Transurethral Surgery

A. Operating Facilities for Transurethral Surgery.- I. General Considerations.- II. The Operating Suite for a Transurethral Unit.- 1. The Operating Room for Transurethral Procedures.- 2. The Anesthetic Room.- 3. The Instrument Room.- 4. Ancillary Rooms.- 5. The Recovery Area.- 6. The Siting of Transurethral Operating Suites.- B. Instruments and Their Care.- I. Instruments for Transurethral Surgery.- 1. Diagnostic Instruments.- 2. Operating Cystoscopes.- 3. Water Connections for Diagnostic and Operating Cystoscopes.- 4. Electro-resectoscopes.- a) The Resectoscope Sheath.- ?) Insulation-Coated Sheaths.- ß) The External End of the Resectoscope Sheath.- ?) The Obturator.- b) The Electrotome.- ?) Loop Control Mechanisms.- ß) Cutting Loops and Other Work Pieces.- ?) The Telescope.- c) Irrigation Fluids for Transurethral Surgery.- d) The Fiber Optic Light Source.- e) The High Frequency Diathermy Unit.- f) Lubricating Agents.- g) Sundries: Lighting Cable, High Frequency Cable, Irrigation Supply, and Drainage Hoses.- 5. Lithotrites.- a) Preliminary Considerations.- b) The Punch Lithotrite According to MAUERMAYER.- ?) The Sheath.- ß) The Operating Module.- c) The Urat-I-Lithotrite.- d) The Ultrasonic Lithotrite.- 6. The Continuous Irrigation Resectoscope.- 7. The Suprapubic Aspiration Trocar.- 8. The Laser Operating Cystoscope.- 9. The Operating Urethroscope.- II. Cleaning, Sterilization and Maintenance of Endoscopic Instruments.- 1. Instrument Cleaning.- a) Preliminary Disinfection.- b) Cleaning the Sheaths and Accessories (Excluding Telescopes).- c) Cleaning the Telescopes.- d) Inspecting the Light Cables.- 2. Sterilization and Decontamination of Instruments.- a) The Decontamination Process.- b) Sterilization.- III. High Frequency Technology: Applications and Hazards. K. FASTENMEIER and G. FLACHENECKER.- 1. Cutting and Coagulating with High Frequency Current.- 2. The Electrical Circuit in Transurethral Resection.- a) Cutting Loop and Connecting Cable.- b) Indifferent Electrode.- c) Current Pathways Within the Patient - Effect of Electrical Properties of Instruments and Lubricants.- d) Insulation Faults Within the Instrument - Electrical Conductivity of Irrigation Fluid.- e) Capacitive Effects.- 3. Hints for the Avoidance of Electrical Hazards During Transurethral Resection.- C. Preoperative Requirements.- I. Assessment of the Patient.- 1. The History.- 2. Urological Assessment.- a) Rectal Examination.- b) Radiologic Investigation of the Urinary Tract.- ?) Excretion Urogram.- ß) Cystourethrogram.- c) Indications for Preoperative Outpatient Cystoscopy.- II. Indications for Surgery.- 1. General Considerations.- 2. General Indications for Prostatectomy.- a) Acute Retention of Urine.- b) Recurrent Retention.- c) Increasing Residual Volume.- d) Chronic Retention with Upper Tract Obstruction.- e) Recurrent Ineradicable Infection.- f) Hemorrhage from Prostatic Veins.- g) Bladder Calculi.- h) Bladder Diverticula.- i) Severe Outflow Disorders Without Residual Urine.- j) Bladder Tumors.- 3. Rare Indications for Transurethral Surgery.- a) Chronic Prostatitis and Prostatic Abscess.- b) Prostatic Tuberculosis.- c) Multiple Prostatic Calculi.- 4. Indications for Transurethral Prostatectomy.- a) Prerequisites of the Surgeon.- b) Early Surgery.- c) General Indications for Transurethral Resection.- 5. Contraindications and Limitations to Transurethral Prostatic Adenomectomy.- a) The very Large Adenoma.- b) The Markedly Protuberant Mobile Median Lobe.- c) Bladder Calculi.