The incision extends from the symphysis to the umbilicus or nearby. The linea alba of the rectus fascia is incised and the rectus muscle retracted laterally. The posterior rectus fascia is incised in the superior portion and the transversalis fascia is incised in its inferior portion. The retropubic space may be enlarged by blunt dissection. Lateral retraction of the wound may cause bleeding from the inferior epigastric artery or vein as they branch into the rectus muscle. The vas deferens may be identified as it courses over the lateral pelvic wall and may be followed to the point where it crosses under the distal ureter. This provides a good method for following a distal ureter that has been previously operated upon.

If the bladder is to be opened or the prostate or ureter is approached transvesically, the bladder should be filled with sterile saline before the incision is made. The distended bladder pushes the peritoneum away from the inferior portion of the wound, facilitating safe entry to the retropubic space and bladder.

This incision is used as an approach to the portion of ureter overlying the sacrum.

A hockey-stick incision (Fig. 1) 1571 is made, originating at the lateral border of the rectus, two finger-breadths above the pubic tubercle, and extending laterally 2.5cm (1inch) medial to the inguinal ligament. The external oblique aponeurosis and the internal oblique muscles are opened in the direction of their fibres and the transversalis fascia is incised. The use of narrow Deaver retractors on sponges aids medial retraction of the transversalis fascia and peritoneum. The ureter can be identified as it crosses the pelvic vessels: it is usually retracted with the peritoneum and is more medial than expected.

The patient is placed in the lateral position with the twelfth rib over the kidney bar (Fig. 2) 1572. The lower leg is flexed and a pillow is placed between the upper leg and the lower knee and ankle. The upper leg is supported by pads under the ankle where it rests on or does not reach the table. A small pad is placed under the dependent axilla to take the pressure from the brachial plexus. With the patient directly lateral, the kidney bar is raised and the table is flexed and tilted in the Trendelenburg position, so that the flank of the patient remains parallel to the floor. Four-inch adhesive tape is placed just over the greater trochanter and is fixed to the operating table to hold the patient in position. A second adhesive strap may be used to stabilize the shoulder. Supporting towel rolls may be used anteriorly and posteriorly to support and maintain this position. When patients are placed on their right side, flexion of the table and elevation of the kidney bar may cause partial venocaval obstruction and acute falls in blood pressure.

This incision is used for exposure of the upper ureter and lower pole of the kidney. It is usually not cephalad enough to allow adequate control of the renal pedicle or exposure for a pyelolithotomy.

The basic ‘kidney’ position is used, with the centre of the field 2.5cm (1inch) below the twelfth rib. The incision, which starts at at the sacrospinalis and ends at the lateral border of the rectus, is curved caudad at a 25° angle from transverse to avoid injury to the subcostal nerve. The latissimus dorsi and external oblique muscles are incised (Fig. 3) 1573. The internal oblique fascia and lumbodorsal fascia (posterior extension of transversalis fascia) are incised until a wide area of retroperitoneal fat is identified. The twelfth intercostal nerve may be identified between the internal oblique and transversalis (lumbodorsal) fascia. It must be dissected and moved laterally because injury to this nerve may cause chronic incisional pain.

This incision may be used for pyelolithotomy, nephrolithotomy, or simple nephrectomy. A basic ‘kidney’ position is used. The incision extends from the erector spinae muscle to the edge of the rectus abdominis. The muscles over the rib are cut with electrocautery and the rib periosteum is incised. A periosteal elevator is used to elevate the muscles and fascia from the rib. The rib must be dissected from the posterior fascia and the neurovascular bundle. The more medial external and internal oblique fascia are incised and the transversalis fascia is incised and split after the peritoneum is bluntly dissected from its inferior surface. The pleura is not usually encountered.

This incision allows better kidney exposure than the subcostal or twelfth rib incision. However, the pleura covers two-thirds of the posterior surface of the eleventh rib, and injury to it must be avoided. Dissection of the diaphragmatic pleural attachments that tether the pleura to the posterior surface of the eleventh and twelfth ribs allows the pleura to be retracted cephalad.

This is the most common incision used for radical nephrectomy and for retroperitoneal dissection for tumours and nodes.

