Surgical Procedures

Adult Circumcision

A biopsy is conducted by removing a sample of skin or tissue from a patient’s body for examination under a microscope to diagnose a medical condition.A biopsy can be obtained of the skin by removing a small amount of tissue with a special instrument. This can be done with local anesthesia to avoid pain. Biopsies of the prostate or kidney are typically obtained with specially designed needles that allow for the removal of small amounts of tissue. The needle is guided with ultrasound or special X-rays such as a CT scan. Biopsies can also be obtained from the bladder or ureter with specially designed endoscopes that are passed into these structures through normal urine passageways.After the biopsy specimen is obtained, it is sent for examination to a pathologist, who prepares a written report with information designed to help the doctor manage the patient’s condition properly.

Cystoscopy and Stent Placement Retrograde Pyelogram

Cystoscopy, or cystourethroscopy, is a procedure that enables a urologist to view the inside of the bladder and urethra in great detail. It is commonly used to diagnose bladder tumors, identify obstruction of the bladder and look for any abnormalities of the bladder and its lining.

The procedure is usually performed as an outpatient procedure in a urology clinic or treatment room. Prior to the procedure, the patient will need to empty their bladder and will then be positioned on an examination table. After administration of local anesthesia, a cystoscope is inserted through the urethra into the bladder. The cystoscope is a thin, lighted tube that is either flexible or rigid. Water or saline is then instilled into the bladder through the cystoscope. As the fluid fills the bladder, the bladder wall is stretched thus allowing detailed viewing by the urologist. Under normal conditions, the bladder wall should appear smooth and the bladder should be normal size, shape and position and there should not be any blockages. If any tissue in the bladder wall appears abnormal, a small sample can be removed through the cystoscope to be analyzed.

The average cystoscopy takes about 10 to15 minutes.

After the cystoscope is removed, the patient’s urethra may be sore and they may feel a burning sensation for up to 48 hours. If discomfort persists, fever develops or urine appears bright red, a physician should be notified.

Cystoscopy with Internal Optical Urethrotomy (IOU)

Definition

cystoscopy = placing a small telescope into the bladder

internal = within a structure (in this case the urethra)

optical = under direct vision through the scope

tomy = “tome” or to cut

This procedure is done to open up a stricture (scar tissue) in the urethra.

The most common reasons to have a stricture are:

  • a history of prior urethral procedure
  • an old injury to the urethra
  • history of gonorrhea or other infection (urethritis) involving the urethra

Soft strictures and scars that are very short may respond to simple office dilatation (gentle spreading with specialized instruments). Other may need a more formal procedure to maximize results and diminish the incidence of recurrence. Strictures can occur in different places throughout the length of the urethra. They also range in length. Success of the procedure correlates with location of the stricture, shorter length, and whether this is the first IOU procedure. Re-do procedures and those for longer strictures have a higher failure rate.

The symptoms characteristic of a urethral stricture are those of “obstructive” urination pattern.

The most common symptoms are:

  • straining (need to push to begin urination)
  • hesitancy (delayed onset of urination following the urge to urinate)
  • slow or diminished force of stream
  • a thin or forked (split or coming out as a spray) stream
  • intermittence (urine stream that starts and stops)
  • sensation of incomplete emptying

Other symptoms that may be associated are what we call irritative symptoms and include: frequency of urination, urgency to urinate and nocturia (getting up at night to urinate).

Preparation

There is no particular preparation for this procedure. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time. For simple office dilatation procedures, you may eat prior to the procedure.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water.

If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti- inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The actual procedure usually takes less than one hour depending on the length, density, and location of the stricture. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters called stirrups). If the extent of the stricture is not clear, we might do a special x-ray (urethrogram) by injecting contrast dye into the urethra through a catheter. This may have already been done prior to the day of the IOU. If we realize that the length of the stricture is too long to safely or effectively perform an IOU, we may stop the procedure at this point.