- ?) Endoscopic Approach to Calculus and Adenoma.- ß) Cystotomy for the Calculus and Transurethral Resection at a Subsequent Date.- ?) Cystotomy and Prostatectomy as a Single Procedure.- d) Bladder Diverticulum and Prostatic Adenoma.- ?) Large Diverticulum and Bladder Neck Fibrosis.- ß) Multiple Diverticula.- e) Bladder Diverticulum, Bladder Calculus and Prostatic Adenoma.- f) Urethral Stricture.- g) Paraurethral Abscess During Preliminary Catheterization.- h) Unusually Short Suspensory Ligament of the Penis.- i) Large, Irreducible Hernias.- j) Epididymitis and Severe Urinary Tract Infection.- k) Ankylosis of One or Both Hip Joints.- l) Prostatic Carcinoma Amenable to Radical Surgery.- 6. Limits of Operability.- a) Initial Considerations.- b) Cardiovascular Disease.- c) Pulmonary Disease.- d) Cerebrovascular Disease.- e) Renal Insufficiency.- f) Liver Damage.- g) General Decreptitude.- h) Mental Subnormality and Psychosis.- i) Inoperable Carcinoma in Other Organs.- j) Coagulation Disorders.- k) Diabetes Mellitus.- l) Obesity.- m) Thrombophlebitis, Varicose Veins.- III. Preoperative Treatment.- 1. Draining the Bladder.- a) Intermittent Catheterization.- b) Permanent Drainage.- ?) The Dye Test.- ß) Indwelling Catheters.- ?) Slow Decompression of the Bladder.- ?) Immediate Decompression of the Bladder.- ?) Cystostomy.- 2. Vasectomy.- a) Indications.- b) Technique.- 3. The Treatment of Urinary Infections.- 4. Balanitis and Inflammation of the Prepuce.- 5. Chance Finding of Urogenital Tract Tumors.- 6. Strictures of the Urethra.- 7. Preoperative General Medical Preparation.- IV. Preoperative Endoscopy.- 1. General Considerations.- 2. Introducing the Instrument.- a) Surgical Anatomy.- b) Physiologic Urethral Constrictions.- ?) The External Meatus.- ß) The Transition from Fossa Navicularis to Penile Urethra.- ?) The Penile Urethra.- ?) The Transition from Bulbar to Membranous Urethra.- c) Curvature of the Urethra.- ?) Curvature at the Penoscrotal Angle.- ß) Curvature in the Bulb.- ?) Ventral Curvature of the Urethra Due to a Median Lobe.- 3. Aids to Passing the Instrument.- a) Internal Urethrotomy with the Otis Urethrotome.- ?) Preliminary Considerations.- ß) Technique of Otis Urethrotomy.- ?) The Modified Otis Urethrotome.- b) Sachse Urethrotomy Under Direct Vision During Instrumentation.- c) Instrumentation Under Direct Vision.- d) Optical Aids to Passage of the Sheath.- 4. Trauma During Instrumentation.- a) Preliminary Considerations.- b) Injuries Below the External Sphincter.- c) Injuries Above the External Sphincter.- ?) Ventral Injuries.- ß) Dorsal Injuries.- ?) Subtrigonal Perforation.- 5. Orientation at the Site of Resection.- a) Telescopes for Inspection of the Bladder and Bladder Neck.- ?) The End Viewing Telescope.- ß) Diagnostic Telescopes.- ?) Retrograde-Viewing Telescopes.- b) Directional Features of the Bladder Neck.- ?) Group I Features: Distal-Proximal.- ß) Group II Features: Clockwise Rotation.- ?) Group III Features: Lateral-Medial, Dorsal-Ventral.- 6. Examination of the Bladder Neck.- a) Preliminary Considerations.- b) Assessing Bladder Neck Length.- c) Depth Assessment of the Urethral Cleft.- d) Dorsal Tissue Volume.- e) The Verumontanum.- ?) Free-Standing Verumontanum.- ß) Covered Verumontanum.- ?) Poorly Visible Verumontanum.- ?) Aids to Seeking the Verumontanum.- ?) The Topographic Relationship of Verumontanum and Distal Extremity of the Lateral Lobe.- f) The External Sphincter.- ?) Initial Anatomical Considerations.- ß) Endoscopic Appearance of the External Sphincter Region.