The patient is first placed in the kidney position with the eleventh rib over the kidney bar. He is then turned so that the lower body is elevated by 10 to 20° and the chest is at a 45° angle to the table (Fig. 4) 1574. The rib is incised as described above. The diaphragm and pleura are incised, care being taken to avoid injury to the parenchyma of the lung. The incision is then extended to include external and internal oblique, rectus fascia, and transversalis muscle.

When the urinary tract has been opened by pyelotomy, ureterotomy, or cystotomy, it should be drained postoperatively. Whether a traditional Penrose drain or a newer Jackson-Pratt flat or round drain should be used is controversial. Stuffed drains should be avoided. The end of the drain should be placed in a site that is dependent when the patient is supine. The drain should exit through a separate stab wound and should be advanced when drainage is minimal or scant (average 4 to 5 days) and removed 1 day later. If urinary drainage is prolonged (more than 10 days), causes of fistula (tumour, distal obstruction, infection, foreign body) should be investigated. If these have been ruled out, the drain may be slightly advanced as its tip may hold open the leaking site.

When the urinary tract has been entered, divided, or anastomosed, conventional wisdom usually advocates the placement of a stent. In the urological sense a stent is a hollow tube, usually with side drainage holes, which facilitates the flow of urine through and also around it. Stents may be simple ureteral catheters (4–6 F), paediatric feeding tubes (5–8 F), or self-retaining catheters with a curled proximal and distal tip which hold themselves in position. Stents are usually left in position for 7 to 21 days, depending on the degree of compromise of the tissue that they protect.

This procedure is performed as an emergency procedure when a patient presents with a tight phimosis and is unable to void or has an unreducible paraphimosis.

The pudendal nerves under Buck's fascia at 2 and 10 o'clock at the base of the penis are blocked with a local anaesthetic without adrenaline.

The stenotic prepuce opening is dilated with haemostat until a plane can be developed between the glans and the foreskin. A clamp is then placed at 12 o'clock to a distance of 5 mm from the corona. After 5 min, the clamp is removed and the foreskin is cut on each side; the full thickness of each edge is sutured with a haemostatic 3–0 interrupted absorbable suture. Care should be taken to place a haemostatic suture at the apex of the V. Delayed completion of the circumcision is not usually required except for cosmetic purposes.

After blocking the penile nerve with anaesthetic, a scalpel is used to incise the retracted foreskin vertically at 12 o'clock, centred at the junction of the shiny and dull skin. Both skin layers need to be incised, and the edges sutured transversely with 3–0 absorbable sutures (5–0 in children).

The meatus may be congenitally stenotic in a child or stenotic in an adult as a result of previous instrumentation or inflammation associated with chronic balanitis and phimosis. After urethral instillation of topical anaesthesia, a straight haemostat is placed within the meatus and the orifice is gently dilated. If necessary, in addition to topical anaesthetic, local anaesthetic may be injected at 6 o'clock through the mucosa and a haemostat may be placed on the ventral 5 mm of the meatal orifice. After 5 min of haemostatic clamping, the orifice is opened by 4 to 5 mm with a scissors, and the edges and apex are sutured with 4–0 absorbable sutures (No sutures are necessary in infants). Vasoline gauze is then applied. The tip of an ophthalmic antibiotic ointment tube may be used to dilate the meatus three times a day.

Following preparation the penis and anaesthesia with 1 to 2 per cent plain lidocaine, site of the corona of the glans is marked with a marking pen and a V is indicated opposite the frenulum. The prepuce is retracted and freed from the glans. A second circumferential line is drawn 1 cm proximal to the coronal sulcus (Fig. 5) 1575. Both lines are incised circumferentially, with division of the skin on the dorsum and elevation and excision of the skin from the dartos fascia. Bleeding points can be fulgerated or tied with 4–0 absorbable sutures. Two running of multiple interrupted 3–0 absorbable sutures are used to create a haemostatic closure of the skin of the shaft and corona. Vasoline gauze is used as a dressing.

If loss of penile skin has occurred, a scrotal flap may be raised and advanced with its subcutaneous tissue to fill the defect. Absorbable 4–0 and 3–0 subcutaneous and skin sutures are used.