After the urethrogram, the cystoscope (which has continuous fluid running through it) is carefully inserted up to the area of the stricture. We may insert a small wire through the tiny, scarred opening to act as a guide. The stricture is sometimes opened with a tiny knife. In other instances, we may use a special type of blade instrument that has an electric current. Lastly, certain types of lasers are useful in opening scar tissue. Once we are satisfied that the channel is sufficiently open, we advance the scope into the bladder. We then examine the bladder to ensure that everything is within normal limits. At the end of the procedure, a catheter may be placed into the bladder to allow proper healing of the opened channel.

Post Procedure

If the procedure is done in a hospital or ambulatory center, you will be in the recovery room until you are ready to be discharged home. If done in the office, you will be sent home shortly after the procedure.

It is normal for you to feel a sense of urgency to urinate. This is from the procedure and from the presence of the catheter. In most patients, this resolves within a couple of hours, but could last until the catheter is removed. Some patients require medications to help relax the bladder while the catheter is in. Your catheter will be attached to a bag. The urine will either be clear or minimally tinged with blood. The bag can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. You will usually be given a larger bag for overnight urine collection while you are sleeping. We assure you that it is quite simple.

Sometimes, we may instruct you on how to catheterize yourself (to dilate the scar periodically) for a period of time after the procedure.

Expectations of Outcomes

Usually, patients are very satisfied after the procedure. The improvements that are typically noted immediately after the operation are:

  • stronger force of stream
  • decreased standing around waiting for the urination to commence
  • decreased need to push
  • loss of forking (splitting) of the urine stream
  • loss of intermittence (i.e. where the flow used to start and stop and start, etc.)
  • loss of the sensation that you are “not really emptying your bladder”

Occasionally, it may be difficult to control the urine for a period of time. You may notice that you are still voiding frequently and with some urgency (sensation that forces you to get to the bathroom quickly). These symptoms can take a long time to disappear. In patients that were significantly obstructed for a prolonged period, these symptoms may never fully resolve.

Nocturia (getting up at night to urinate) is typically the last symptom to resolve. In many instances, it may become less frequent, but never fully disappear. The reason is that nocturia can be due to dozens of other physiological issues and also because the night-time ritual becomes somewhat habitual.

*Uncommonly, the stricture cannot be opened. The two most common reasons are that it is too long and dense, or that a wire cannot be successfully passed beyond the area. In certain cases of the latter, it may be risky to cut the scar “blindly”. If this were the case, we may need to place a suprapubic catheter into your bladder. A suprapubic catheter is a small tube that is inserted into the bladder through a tiny hole in the lower abdomen. It, too, would be initially attached to a drainage bag. The tube would remain temporarily until further management is discussed with you in the office. Please refer to the literature on suprapubic catheter placement.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes, which may include, but are not limited to:

  • Hematuria (Blood in the Urine): Typically, there is no bleeding from this procedure. In rare instances, a blood vessel may open. The bleeding is almost always minimal and self-limited. Rarely, the bleeding may form small clots that would need to be irrigated out through the catheter. Recurrent bleeding following removal of the catheter is very uncommon.
  • Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation.

This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.

If you have symptoms of any of the above, you must contact us immediately or go to the nearest emergency room.

  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as an IOU. However, in any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain.

We may sometimes ask the medical doctors to be involved with the management of either of these problems:

