Urology Surgical Tech Set Ups

A Percutaneous Nephrolithotomy, aka PCNL is performed when a patient forms kidney stones that are too large or too hard to extract through a regular lithotripsy or ureteroscopy.

The patient will be positioned prone, and a tube will be placed through the urethra into the kidney so the area can be easily seen under x-ray.

A small incision with a 15 blade is made on the patient’s back in the location where the stone is seen under x-ray. Under fluoroscopy, a tube/sheath will be placed through the incision to the kidney.

A nephroscope will then be put through the sheath for direct visualization to the stone. Instruments can be passed through the nephroscope to break up the stone and pull out the pieces.

A stent is usually placed at the end of surgery to help with drainage.

The surgeon will not need much from the surgical technologist, and this surgery is even done sometimes without a tech helping.

The surgeon will need an ultrasound probe and the syringe with the implantable seeds.

The ultrasound probe will be inserted in the rectum, and needles will be placed in the perineum.

The ultrasound probe will help guide the needles into the prostate, and then the seeds can be injected into the prostate.

This process will be repeated several times until all the seeds have been implanted, and then the urologist will do a cystoscopy to check the patients bladder. For the cystoscopy you will need a camera cord, light cord, cystoscope, and the cannula and sheath.

There is not much to set up on the back table for a prostate biopsy procedure, and sometimes the patient is even fully awake for these.

The most important things to have is the biopsy needle which is usually brought by a rep, a speculum, and suction. There is no skin incision, and the biopsy sites are usually left to heal without sutures because they are so deep.

It is also extremely important that all of the biopsies are placed in their individual specimen cups and labeled properly since the doctor is attempting to find cancer, and needs to know exactly where the biopsies come from.
I always triple check the names, even if it frustrates everyone in the room.

Some surgeons take a few specimens, and I’ve also known some to take 20+.

Positioning: Supine

Drapes: Towels, universal drape

You should have regular length, as well as long instruments for this surgery. The deeper you go, the longer the instruments will need to be.

Surgery Steps: The surgeon will begin by making their incision using a 15 blade loaded onto a #3 knife handle. They will dissect down using adsons, debakeys, metz, and a variety of clamps such as hemostats and tonsils. They will use a variety of retractors depending our deep they are. Army-navy, weitlaners, rakes, and richardson retractors may all be used. When the final depth is reached, a bookwalter will more than likely be placed.

Silk ties are generally used to separate the peritoneum from the bladder. Silk ties will be placed on the vas deferens, and it will be ligated. The ureter will then be found after dissection of the peritoneum. A vessel loop will then be used on the ureter, and if then dissected. Some more silk ties will be placed. Either clips or a stapler will then be used on the bladder pedicles.

Fascia around the prostate will be divided, and the urethra will be divided. Lymph nodes may now be taken out as well.

The next step will be to make the ideal conduit.

A part of the distal ileum will be taken. The ureters will be anastomosed to the conduit using usually Vicryl suture. The end of this conduit will then be pushed through the stoma location on the abdomen near the initial incision. The stoma will be formed on the outside of the body, and will be sutured into place.

Tips: Always have ties, staples, and vessel loops available on you table. Be sure to have your long instruments available, as well as a long bovie tip.

You will begin by throwing off your suction tubing and bovie. An incision is made in the abdomen with a 10 blade loaded on a #3 knife handle and the surgeon will dissect down using a variety of right angles, tonsils, clip applier, and metzenbaum scissors. They will more than likely place a bookwalter to retract after going down deeper using richardsons and malleables.
You will then switch to long instruments and a long bovie tip.
Ties should always be loaded up on tonsils ready to pass, clips should also always be available, as well as kitners loaded on kellys.
Specimens will be passed to you and should be labeled as they are taken out. Lymph nodes may also be taken.

You will begin by throwing off your camera cord, light cord, and irrigation tubing. The camera should be white balanced, and lube should be used on the tip of the scope.
At the end of the case a stent may be placed. You will ask the surgeon if they want the string left on or taken off. You will use your suture scissors to remove the string if wanted.