If the skin of the penis is burned or avulsed, all skin distal to the injury should be removed to 1 cm from the corona to prevent lymphoedema. A circumferential split thickness graft is wrapped and sutured to the coronal and proximal skin edges with 4–0 absorbable sutures, which are left long. Cotton wool soaked with mineral oil should be tied in place with the long sutures. A Foley catheter is inserted, and the penis suspended inside a styrofoam cup.

Trauma to the erect penis may cause a corporal cavernosal rupture and subsequent haematoma. Repair requires circumferential incision of the skin of the shaft just proximal to the corona. This is retracted to allow evacuation of the haematoma, and identification of the rupture of the fascia of the corpora; the edges of the tear can then be sutured with inverting 2–0 non-absorbable sutures. The skin of the penis and corona is repaired with 3–0 interrupted absorbable sutures.

Trauma or tumour of the penile shaft may require partial penectomy. Tumour excision requires a 2-cm margin. Repair requires 3 cm of residual shaft to have a directable stream (otherwise, perform total penectomy and perineal urethrostomy). After anaesthesia, a 64-mm (0.25 in.) Penrose drain should be used to apply a tourniquet to the base of the penis, and the skin is then incised 2 cm proximal to the tumour margin. The corpus cavernosum is divided, leaving the urethra and corpus spongiosum, which are dissected distally. The urethra dorsally is spatulated and 1 cm beyond the cut corpora, and sutured to the ventral skin. The dorsal vessels are ligated and the corpora closed with interrupted 2–0 absorbable sutures and secure spongiosum haemostasis. Before closing the skin, the tourniquet should be removed and haemostasis attained.

Testicular torsion is an acute emergency and must be reduced within 6 h to prevent permanent damage.

The procedure can be performed under general or local anaesthesia. A transverse incision over the testes allows the tunica vaginalis to be opened. Following evacuation of the hydrocele, the torsion is reduced by rotating the testes (right, clockwise; left, counter clockwise). Excess tunica is trimmed and the hydrocele obliterated by approximating the edges of the tunica behind the testes. The testes should be fixed laterally and inferiorly with 2–0 non-absorbable sutures. A 6.3-mm (0.25 inch) Penrose drain should be inserted for 24 h following closure of the dartos fascia and skin with 3–0 and 4–0 absorbable sutures.

With the patient under general or local anaesthesia, a 4- to 5-cm incision is made through the dartos fascia to the tunica vaginalis. The tunica is opened and the testes and cord are delivered through the incision. The vas and cord contents are ligated separately, using 2–0 non-absorbable sutures, and the testes is removed. After correction of bleeding from small scrotal vessels, the dartos and subcuticular tissue is closed with a running 2–0 or 3–0 absorbable suture and the skin is closed with interrupted 3–0 absorbable sutures. For bilateral orchidectomy, a single midline skin incision may be used.

This procedure is performed for primary removal of a testicular tumour. An inguinal incision is made parallel to the inguinal ligament, as for inguinal hernia repair. The external ring is identified and the external oblique fascia is opened into the ring, avoiding the ilioinguinal nerve. The cord and its contents are dissected medially and laterally from the external oblique fascia and from the posterior wall, exposing the pubic tubercle. The cremasteric fibres from the internal oblique muscle are dissected from the cord and the internal ring is opened 2 to 3 cm by clamping and dividing the internal oblique muscle. The testes is pushed cephalad into the incision; its gubernacular attachments are dissected, cut, and suture ligated. A narrow malleable or McBurney retractor is placed to elevate the edges of the internal ring and the cord and vas are dissected into the retroperitoneum and separated from the peritoneal reflection. The vas and cord contents are doubly ligated with 0 or 00 non-absorbable sutures and the suture ends are left 2.5 cm (1.0 in.) long, so that they can be identified if retroperitoneal lymph node dissection is required. After removal of the testes and cord, the posterior wall is repaired by suturing the conjoint tendon to the inguinal ligament with 0 non-absorbable sutures. The external oblique fascia is closed with a running 2–0 non-absorbable suture. The subcutaneous tissue (3–0 absorbable) and skin (subcuticular) are closed in the usual fashion. No drain is required.

Rupture of the testis may occur secondary to blunt trauma and may result in a massive scrotal haematoma. Exploration is performed through a scrotal incision, which allows blood to be evacuated and the tunica of the testis to be repaired with interrupted 3–0 absorbable sutures. Debridement should be kept to a minimum. A 6.4 mm (0.25 inch) Penrose drain is left through a stab wound in the most dependent portion of the scrotum.

