Table of Contents

I - Diagnostic Endoscopy.- I - Endoscopic armamentarium.- A. Endoscopes.- I. Direct vision endoscopes.- 1. Advantages.- 2. Cystoscopes.- 3. Urethroscopes.- a) Internal illumination.- b) External illumination.- IL Lens endoscopes.- 1. Advantages.- 2. Optical systems used in endoscopes.- a) Right angle.- b) Obliquely forward.- c) Retrograde.- d) Directly forward.- e) Adjustable.- 3. Telescopes.- a) Wiring circuit.- b) Catheter guides and deflectors.- c) Protection of catheters.- d) Carriage for telescopes.- III. Endoscope sheaths.- 1. Illumination. Types of sheaths.- 2. Beaks and fenestrae of sheaths.- 3. Light posts.- 4. Stopcocks.- 5. Obturators.- 6. Locks.- IV. Sizes of endoscopes.- V. Instruments designed for endoscopic surgery.- 1. Stern McCarthy visual prostatic electrotome.- 2. Resectoscope made by Wolf (Germany).- 3. Modifications of the McCarthy electrotome.- 4. Visual lithotrites.- Telescope.- B. Instruments used through endoscopes.- I. Electrodes.- II. Forceps, rongeurs, and scissors.- III. Infiltration needles.- IV. Ureteral catheters (Chap. II).- V. Special ureteral catheters.- VI. Ureteral instruments.- 1. Bougies.- 2. Calculus dislodgers.- a) Wire basket.- b) Looped ureteral catheter.- c) Forceps.- 3. Transilluminator.- C. Cystoscopic attachments.- I. Cystoscope holders.- II. Teaching attachment.- III. Photographic attachments.- D. Sources of light for endoscopes.- I. Bulbs.- II. Quartz tube.- III. Batteries.- IV. Electric house current.- E. Care and maintenance of endoscopes.- I. Routine care.- 1. Basic precautions to prevent breakage.- 2. Disinfection.- II. Minor repairs and adjustments.- 1. Light failure.- a) Light bulb.- b) Contact rings of lamp post.- c) Contacts between cord and lamp post.- d) Light cord.- e) Connection of cord to battery terminals.- f) Rheostat.- g) Connections inside battery container.- h) Batteries.- 2. Blurred vision.- F. The cystoscopic room (theatre).- I. Aseptic technique, cleanliness and decorum.- II. Floor.- III. Electric switches.- IV. Darkened room.- V. Anesthetic equipment.- G. Cystoscopic room equipment.- I. Cystoscopic table.- II. Cystoscopic stools.- III. Irrigating fluid supply.- 1. Flask system.- 2. Sterilizer near ceiling.- 3. Pressurized from container on floor.- 4. Water sterilizer-pitcher-jar.- 5. Control of water by foot switch.- H. Endoscopic armamentarium in the armed forces.- II - The cystoscopic procedure.- A. Value of properly performed cystoscopy.- The cystoscopist.- 1. Training.- 2. Dexterity.- B. Indications and contraindications for cystoscopy.- I. Indications.- II. Contraindications.- C. Routine supplies for cystoscopy.- I. Sterile set-up.- II. Lubrication.- III. Drapes.- IV. Media for distending bladder.- 1. Water.- 2. Urine.- 3. Oil.- 4. Air.- D. Preparation of the patient.- I. Prophylactic antibiosis.- II. Bowel preparation.- III. Analgesia.- IV. General or spinal anesthesia.- V. Local anesthesia.- 1. Anesthetic agents.- 2. Application.- 3. Untoward reactions.- E. Position of the patient.- F. Checking of equipment.- I. Instruments.- II. Light bulbs.- G. Introduction of the cystoscope.- I. Information gained from passing the cystoscope.- 1. Stricture.- 2. Elevated posterior lip.- 3. Elongated prostatic urethra.- 4. Residual urine.- II. The causes of difficulties encountered during passage of the cystoscope.- H. Procedures for obtaining clear visualization.- I. Adequate intensity of illumination of the interior of the bladder.- II. Distention of the bladder.- III. Washing debris from the bladder.- IV. Manipulation of the inflow of fluid through the sheath.- V. Proper manipulation of the objective lens.- I. Orientation with different lenses (see Chap. I).- J. Routine bladder examination.- I. Blind spot.- II. Diverticular cavity.