  • Recurrent Urethral Stricture: A recurrence of the stricture can occur weeks, months, or even years after this sort of procedure. Each time the procedure is repeated, the incidence of recurrence is greater. The incidence of recurrence is also proportional to the initial length of the stricture being opened.
  • Urinary Incontinence: If your bladder was obstructed for years by a stricture, and possibly also by your prostate, it may have learned to over-compensate by squeezing with more force. The bladder is a muscle, and like any other muscle, it thickens and gets stronger with more work. Now that the obstruction is gone, it can take weeks or longer for the bladder to readjust. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel.
  • Incontinence, however, is quite rare after an IOU procedure because the sphincters controlling the continence are more proximal (closer to the bladder) than is the urethral stricture.
  • Urinary Retention: Sometimes a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If you presented with long-standing urinary retention (complete inability to urinate), this may not resolve following an IOU procedure. Patients whose retention was more sudden and painful are quite likely to void after the procedure.
  • Perforation: If the incision or cut is deep, a hole can be made through the urethra. This actually may be a desired result in cases of severe, dense strictures. In this regard, it is not necessarily a complication. This finding does not change the course of the case. It heals within a few days to a week over the catheter that is left in place anyway.
  • Occasionally, fluid from the scope can go through the hole and cause swelling of the penis. The treatment, again, is to leave the catheter in for a few days, perhaps institute a short course of antibiotics, and just allow the swelling to resolve over the next 1-3 days.
  • Erectile Dysfunction: According to the literature, anywhere from 1-2% of patients complain of some degree of erectile dysfunction (ED or impotence) after any instrumentation of the urethra.

This problem has always been quite puzzling to urologists in that a sound “cause and effect relationship” has not been demonstrated. It is more common when water has caused swelling of the penis.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Cystoscopy with Urethral Bulking Agent Injections

Definition

cystoscopy = placing a small telescope into the urethra and urinary bladder

urethra = tube from the bladder through which you urinate

bulking agent = a substance used to thicken or bulk-up tissue

There are different types of bulking agents currently in use. The type used in you will depend on your surgeon’s preference as well as on your full understanding of the pros and cons of each type. If collagen (protein substance derived from an animal) is going to be used, you will undergo a small-dose test injection (under the skin on your arm) to ensure that you have no allergic reaction to the substance.

The indication for this procedure is to correct urinary incontinence (the involuntary loss of urine). The procedure is performed in both females and males. Although there are different types of urinary incontinence, urethral bulking injections are primarily used to correct Type III incontinence (commonly referred to as intrinsic sphincter deficiency or ISD). Essentially, this type of incontinence is when the inner walls of the urethra lack adequate closure (the “pressing-together” of the walls to obstruct the flow of urine). Patients with ISD typically leak urine easily and often continuously. In the most severe of circumstances, a patient would never actually feel the need to urinate because their bladder is always empty from the constant leakage. While there are many causes, most patients with ISD have a history of radiation treatments to the pelvis or a prior history of prior surgery to correct stress urinary incontinence.

Other risk factors include a post-menopausal state (loss of estrogen causes the tissue to atrophy or “thin-out”) and perhaps a history of smoking. In men, there may have been a history of prostate surgery for either benign enlargement (BPH) or for cancer. Urethral collagen injections may also be appropriately used in patients with mixed incontinence (different types of incontinence contributing to the overall leakage) if it is thought that ISD is one of the contributing factors. In other words, if one aspect is corrected, the other types of incontinence may not be severe enough to cause significant leakage.

In almost every instance, a patient will have undergone a urodynamic test (special computerized test on the bladder and urethra) to determine the presence of ISD. By the time this injection procedure is recommended, medications or special exercise therapies may have been tried and have failed or been poorly tolerated. Urethral injections are very minimally invasive and can be done in a hospital or even office-procedure setting. The level of anesthesia used will depend on the physician’s and patient’s preferences. It can be done with just some local numbing medicine and/or with some sedation. If heavy sedation is going to be used, the procedure would have to be done in a hospital setting.

Preparation

If for some reason you are having your procedure done under sedation (as opposed to just local anesthesia), you will be asked not to eat or drink anything after midnight on the evening prior to your procedure. You may brush your teeth in the morning but not swallow the water.

If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

Urethral bulking injection(s) usually take less than half an hour depending on how many injections will be administered. Your position on the table will be lithotomy (flat on your back with your legs gently elevated in holsters called stirrups).

