: Bassini, Halsted, & McVay have higher chances of recurrence & is more

painful, while Shouldice has lower chances of recurrence but isnt popular. Tension-Free

Repair is MOST POPULAR NOW.

Bassini Repair:

Conjoint tendon is sutured onto the inguinal ligament Spermatic cord remains under the external oblique aponeurosis

Halsted Repair:

Resemble Bassini repair Except place the external oblique aponeurosis beneath the cordMcVay Repair:

Resemble Bassini repair Except suture the conjoined tendon onto the Coopers ligament


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Shouldice Repair (GOLD STANDARD FOR HERNIORRHAPHY):

Divide the transversalis fascia deep inguinal ring is closed around the cord conjoined tendon and internal oblique muscle are approximated in layers to the inguinal

ligament

Advantages & Disadvantages: cheap, easy to perform recurrence rate, pain, discomfort, ect.

Hernioplasty Process:

Insertion of a prosthetic mesh to cover and support posterior wall of the inguinal canal The mesh is cut to size and is then sutured to the posterior wall behind the cord Alternatively, the mesh can be placed deep in the defect of the posterior wallMost widely used Techniques include:

Plug--insert the plug into the internal ring, with or without sheet of mesh Lichtenstein--use mesh to cover the entire inguinal floor Both

Laparoscopic Hernia Repair:

Performed under general anaesthesia, using either a transperitoneal or extraperitonealapproach

Not appropriate for large or irreducible hernias Advantages of laparoscopic hernia repair include reduced post-operative pain and earlier

return to work

Disadvantages include increased risk of femoral nerve and spermatic cord damage, risk ofdeveloping Intra-peritoneal adhesions with the trans-peritoneal procedure, and greater

cost and duration of the operation

Includes Total Extra-peritoneal approach (TEP)/Trans-abdominal pre-peritonealapproach (TAPP)/Intra-peritoneal onlay Mesh (IPOM)

TEP is preferable to TAPP because of its lower complication and recurrence rates TAPP should be reserved for patients with prior lower abdominal wall incisions that make

the dissection of the peritoneum from the underside of the incision impossible.

Patients who cannot tolerate general anesthesia or who have had extensive lowerabdominal surgery shouldnotundergo laparoscopic herniorrhaphy.

Benefits of Biological Mesh:

Safe Strong Least of infection and rejection Resists adhesions Fewer complications than synthetics


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DIAGNOSIS OF URINARY DISEASES

Classification of Pain:

Renal Pain:

Located in the ipsilateral costovertebral angle just lateral to the sacrospinalis muscle andbeneath the 12th rib.

Caused by acute distention of the renal capsule, generally from inflammation orobstruction.

May be associated with gastrointestinal symptoms; Renal pain may also be confused with pain resulting from irritation of the costal nerves,

most commonlyT10-T12.

Ureteral Pain:

Usually acute and secondary to obstruction. Hyperperistalsis and spasm

Vesical Pain:

Inflammatory conditions of the bladder usually produce suprapubic discomfort Acute urinary retention Overdistention and inflammation

Prostatic Pain:

Usually secondary to inflammation with secondary edema and distention of the prostaticcapsule;

Poor localizationPenile Pain:

Usually secondary to inflammation in the bladder or urethra, pain at urethral meatus.Testicular Pain:

Primary pain arises from within the scrotum, secondary to acute epididymitis Chronic scrotal pain is usually related to noninflammatory conditions The pain is generally characterized as a dull, heavy sensation that does not radiate.HEMATURIA:3 red cell per High-power field

IMPORTANT: Urinary infection is the most common cause of hematuria.

Classification:

Hematuria gross or microscopic Occurrence of hematuria during urination Pain association Specific shape of clots


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Differences:

Initial hematuria usually arises from the urethra; Total hematuria indicates bleeding is most likely from the bladder/UUT Terminal hematuria occurs at the end of micturition and is usually secondary to

inflammation in the area of the bladder neck or prostatic urethra.

Association with Pain: Pain in association with hematuria usually results from upper urinary tract hematuria

with obstruction of the ureters with clots.