- K. Ureteral catheterization.- I. Ureteral catheters.- 1. Tips.- a) Whistle.- b) Olive.- c) Coude.- d) Filiform.- e) Conical or Garceau and Braasch bulb.- 2. Size.- 3. Flexibility.- 4. Opacity.- 5. Graduation markings.- II. Technique of ureteral catheterization.- III. Manipulations to facilitate ureteral catheterization.- L. Differential renal function.- I. Chromocystoscopy.- 1. Indigocarmine.- 2. Trypan red.- 3. Neoprontosil.- II. Phenolsulphonaphthalein (P. S. P.).- III. Urea clearance.- M. Kidney study (retrograde cystoscopy).- N. Removal of the cystoscope.- O. Cystoscopy hipogastrica.- P. Experimental and practice cystoscopy.- I. Female dogs.- II. Phantom bladder.- III - Postendoscopic care, reactions and complications.- A. Postendoscopic care.- B. Reactions and complications.- C. Prophylaxis of complications.- I. Gentleness.- II. Alertness.- III. Carefulness.- IV. Good judgment.- V. Avoidance of overeagerness.- VI. Definite prophylaxis.- D. Unavoidable reactions and complications.- I. Sensitivity to drugs.- II. Presence of disease.- E. Diagnosis and treatment of reactions and complications.- I. Fever, spasm and pain.- II. Sensitivity to the local anesthetic.- III. Urethral bleeding.- IV. Perforation.- V. Extravasation.- VI. Anuria.- IV - The normal bladder and prostatic urethra.- A. Divisions of the bladder.- B. Vascular pattern.- C. Bladder neck.- D. Trigone and ureteral orifices.- E. Distending the bladder.- F. Bladder tone.- G. Capacity.- H. Variations of the normal bladder.- I. During pregnancy.- II. In the aged.- I. The prostatic urethra.- V - Abnormal ureteral orifices.- A. Congenital anomalies.- I. Agenesis.- 1. Unilateral.- 2. Bilateral.- II. Imperforate.- III. Ectopic location.- 1. Below normal.- 2. Above normal.- IV. Duplication.- 1. Unilateral.- 2. Bilateral and multiple.- V. Abnormal shape and size.- 1. Atresic.- 2. Constricted.- 3. Dilated.- 4. Unusual shape.- B. Acquired abnormalities of size, shape and position.- I. Dilated.- 1. Golf hole.- 2. Impacted calculus.- 3. Incompetent ureterovesical valve.- II. Position higher than normal.- 1. Retracted.- 2. Surgical reimplantation.- 3. Following ureteral meatotomy.- 4. Following resection of bladder tumors.- III. Constricted.- 1. Following surgery.- 2. Following infection.- C. Edema.- I. Calculus.- II. Catheterization.- III. Tumor.- IV. Infection.- D. Protrusion of the ureteral meatus.- I. Calculus.- II. Ureterocele.- III. Tumor.- E. Ulceration.- I. Tuberculous.- II. Nontuberculous.- F. Projections from the ureteral orifice.- I. Blood clot.- II. Calculus.- III. Pus.- IV. Tumor.- V. Prolapse of ureteral mucosa.- G. Propulsions through the ureteral orifice.- I. Bloody jet.- II. Pus.- III. Dye.- VI - Abnormal appearance of mucosal blood vessels in the bladder and posterior urethra.- A. Abnormal grouping of blood vessels.- I. Acute hemorrhagic cystitis.- II. Hunner ulcer.- III. Scars.- B. Decrease in number and size of blood vessels.- I. Chronic cystitis.- 1. Herpes vetularum.- 2. Fibrosis.- II. Anemia.- C. Increase in number and size of blood vessels.- I. Subacute cystitis.- 1. Infection, trauma, chemical irritation.- 2. Allergy.- 3. Endocrine imbalance.- II. Bladder tumor.- III. Prostatic adenoma.- D. Prominent blood vessels.- I. Bladder neoplasm.- II. Large prostatic adenoma.- III. Recurrent prostatic adenoma.- IV. Sclerosis of blood vessels of the bladder mucosa.- V. Varicosities of the bladder.- VII - Bladder contour abnormalities associated with normal mucosa.- A. Abnormalities in bladder size and tone.- I. Contracted (usually hypertonic) bladder.- 1. Congenital.- 2. Fibrosis.- 3. Myogenic hypertonia.- 4. Neurogenic hypertonia.- II. Enlarged (usually hypotonic) bladder.- 1. Congenital.- 2. Myogenic.- 3. Neurogenic.