A cystoscope (small telescope used to look in the urethra) is placed into the urethra and the urethra and bladder are once again examined. The scope is then positioned at the point where the injection(s) is/are going to be administered. If local anesthesia is going to be used, a small needle will be used to inject numbing medicine into the areas that are going to receive the bulking agents. In some instance, the numbing medicine may be injected through the skin of the perineum (area outside of the urethra in front of the anal region) prior to putting the scope in.

The needle for the bulking agent injection(s) can be passed directly through the scope or alongside the scope depending on the surgeon’s preference. The material is injected into the inner walls of the urethra under direct vision until the surgeon is satisfied with the degree of thickening of the wall. The location of each injection, the number of actual injections, and the total amount of bulking agent used will vary with each patient’s anatomy and degree of incontinence.

Once the surgeon is satisfied that there is proper closure of the tissue, the procedure is over.

Post Procedure

After the procedure, you will be observed for a short time prior to going home. If you had sedation in the hospital, you may need to be observed for a longer period than if you only had local anesthesia.

We will let you go home when we believe you are ready from an anesthesia standpoint; or, we may observe you until we see you urinate on your own. Sometimes the bulking agent (possibly combined with some swelling from the scope itself) may cause urinary retention (the inability to urinate). If you are still under our supervision, we will catheterize you to empty your bladder. If you have already gone home, you will need to return to the office or hospital in which the procedure was performed. If you require catheterization, we will usually remove the catheter after your bladder is emptied so that you can try again.

*If you return to an emergency room with complaints of urinary retention, please do not allow a catheter to be placed until the emergency room physician speaks with your urologist first.

You have no real restrictions after the procedure. If you received sedation, you should stay at home and rest for the remainder of the day. Certainly, you should not drive or operate any machinery. You may shower, bathe, or swim. It may burn or sting the first few times that you urinate.

You may also see a blood-tinge or discoloration of your urine for 1-2 days. This is not uncommon. Your stream may be a bit slow or intermittent (start and stop) the first few times that you urinate as well.

Expectations of Outcome

Most patients are quite satisfied with the results of the procedure in that they are significantly or completely improved.

There are many possible outcomes, however, and they are as follows:

  • The first treatment may be a complete success in that you urinate well and do not leak at all.
  • It may be a partial success in that you urinate well but still leak a little.
  • It may be that you don’t leak at all but have difficulty passing your urine (slow or obstructed stream).
  • It may not have worked at all in that your leakage is not improved.
  • It may be a complete or partial success for a while and then the leakage recurs in the future.

In other words, results are not always predictable. In cases of severe incontinence, more than one treatment is often necessary. Repeat future treatments may also be needed.

Permanent urinary retention is extremely rare.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to: Urinary Retention (Inability to Void): As previously mentioned, it is possible to have too much closure and actually be unable to void. Usually this is corrected by one or a
few catheterizations. A permanent problem is extremely rare.

  • Urinary Tract Infection or Urosepsis (Bloodstream Infection): Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate.

This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.

If you have high temperatures or any symptoms of severe illness (fevers, shaking chills, weakness or dizziness, nausea and vomiting, confusion) let your doctor know immediately and proceed to the nearest emergency room.

  • Bleeding: There is usually a tiny degree of blood in the urine for a day or so. Prolonged bleeding is very rare and almost always responds to observation alone.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office.

Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional.

While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Cystoscopy, Cystoscopy with Biopsy, and Cystoscopy with Removal of Stent

Definition

Cystoscopy, except in special circumstances, is an office-based procedure. Simply put, it is the placement of a small telescope into the bladder by way of the urethra (the tube through which you urinate). Because the urethra is fully visualized as well, it is sometimes referred to as cystourethroscopy. The scope provides lighting and magnification so that we may carefully examine the anatomy inside. With this minor procedure we are able to see tumors, areas of inflammation, abnormal variations in anatomy, stones, drainage of urine from the kidneys into the bladder, etc. The procedure takes just a few minutes and can be done using only numbing jelly to minimize discomfort.