Varicocelectomy is performed for infertility, chronic pain, or for varicocele-induced testicular atrophy. A 5 to 6 cm inguinal incision is made, and the external oblique fascia is opened. The internal oblique muscle is opened and the cord is dissected from the retroperitoneal attachments. With the patient in the reverse Trendelenburg position (to fill the venous plexus), the dilated veins can be identified, dissected, and doubly ligated, care being taken to avoid the spermatic artery. The inguinal incision is closed in layers, as previously described.

Under general or local anaesthesia, a 4- to 5-cm transverse incision is made on the anterior scrotal surface. The cut edges of skin and dartos fascia are grasped with Allis clamps and the tunica is opened wide enough to allow extrusion of the testes. Six to eight sutures of 3–0 or 4–0 absorbable material are used to imbricate the tunica behind the testes. Using the Allis clamps for counter traction, the testes are replaced in the scrotal cavity, and the dartos fascia and skin are repaired as previously described.

The bladder is filled with saline solution until it is palpable in the suprapubic area. A lower midline extraperitoneal incision is then used to open the retropubic space. A Balfour retractor is inserted and the bladder is separated from the symphysis by blunt dissection; the peritoneum is similarly separated from the dome of the bladder. After grasping each side of the bladder with Allis clamps, the bladder is vertically incised in the midline. The ureteral orifices need to be identified. Saline-soaked sponges are inserted in the bladder dome, which is retracted cephalad with a Deaver or other curved retractor; a Balfour retractor is used to retract the bladder walls laterally to expose the bladder neck. A complete incision through the mucosa of the bladder neck is made circumferentially, avoiding the sites of the ureteral orifices. An index finger is inserted into the prostatic urethra and through the anterior prostate tissue to the prostatic capsule ( Fig. 6(a) 1576,(b)); rolling the finger laterally on both sides will free the proximal prostate from its capsule and its attachment at the bladder neck. The adenoma is grasped with a triple hook and pulled in a cephalad direction. Finger dissection is continued circumferentially and distally until the entire prostate is attached only by the urethra. Traction should then be ceased, to avoid sphincter injury, and the urethral attachment is cut at the level of the distal prostate.

The prostate fossa vesicle neck junction is grasped with long Allis clamps at 5 and 7 o'clock, and 0 absorbable sutures are used to achieve haemostasis at these angles (Fig. 6(c)) 1576. Pulling cephalad on the 5 and 7 o'clock sutures allows the prostatic fossa to be inspected after placing a narrow Deaver and lifting the anterior prostatic capsule. Bleeding points should be controlled with 2–0 absorbable sutures on a short non-cutting needle; if oozing is persistent, the prostatic fossa may be umbricated with 2–0 absorbable sutures. Before closing the bladder, urine must be observed to efflux from the ureteral orifices. A well-lubricated 22 F three-way Foley catheter with a 3.0 cm³ balloon is placed into the urethra. A 28 F suprapubic tube is placed in the bladder and fixed to the bladder wall. The bladder wall is closed in two layers, mucosa–muscularis (running) and muscularis–advential (interrupted) with 3–0 and 2–0 absorbable sutures. Through and through irrigation is performed via the Foley and the suprapubic tube until the effluent is clear: gentle traction on the urethral catheter may be required. The suprapubic tube is sutured to the skin and a 64 mm (0.25 inch) Penrose drain placed in the retropubic space is brought out through the wound or through a separate stab wound. The rectus muscle is approximated with 2–0 absorbable sutures, the rectus fascia is closed with 0 absorbable interrupted sutures, and subcutaneous tissue and skin are closed in the usual fashion. If the urine is clear, the suprapubic tube is removed in 48 h and the Foley catheter is removed in 5 to 7 days.

A patient with urinary retention in whom a urethral catheter cannot be inserted may be treated by drainage through a suprapubic puncture. Previous abdominal exploration, indicated by a suprapubic scar, may have resulted in intestinal loops overlying the bladder. In this situation, blind puncture is contraindicated.

