Thursday, February 18, 2010

Urology

I quickly skim over the page on TURPs in my textbook, realise I am running late and race in to the hospital, only to find the theatre change rooms and in fact, the whole corridor, completely deserted. But I bravely battle on, and before I finish changing into scrubs, my favourite nurse arrives and all is well. She even helps me put on my little scrubs hat so it goes all the way over my ears and doesn’t look dorky.

When I get to theatre I mention that I am pretty exciting about actually scrubbing in, and they all give me the “your puppy has been sent to the farm” look and inform me that there is no need to scrub for any of today’s procedures.

Maybe I look sad, or a little slow, but the urologist goes pretty easy on me. He doesn’t want to ask me what a TCC is, in case I don’t know ... but I’ve just done a urology PBL case, so I can confidently answer “transitional cell carcinoma”. He is amazed – “you’ll be alright!” he declares. It can’t be that easy, so I wait for the trap. But the urologist later admits, “I don’t ask medical questions anymore, because I don’t understand the answers”.

Urology surgery is incredibly brutal - the urologist wears a splash-proof mask, waterproof gown and gumboots, for starters. And when he threads giant metal instruments through the penis to the bladder or the prostatic urethra and cuts, probes and cauterises away, the blood (mixed with 1.5% glycine solution) flows and flows into the catchment area ... and sometimes onto the floor.

The TURPs are the worst. The smell of burning flesh is only noticeable after a few minutes of cauterisation, but it soon spreads throughout the operating theatre. On the big screen it looks, as the urologist puts it, “like shearing, but in reverse – from the inside out”, with the white cauterised prostate, pink flesh showing from underneath, the occasional bleeding vessel. Or in the larger prostates, the frequent, large bleeding vessels. After he cauterises the prostate with a wire loop, he uses a roller-ball diathermy to finish off the area, stopping any bleeding and making the surface smooth. And then the worst part – after flushing, he scoops up the chunks of prostate that he has removed and puts them in jars for pathology. I am surprised at the volume of material – small handfuls of prostate pieces. And they look and smell like bacon chips.

One man had developed bladder diverticulae due to an enlarged prostate that gave him chronic urinary retention. The prostate almost completely blocked his urethra before the operation, so the force the detrusor muscle had to exert in order to squeeze urine past this tiny opening had caused little outpockets of bladder to form in between bands of detrusor. Too look at, it is much like diverticular disease of the bowel.

It is all very interesting, but I can’t help but drift back to the anaesthetics. I put in some more cannulas, give jaw support to apnoeic patients, place three laryngeal masks and even get to inject some ... white stuff. And then the anaesthetist asks if I want to scrub in for a spinal block! My answer is most definitely yes (and not just because I desperately want to scrub in). He shows me how to find the right spot, inject the local and use that needle to mark the spot for the longer spinal needle. I get to feel the different grades of resistance as the needle passes through the skin, muscle, ligaments and finally the ‘give’ as it passes into the subarachnoid space. We remove the stylet from the middle of the needle, and I am relieved when CSF finally wells and drips out of the end and he can inject the anaesthetic. Then later in the list, another patient comes in who elects to have a spinal block – and the anaesthetist lets me do most of it myself (under very close supervision)! He then tells me it's probably the fastest student spinal block he's seen, so I watch nervously for signs of pain during the surgery, but it all goes well.
100% success rate on spinal blocks – much better than cannulation!