Through the cystoscope, we can pass instruments to take biopsies (tissue samples) of areas that we believe are abnormal. Small biopsies can sometimes be done in the office. An area that we biopsy can also be cauterized (burned) if there is any bleeding. Cauterization can also be used to kill cells that we perceive to be abnormal. Patients who undergo hospital procedures for kidney stones often have a stent placed during the procedure. This is a plastic tube that goes from the kidney down to the bladder. Except for unusual circumstances, we can remove a stent in the office while doing a cystoscopy.

Occasionally, patients request sedation (relaxing medication) for biopsy procedures or stent removals. If you are anxious, please let us know during the consultation so that we may consider sedation if we feel it is appropriate.

Preparation

There is no particular preparation for a cystoscopy. While it is not absolutely necessary, we would prefer that you have someone to drive you home. Some patients unexpectedly feel light-headed or uncomfortable after any procedure. If you do not have anyone available, we may ask that you relax for a while in our waiting room after the procedure before going home.

*If you had any sedation given, you must have somebody drive you home. For your own
safety, we will make few exceptions.

*For women of child-bearing age, it is important that you are not pregnant. Please let us know if there is any suspicion that you may be. While cystoscopy itself is not contraindicated in pregnancy, we would prefer to know prior to the procedure. We may decide to give you a dose of an antibiotic tablet. We may check a urine pregnancy test prior to the procedure.

Procedure

To review the basics of what we discussed in the office: The actual procedure typically takes a few minutes for a plain cystoscopy. Removal of a stent may add a bit more time. Biopsy(s) and possible cauterization can add more time.

We may decide to give you an antibiotic tablet just before or after the procedure. We will have you lie on your back with your legs in stirrups (holsters). Your urethra will be cleaned with an antiseptic to create a sterile field. Numbing jelly may be placed in your urethra and allowed to remain for a short time. Next, the scope is guided through the urethra (under direct vision) and into the bladder. Some urologists will look directly into the end of the scope. In other cases, a camera will project the image onto a small television screen. In a simple cystoscopy, we would remove the scope once we visualized all of the important areas. If a biopsy is to be taken, you might feel a little pinch when the tissue is grabbed. After the tissue is removed, we may cauterize (burn) the area with a special instrument. Again, you may feel a little sting. When a stent is removed, you may feel a twinge of discomfort in the area of the kidney. The stent typically comes out in just seconds.

Post Procedure

After the procedure, you might have a little stinging in the urethra until the next time you urinate. In some patients, it may last a bit longer. While it is quite unusual to see any blood in a female patient (except in some cases of stent removal), we occasionally see blood after cystoscopy in men. This is more common in men with large and obstructing prostates, in situations where the urethra contains a stricture (narrowing due to scar tissue), or again in cases of stent removal.

You have no restrictions after a cystoscopy and may even return to work if you choose. Ideally, we would prefer that you take it easy at home for the remainder of the day or evening.

If you received sedation, we insist that you return home with your family member or friend and relax for the remainder of the day or evening.

Expectations of Outcome

If a biopsy is performed, the specimens are sent to a pathology laboratory for evaluation by a trained pathologist. We understand that you are anxious to have the results and ask for your patience. We will call you as soon as they are available to us.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to: l Urinary Tract Infection or Urosepsis (Bloodstream Infection): Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate.

This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill.

This type of infection often presents with the urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may need a short hospitalization for intravenous antibiotics, fluids, and observation.

This scenario is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.

If you have symptoms of any of the above, you must contact us immediately or go to the nearest emergency room.