- B. Abnormal contour of ureteral orifices (see Chap. V).- C. Abnormal orifices in the bladder wall.- I. Cellules.- II. Diverticular orifice.- Appearance of interior of diverticulum.- III. Fistulous orifice.- 1. Congenital.- 2. Intestinovesical or from abscess.- 3. Vesicodermal fistula.- 4. Vesicovaginal fistula.- IV. Herniation of the bladder.- V. Rupture through the bladder wall.- D. Depressions in the bladder wall.- I. Cystocele.- II. Following surgical removal of the rectum.- III. Sacculation.- 1. From chronic overdistention.- 2. Following surgical procedures on the bladder.- E. Elevation of the bladder floor.- I. From anteflexed or anteverted uterus.- II. From cervix.- III. From miscellaneous masses posterior to the bladder.- F. Protrusions of the fundus and dome.- I. From the uterus.- II. From extravesical masses.- G. Irregular flat or sessile protrusions.- I. Invasive malignant neoplasms.- 1. Prostatic carcinoma.- 2. Sarcomata.- 3. Squamous cell carcinoma.- II. Nonmalignant neoplasms.- 1. Myogenic and congenital.- 2. Neurofibromata.- 3. Fibromata.- III. Papular cystitis.- H. Pedunculated protuberances.- I. Fibroma and fibroadenoma.- II. Myogenic.- I. Ridges in the bladder wall.- I. Hypertrophy of the interureteric ridge.- II. Trabeculation.- Causes.- III. Undermined or floating trigone.- IV. Postoperative.- J. Septa in the bladder wall.- I. Hourglass.- II. Septate.- III. Multilocular.- VIII - Color abnormalities of the bladder mucosa without change of contour.- A. Red and pink discoloration (predominating).- I. Generalized red discoloration.- Acute cystitis.- II. Patchy areas of red and pink discoloration.- 1. Acute cystitis.- 2. Eechymotic areas.- 3. Cystitis granulomatosa.- 4. Trichomonas vaginalis.- 5. Bilharziasis.- 6. Blastomycosis.- 7. Tuberculosis.- 8. Gonococcus infection of the bladder.- 9. Syphilis.- 10. Stellate areas of red discoloration.- 11. Irregular pink discoloration of the trigone.- 12. Red area in dome.- B. Red, White, light grey and light pink discoloration.- I. White irregular areas.- 1. Alkaline incrusted cystitis.- 2. Irradiation reaction.- 3. Leukoplakia.- 4. Thrush infection.- II. Sloughing tissue.- 1. Severe infection.- 2. Gangrenous cystitis.- 3. Trauma.- III. Ulceration.- 1. Tubercolosis.- 2. Nontuberculous ulcerations.- 3. Actinomycosis.- IV. Invasive malignant neop]asms.- C. Blue discoloration.- Varicosities.- IX - Abnormalities of both color and contour within the bladder.- A. Smooth, regular red protrusions.- I. Benign bladder tumors.- 1. Arising from the bladder wall.- 2. Arising from embryonic rests.- II. Granulomatous tissue.- III. Malignant invasive tumors of the bladder.- 1. Sarcoma and mixed sarcomatous tumors.- 2. Squamous cell carcinoma.- 3. Teratoma.- IV. Malignant extravesical tumors.- B. Smooth red multilobulated protrusions.- I. Edema.- 1. Diffuse edema.- 2. Localized areas of edema.- 3. Bullous edema.- a) Allergy.- b) Amebiasis.- c) Intestinovesical fistula.- d) Indwelling urethral catheter.- e) Invading neoplasm.- II. Neoplasms.- 1. Benign.- a) Chronic cystitis.- b) Cystitis glandularis.- 2. Malignant.- C. Irregular red intravesical protrusions.- I. Neoplasms.- 1. Carcinoma.- 2. Osteogenic sarcoma.- 3. Amyloidosis.- II. Granulation tissue.- 1. Nonspecific infections.- 2. Subacute and chronic specific infections, stones, foreign bodies, neoplasms and trauma.- D. Irregular red and white protrusions.- I. Material causing white discoloration.- 1. Calcareous deposit; sloughing tissue.- 2. Mucopurulent and epithelial exudate.- 3. Miscellaneous.- a) Combination of substances.- b) Gauze sponge.- c) Fragment of bone.- II. Lesions causing red and white protrusions.- 1. Neoplasm.- 2. Severe chronic infections.- E. Red and pink papillary projections.- I. Bullous edema.