Acute urinary infection (most common cause of hematuria)Shape of Clots:

The presence of wormlike clots, particularly if associated with flank pain, identifies thehematuria as coming from the upper urinary tract

Hematuria, particularly in the adult, should be regarded as a symptom of malignancyuntil proved otherwise and demands immediate urologic examination

ABNORMALITY OF VOIDING VOLUME

Classification:

Polyuria: Greater than 2000ml per day with normal drinking Oliguria: Less than 400ml per day with normal drinking; Anuria: Less than 100ml per day (prerenal, renal and postrenal anuria) Pre-renal anuria (Inadequate renal irrigation) Renal anuria (Dysfunction of urinary production) Post-renal anuria (Obstruction of urinary tract)

Symptoms:

Irritative Frequency; Urgency Dysuria

Obstructive:

Decreased force of urination Urinary hesitancy Intermittency Postvoid dribbling Straining


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INCONTINENCE

Classification:

Continuous Incontinence Stress Incontinence Urgency Incontinence Overflow Urinary Incontinence Enuresis

Sexual Dysfunction:

Loss of Libido Impotence Failure to Ejaculate Absence of Orgasm Premature Ejaculation Hematospermia

Diagnosis:

Physical Examination Urinalysis (Midstream urine sample preferred) Abdominal Plain Radiography Intravenous Urography (Requires normal renal function, Renal Parenchyma

/Urolithiasis)

CT Ultrasound MRI

Invasive Examination:

Cystoscope/Ureteroscope/Nephronscope Retrograde Urography/ Urethrography (Performed by cystoscope/urethral meatus)

GENITOURINARY TRAUMA

General Considerations:

10% of E.R. trauma visits Often associated with multi-system trauma Subtle presentations, easily overlooked Diseased GU organs susceptible to injury

Evaluation (Primary Survey):

Airway with Cervical spine protection Breathing high-flow oxygen Circulation (Control of external bleeding)

Disability (Assessment of neurologic status)


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Exposure /Environment

Renal Trauma:


Most commonly injured GU organ Often in association with multi-system organ injury Blunt >80% Penetrating 1cm, without extension into the renal pelvis Grade IV: Laceration extends to renal pelvis Grade V: Shattered kidneyNon-operative management:

Hemodynamic stable patient can usually be managed non-operatively 98% of renal injuries can be managed non-operatively (Bed rest/antibiotics/water) Grade IV &V injuries more often require surgical exploration


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Surgical Indications:

Absolute:

Persistent renal bleeding with hemodynamic instability Expanding perirenal hematoma Pulsatile perirenal hematoma

Relative:

Penetrating injuries Extensive urine extravasation Grade 5 injury Non-viable tissue (>20%) Arterial injury (main or segmental)

Methods:

Partial Nephrectomy Total Nephrectomy

IMPORTANT: TOTAL NEPHRECTOMY ONLY IF: Vasculature is completely avulsed The kidney is ischemic Life threatening Uncontrollable hemorrhage

Principles of Renal Reconstruction:

Complete renal exposure Debridement of non-viable tissue Hemostasis Suture ligature (Gelfoam, Surgicel/Argon beam coagulation) Water-tight closure of collecting system Approximation/coverage of parenchymal defect

Complications:

Early:

Urine extravastion (most common) Hemorrhage, shock Urinoma formation

Late:

Infection Abscesses Loss of renal function Hypertension


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Bladder Trauma:


Relatively uncommon Often in association with multi-system organ injury Significant mortality rate (10-20%) Have high index of suspicion of urethral disruption injury Bladder more susceptible to injury when full

Types of Trauma:

Blunt:

Most common type of bladder injury Usually motor vehicle accidents 2/3 contusions, 1/3 ruptures 10-25% have associated bladder injury 85-90% of bladder injuries have associated pelvic #

Penetrating: Less common Often associated with major organ injuries

Iatrogenic:

Open or laparoscopic pelvic surgery Gynecologic, vascular, urologic or general surgery

Spontaneous Rupture:

Underlying pathology Cancer, obstruction, XRT, TB, sensory neurologic deficit

Presentations:

Gross hematuria (the classic finding) 95% blunt injuries have gross hematuria Inability to void Abdominal pain Abdominal bruising Pelvic mass Peritoneal signs Shock

Classification:

Extraperitoneal Injury(Most common treatment by catheter drainage)

Surgery in the case of bone fragment into bladder/Open pelvic Fracture/Rectalperforation/Poor catheter drainage

Intraperitoneal Injury:

Rapid raising intra-peritoneal pressure can cause rupture of bladder


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Surgery treatment

Complications:

Intraperitoneal

Urinary frequency Shock Peritonitis

Extraperitoneal

Shock Pelvic abscessUreteral Trauma:

Etiology:

External trauma very rare


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Unilateral Injury: (3 possibilities) Asymptomatic (Ureter ligation leads to silent kidney atrophy) Loin pain and fever (Pyonephrosis) Urinary fistula (Through the abdominal/vaginal wound)

Complications:

Early:

Hydronephrosis Urinoma Infection

Late:

Stricture Loss of renal function Stone formation

URINARY TRACT INFECTION

IMPORTANT DEFINITIONS: Upper urinary tract infection: Infection occurs in kidney, pelvis and ureter Lower urinary tract infection: Infection occurs in bladder and urethra Cystitis: Infection occurs mainly in bladder, and usually with urethritis Urethritis: Infection occurs mainly in urethra

Classification:

Upper urinary tract infection or lower urinary tract infenction Pyelonephritis vs cystitis vs urethritis First Infection vs Recurrent infection Complicated vs Uncomplicated

Diagnosis:

Location of infection: Upper or Lower Pathogen: From urine culture Any anatomic abnormalities in urinary tractPyelonpehritis:

Symptoms:

Fever Flank pain Tenderness on flank Dysuria


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Urinary Urgency/Frequency

Cystitis:

Symptoms:

Dysuria Urinary urgency Urinary frequency with Hematuria Suprapubic pain Foul-smelling urine No feverManagement:

Hydration Antibiotics (Trimethoprim & Fluoroquinolone for 3 days)

Patients with complicated cystitis: Recurrence in recent three months History of abnormalities in urinary tract History with multiple antibiotics previously Pathogen diagnosis should be based on urine cultureManagement:

Urine culture for recurrent UTI Ultrasound screening for any abnormalities of urinary tract CT scan or IVU for any abnormal finding from ultrasound screening Uroflowmetry with residual urine for patient with difficult voiding Control Diabetes Mellitus Antibiotics in initial stage Antibiotics should be based on urine culture The effective antibiotics should be maintained for over two weeksProstatitis:

Classification: Acute bacterial-Category I(Acute urinary symptoms with bacteremia) Chronic bacterial-Category II(Chronic urinary symptoms with bacteria in prostate) Nonbacterial-Category III(Chronic urinary symptoms without bacteria in prostate) Asymptomatic prostatitis-Category IV(inflammation in prostrate without symptoms)Category 1:

Symptoms:

UTI symptoms (dysuria, urgency, frequency, nocturia)

Urinary hesitancy, fever, chills, malaise


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Enlarged, tender prostate on DRE

Treatment:

Bed resting (Anti-pyretics) Urine Culture Suprapubic drainage if patient were in urinary retention Treat with broad spectrum antibiotics Continuing oral antibiotics for 4 weeks after to eradicate bacteria in prostateCategory 2:

Symptoms:

Episodes of dysuria, frequency, pelvic, perineal pain, usually without fever Prostate secretion test culture should be done for further treatment

Treatment:

Antibiotics option E coli present in 80% of cases TMP-SMX and fluoroquinolones orally for 4~6 weeks Option could be based on culture sensitivities when it is available -Blocker (Could relieve urinary symptoms) Analgesics (could relieve chronic pain) Cernilton (Pollen agents)Orchitis:

Classification:

Acute bacterial orchitis Secondary to UTI Secondary to STD Nonbacterial infectious orchitis Noninfectious orchitis Chronic Orchitis Chronic Orchialgia

Symptoms:

Unilateral testis pain and swollen Fever ( acute cases) abdominal discomfort, nausea, and vomiting The skin of the involved hemiscrotum is erythematous and edematous Most cause of bacteria is E.Coli and Pseudomonas


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Treatment:

Bed rest Scrotal support Hydration Antipyretics & Analgesics Antibiotic therapy (Same principle as acute or chronic bacterial prostatitis)GENITOURINARY TUBERCULOSIS

Definition:Tuberculosis involving kidney, ureter, bladder and male genitals, cause is

Tubercle bacillus.