  • Blood Clots in the Urine: Rarely, the scope can traumatize a blood vessel on the surface of the prostate or less commonly in the bladder. In this instance, you may develop hematuria (blood in the urine). In patients having a biopsy, we rarely have any significant bleeding because we only take small samples. There are instances where a scab (from the cauterization) can fall off and a patient subsequently develops hematuria one or a few days later. In almost all instances, the urine clears on its own over the next few days. Ongoing bleeding with the development o clots is uncommon. If the clots block the bladder, a catheter may need to be inserted to flush out the clots. If bleeding persists, we may have to look back in the bladder to control or cauterize the bleeding.
  • Urinary Retention: In men, pressure from the scope can occasionally cause swelling of the prostate. It may block the flow of urine and cause “retention”. This is more common in men with a prior history of an enlarged prostate (BPH) or difficulty urinating. In most circumstances, it resolves with a catheter over the next few days. Less commonly aremedications or a prostate procedure required.
  • Perforation: The wall of the bladder can be perforated from a biopsy. In most cases, all we need to do is leave the catheter in for an extra few days to allow self-healing. If the perforation occurs in a specific area of the bladder, we may need to perform a formal bladder repair through an incision in the abdomen, or place a drainage tube in the lower abdomen to evacuate this fluid.
  • Inability to Pass the Scope: Occasionally, a severe stricture (scar in the urethra) or bladder neck contracture (full circumference scar at the neck of the bladder) may prevent safe passage of a scope into the bladder. In these instances, we would remove the scope and perhaps suggest a cystoscopy procedure in the hospital using anesthesia.
  • Inability to Remove a Stent: It is quite unusual that we cannot easily remove a stent. In patients that have had a stent in place for a long time, or in patients that have made stones that stick to the stent, it can quickly become difficult to remove in the office. If we notice resistance to removal of the stent, we will remove the scope and recommend that the procedure be done under anesthesia in the hospital. Sometimes, other procedures are necessary. In rare instances, the ureter (tube that transports urine from the kidney to the bladder) can be injured during a difficult stent removal. Treatments may include replacement of a new stent, placement of a tube or stent through the back and into the kidney, or even open surgery to repair the injury if it is severe.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Excision of Urethral Diverticulum

Definition

Urethra = the tube through which one urinates

Diverticulum = an out pouching or small pocket due to a defect in the wall of the urethra

Urethral diverticula are far more common in women than in men. Their exact cause is unknown but may include one or a combination of infections in urethral glands, trauma from childbirth, or prior disposition from congenital (born with) defects in the wall of the urethra. The symptoms may be any one or a combination of chronic (persistent) or recurrent urinary tract infections (UTIs), symptoms that mimic infection, dyspareunia (painful intercourse),discharge of pus from the urethra, or post-void (after urination) dribbling of urine. Because urine pools (sits at the bottom) in a diverticulum, the urine may grow bacteria and become a constant source of irritation and infection. The most common symptoms of urinary tract infections are:

  • urinary frequency
  • urinary urgency (a frequent sensation of a need to urinate or a need to get to the bathroom quickly)
  • dysuria (burning with urination)

A urethral diverticulum is an anatomic defect, and so surgery may be necessary if a patient is symptomatic from its presence and does not respond to antibiotic therapy. The diagnosis of adiverticulum may be easy if it is large and tender. In this instance, the urologist may feel it during a pelvic examination. Often the urethra is very tender and may express discharge when a finger is pushing up on it. When it is not as apparent, but there is suspicion, a special type of contrast (dye) x-ray called a urethrogram may confirm its presence. A urethrogram involves a catheter in the urethra with injection of a dye in the catheter. Sometimes, a highly specialized test called an MRI (magnetic resonance imaging) can confirm the diagnosis. Occasionally, cystoscopy (looking in the urethra with a small telescope) is helpful. In many instances all tests are negative, and only the patient’s symptoms and the urologist’s suspicion will suggest the diagnosis.

Preparation

There is no particular preparation for this procedure. As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter).
Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

*It is usually to your advantage not to strain to have a bowel movement in the week after the procedure. We recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas, and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should administer an enema one hour before bed the night before your procedure.

