Genitourinary Surgery: Cystoscopy, TURP, Nephrectomy, and Robotic-Assisted Procedures

Genitourinary Surgery: Cystoscopy, TURP, Nephrectomy, and Robotic-Assisted Procedures

Genitourinary (GU) surgery encompasses procedures involving the kidneys, ureters, bladder, and urethra. As a surgical technologist, your scrub role in GU cases demands a thorough understanding of specialized equipment, sterile technique, and patient safety considerations unique to this specialty.

The Scrub Role in Endoscopic GU Procedures

Endoscopic GU procedures are performed through natural body openings or small incisions using telescopic instruments. Your responsibilities begin well before the patient enters the room. You are accountable for verifying the integrity of all scopes, confirming that irrigation systems are correctly assembled and primed, and maintaining a sterile field throughout the procedure.

Communication with the circulator is essential. The circulator manages the light source, video tower, and irrigation fluid bags from outside the sterile field, while you control the sterile components — the scope itself, the light cable, and the sterile irrigation tubing. Never allow the sterile light cable to contact an unsterile surface, and always handle the scope with care to avoid damaging the delicate optics.

Cystoscopy: Setup and Equipment

Cystoscopy is the direct visual examination of the urethra and bladder using a cystoscope. It is one of the most frequently performed urologic procedures. The cystoscopy tower typically includes a light source, camera processor, and monitor. The cystoscope itself consists of a rigid or flexible scope, a sheath, and an obturator.

Setup steps in order:

1. Inspect the cystoscope for cracks or lens damage before use.

2. Connect the sterile light cable to the scope; hand the non-sterile end to the circulator to connect to the light source.

3. Connect the camera head to the scope eyepiece and white-balance the camera (the circulator activates the processor).

4. Attach sterile irrigation tubing to the inflow port of the cystoscope sheath.

5. Prime the tubing to remove air before the scope is introduced into the patient.

6. Confirm irrigation fluid — typically sterile water or normal saline depending on the procedure — is at the correct temperature and that the bag is not expired.

For diagnostic cystoscopy, sterile water or normal saline is commonly used. For procedures involving electrosurgery (such as fulguration of bladder tumors), a non-electrolyte, non-hemolytic irrigant must be used to prevent electrolyte disturbances and ensure effective current passage.

Transurethral Resection of the Prostate (TURP)

TURP is performed to remove obstructing prostate tissue through the urethra. The resectoscope is the key instrument. It consists of:

• Outer sheath: maintains access and carries irrigation inflow and outflow ports
• Working element: houses the electrosurgical loop and controls
• Resection loop: the active cutting electrode
• Obturator: used to guide the sheath atraumatically into the urethra during insertion
• Irrigation tubing: continuous irrigation maintains visualization and clears resected tissue

Irrigation fluid safety is critical in TURP. Large volumes of irrigant are used, and if the fluid is absorbed systemically through open venous sinuses, the patient can develop TURP syndrome — a dilutional hyponatremia presenting with confusion, bradycardia, and hypertension. Because monopolar electrosurgery is traditionally used in TURP, a non-electrolyte solution (such as glycine or sorbitol) has historically been required. Bipolar TURP systems allow the use of normal saline, reducing absorption risks. Always confirm with the surgeon and circulator which system is in use before drawing up irrigation.

Your scrub role during TURP includes passing the resectoscope components in the correct assembly order, maintaining a continuous supply of irrigation, and anticipating the surgeon's needs as tissue chips are evacuated with an Ellik evacuator.

Nephrectomy: Open and Laparoscopic

Nephrectomy is the surgical removal of a kidney, performed for cancer, trauma, or end-stage disease. Open nephrectomy requires a flank or transabdominal incision, a major retractor system (such as a self-retaining retractor), and vascular instruments for controlling the renal hilum. Laparoscopic nephrectomy uses trocar access, a camera, and energy devices. In both approaches, careful handling of vascular clamps and hemostatic instruments is essential. The renal vein and artery must be individually controlled; be prepared to pass clips, stapling devices, or ties rapidly when the surgeon is at the hilum.

Robotic-Assisted GU Surgery

Robotic-assisted laparoscopic procedures — including robotic prostatectomy (RALP) and robotic nephrectomy — are now standard in many facilities. The surgical robot places additional demands on the scrub role:

• Draping the robotic arms must follow the manufacturer's protocol precisely. Each arm is covered with a sterile robotic arm drape before the robotic instruments are inserted.
• Drapes are applied from the sterile field outward; the scrub technologist controls the sterile portion while the circulator unfolds the non-sterile portion.
• Robotic instruments (monopolar scissors, bipolar forceps, needle drivers) are docked into the arms after draping; confirm each instrument is fully seated and locked.
• Instrument exchanges during the procedure must be performed without contaminating the sterile cannulas.
• The scrub technologist also manages the bedside laparoscopic camera if a 30-degree scope is used, passing it carefully to avoid dropping or contaminating it.

Key safety point: In any robotic case, clearly communicate with the surgeon before moving anything near the patient-side cart. Robotic arms can cause unintended patient injury if moved without awareness of their position relative to the patient.

Scope of Practice and Patient Safety

Regardless of the procedure, surgical technologists work under the direct supervision of the licensed surgeon. You do not diagnose, interpret findings, or make clinical decisions. Your role is to maintain the sterile field, pass instruments accurately and efficiently, and alert the team to any break in sterility. In GU surgery specifically, always confirm irrigation fluid type with the surgical team before connecting it, and monitor irrigation inflow and outflow to support the team's awareness of fluid balance.