The bladder should be palpated just above the symphysis. Anaesthesia is established by infiltration of the skin and prevesical tissue with 2 per cent Lidocaine. A No. 11 scalpel tip is used to puncture the skin and, if possible, the rectus fascia. A trocar is placed in the midline, just superior to the symphysis, and at an angle of 25 to 35° behind the symphysis, and pressure is applied until the bladder is punctured. The drainage catheter is inserted through the trocar and sutured to the skin, being careful not to occlude outflow.

If trocar cystostomy fails or is contraindicated, open surgery may be undertaken with the patient under general or local anaesthesia. A 5-cm (2-inch) vertical midline incision is made just above the symphysis. The anterior rectal fascia is opened, the rectus muscle is split, the transversalis fascia is opened, and the distended bladder is palpated and dissected 2.5 to 5.0 cm (1–2 inches) on either side of the midline. If possible, the bladder is grasped with two Allis clamps, 2–0 absorbable stay sutures are placed, and a vesicostomy incision is made. An 18 F Foley or a Malecot catheter is placed in the bladder and the holding sutures are used to tie the catheter in place. The rectus fascia is closed with interrupted 0 absorbable sutures. The catheter is also sutured to the skin.

During abdominal or pelvic operative procedures, or during enteric-vesical fistula repair, it may become necessary to remove a portion of the bladder. The bladder should be incised with a 2-cm margin from the tumour or inflammatory area. The edges of the cut bladder are grasped with Allis clamps and the affected area is removed. Bleeding vessels are ligated with 2–0 or 3–0 absorbable sutures. The bladder is closed in two layers with a mucosal–muscular layer of running 3–0 absorbable sutures and a muscularis–advential layer of interrupted 2–0 absorbable sutures. A Foley catheter is needed for 7 days, and the perivesical space requires a Penrose drain. After 7 days, a cystogram should be performed: if no leaks are seen, the catheter may be removed.

If the bladder is inadvertently opened during an operative procedure, the edges should be debrided and closed in two layers, as previously described. Placement of a Foley catheter for 7 days and perivesical Penrose drainage is also required. A suprapubic tube is unnecessary.

The lower ureter may be severely compromised during the course of abdominal procedures, including vascular, colorectal, and gynaecological surgery, or following severe trauma. When the lower third of the ureter is injured, resection and reanastomosis are not advisable. It is preferable to excise the distal ureter and reimplant in the bladder with a tunnel, when ureteral length is sufficient, or with a non-tunnelled ureterovesical anastomosis, when the ureter is short.

Bladder and ureteral mobilization increase the available ureter length. Cephalad and lateral dissection of the ureter, being careful not to interrupt the medial blood supply, increases the length of the ureter by 3 or 4 cm. In extreme circumstances, the kidney can be dissected, the renal pedicle skeletonized, and an additional 3 to 4 cm of ureteral length achieved.

The bladder is mobilized by dissecting its lateral attachments and sacrificing the contralateral superior vesical artery. A cystotomy is made, and the bladder is retracted cephalad; its posterior lateral wall is fixed to the psoas minor muscle with three 2–0 absorbable sutures, being careful to avoid the iliohypogastric nerve. The ureter is then brought through a stab wound and either tunnelled or is spatulated and anastomosed to the vesical mucosa with 4–0 absorbable sutures. The ureter must be fixed to the exterior vesical wall with 4–0 absorbable sutures to prevent retraction. Ureteral stenting (10 days) and proper perivesical drainage and antibiotics are required.

Injury to the middle and upper third of the ureter may be repaired by primary end-to-end anastomosis. The ureteral ends must be located in the retroperitoneum; the ureter can be distinguished from other anatomical structures by pinching with a non-toothed forceps and observing for peristalsis. A traction suture is placed in each end and the ureter is dissected on the lateral border to increase its length sufficiently to allow anastomosis. The ends of the ureter are cut obliquely to create the spatulated anastomosis (Fig. 7) 1577. A retention stent bridging the anastomosis may be placed from the renal pelvis to the bladder. The ureter is closed with either two running 4–0 absorbable sutures, or by multiple interrupted 4–0 sutures. An omental wrap may be used to prevent periureteral fibrosis. A Penrose drain is left in place until drainage has ceased.

A ureterolithotomy may be performed in the mid- or upper ureter through a twelfth rib or a muscle-splitting subcostal incision and in the lower ureter through a midline retroperitoneal approach or through the muscle-splitting Gibson incision.