- II. Papillary tumors.- 1. Papillomata.- 2. Aniline tumors.- 3. Leukoplakia; bilharzia.- 4. Colloid urachal tumors.- 5. Hamartoma.- F. Discolored cystic, vesicular and polypoid elevations.- I. Entamoeba histolytica.- II. Cystitis cystica.- III. Cystitis emphysematosa.- IV. Dermoid cysts and teratoma.- V. Echinococcus disease.- VI. Endometriosis.- VII. Gonococcal infection, healed.- VIII. Hemangioma.- IX. Herpes zoster.- G. Yellow or greyish yellow elevations of the bladder mucosa.- I. Cystitis follicularis.- II. Lipomata.- III. Leiomyomata.- IV. Malakoplakia.- V. Osteoma.- VI. Tubercles.- H. Blue elevations.- I. Varicose veins.- II. Endometriosis.- III. Metastatic melano-epithelioma.- I. Reddish brown elevations.- Lichen planus.- J. Discolored depressions.- I. Lacerations and rupture.- II. Following electrosurgical procedures.- III. Ulceration.- 1. Chronic infections.- a) Tuberculosis.- b) Nontuberculous.- c) Actinomycosis.- 2. Neoplastic.- K. Lesions showing all types of color and contour abnormalities.- I. Vesical bilharziasis.- 1. Hemorrhagic areas.- 2. Edema.- 3. Discolored white areas.- 4. Ulcerations.- 5. Tubercles.- 6. Protrusions.- a) Nodules.- b) Cystic.- c) Papillomata.- 7. Complicating lesions.- 8. Diagnosis.- II. Carcinoma of the bladder.- 1. Variable appearance.- 2. Differential diagnosis.- III. Gangrenous cystitis.- IV. Syphilis.- V. Pemphigus vulgaris.- VI. Vesical tuberculosis.- X - Abnormal bladder contents.- I. Blood clots.- 1. Location.- 2. Identification.- 3. Evacuation.- II. Calculi.- 1. Identification.- 2. Location.- a) Floor.- b) Fundus.- c) Dome.- 3. Number and size.- a) Estimation of size.- 4. Shape and color.- a) Composition in general.- b) Light colored phosphatic.- c) Faceted phosphatic.- d) Brown spiculed ("mulberry") oxalate.- e) Dark ("Jackstone") oxalate.- f) Pale yellow to deep brown mixed.- g) Characteristic color.- III. Foreign bodies.- 1. Inserted by patients.- 2. Incrustation.- 3. Bone fragments.- 4. Floating objects.- a) Debris and oil.- b) Paraffin.- c) Wood.- 5. Following medical or surgical procedures.- a) Gauze sponge.- b) Nonabsorbable suture material.- c) Urological equipment.- IV. Shreds of mucus, pus and epithelial cells.- V. Sloughing tissue.- XI - Abnormalities of the bladder neck and posterior urethra in the male.- I. Contracture of the vesical orifice.- 1. Appearance at the margin of the vesical neck.- 2. Appearance from within the bladder.- 3. Appearance from the prostatic urethra.- II. Intrusion into the bladder neck and prostatic urethra.- 1. Median bar.- 2. Median lobe prostatic hypertrophy.- 3. Lateral lobe prostatic hypertrophy.- 4. Ventral lobe prostatic hypertrophy.- 5. Prostatic abscess.- 6. Carcinoma of the prostate.- 7. Carcinoma primary in the mucosa.- 8. Polypi and cysts.- III. Rigidity of the prostatic urethra and bladder neck.- IV. Abnormal dilatation of the vesical orifice.- 1. Congenital defects and neurogenic lesions.- 2. Urinary obstruction.- 3. Prostatic adenoma; postoperative.- V. Post inflammatory fibrosis of the prostatic urethra.- VI. Dilatation of prostatic duct orifices.- Orifice of prostatic diverticulum or abscess.- VII. Abnormalities of the verumontanum.- 1. Congestion and infection.- a) Granulation tissue.- 2. Enlargement.- VIII. Abnormal red discoloration of the mucosa of the prostatic urethra.- IX. Calculi and foreign bodies in the prostatic urethra.- X. Posterior urethral valves.- XI. Interpretation of findings in the prostatic urethra.- 1. Close view.- 2. Distortion due to passage of the endoscope.- XII. Cystoscopy for diagnosis of prostatism.- XII - Abnormalities of the bladder neck and urethra in the female.- I. Contracture of the vesical orifice.- II. Dilatation of the vesical orifice.- III. Increased curvature of the urethra.