14 Urology 14

14 Urology

14.1 Positioning techniques depending on various surgical indications – 174 14.1.1 Supine position – 174

14.1.2 Lithotomy position – 176 14.1.3 Flank position – 178

14.1.4 Modified supine position – 180

14.1.5 Prone position – 182

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14.1 Positioning techniques depending on various surgical indications

14.1.1 Supine position

. Figs. 14.1–14.3.

Indications Operations to:

Penis: e.g. penis deviation (Nesbit), hypospadia correction, epispadia correction.

Testicles: e.g. vasectomy, varicocele ligature, vasovasostomy and epididy- movasostomy, microepididymal and testicular sperm extraction (MESA and TESE), spermatocelectomy, epididymectomy.

Abdominal operations: e.g. suprapubic cystostomy, retroperitoneal lymph- adenectomy, transperitoneal nephrectomy possibly with cavotomy and tu- mour thrombectomy, intraperitonealisation of the ureters, augmentation of the bladder, ureterocystoneostomy, ureter resection and reconstruction, ureterolithotomy.

Preparations

4

Arm positioning devices Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Spread out both arms on the arm positioning devices

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

. Fig. 14.1. Supine position with arms in abduction

. Fig. 14.3. Maximum 90° abduction and supination position of the arms

. Fig. 14.2. Positioning the head on a double wedge cushion

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14.1.2 Lithotomy position

. Figs. 14.4–14.7.

Indications

All endourological operations: urethrocystoscopy, transurethral resections (bladder, prostate), punch lithotripsy, retrograde presentation of the upper urinary tract, placement of ureter stent (pigtail), ureter endoscopy (with biopsy and stone extraction).

Penis: total penectomy with placement of the neourethra.

Urethra: open-surgery urethra grafts, excision of urethra diverticula, complete urethrectomy.

Prostate: transvesical adenoma nucleation, pelvic lymphadenectomy and radical prostatectomy.

Bladder: radical cystectomy with continent or incontinent substitute blad- der, bladder elevations for stress incontinence, Scott sphincter implantation, vesicovaginal fistula occlusion.

Preparations

4

Arm positioning devices

4

2 Goepel leg holders or 2 special pneumatic leg holders and 2 adapter pieces

4

Gel pad

4

Possibly 2 shoulder supports Positioning

4

Standard operating table position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal or diagonal positioning of the operating table in the theatre

When positioning the patient, take appropriate measures to prevent

decubitus at areas which are subjected to pressure

4

Spread out and pad both arms on the arm positioning devices

Adapt the Goepel leg holders with the provided champs

Position the legs and remove the leg plates

4

Position the pelvis slightly over the edge of the buttocks plate

4

Check the leg positioning: lower the still raised legs until the thighs are nearly horizontal

4

Possibly position the legs again in this phase and raise them again after the end

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

. Fig. 14.4. Lithotomy position with Goepel leg holders

. Fig. 14.7. Diagram to show the optimum positioning of the legs in the lithotomy position

. Fig. 14.6. Positioning with lowered leg holders and positioning on vacuum mat . Fig. 14.5. Lithotomy position with vacuum mat and leg holders with one-hand operation

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14.1.3 Flank position

. Figs. 14.8–14.10.

Indications

Kidneys: percutaneous nephrostomy, kidney and kidney cyst puncture pos- sibly with sclerosing, percutaneous nephrolitholapaxy, nephropyeloplasty, tumour nephrectomy, partial nephrectomy, pyelolithotomy, nephrolithotomy, adrenalectomy.

Preparations

4

Arm positioning devices

4

Gel ring, gel cushion, Goepel leg holder, lateral supports, radial adjusting clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4

Standard operating table position 1 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the side rail of the head plate, position the Goepel leg holder and place a gel padded mat on the operating table

Spread out the arm on the side not being operated

4

Move the patient onto the healthy side, with the back near the edge of the operating table

4

Gradually hinge open the operating table by lowering the pelvic and back plate (operating table in roof position)

4

Raise the head plate and position the head on a padded cushion with gel ring to leave the ear free

4

Position and fix the arms

4

Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4

Thorax 90° position, pelvis 45° position

4

Fit the radial adjustment clamps to the small side rails of the leg plates and position the body supports on the level of the sacrum and symphysis

position the legs with the padded cushions (normal and

flat) and possibly wedge cushions

4

Fix the lower leg and positioning aids with the body belts

position the legs with the tunnel cushions

Position the upper leg in external rotation

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

. Fig. 14.10. The operating table is moved as far as possible towards the head to allow for an optimum flex position

. Fig. 14.9. The pelvis is tilted back 20–40°

and the legs are positioned with a tunnel cushion

. Fig. 14.8. In the lateral position, the pelvis is at the highest point on the operating table adjusted to the flex position

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14.1.4 Modified supine position

. Figs. 14.11, 14.12.

Indications

Kidney and ureter: nephroureterectomy, tumour nephrectomy Neuromodulation: implanting the neuromodulation stimulator.

Preparations

4

Arm positioning devices

4

Wedge cushions, radial adjusting clamps, body supports Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Spread out and pad both arms on the arm positioning devices

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

4

Normal positioning of the operating table in the theatre

. Fig. 14.11. Positioning with wedge cushions

. Fig. 14.12. Supported with a body support on the opposite side

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14.1.5 Prone position

. Figs. 14.13–14.17.

Indications

Neuromodulation: percutaneous neuromodulation testing, implanting the neuromodulation electrodes.

Preparations

4

Two arm positioning devices

4

Special head positioning cushion for prone position

Thorax, pelvic and wedge cushion, padded roll Positioning

4

Standard operating table position 1, position 2 or universal operating table

Anaesthetic preparation and induction in supine position with 2 adapted

arm positioning devices

4

Transfer to the prepared operating table in the induction room

Position both tables next to each other, with the prepared table lowered

Place the patient in prone position on the padded cushion of the prepared

operating table and take him into the theatre

4

Position the head on the special head positioning cushion

Position both arms on the arm positioning devices

4

Apply the neutral electrode and connect to the HF surgery device

Arrange self-adhesive covers for preoperative skin disinfection

Position the operating lights

4

Patient warming system

. Fig. 14.13. Prone position with padded cushions for prone positioning and gel cushion for anatomically correct position ing of the cervical spine and head (universal operating table 1150.30)

4

Normal positioning of the operating table in the theatre

. Fig. 14.14. Prone position with the same positioning aids (CRP operating table 1150.16)

. Fig. 14.17. Shoulders and upper arms are free

. Fig. 14.16. Arm positioning for the prone position: the distal joint is positioned lower than the proximal joint

. Fig. 14.15. Arms positioned in maximum 90° abduction and arm positioning device adapted at shoulder height