Clinical Manifestation:

Frequency, urgency and dysuria

Hematuria Pyuria Lumbago Systemic Symptoms

Diagnosis:

Urine Rate (Important) Acid Fast Staining Urine Culture US KUB+IVP CT & MRI Cystoscopy

Treatment:

Systemic Therapy Chemotherapy Surgical Treatment (Nephrectomy/Reconstructive Surgery) Postoperative Chemotherapy Bladder Contracture (Only considered after cure of TB)

URINARY TRACT OBSTRUCTION

Classification:

Congenital or Acquired Mechanical or Dynamical Upper urinary tract or Lower urinary tract Disorders of the tract or other systems


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Upper Urinary (Kidney/Ureter/Multifactoral) or Lower Urinary (Prostate/Urethra) Tract

Congenital UPJ Obstruction

Causes:

Congenital (Aperistaltic segment of ureter) Acquired (Compression from bands)

Results of UTO:

Lowered GFR Lowered Renal Blood Flow

Complications:

Renal Parenchymal Atrophy (Renal Failure) Urosepsis (Bacteria in circulatory system)Hydronephrosis:Blockage in urine drainage from pelvis, leading to elevated

pelvic pressure and dilated calyces, resulting in renal parenchyma atrophy (Renal

failure).

Severity depends on:

Duration Degree (Complete or Incomplete) Site

Symptoms:

Congenital (Asymptomatic to abdominal mass) Acquired (Symptoms of primary disease) Complete Obstruction (Renal Colic) Intermittent (Persistent and complete obstruction)

Diagnosis:

Confirmation Severity & Renal Function

Clinical Findings:

Laboratory:

Infection (Urinalysis/Leukocytosis) Renal Function (Azotemia/Electrolyte Imbalance)

Imaging:

Sonography (Thin renal parenchyma) KUB Excretory Urography (Reveals entire cause unless severely impaired renal function) Retrograde Uropathy (Percutaneous Urography in case of failure)


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CT & MRI (Differentiate from solid tumors)

Treatment:

Treating primary disease Relief of obstruction (JJ-Drainage/Nephrostomy) Nephrectomy (ONLY in Irreversible kidney damage)

BENIGN PROSTATIC HYPERPLASIA

Definition: Hyperplasia of prostatic epithelial cells that leads to formation of large

nodules in periurethral region, why may eventually cause complete obstruction of the

urethra.

General factors:

Mostly occurs in peripheral zone Most common benign tumor in men

Symptoms:

Men > 50yrs. Prostate size has poor correlation with symptoms (Middle lobe causes severe symptoms) Severity based on obstruction, progressive speed, and associated infection Urination frequency, urgency, nocturia & dysuria

Symptoms of Complications:

UTI Odynuria Bladder stone Hematuria Renal failure (Hydronephrosis)

IPSS:International-Prostate Symptom Score, used to determine severity.

Mild: 0-7 Moderate: 8-19 Severe: 20-35

IMPORTANT: BPH determined by Digital Rectal Examination (DRE).

Tone of anal sphincter Prostate size & consistency Nodules

Diagnosis:

DRE Uroflowmetry/Urodynamic Study Ultrasonography Prostate Specific Antigen (Marker for Prostate Cancer)


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Cystoscopes (When Transitional Cell Carcinoma suspected)

Treatment:

Watching waiting Medical therapy (Alpha-blockers/Finasteride) Phytotherapy (Plant extracts)

Surgical Treatment:

Transurethral Resection of Prostate (TURP) (95% perfomed endoscopically) Open Prostatectomy (When too large for endoscopic resection) (Suprapubic/Retropubic)

URINARY STONES

Definition:Aggregation of dietary minerals from the urine that forms in the kidney.

95% form in Upper Urinary Tract, 5% in Lower Urinary Tract.


Third most common disease Etiology still unknown Recurrence rate at 50% within 5 years

Factors for formation:

Urine stagnation UTI Food/Drugs Abnormal Metabolism/Endocrine Dysfunction

Sites of formation:

Renal Ureteral Vesical Prostatic & Seminal vesicle Urethral & PrepuceRenal

Symptoms:

Pain Hematuria Nausea/Vomitting

Diagnosis:

X-Ray Ultrasonography


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Spiral CT

Complications:

Infection Hydronephrosis Renal tissue destruction

Treatment:

Conservative:

Drugs Water

Invasive:

Extracorprela Shockwave Lithtripsy (ESWL) (Using shock waves) Percuaneous Nephrolithotomy (PCNL) Trnasurethral Lithotripsy (TUL) LaparoscopyUreteral Stones (Originates from kidney and may result in complicatinginfection)

Symptoms:

Pain Nausea/Vomiting Hematuria Infection

Diagnosis:

Laboratory (Same as Renal)

Imaging:

CT B Ultrasonography KUB

Complications:

Renal Damage Anuria Infection

Treatment:

Passes spontaneously if < 0.5cm in diameter Large stones require ureteral stent


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ESWL & PCNL (When stones in upper two-third of ureter) Vesical Stone: Stones containing calcium, present in lower urinary tract.