- IV. Normal urethral mucosa.- V. Fibrosis and stricture of the urethra.- VI. Increased redness of the urethral mucosa.- VII. Irregularities at the bladder neck.- 1. Edema.- 2. Granulations.- 3. Neoplasm.- 4. Polypoid growths.- VIII. Irregularities in the urethra.- 1. Granulations.- 2. Neoplasm.- 3. Polypoid growths.- 4. Sacculation.- IX. Diverticular orifice.- 1. Calculus in diverticulum.- 2. Neoplasm in diverticulum.- X. Periurethral ducts.- XI. Urethral meatus.- XIII - Urethroscopy and miscellaneous endoscopic procedures.- I. Urethroscopy.- 1. Urethroscopes.- 2. Technique of urethroscopy.- 3. Normal urethra.- a) Prostatic.- b) Membranous.- c) Bulbous.- d) Penile.- 4. Abnormal urethral contour.- a) Constriction.- b) Depression, sacculation and dilatation.- c) Intrusions.- 5. Abnormal color of the urethral mucosa.- a) Increased redness.- b) White or light colored areas.- 6. Orifices.- a) Urethral diverticulae.- b) Periurethral gland duct.- c) Ectopic ureteral orifice.- II. Miscellaneous diagnostic endoscopy.- 1. Endoscopy of the intestinal bladder.- 2. Endoscopy of the kidney.- 3. Endoscopy of the vagina.- 4. Intraperitoneal and gastric endoscopy.- II - Endoscopic Surgery.- XIV - Miscellaneous endoscopic surgical procedures and treatments.- I. Endoscopic ureteral treatment.- 1. Ureteral dilation.- 2. Renal pelvic drainage by ureteral catheter.- II. Endoscopic manipulations for removal of ureteral calculi.- 1. Ureteral dilatation.- a) Catheters.- b) Bag distention.- 2. Injection into ureter.- 3. Instruments for extraction of calculi.- a) Filiform and dental floss.- b) Looped catheter.- c) Corkscrew catheter.- d) Wire basket.- 4. Reactions and care.- III. Ureteral Meatotomy.- 1. For calculus.- 2. For stricture.- IV. Endoscopic renal treatment.- 1. Through nephrostomy opening.- a) Renal calculi.- b) Foreign body.- V. Ejaculatory duct catheterization.- VI. Application and injection of medicaments.- VII. Application of radium or its elements to bladder tumors.- 1. Radiation element.- 2. Radon emanation seeds.- VIII. Biopsy of bladder lesions.- 1. Indications.- 2. Armamentarium and technique.- 3. Biopsy of intraureteral tumors.- IX. Electrocoagulation.- 1. Indications.- 2. Armamentarium and technique.- X. Removal of foreign bodies from the bladder.- 1. Forceps or cystoscopic rongeurs through the cystoscope.- 2. Manipulation through the vagina.- 3. Floating foreign bodies.- Paraffin.- XI. Litholapaxy.- 1. Advantages, indications and contraindications.- 2. Visual versus blind lithotrites.- a) Litholapaxy performed under vision.- b) Blind litholapaxy.- 3. Evacuation of fragments.- XII. Extracystoscopic endoscopic poeedures.- 1. Through the urethra.- 2. Through a suprapubic cystostomy.- XIII. Endoscopic treatment of urethral strictures.- 1. Dilatation.- 2. Incision and resection.- XIV. Intraperitoneal and gastric endoscopic treatment.- XV - Endoscopic surgery - a specialty within a specialty.- I. Advantages and disadvantages of endoscopic surgery.- 1. Advantages.- a) Better tolerated.- b) Less postoperative pain.- c) Shorter hospitalization.- d) No external wound.- e) More accurate and more adequate removal of tissue.- f) Shorter operative time for removal of small lesions.- 2. Disadvantages.- a) Long apprenticeship and technical difficulty.- b) Requires large calibre urethra.- c) Longer operative time for removal of large lesions.- d) Multiple stage operation.- II. Training the endoscopic surgeon.- 1. Difficulties and importance.- 2. Preliminary endoscopic training.- 3. Instruction.- 4. Who should be trained.- a) All trainees in preparation for the specialty of urology.- b) Trainees possessing abundant manual dexterity.- c) Some urologists.- d) Not the occasional endoscopic operator.- e) Not general practitioners or most general surgeons.