- ?) Further Aids to Recognition of the Sphincter Region.- ?) The Sphincter Test of Tammen.- ?) The Sphincter Test of Hartung.- g) The Internal Urinary Meatus.- ?) The Internal Meatus in Small Adenoma, Bladder Neck Fibrosis, and Transverse Bar.- ß) Endourethral Hyperplasia.- ?) Endovesical Hyperplasia.- h) The Internal Sphincter.- i) The Bladder Base and the Retroprostatic Recess.- j) The Urinary Bladder.- ?) Incidental Finding of Bladder Disease.- ß) Relation of the Bladder to the Operative Field.- D. General Resection Technique.- Cutting Methods and Techniques.- I. Introduction.- II. Holding the Instrument.- 1. Two-Handed Technique.- 2. Single-Handed Technique.- III. Irrigation Technique.- 1. The Irrigation Supply.- 2. Air Bubbles in the Field.- 3. Evacuation of Irrigation Fluid and Resection Chips.- a) Standard Drainage Technique.- b) Evacuation by a Drainage Port.- c) The Collecting Sieve.- d) Ellik Bulb in the Drain Hose.- e) Technique with Central Irrigation Cock.- f) Drainage by Specially Designed Instruments or Suprapubic Trocar.- ?) General Considerations.- ß) The Iglesias Irrigating Resectoscop.- ?) Resection with Trocar Drainage.- g) Urodynamic Aspects of High and Low Pressure Irrigation During Transurethral Prostatic Resection. By W. SCHÜTZ.- h) Special Devices for Evacuation of Resection Chips.- ?) Preliminary Considerations.- ß) Use of the Ellik Evacuator.- ?) Evacuation by Metal Piston Syringe.- ?) The Extraction of Outsize Tissue Fragments from the Bladder.- IV. Cutting Technique.- 1. The Cut Proper.- a) The Cut with Predetermined End Point.- b) The Cut with Predetermined Starting Point.- c) The Extended Cut.- d) Retrograde Cutting.- e) Entrapment Cutting.- 2. Practical Aspects of Resection.- a) The Single Cut.- b) Serial Cutting.- c) Excavating the Capsule.- d) Cutting Rate.- V. The Recognition of Individual Tissues During Surgery.- 1. Preliminary Considerations.- 2. Surgigal Anatomy.- 3. Prerequisites for the Recognition of Tissue Structure.- 4. The Appearance of Individual Types of Tissue.- a) Adenoma Tissue.- b) Fibromuscular Tissue.- c) The Prostatic Capsule.- d) Fatty Tissue.- e) Sphincter Fibrosis Tissue.- f) Bladder Muscle Fibers.- g) Infiltration by Urogenital Tumors.- h) Infiltration by Extrinsic Tumors.- i) Ejaculatory Ducts.- j) Seminal Vesicles.- k) Bloodvessels.- l) Prostatic Calculi.- m) Prostatic Abscess.- VI. Accidental Injuries.- 1. Injuries to the Prostatic Capsule.- a) Preliminary Considerations.- b) Threatened Perforation.- c) Covered Perforation.- d) Free Perforation.- e) Subtrigonal Perforation.- ?) Preliminary Considerations.- ß) Subtrigonal Perforation During Instrumentation.- ?) Detachment.- ?) Complete Subtrigonal Perforation.- 2. Other Types of Accidental Injury.- a) Injury to the Ureteric Orifice.- ?) Types of Injury.- ß) Sequelae.- b) Injuries to the External Sphincter.- ?) Preliminary Considerations.- ß) Appearance of the Injury.- ?) Aftercare.- ?) Grading of Incontinence According to Severity.- ?) Conclusion.- c) Intraperitoneal Perforation.- d) Excessive Blood Loss.- 3. Concluding Remarks on Accidental Injuries.- E. Special Resection Technique.- I. General Considerations.- II. Basic Rules of Resection Technique.- III. Resection of Small Adenomas.- 1. Step 1: The Marking Groove at 6 o'clock.- 2. Step 2: Extending the Groove Laterally.- 3. Step 3: Deepening the Groove Down to the Capsule.- 4. Step 4: Removing the Lateral Lobe Base.- 5. Step 5: Resecting Ventral Tissue.- 6. Step 6: Resecting the Roof of the Cavity.