Procedure

To review the basics of what we discussed in the office: The actual procedure usually takes one to two hours. The procedure can be done under general anesthesia (complete sleep), a spinal (numb from the waist down), sedation (near complete sleep), and often with just local anesthesia (injection of numbing medicine directly into the operative area). The anesthetic type will depend on your preference as well as on the suggestion of the surgeon.

You will be placed in the lithotomy position (lying down on your back with your legs fairly elevated in holsters called stirrups). Prior to beginning, we may want to repeat the urethrogram (special x-ray using injection of contrast dye into the urethra) to re-establish the exact location of the diverticulum. A catheter is then placed into the bladder so that it can act as a guide to the urethral surgery. There are times in which the urologist may decide to place a suprapubic tube (tube in the bladder that is placed through a small hole in the lower abdomen) as well. This is often done when: the diverticulum is very large, proximal (closer to the bladder than to the far end of the urethra), associated with significantly infected tissue, or is an operation for a recurrence of the diverticulum.

A diverticulectomy (removal of the diverticulum) is most commonly done through a small incision directly over the diverticulum. Dissection is performed so that the entire wall of the diverticulum is separated from the normal healthy surrounding urethral tissue. Once the diverticulum is excised, the urethra and overlying tissue (in most cases the vaginal tissue since this procedure is so rarely done in men), are sutured together in overlapping layers. A catheter is left in the bladder so that urine does not flow past the surgical area for several days to a couple of weeks depending on the particular circumstances. In some instances, a gauze packing is placed in the vagina as well. It can be removed the following day or two by you (if at home)if directed by your physician. If you are admitted to the hospital, it may be removed by one of the doctors or nurses.

If during the surgery the tissue appears unhealthy or thin, it may be necessary to use healthy tissue from a nearby area of the body in the repair of the urethra. The most common tissue used is fat tissue from the labia majora (outer vaginal lip). This is brought over from an incision in the labia.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged home. It is less common to require hospital admission. It is normal for you to feel a sense of urgency to urinate. This is from the procedure and from the presence of the catheter. In most patients this goes away within a couple of hours, but could last until the catheter is removed.

The catheter may remain for up to a week depending on the size of the diverticulum, the quality of the tissue sutured, and your surgeon’s preference. Some patients require medication to help relax the bladder while the catheter is in. It will be connected to a small bag that can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. You may also be given a larger bag to attach to the catheter for overnight drainage while you are sleeping. We assure you that it is quite simple.

There may be some blood staining, and so you are encouraged to wear protective liners or pads for a few days. The urine is usually clear, but do not be surprised if it is slightly blood-tinged in the first few days. You may shower but no bathing or swimming for at least one week (unless otherwise indicated). Some surgeons will instruct you to take warm baths a couple of times per day a few days after the surgery. We ask that you refrain from very strenuous activity until your follow-up office visit. You might be a bit sore for a couple of days and so when you sit, you may want to put a soft pillow down on the chair.

*You must refrain from any type of sexual activity until otherwise instructed.

We strongly encourage you to take a few days off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. We may provide you with a prescription for pain medication although significant pain is unusual. An antibiotic prescription may also be given and should be taken until completion. If any side-effects occur, contact our office immediately.

We use absorbable (self-dissolving) suture material and so there are no sutures to remove. They will break and fall out or dissolve on their own within 2-3 weeks.

Expectations of Outcome

Diverticulectomy is usually a successful operation. if the entire diverticulum is excised, it rarely recurs. Some diverticula are quite extensive (occupying a long segment of the urethra or encircling the entire urethra) or associated with grossly inflamed or infected adjacent tissues. In these cases. the repair could be unexpectedly more complex and require tissue flaps or staged procedures (more than one time n the operating room). These cases can sometimes require an unexpected hospital admission, and are usually associated with higher complication rates.