- 5. Preliminary practice.- a) Beef heart.- b) Clay model.- III. Armamentarium and supplies.- 1. Resectoscopes or electrotomes.- a) Stern-McCarthy electrotome.- b) Modifications of the McCarthy electrotome.- c) One hand operated resectoscopes.- d) Control of the cutting loop.- e) Rotating modifications.- f) Loop electrodes.- g) Resectoscopes for bladder tumors.- 2. Electrosurgical units.- 3. Table and stool.- 4. Attachments to the table.- 5. Irrigating fluid.- a) Sterile water.- b) Isotonic and nonhemolytic fluids.- c) Satisfactory irrigating fluids.- d) Glucose.- e) Glycene.- f) Sorbitol, Mannitol.- 6. Miscellaneous armamentarium.- a) Aspiration apparatus.- b) Alligator forceps.- c) Drapes.- 7. Lithotrites and lithotriptoscopes.- XVI - Electrosurgical units.- I. Development of eleetrosurgical currents.- II. Characteristics of electrosurgical currents.- a) Requirements for surgery.- b) Cutting current.- c) Coagulating current.- b) Combination currents.- e) Modern electrosurgical units.- III. Effect of currents on tissue.- a) Electrodes.- b) Tissue change.- c) Faradism.- IV. Checking machine failures.- V. Care of the machine.- XVII - Indications for endoscopic surgery.- I. Training, ability and experience of the surgeon.- II. Differential diagnosis.- 1. Indefinite symptoms.- 2. Residual urine.- 3. Bladder tone.- 4. Cystoscopic examination.- 5. Cystogram.- III. Size of the lesion.- 1. Duration of the operation.- 2. Estimate of size and consistency of the prostate.- a) Digital palpation through rectum.- b) Cystograms and urethrograms.- c) Cystoscopic examination.- Endoscope used.- Lateral lobes.- Length of prostatic urethra.- Intravesical protrusion.- d) Correlation of all examinations.- 3. Correlation of size with amount of tissue removed.- 4. Estimate of size of vesical tumors and stones.- a) Cystoscopic examination.- b) X-ray examination.- Stone.- Tumor.- 5. Indications based on size.- a) Stone.- b) Tumor.- IV. Invasion and malignancy of bladder tumors.- 1. Invasion.- 2. Malignancy.- V. Position of the lesion.- 1. Bladder tumors.- a) In the dome.- b) On the floor.- c) In the fundus.- 2. In a diverticulum.- 3. Beneath an overhanging prostate.- VI. Prostatic carcinoma.- 1. Use hormone therapy first.- 2. Occult carcinoma.- VII. Bladder neck contracture and median bar.- 1. Suitable for endoscopic surgery.- 2. Difficult to evaluate.- 3. Contracture in women.- 4. Contraindications.- VIII. Chronic prostatitis and prostatic calculi.- 1. Intractable prostatitis.- 2. Prostatic abscess.- 3. Tuberculous prostatitis.- 4. Prostatic calculi.- IX. Neurogenic bladder dysfunction.- 1. Difference of opinion.- 2. Positive indications.- 3. Acute neurological lesions.- X. Multiple lesions.- 1. Obstruction and stone.- 2. Obstruction and tumor.- 3. Obstruction and diverticulum.- XI. Multiple stage operations.- XII. Surgical risk.- 1. Tolerance to endoscopic surgery.- 2. Evaluation of surgical risk.- 3. Improving the risk.- 4. Poor renal function.- 5. Poor risks.- XVIII - Examination, preoperative care and selection of the anesthetic.- I. Preoperative examination.- II. Preoperative care.- 1. Bladder drainage.- 2. Poor surgical risk.- 3. Decompression of the bladder.- 4. Suprapubic cystostomy.- a) Trocar cystostomy.- b) Permanent cystostomy.- c) Resection mortality.- 5. Bed rest.- a) Cardiac decompensation and extreme hypertension.- b) Avoid bed rest whenever possible.- 6. Cardiac care.- 7. Infection.- a) Chemotherapy.- b) Ureteral catheterization.- 8. Vasligation.- 9. Dilatation of urethral stricture.- 10. Fluids.- III. Selection of the anesthetic.- 1. General considerations.- 2. Intraprostatic.- 3. Intradural spinal.- 4. Miscellaneous.- 5. Preoperative sedation.- XIX - Technique with the Stern-McCarthy electrotome.