- 7. Step 7: Resection of Apical Tissue.- a) Preliminary Considerations.- b) Step 7 a: Apical Resection in the Immediate Vicinity of the Verumontanum.- c) Step 7 b: Extending the Resection Field Laterally.- d) Step 7c: Resecting the Ventral Apex.- 8. Aids to Resection of Apical Tissue.- a) Examining the Neck of the Empty Bladder.- b) Advancing and Withdrawing the Sheath (Wobble Test).- c) Recognizing Tissues Around the Apex.- d) Rectal Palpation. Around the Prostatic Apex.- ?) Advantages of Rectal Support.- ß) Disadvantages of Rectal Support.- ?) Pressing Indications for Rectal Support.- e) Faradic and Hydraulic Stimulation of the External Sphincter.- IV. Resecting Large Adenomas.- 1. Preliminary Considerations.- 2. Nesbit's Method.- a) Step 1: Formation of a Ventral Plateau.- b) Step 2: Cutting the Trench.- c) Step 3: Tissue Ablation.- d) Step 4: Resection Down to the Prostatic Floor.- e) Conclusion.- 3. Excavating the Cavity.- a) Basic Principles.- ?) Small Single Cuts.- ß) Extended Cutting.- b) Control of Instrument and Loop.- ?) The Linear Cut.- ß) Depth of Tissue Penetration.- ?) The Extended Cut: Three Elements Combined.- c) Determining the Depth of Cut.- ?) The Trench Method (Segmental Method).- ß) The Tangential Method.- 4. Resecting Endovesical Lateral Lobes.- a) Surgical Anatomy.- b) Resection Technique.- 5. Resecting Endovesical Median Lobes.- a) Surgical Anatomy.- b) Resection Technique.- 6. Barnes' Method.- a) Preliminary Considerations.- b) Resection on the Prostatic Floor.- c) Lateral Lobe Resection.- d) Conclusion.- 7. The Method of Alcock and Flocks.- a) Preliminary Considerations.- b) Removing the Median Lobe.- c) Removing the Lateral Lobes.- d) Removing the Ventral Tissue.- e) Resecting the Prostatic Apex.- f) Conclusion.- 8. Final Inspection at the End of Operation.- a) Inspection of the Bladder.- ?) Looking for Injuries.- ß) Looking for Retained Resection Chips and Coagula.- ?) The Large Free Fragment.- b) Inspecting the Cavity for Complete Clearance of Tissue.- ?) Scanning the Cavity Wall.- ß) Inspection of Paracollicular Tissue.- V. Resecting Outsize Adenomas.- 1. Preliminary Considerations.- 2. Points of General Technique.- a) Tissue Volume per Cutting Run.- b) Rapid Evacuation of Irrigating Fluid and Chips.- 3. Trocar Drainage.- 4. Resection According to Iglesias.- 5. The'Rasp' Technique of Reuter.- 6. Subdividing the Field into Cutting Zones.- 7. Marking Trenches.- 8. Optimal Hemostasis.- 9. Determination of Blood Loss.- 10. Encumbrance of the Surgeon.- 11. Nesbit Technique.- 12. Our Own Method.- a) Phase 1.- ?) Step 1.- ß) Step 2.- ?) Step 3.- ?) Step 4.- b) Phase 2.- c) Phase 3.- 13. Conclusion.- F. Hemostatic Technique.- I. Blood Loss During Transurethral Prostatic Surgery.- 1. Preliminary Considerations.- 2. A Method for Blood Loss Estimation.- 3. The Significance of Blood Loss Determination.- II. Arterial Bleeding.- 1. General Considerations.- 2. Surgical Anatomy.- 3. "Anatomical" Operative Techniques.- a) The Nesbit Technique.- b) The Technique of Alcock and Flocks.- c) Other Techniques.- 4. Detecting Hemorrhage.- a) Preliminary Considerations.- b) Instrument Factors.- c) The Value of Experience.- 5. Prerequisites for the Detection of Hemorrhage.- a) A Suitable Instrument (Habituation to a Preferred Instrument).- b) Resection Technique.- ?) Clear Visibility of the Resection Cavity.- ß) Dividing the Operation into Stages.- ?) Matching the Irrigation Rate.- ?) Position of Instrument and Cutting Loop.- ?) Immediate Closure of all Arteries.