HOME > operative reports > Urology

operative reports

Urology

* Our thanks to Medscape for allowing reproduction of this procedure. (Please see copyright information and references at end of report.)

OPERATIVE PROCEDURE:

After a suitable level of general anesthesia was reached, the operative field was prepped and draped for surgery. A traction suture of 5-0 silk was taken through the glans. The skin overlying the 1 cm of urethra proximal to the distal penile meatus was extremely thin and attenuated. Marked chordee was present.

A circumferential coronal incision was made and carried around, leaving lateral mucosal wings to rotate ventrally subsequently. By sharp tedious dissection, the very thinned skin overlying the distal urethra was dissected free of its attachments to the urethra and the distal shaft. Moderate bleeding was encountered in the region of this dysplastic corpus spongiosum. The shaft skin was sharply stripped down to the base.

An artificial penile erection was produced by putting a vessel loop tourniquet at the base, and then inserting a 25-gauge butterfly needle into the corpora, injecting normal saline. This showed a moderate degree of distal chordee. The ventral tissue on either side of the dysplastic urethra was excised further. Mild residual chordee remained, and it was elected to perform a contralateral dorsal wedge excision of Buck fascia with a dorsal tilt. The midline neurovascular bundle was marked and, at a suitable point where the maximal bend was encountered, a triangle of Buck fascia was excised on either side of the midline dorsal neurovascular bundle. These triangles were then closed to themselves with interrupted 5-0 Mersilene sutures. Repeat artificial erection now demonstrated perfect straightening.

Attention was then turned to the urethra. The thin distal urethra was intact, and the urethral meatus was present in a subcoronal position. The urethra calibrated to a #8 French. It was noted that enough glans, urethra and mucosa were present in order to tubulize the urethra to advance it more distally on the glans. With a #8 sound in place, careful markings on the glans were made to bring a midline mucosal island together. With a tourniquet on the shaft, these incisions were then marked and lateral glans wings were dissected laterally. The midline urethral mucosa was then tubulized to itself with a running 7-0 Vicryl suture. The surrounding tissue at the base of the closure was then brought together with tissue overlying the more proximal urethra in order to cover the thin mucosal aspect of the distal, unconstructed urethra. These maneuvers advanced the meatus to the tip.

The glans wings were then brought together over it with interrupted 6-0 Vicryl sutures. The neourethra was sewn to the glans mucosa with interrupted 7-0 Vicryl, and the epithelium of the glans was closed with running 7-0 Vicryl.

The shaft skin was then sharply split down the middle for a distance, and the right lateral wing was rotated ventrally off to the left in order to fill the gap. The subcutaneous tissue was closed to itself with interrupted 6-0 Vicryl, and the skin was closed to itself and to the coronal mucosa with interrupted 6-0 Vicryl. Prior to doing this, the coronal mucosal wings were brought together in the midline, suitably trimmed, and then closed to themselves with interrupted 7-0 Vicryl.

At the end of the procedure, a #8 Firlit drip stent was positioned in the bladder, and sewn to the glans with 2 interrupted 5-0 nylon sutures. The penis was dressed with Xeroform, bacitracin ointment, Elastomull and Bioclusive dressing. Double diapers were applied.

Sponge, needle and instrument count reported as correct. The patient then awakened from anesthesia after the anesthesiologist performed a caudal block, and went to the recovery room in satisfactory condition.

OPERATIVE PROCEDURE: Circumcision

PREOPERATIVE DIAGNOSIS: PHIMOSIS
POSTOPERATIVE DIAGNOSIS: SAME
ANESTHESIA: GENERAL
ESTIMATED BLOOD LOSS: NONE
COMPLICATIONS: NONE
DRAINS: NONE
SPECIMENS: FORESKIN TO PATHOLOGY

INDICATIONS: Eleven-year-old with phimosis, which is symptomatic and requires circumcision.

FINDINGS: Phimosis.

PROCEDURE: The patient was taken to the operating room. After the induction of general anesthesia, placed in the supine position and prepped and draped in the usual sterile fashion.

The foreskin was able to be retracted after the patient was asleep, and the glans was also prepped. After draping, the foreskin was retracted and the frenulum was found to be tethering the glans. We dissected out the frenulum, divided and cauterized this very carefully, straightening out the penis.