- I. Difficulties in mastering the technique.- II. Importance and checking of armamentarium.- 1. Loop electrode.- 2. Illumination.- 3. Electrosurgical unit.- 4. Indifferent electrode.- III. Position of the patient.- IV. Position of the operator.- V. Introducing the resectoscope.- 1. Preliminary dilatation.- 2. Hinged obturator to follow urethral roof.- 3. Bypassing a false passage.- 4. Perineal urethrotomy.- 5. Internal urethrotomy.- VI. Observation of the bladder neck and posterior urethra.- 1. Use of different optical systems.- 2. Composite view.- VII. Holding the resectoscope.- VIII. Starting the resection.- 1. Removal of first pieces.- 2. Avoidance of the trigone.- IX. Orientation.- X. Method and rhythm.- 1. Planned approach.- a) Superficial to deep.- b) 6 to 12 o'clock positions.- c) Removal by sections.- d) Advantages of starting the resection at the 6 o'clock position.- 2. Coordination of movements.- a) Foot and eye.- b) Fenestra alternately against and removed from tissue.- c) Manipulation of water inflow.- d) Logical sequence of procedure.- e) Sequence for bladder tumors.- XI. Visualization.- 1. Importance of clear visualization.- 2. Causes and correction of poor visualization.- a) Water or debris on ocular lens.- b) Poor illumination.- c) Debris and air bubbles covering the objective lens.- d) Pieces of tissue.- e) Debris clinging to loop.- f) Inadequate inflow of irrigating fluid.- g) Objective lens too far from tissue.- h) Objective lens against tissue.- i) Excessive bleeding.- j) Clots covering the field of vision.- XII. Identification of tissue.- 1. Importance.- 2. Objective lens close to tissue.- 3. Prostatic tissue.- 4. Highly malignant tissue.- 5. Bladder neck fibers.- 6. False or surgical capsule.- 7. True capsule.- 8. Bladder muscle.- 9. Near perforation.- 10. Complete perforation.- Pericapsular fat.- 11. Openings which are not perforations.- a) Venous spaces.- b) Ejaculatory ducts.- 12. Survey at conclusion of operation.- XIII. Manipulation of the resectoscope.- 1. Swinging against and away from nonresected tissue.- 2. Removal of intravesical middle lobe.- 3. Tissue located ventrally.- a) Ventral lobe.- b) Tags located ventrally.- c) Tumors located ventrally.- 4. Undermining the trigone.- 5. Resecting tissue about the verumontanum.- 6. Evacuation of tissue and clots.- a) By manipulation of the sheath.- b) By suction, pressure or alligator forceps.- c) Technique for use of suction.- XIV. Locating and controlling bleeding.- 1. Pinpoint electrocoagulation.- 2. Lens close to tissue.- 3. Systematic search for bleeders.- 4. Pressure of the shearth against a bleeder.- 5. Rebound bleeding.- 6. Bleeding under clots.- 7. Bleeding behind tags of tissue.- 8. Vessel spurting into lens.- 9. Bleeding behind the bladder neck.- 10. Venous bleeding.- 11. Injection of vasoconstrictors.- XV. Concluding the operation.- 1. Selection of pieces for microscopic examination.- 2. Examination at the end of operation.- a) Prostatic urethra.- b) The inside of the bladder.- 3. What constitutes adequate removal of tissue.- a) Prostate.- b) Bladder tumors.- XVI. Incision of the dorsal bladder neck and trigone.- 1. Combined hypertrophy of the trigone and elevated bladder neck.- 2. Elevation of bladder neck only.- 3. Exposure of subtrigonal adenoma.- XVII. Transurethral diverticulotomy.- XVIII. Insertion of the catheter.- 1. Hemostatic bag catheter.- 2. Catheter passed through the resectoscope sheath.- 3. Immediate bladder irrigation.- XIX. Rapid resection of large prostates and bladder tumors.- 1. Swift technique.- 2. Rapid identification of tissue.- 3. Powerful electrosurgical unit.- 4. Control of bleeding.- 5. Large pieces of tissue.- XX - Variations in technique of endoscopic prostatic resection.