- c) Rationale for Immediate Hemostasis.- 6. General Rules for the Detection of Arterial Bleeding.- a) Finding Arteries During Resection.- b) Appearance of the Vessel Stump.- c) Multiple Arteries.- 7. The Technique of Coagulating Vessels.- 8. Special Problems of Hemostasis.- a) Arteries Spurting into the Instrument.- b) Ricochet Bleeding.- c) Bleeding from Behind a Tissue Eminence.- d) Bleeding Under Coagula.- e) Massive Hemorrhage.- f) Ventral Bleeds from the Vesicoprostatic Junction.- g) Poor Hemostasis in Previously Coagulated Tissue.- h) Arterial Bleeding at the Margin of a Venous Sinus.- i) Pseudohemostasis.- j) Hemorrhage in Distal and Proximal Extremities of the Field.- III. Venous Bleeding.- 1. General Considerations.- 2. Surgical Anatomy.- a) The Submucous System.- b) The Deep System.- 3. Detection of Venous Bleeding During Surgery.- a) Inspection of Irrigation Drainage.- b) Visible Blood in the Resection Field.- c) Inspection of the Resection Field.- 4. Closure of Venous Sinuses.- IV. Final Inspection of Hemostasis.- V. Summary.- G. Transurethral Bladder Surgery.- I. Introduction.- II. Morbid Anatomy.- III. Further Aspects of the Assessment and Classification of Bladder Tumors.- 1. Site Within the Bladder.- 2. Tumor Morphology.- a) Surface Structure.- b) Direction of Growth.- 3. Tumor Size.- a) Endovesical Tumor Bulk.- b) Diameter of the Tumor Base.- 4. Solitary and Multiple Tumors.- 5. Recurrence Rates.- IV. Assessing the Patient.- 1. Preliminary Considerations.- 2. History.- 3. Radiologic Investigation.- a) Excretion Urogram.- b) Cystogram.- c) Cystourethrogram.- d) Pelvic Angiogram.- e) Computer Tomogram.- f) Lymphangiogram.- 4. Ultrasound in Diagnosis.- 5. Cystoscopy.- a) Preliminary Considerations.- b) Diagnostic Cystoscopy.- c) Examination of the Internal Meatus.- d) Dynamic Cystoscopy.- e) Examination of the Ureteric Orifices.- f) Determining the Size of the Tumor Base.- g) Examination of Diverticula.- h) Vaginal (Rectal) Palpation During Cystoscopy.- 6. Bladder Biopsies.- a) Biopsy by Endoscopic Forceps.- b) Resectoscope Biopsy.- 7. Bimanual Examination Under Anesthesia.- V. Operating on Bladder Tumors.- 1. Preliminary Considerations.- 2. Coagulation of Bladder Tumors.- a) Preliminary Considerations.- b) Technique of Coagulation.- c) Local Anesthesia for Coagulation and Small Resections.- d) Healing After Coagulation.- 3. Electroresection of Bladder Tumors.- a) Preliminary Considerations.- b) Anesthesia for the Resection of Bladder Tumors.- c) Methods of Avoiding Obturator Stimulation.- d) High-Frequency Current for the Resection of Bladder Tumors.- e) Instruments for Resection of Bladder Tumors.- 4. Technique of Bladder Tumor Resection.- a) Horizontal Approach.- b) Vertical Approach.- c) Dividing the Stalk.- d) The Resection of Large Exophytic Growths.- e) Hemostasis.- 5. Special Types of Tumor Resection.- a) Resecting Tumors on the Posterior Wall of the Bladder.- b) Resecting Tumors on the Lateral Wall of the Bladder.- c) Resecting Tumors Close to the Internal Meatus in the Male.- d) Resecting Tumors Close to the Internal Meatus in the Female.- e) Resecting Tumors on the Bladder Vault.- f) Resecting Tumors of or Around the Ureteric Orifice.- 6. Tissue Recognition During Resection of Bladder Tumors.- 7. Systematic Tissue Sampling as a Guide to Complete Resection.- a) Single Sample with Directional Orientation.- b) Sampling in Tissue Layers.- c) Biopsy Technique for the Diagnosis of Carcinoma in Situ and Other Early Urothelial Carcinomas.- 8. Controlled Perforation.