Surgery Steps: 

The cystoscope will be inserted into the urethra, and will be looked at with the camera. After the urethra, the scope will enter the bladder, and the doctor will take a moment to inspect it. The cystoscope will then be removed and the resectoscope may be utilized. Either monopolar or bipolar (dr pref) will be used to dissect pieces of prostate or bladder tissue. After fair amounts have been dissected, an Elik evacuator or Toomey syringe may be used to flush out the pieces of tissue floating around. The doctor will make sure there is no bleeding, and then remove the resectoscope. A Foley catheter will more than likely be inserted. 

 

Instruments

Misc.: Cystoscopes, Resectoscope, Cysto. Bridges, Catheter nipples, Cysto sheathsElik Evacuator, Toomey Syringe

 

Extra Equipment: Camera cord, light cord, suction tubing, irrigation tubing, medicine cups, pitcher

 

Drapes: Under buttocks drape, leggings, cystoscopy drape

 

Notes: If alone with a doctor, they will need help holding tubing and wires. Cystoscope needs to be lubricated before insertion. If using an Elik evacuator, it needs to be filled with fluid completely so there are no bubbles visible. 

 

Lube should always be used for men and women to ensure that the scope can easily slide into the urethra without causing any harm to the tissue.

This surgery technically isn’t sterile, so you may see people not wearing gowns or sterile gloves while “scrubbing in.”

Surgery Steps: The cystoscope will be inserted into the urethra, and will be looked at with the camera. After inserting the scope through the urethra, the scope will enter the bladder, and this is when a urine sample may be taken if requested. A regular specimen cup can be used for this and should be labeled and passed off quickly to prevent any spilling or mixups.

The doctor will closely watch the bladder as they fill it with fluid (usually sterile water). They will be watching the ureters, and looking for any abnormalities or bleeding, and making sure the ureters are working properly. Once done visualizing the bladder, the cystoscope can be removed if nothing looks suspicious.

Usually a stent is placed at the end of a cystoscopy. If so, a guide wire will be needed, as well as the correct sized stent. The nurse in the room will open up the stent once the surgeon has confirmed the size after measuring the length. I always ask whether the surgeon wants me to cut the string off of the stent or not. Most want the string cut. If they do want the string cut off, make sure that you don’t tear the string through the hole on the stent.

X-ray is almost always used during a stent placement to ensure it’s placed in the correct spot.

Instruments/ Cystoscopy table set-up
Misc.: Cystoscopes, Cysto. Bridges, Catheter nipples, Cysto sheaths, Pitcher, Medicine Cups

Equipment: X-ray, camera cord, light cord, suction tubing, irrigation tubing

Drapes for Cystoscopy Surgery: Under buttocks drape, leggings, cystoscopy drape

Notes: If alone with a doctor, they will need help holding tubing and wires. I tend to always wear x-ray lead since the surgeon usually uses x-ray when placing stents. The cystoscope needs to be lubricated before insertion.

Surgery Steps: An incision is made into the scrotum, and the Vas is located and separated from all other neighboring tissues. A section of the vas deferens will be cauterized or ligated. Then, the two ends will be put back into the scrotum. The same thing will be done on the other side. Closure can then begin. 

 

Extra Equipment: Suction, ESU

 

Patient Positioning: Supine

 

Drapes: Folded towels around surgical site, laparotomy drape

 

Surgery Steps: An incision is made with a 15 blade either inguinally or in the scrotum. Dissection will occur, and the testis will be found. Then, the spermatic cord will be identified and cut, and the testis can then be removed. The same thing can be done on the other side.  Lastly, closure can begin.

 

Extra Equipment: Suction, ESU

 

Patient Positioning: Supine

 

Drapes: Folded towel under scrotum, folded towels around surgical site, laparotomy drape

 

Notes: A prosthesis may be placed after the testis removal.