More frequent in males than females (90%)

Symptoms:

Bladder neck obstruction Hematuria Vesical distention Urethral stricture Urethral pain & urine interruption

Diagnosis:

Laboratory:

HematuriaImaging:

X-Ray US/CT/Endoscope

Treatment:

Small stones pass spontaneously Large stones require TUL or Vesicolithotomy

GENITOURINARY TUMOR

Kidney Cancer: Any cancer arising in kidney or renal pelvis, but most are RCC,which arise from proximal convoluted tubules.

General Facts:

Renal Cell Carcinoma (RCC) accounts for 3% of malignancies MOST LETHAL urologic cancer More in male than female (3:1)

Etiology: Lifestyle factors (Smoking/Obesity) Preexisting renal conditions (Polycystic renal disease/Chronic renal failure)

Symptoms:

Asymptomatic & nonpalpable Detected accidentally using non-invasive imaging Weight loss/fever/anemia/night sweat (COMMON SYMPTOMS) Paraneoplastic syndromes (Only found in 30% of symptomatic patients)

Diagnosis:


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Laboratory findings:

Anemia Hematuria

Imaging:

X-Ray CT Ultrasonography

Staging:

Stage I: Tumor < 7cm, remains in kidney, 95% of 5-year survival Stage II: Tumor > 7cm, remains in kidney, 88% of 5-year survival Stage III: Tumor in major veins, 1 regional lymph node involved, 59% 5-year survival Stage IV: Tumor beyond Gerotas fascia, >1 lymph node involved, 20% 5-year survival

Treatment:

Radical Nephrectomy (For stages I, II, IIIa) Partial Nephrectomy (Solitary tumor < 4cm)Bladder Cancer:

General Considerations: Most common GUT cancer in China More than 90% are Transitional Cell Carcinomas Superficial & Invasive

Stages:

Tis (Pre-invasive carcinoma/in situ carcinoma) Ta (Non-invasive papillary carcinoma) T1 (Tumor does not extend beyond lamina propria) T2 (Tumor invades muscle) T3 (Tumor invades perivesical tissue) T4 (Tumor invading neighboring structures) (T4a invading prostate/vagina) (T4b tumor

fixed to pelvic wall)

Symptoms:

85% present painless hematuria 20% present irritative bladder symptoms (Dysuria/urgency/frequency)

Diagnosis:

Laboratory:


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Testing for hematuria Cystoscopy (GOLDEN STANDARD)

Imaging:

Intravenous Urography (IVU) US CT

Treatment: Principle: Based on tumor stage, patient age and general health TURBT + Instillation (Non-muscle invasive tumor) Cyestectomy (Muscle invasive tumor) (Partial or radical) Radiotherapy & Chemotherapy Intravesical Chemotherapy (Used to prevent tumor recurrence)

LAPAROSCOPIC ADRENAL SURGERY

Contraindications: Large carcinoma with local invasion Tumors > 12cm Uncorrected coagulopathyTransperitoneal Vs. Retroperitoneal:

Longer vs. shorter operative time Higher vs lower analgesic requirement Higher vs lower complication rateRight Adrenalectomy:

Retraction of liver Peritoneal Incision Exposure of IVC Adrenal vein ligation

Adrenal gland mobilization Specimen extractionLeft Adrenalectomy:

Trocar Insertion Mobilization of splenic flexure, spleen & tail Adrenal vein ligation Adrenal mobilization Colonic mobilization


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Advantages of retroperitoneal approach: Avoiding potential peritoneal adhesions from previous injuries Avoid potential visceral injury Avoid bowel complications

Bilateral & Partial Adrenalectomy Indications: Cushings Syndrome Bilateral pheochromocytomas Bilateral aldosterone-producing tumorsConclusions:

LA is ideal for all benign tumors < 12cm Transperitoneal approach recommended for most patients

Surgery Genitourinary

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