- a) Preliminary Considerations.- b) The Technique of Controlled Perforation.- c) Irrigation During Controlled Perforation.- 9. Resecting the Periphery of a Tumor.- 10. Palliative Resection.- VI. Accidents During Resection of Bladder Tumors.- 1. Preliminary Considerations.- 2. Types of Perforation.- a) Intraperitoneal Perforation.- b) Extraperitoneal Perforation.- c) Gas Detonation.- VII. Check Cystoscopy Following Transurethral Resection of Bladder Tumors.- VIII. Concluding Remarks on Bladder Tumor Resection.- IX. Other Transurethral Bladder Operations.- 1. Incising the Neck of Bladder Diverticula.- a) Preliminary Considerations and Indications.- b) Operative Technique.- 2. Injecting Drugs into the Bladder.- H. Special Resection Procedures Around the Bladder Neck.- I. Introduction.- II. Electroresection of Prostatic Carcinoma.- 1. Preliminary Considerations and Indications.- 2. Operative Technique.- a) Commencing the Operation.- b) Hemorrhage.- c) Evacuation of Chips.- d) Resection of the Prostatic Apex.- e) How Much to Resect?.- f) Resection for Recurrent Hemorrhage.- g) Resection of Necrotic, Infected Tumors.- h) Resecting Tumor Infiltrating the Bladder.- III. Resection for Bladder Neck Fibrosis.- IV. Resection for Outflow Obstruction in the Female Bladder.- 1. Preliminary Considerations.- 2. Symptoms of Female Bladder Outflow Obstruction.- 3. Diagnosis of the Disorder.- a) Cystoscopy.- b) Urodynamic Investigations.- c) Differential Diagnostic Considerations.- 4. Morbid Anatomical Change and Outflow Disorders of the Female Bladder.- 5. Treatment of Bladder Outflow Disorders.- a) Transurethral Resection.- b) Postoperative Treatment.- 6. Assessing the Operative Success Rate.- V. Resection and Prostatic Calculi.- VI. Resection and Prostatic Abscess.- VII. Resection and Chronic Prostatitis.- VIII. Resection and Prostatic Tuberculosis.- IX. Palliative Resection.- X. Electroresection in Patients with Cardiac Pacemakers, Artificial Heart Valves or Vascular Prostheses. By W. SCHÜTZ.- XI. Resection for Impaired Micturition Following Rectal Surgery.- XII. Resecting Papillary Tumors of the Prostatic Urethra.- XIII. Resection of Bladder Diverticula.- XIV. Resection and Bladder Calculi.- XV. Resection of Bleeding Adenomas.- XVI. Resection in the Presence of Bladder Tumor.- XVII. Resection Following Open Adenomectomy.- I. Litholapaxy.- I. Preliminary Considerations.- II. Preliminary Assessment of the Patient.- III. Indications.- IV. The Technique of Litholapaxy.- 1. Preliminary Considerations.- 2. Ultrasound Litholapaxy.- a) The'Aachen' Ultrasound Lithotrite.- b) Technique with the Ultrasound Lithotrite.- 3. Urat-I Litholapaxy.- a) Apparatus.- b) The Probe.- c) Hazards of the Technique.- d) Anesthesia for Pressure Wave Litholapaxy.- e) Instruments for Pressure Wave Litholapaxy.- f) The Technique of Electrohydraulic Litholapaxy.- 4. The Punch Lithotrite.- 5. Technique of Evacuation.- 6. Difficult Litholapaxy Due to Anatomical Factors.- 7. Postoperative Care.- K. The Zeiss Loop and the Placement of Indwelling Ureteric Catheters.- I. Extracting Ureteric Calculi with Endoscopic Instruments.- 1. Preliminary Considerations.- 2. Indications for Using the Zeiss Loop.- 3. Description of the Zeiss Loop.- 4. Introducing the Zeiss Loop.- a) The Standard Loop.- b) The Tilting Loop.- c) Checking Loop Position.- 5. Techniques of Calculus Extraction.- a) Traction Technique.- b) The Indwelling Loop.- 6. Hazards.- II. Placement of Indwelling Ureteric Catheters.- 1. Passing Plain Catheters.