The ureter is approached retroperitoneally. It will often lie not against the posterior abdominal wall, but on the posterior surface of the reflected peritoneum. If it is distended, the ureter may be easily identified and followed to the point of obstruction. A Babcock clamp or an occluding suture should be placed on the ureter above the calculus to prevent cephalad stone migration. Using a curved no. 12 Bard-Parker blade, the full thickness of the ureteral wall is incised: the stone can be felt with the tip of the knife blade (Fig. 8) 1578. A small right angle clamp slipped under the ureter is used to lever the stone out: grasping the stone may cause it to fragment. The ureter is then irrigated with an 8 F red rubber catheter or feeding tube, ensuring that flow goes to the bladder and that distal obstruction is not present. A retention stent may be placed. The muscular and adventitial layers of the ureter are closed primarily with one layer of interrupted 4–0 absorbable sutures. The mucosa is not approximated because of the possibility of ureteral narrowing.

A twelfth rib incision is preferable, although if previous surgery has been performed on the kidneys, an eleventh rib extrapleural incision may be necessary. The kidney is dissected from its attachments and Gerota's fascia is split and retracted medially and laterally. The pelvis is approached posteriorly. The ureteropelvic junction is identified and a 64-mm (0.25 inch) Penrose drain is looped around the upper ureter. The pelvis is cleaned of excess fat and after 4–0 stay sutures have been placed, a pyelotomy incision is made so that it can be directed toward a calix and so that the incision does not extend through the ureteropelvic junction. The stone is levered out. A nephroscope may be used to inspect the infundibula and calices for residual calculi.

If a calculus cannot be removed from the calices, a nephrotomy incision may be made. The fifth finger is used to press the stone against the renal parenchyma. The site of the stone is identified by feeling it with a Keith needle, and the renal capsule overlying this segment of the kidney is incised in a radial fashion. The back of the knife handle is used to dissect the parenchyma. A nasal speculum is used to retract the parenchymal edges. With the fifth finger pushing against the stone, it is levered out of the kidney with a small curved clamp. The nephrotomy is closed with interrupted 3–0 absorbable sutures, using a piece of fat under the knot to prevent parenchymal laceration.

With the patient placed in the flank position, a twelfth or eleventh rib extrapleural incision is made. Gerota's fascia is opened and blunt and sharp dissection is used to separate the kidney from its envelope. The lower pole is dissected and the ureter is doubly ligated and divided. The gonadal vein courses with the ureter; one should not be confused with the other.

The vascular pedicle is isolated and the artery and vein dissected. The artery is clamped with right-angled clamps, divided between the distal two, and then doubly ligated with a 0 silk suture. The renal vein is then clamped and doubly ligated with 0 silk sutures. The kidney is then removed and all small bleeding points are fulgerated or ligated. A simple nephrectomy leaves the adrenal intact.

A radical nephrectomy, usually performed for carcinoma of the kidney, is commonly performed through a tenth rib thoracoabdominal incision. When performing a radical nephrectomy, Gerota's fascia and its contents, which include perinephric fat and the adrenal gland, are removed.

Nephroureterectomy is performed through a flank incision for transitional cell carcinoma of the ureter or renal collecting system. A radical nephrectomy is performed, and the ureter is dissected as deeply into the retroperitoneum as possible. Once this portion of the procedure is completed, the incision is closed and the patient is placed supine. A midline lower abdominal intraperitoneal incision is made and the ureter is dissected to its insertion in the bladder, the bladder is opened and a 1- to 2-cm cuff of bladder around the ureterovesical junction is excised with the ureteral segment. The bladder defect and bladder incision are closed in two layers, as for a partial cystectomy.