We then made a circumferential incision approximately 1 cm proximal to the glans with the foreskin retracted; we took this through the skin. We then replaced the foreskin in its normal position and made a mirror-image circumferential incision around the coronal sulcus. We connected both incisions sharply and sharply removed the foreskin. We then achieved meticulous hemostasis with electrocautery. We took great care to avoid injury to the deep structures or the urethra.

After satisfactory hemostasis, we approximated the skin with 4-0 chromic interrupted sutures with a U-stitch ventrally.

At the termination of the procedure, there was excellent hemostasis. The glans was healthy. There was a good cosmetic result. We placed 3 mL of 0.25% Marcaine without epinephrine circumferentially around the base of the penis for a ring block. We sterilely dressed the wound.

The patient tolerated the procedure well and was transferred to recovery in good condition.

OPERATIVE PROCEDURE:

FINDINGS: Endoscopy and x-ray revealed grossly normal upper tracts. However, the bladder seemed to be diffusely inflamed and covered with some kind of mucoid granulomatous covering with multiple small white, granulomatous tags, which were biopsied. There was one area that looked like a broad-based papillomatous area, which this also was biopsied to rule out carcinoma, especially carcinoma in situ. There was no other gross pathology noted.

PROCEDURE: Following induction of anesthesia, the patient was placed in the lithotomy position, prepared and draped in the usual fashion.

Endoscopy was performed using a #21 Storz panendoscope with the findings as described above. Cone-tip pyelograms were unremarkable. The areas, as described above, were biopsied and involved almost the entire bladder. The area biopsied was cauterized.

OPERATIVE PROCEDURE: Cystoscopy/Transurethral Prostatic Vaporization

With intravenous gentamicin and Kefzol antibiotic prophylaxis, the patient was placed in the dorsal lithotomy position, and prepped and draped in a sterile fashion.

A #25 French Circon continuous-flow resectoscope was passed per urethra without difficulty. The urinary bladder demonstrated 2 to 3+ trabecular changes diffusely. The right and left ureteral orifices were AO, normal in location and appearance. A significant intravesically projected supracervical median prostatic lobe was present. Lateral lobar anatomic obstruction was also noted. The prostatic urethral length was approximately 3 cm. Mild inflammatory changes were noted, compatible with previously indwelling urethral Foley catheter. No evidence of intravesical calculi nor neoplasia was identified.

Using a VaporTrode, the obstructive prostatic tissue was electrovaporized. Hemostasis was similarly achieved using the VaporTrode. Cutting current of 250 and a coagulation current of 60 with pure cut were the settings used.

The patient tolerated the procedure well. Upon successful vaporization, the resectoscope was withdrawn, after obtaining one small specimen by undermining tissue with the Vaportrode during the course of the procedure. An excellent passage of efflux of irrigating fluid was noted per urethra. Excellent hemostasis was in evidence.

A #22 French 3-way urethral Foley catheter was then easily introduced without difficulty. The balloon was inflated to 10 mL and continuous bladder irrigation established.

*VaporTrode - New term - See FOUND - New Surgical Terms

OPERATIVE PROCEDURE: Laparoscopic Bladder Neck Suspension

Trocar placement may vary according to the preference of the surgeon. Usually, a 10-mm trocar is placed through an intraumbilical incision and another 10-mm trocar is placed suprapubically, followed by two 5-mm trocars placed laterally. Laparoscopes with different viewing angles are available. The selection of a straight or angled optic is the surgeon's personal choice. We prefer the straight, forward optic.

After establishment of the pneumoperitoneum and insertion of the trocars, the initial landmarks are visualized. The most important one is the left umbilical ligament, which delineates the lateral border of the dissection. The Foley catheter is easily visible and helps in locating the bladder. In a patient with multiple surgeries, locating the bladder is sometimes difficult. Normally, the pubic bone can be seen, even in very obese patients. Even if it is not well visualized, it can be located by gentle probing with a surgical instrument.

Use of the pubic bone as the inferior border of the initial incision into the peritoneum allows the surgeon to avoid the superior vesical artery, which runs anterior to the round ligament but slightly below the level of the pubic bone. Also, the venous plexus along the symphysis is a significant structure and will bleed profusely if incised. Avoiding these vascular structures is important because the bleeding may result in difficulty in visualizing the tissue planes, thereby increasing the difficulty of the procedure.