- 2. Indwelling Ureteric Catheters.- 3. Indications for Indwelling Ureteric Catheterization.- 4. The Double-J Catheter and Its Properties.- a) Technique of Catheterization.- b) Difficulties During Catheterization.- 5. Side Effects.- L. Endoscopic Procedures in the Urethra. By R. Hartung.- I. Introduction.- II. Internal Urethrotomy Under Direct Vision.- 1. History of the Procedure.- 2. Diagnosis of Urethral Stricture in the Male.- 3. Indications for Urethrotomy Under Vision.- 4. Undertaking Surgery.- a) Instruments.- b) Preoperative Preparation of the Patient.- c) Operative Technique.- d) Operative Difficulties.- e) Operative Complications.- 5. Postoperative Treatment Following Viewing Urethrotomy.- III. Endoscopic Laser Surgery to Urethral Strictures.- IV. Endoscopic Surgery for Urethral Tumors.- 1. The Problem.- 2. Technique of High-Frequency Surgery.- 3. Technique of Laser Coagulation.- V. Endoscopic Correction of Cicatricial Bladder Neck Stenosis.- 1. Introduction.- 2. Diagnosis.- 3. Indications for Surgery.- 4. Operative Technique.- VI. Endoscopic Submucous Bladder Neck Infiltration with Teflon in the Treatment of Urinary Incontinence.- 1. Introduction.- 2. Operative Technique in the Male.- 3. Operative Technique in the Female.- M. Urethral Dilatation.- I. Preliminary Considerations.- II. Bougies and Dilators.- III. Patient Assessment.- IV. Dilating the Urethra.- 1. Blind Dilatation.- 2. Dilatation Under Direct Vision.- a) Preliminary Considerations.- b) Technique.- 3. Repeated Dilatation as Definitive Treatment.- 4. Golden Rules of Dilatation.- N. Postoperative Management.- I. Management Following Normal Conclusion of Surgery.- 1. Passing the Indwelling Catheter.- a) Preliminary Considerations.- b) Catheterization After Satisfactory Hemostasis.- c) Catheterization in the Presence of Venous Hemorrhage (Venous Sinuses) ...- 2. Irrigating the Bladder.- 3. Evacuating Clots from the Bladder.- 4. Vigorous Reactionary Hemorrhage on the Day of Operation.- 5. Postoperative Fluid Intake (Management of Irrigating Fluid Overload).- 6. Management of Urinary Infection.- a) Preliminary Considerations.- b) Paraurethral Abscess.- c) Severe Urethritis.- d) Cavernitis.- e) Epididymitis.- 7. Postoperative Mobilization.- 8. Removing the Catheter.- 9. Assessing the Result.- 10. Recatheterization.- 11. Postoperative Medication.- 12. Repeat Resection for Poor Stream.- II. Postoperative Management of Operative Complications.- 1. Postoperative Management of Perforation.- a) Postoperative Management of Extraperitoneal Perforation.- b) Postoperative Management of Intraperitoneal Perforation.- 2. Postoperative Management of Ureteric Orifice Trauma.- 3. Postoperative Management of External Sphincter Injuries.- 4. Postoperative Management of the TUR Syndrome.- III. Postoperative Complications.- 1. Preliminary Considerations.- 2. Persistent Oozing.- 3. Moderate Hemorrhage.- 4. Mild Hemorrhage.- 5. Microscopic Hematuria.- 6. Infective Problems.- 7. Catheter-Induced Bladder Spasm.- a) Regulating Catheter Position.- b) Drug Therapy.- 8. Urge Incontinence.- IV. Late Complications After Transurethral Surgery.- 1. Preliminary Considerations.- 2. Urethral Stricture.- 3. Internal Meatal Stenosis.- a) Preliminary Considerations.- b) Treatment.- ?) Retrograde Incision with the Resectoscope Loop.- ß) Incision by Wire Probe.- ?) "Cold" Incision with the Sachse Knife.- 4. Recurrence of Urinary Symptoms.- 5. Unyielding Urinary Infection.- O. Learning and Teaching Transurethral Operative Technique.- Color Plates.- References.