A patient with a tumour in a solitary kidney or who has suffered trauma and significant parenchymal injury, may require a partial nephrectomy. The renal pedicle is isolated through a tenth or eleventh rib incision (tumour) or via an anterior transperitoneal approach (trauma). In the tumour patient, a rubber dam filled with crushed ice and Ringer's solution is placed around the kidney and the renal artery is occluded with a rubber shod vascular clamp; 10 min is allowed for cooling. The branches of the renal artery are dissected: segmental clamping allows the line of renal incision to be identified. The renal capsule is incised 1 to 2 cm distal to the line of the parenchymal incision, and the back of the knife handle is used to incise the fragile parenchyma. The incision will allow the capsule to be used to close the renal defect. Visible cut vessels are ligated with 3–0 and 4–0 absorbable sutures. The collecting system is cut, and damaged or cancerous tissue is removed. The clamped artery is released and the remaining vessels are sutured. The collecting system is closed with a running 4–0 absorbable suture; the kidney and capsule are closed using 3–0 non-absorbable sutures buttressed by perinephric fat (Fig.9 (a)–(d)) 1579. A peritoneal segment may be used to cover the defect if the excised area is large and the capsule cannot be used. The area should be drained.

Blunt or penetrating renal trauma should be explored from a transperitoneal anterior approach so that control of the renal pedicle can be obtained prior to opening Gerota's fascia. Failure to do this may result in serious blood loss. Renal debridement is kept to a minimum, and every attempt is made to preserve function. Puncture wounds of the kidney may be sutured. Partial nephrectomy for significant trauma may be carried out as described above.

Urinary diversion may be required following trauma to the bladder or both lower ureters, for treatment of a dysfunctional lower urinary tract, or following bladder removal due to cancer.

A midline transperitoneal abdominal incision is made with the patient in the supine position. The left ureter is identified as it crosses the iliac vessels, isolated with a Penrose drain, and dissected deep into the pelvis and cephalad to the lower pole of the kidney, care being taken to avoid its medial blood supply. The pelvic portion is divided and intubated with an 8 F red rubber catheter, which is sutured to the distal ureter. The distal end of the ureter, which remains in the pelvis, is suture ligated with 2–0 absorbable sutures. The right ureter is similarly identified and inubated and mobilized for 7.5 to 10 cm (3–4 inches). A tunnel is created under the left colon, inferior to the inferior mesenteric artery and the left ureter is passed under the colon to the peritoneal opening created for the right ureter (Fig. 10) 1580. Attention must be paid to the curve of the left ureter so that acute angulation and kinking do not occur.

A segment of ileum is identified by allowing the light to shine through the mesentery to identify the vascular arcades. A silk suture is placed at the most distal point on the bowel segment, which should be 10 to 15 cm from the ileocaecal valve. A proximal point on the ileum is also identified: the segment should be sufficient to reach from the posterior abdominal wall to the skin, plus an extra 4 to 8 cm to allow for creation of a stoma and to prevent excess tension. The peritoneum overlying the mesentery is incised and the mesenteric vessels are ligated, as with any bowel resection (Fig. 11) 1581. The proximal mesenteric incision is longer than the distal incision, allowing for rotation of the base of the conduit. The loop is always constructed so that urine is propelled in an isoperistaltic fashion, and the conduit is always placed inferior to the intestinal reanastomosis.

The proximal end of the isolated ileal loop is closed in a water tight fashion with a running Parker-Kerr suture and buttressing sutures of 4–0 silk.

The ureteral anastomoses are performed in the proximal third of the conduit. A 2 by 2 mm portion of the ileal seromuscular layer is grasped and excised, leaving an intact mucosa from which a small plug is excised. The ureter is freshened by cutting it obliquely and it is then anastomosed to the ileal conduit with full-thickness mucosa-to-mucosa 4–0 absorbable sutures. If the blood supply to the ureter has been compromised or if the ureter has been previously irradiated, 5 to 8 F feeding tubes should be used as stents. To prevent torsion, the conduit is fixed to the promontory of the sacrum with one or two 2–0 non-absorbable sutures. All peritoneal traps are closed.

A stoma is created by excising a quarter-sized segment of skin and subcutaneous tissue at a site that is not a major skin fold and where an appliance may be comfortably worn and supported. The anterior fascia is incised, the rectus muscles are separated, and the posterior rectus fascia and peritoneum are incised. The stoma is grasped with a Babcock clamp and advanced through the orifice: it should protrude 4 cm above the skin before fixation and eversion. Four-quadrant everting sutures of 3–0 absorbable material are used to evert the stoma. The conduit is further fixed to the skin by interrupted 4–0 absorbable sutures and to the posterior fascia and peritoneum by three 3–0 non-absorbable sutures ( Fig. 12(a) 1582, (b)).

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