The initial incision is made immediately medial to the left umbilical ligament, above the pubic bone. The first step is to reach the pubic bone. Although it may seem that several tissue planes must be incised, the distance between the peritoneum and the pubic bone is short, even in obese patients. The surgeon should maintain a plane perpendicular to the pubic bone. There is a tendency to shift toward the midline too early, which leads to bladder injury.

Once the pubic bone is reached, the assistant inserts a blunt instrument into the incision and retracts the bladder to the right (mirror image for a left-handed surgeon). This facilitates entry into the space of Retzius. With minimal traction and blunt dissection, the entire space is opened, and all anatomic structures can be identified bilaterally. Occasionally, the urachus may interfere with the dissection and must be transected. The anatomic structures that can be identified at the completion of the dissection are the urethra, the bladder neck, the paravaginal tissue, the obturator muscles, the pubourethral ligaments, and the pubic bone and its symphysis and ligaments. Cooper's ligament is not as easily identified, and a wide dissection of the pubic bone may be required.

At this point, either the MMK (Marshall, Marchetti, Krantz) or Burch procedure can be performed. The placement of the suture into the paravaginal tissue is identical for either procedure. The operator places the left hand into the patient's vagina, displacing the bladder neck toward the left of the patient for application of the right-sided suture. The vaginal wall is only minimally elevated with the vaginal hand; otherwise, the space between the vagina and the pubic bone is reduced. The suture is placed at the urethrovesical (UV) junction just as in the open procedure. The needle (Ethibond 2/0 - 36 inches) is introduced through the suprapubic 10-mm trocar and the needle holder is passed through the left lateral trocar; then the needle is grasped and inserted into the space of Retzius. The right-sided stitch is placed first as described above.

Because the laparoscope is situated exactly on top of the bladder neck, visualization of the anatomical detail is excellent and allows this suture to be placed with extreme precision.

Because of the inherent limitations of laparoscopy with lack of depth perception and restricted access, the next step is the most difficult. This is the placement of the suture into Cooper ligament or into the symphysis, depending upon the procedure. The problem is that because of the lack of depth perception, the suture may be anchored too low onto the bone, thereby achieving only minimal elevation of the bladder neck. Manipulation of the bladder neck with the left hand in the patient's vagina will compensate for the lack of depth perception to a certain extent.

Knotting is best performed using the extracorporeal technique. Tension on the suture is minimized by elevating the vaginal wall during tightening of the knot. The knot may be tied by the surgical assistant, or the surgeon may change gloves and tie the knot. The right-sided stitch is placed and tightened before placement of the left-sided suture. A stitch is placed on each side at the level of the UV junction. In patients with a moderate cystocele, 2 sutures may be placed, with the 2nd suture placed lateral to the 1st as described by Burch. There is no technical difficulty in placing more than 1 suture on each side. The number of sutures placed depends upon the surgeon's preference and the patient's anatomy. Burch described the original procedure with placement of 3 sutures. The number of supporting sutures required in relation to outcome has not been studied.

End of Procedure

This procedure was reproduced with written permission from Medscape. Copyright 1994, 1995, 1996, Medscape, Inc. All rights reserved. This information is selected from Laparoscopic Bladder Neck Suspension on Medscape, the online resource for better patient care.

OPERATIVE PROCEDURE: Ultrasound-Guided Transperineal Permanent Palladium-103 Implantation of the Prostate

PREOPERATIVE DIAGNOSIS: ADENOCARCINOMA OF THE PROSTATE
POSTOPERATIVE DIAGNOSIS: SAME
ANESTHESIA: SPINAL

PROCEDURE: The patient was placed in an extended dorsal lithotomy position. Foley catheter was inserted and the scrotum was retracted onto the anterior abdominal wall. The area was prepped and draped in the usual sterile manner.

Transrectal ultrasound was attached to the fixation device and inserted into the rectum to mimic the preplanning diagram. The template was then attached. A total of 13 hollow, 18-gauge trocars were inserted by the urologist. Once that placement was confirmed, I then inserted a total of 60 palladium-103 seeds. There were 25 seeds with an activity of 1.07 mCi and 35 seeds with an activity of 1.34 mCi. The total activity was 73.2 mCi, with an average activity per seed of 1.22 mCi.

The patient tolerated the procedure well. There was minimal blood loss.

A postimplant cystogram was performed by the urologist and revealed the seeds to be in excellent position. The patient went to the recovery room in stable condition. Followup dosimetry is arranged.