- I. Rectal palpation and counterpressure.- 1. Purpose.- 2. Technique.- II. Encirclement of prostatic tissue.- 1. Technique.- 2. Advantages.- 3. Disadvantages.- a) Landmarks on the floor.- b) Obstructing masses of tissue.- c) Early perforation.- III. Punch prostatectomy.- 1. Technique.- a) Manipulation of the instrument.- b) Control of bleeding.- c) Method of resection.- d) Adequacy of the resection.- 2. Advantages.- a) Little trauma.- b) Volume of water inflow.- c) Tactile evaluation.- d) Direct vision.- 3. Disadvantages.- a) Increased bleeding.- b) Difficult excavation.- c) No magnification.- d) Direct vision.- e) Bladder tumors.- XXI - Endoscopic resection of the bladder neck in the female.- I. Indications.- 1. Urinary obstruction.- 2. Chronic inflammation of the bladder neck.- 3. Hyperplasia of the periurethral glands.- 4. Neurogenic vesical dysfunction.- 5. Collar contracture of the bladder neck and elevation of the posterior lip.- II. Preliminary conservative care.- III. Cystoscopic appearance of collar contracture.- 1. Right angle lens.- 2. Foroblique lens.- 3. Retrograde lens.- IV. In children and infants.- V. Surgical technique.- 1. Technique in general.- 2. Adequate removal of tissue.- 3. Incision of the interureteric ridge.- 4. Bladder neck resection in children.- 5. Postoperative catheterization.- VI. Postoperative care.- VII. Results.- XXII - Immediate complications.- I. Frequency.- II. Injury to the urethra and bladder.- 1. Pendulous urethra.- 2. Prostatic perforation.- 3. Bladder wall perforation.- 4. Resection of the trigone.- 5. Ventral bladder wall resection.- 6. Perforation at the prostaticovesical junction.- III. Recognition of perforation and extravasation.- 1. Importance of recognition.- 2. Suprapubic or perineal pain and rigidity.- 3. Cystourethrograms.- 4. Appearance of the area of perforation.- IV. Treatment of perforation and extravasation.- V. Undermining the trigone.- 1. Method of avoiding.- 2. Treatment.- VI. Injury to the external sphincter.- VII. Excessive blood loss.- 1. Detection.- 2. Treatment.- 3. Fibrinolysis.- VIII. Absorption of irrigating fluid.- XXIII - Postoperative care.- I. Importance.- II. Catheter drainage.- 1. Aseptic closed system.- 2. Maintenance of free drainage.- a) Without irrigation.- b) With irrigation.- c) To prevent bladder overdistention.- d) Change of catheter and use of evacuating tube.- III. Control of bleeding.- 1. Medication.- 2. Electrocoagulation.- 3. Blood transfusion.- 4. Delayed secondary hemorrhage.- IV. Postoperative extravasation.- V. Fluid intake.- VI. Ambulation.- VII. Bowel care.- VIII. Sedatives.- IX. Hiccoughs.- X. Postoperative catheter management.- 1. Removal of the catheter.- 2. Replacement of the catheter.- 3. Persistent residual urine.- 4. Obstruction to passage of the catheter.- XI. Infection and fever.- XII. Hospitalization.- XIII. Dilatation of the urethra.- 1. Sounds.- 2. Kollmann dilator.- XIV. Routine postoperative oders.- Routine postoperative orders for prostatic resection cases.- XXIV - Results and sequelae.- I. General discussion.- II. Statistical reports.- III. Functional results.- IV. Incomplete removal of tissue.- 1. Symptoms and findings.- 2. Repeat resection.- a) Early obstruction.- b) Recurrence of the growth.- V. Urethral stenosis.- 1. Meatal stenosis.- 2. Bladder neck stenosis.- a) Causes.- b) Diagnosis.- c) Treatment.- VI. Urinary incontinence.- 1. Temporary.- 2. Permanent.- VII. Sexual changes.- 1. Libido.- 2. Ejaculation.- VIII. Vesical hypotonia.- 1. Cause.- 2. Management.- a) Catheterization and irrigation.- b) Plastic procedure.- c) Diagnosis of possible causes.- IX. Fibrosis of ureteral orifices.- X. Persistent infection.- XI. Recurrence of malignancies.- 1. Prostate.- 2. Bladder tumors.- References.- Author Index.