Persistence of the symptoms for a few days or longer after the catheter is removed is not uncommon. It is due to the swelling from the surgery and the presence of the catheter. In other words, you may still have urinary frequency, urgency and some burning.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Urinary Tract Infection or Sepsis: Although we may give you antibiotics prior to and after the operation, it is still possible for you to get an infection. The most common type is a simple bladder infection (after the catheter is removed) that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system. Wound Infection: The incision sites can become infected. While it typically resolves with antibiotics and local wound care, occasionally, part or all of the incision may open and require revision and or catheter replacement.

*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.

  • Recurrent Diverticulum: This is rare. When present, it may also represent a new diverticulum. In either instance, a second procedure may be necessary.
  • Urethral Stenosis or Stricture: When the urethra is closed in layers, we attempt to keep the urethral width a certain size. Over time, however, the area can scar down and cause an obstruction to urine flow. If significant, a one-time, or even periodic, office dilatation (spreading) could be necessary. It would be quite unusual (but possible) to require a surgical procedure to open the urethral channel.
  • Vesicovaginal Fistula: If the diverticulum was large or the surrounding tissue thin or unhealthy, the sutured tissues could break down. If this happens, there would be a fistula (abnormal communicating channel or hole) between the urethra and the vagina. If the hole is proximal (closer to the bladder) to the sphincter, you could have a problem with leakage of urine (incontinence) until repaired at a later date. Usually, if the neck of the bladder is healthy, there would not be incontinence. A catheter in the urethra may be placed for an extended period of time.
  • Urinary Incontinence: Urinary incontinence (the involuntary loss of urine) is rare after this surgery. If present before the operation, it is usually due to a pre-existing condition other than the diverticulum. After the surgery, however, it could be made worse when the diverticulum is extensive (occupying a long section of the urethra) or proximal (on the portion of the urethra that is close to the bladder neck). A secondary procedure could be necessary to correct this problem.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Excisional Biopsy and/or Laser Ablation of Condyloma

Definition

Excision = to cut and remove

Biopsy = to take part of a tissue and have it analyzed

Ablation = to destroy and/or make disappear

Condyloma = a wart-like lesion caused by the human papilloma virus (HPV)

Condyloma acuminata are wart-like lesions caused by a few of the near 80 strains or types of strains of the human papilloma virus (HPV). The strains that cause sexually transmitted warts are distinct from those causing warts on the hands or feet. They are usually transmitted by sexual contact, although some believe that transmission is possible without direct sexual contact. The latency period from contact to growth has not been truly defined. In that regard, it may be possible for weeks, months, and perhaps even years to pass between exposure and development of the lesion(s). The penile shaft is the most common site of condyloma. Thescrotum, perineum (area between the scrotum and anus), perianal region (directly around the anus), and prepubic region (area above the penis) are other common sites. Uncommonly, condyloma can occur in the urethra (tube through which you urinate). In women, condyloma present on the labia minora and majora, as well as within the vagina. Certain strains of HPV are known to cause cervical cancer in women, although there is no established link of HPV to penile cancer in men. When left untreated, the individual lesions may grow in size and spread to other areas.

Over the years, condyloma have been treated in many different ways. All of the therapies are administered with the intent of destroying the individual lesion(s). The virus, however, is usually not destroyed and so recurrence (without repeat exposure) is quite possible.

Treatments include:

  • Topical Therapy: Medications applied only to the lesions that destroy tissue on contact
  • Antiviral Topical Therapy: Medicines applied to the entire general area that attack the virus following penetration into the skin or lesion
  • Cryotherapy: Application of liquid nitrogen to freeze and destroy the lesion
  • Cauterization: Application of an electrical heat current to destroy the lesion
  • Laser Ablation: Use of specific types of laser to destroy the lesion
  • Excisional Biopsy: Surgically removing a specimen (done for large lesions or for those where we are not completely certain that the lesion represents condyloma)

The remainder of this section will focus on the procedures (cryotherapy, cauterization, and laser therapy). The proper use of and side-effects of the topically applied medicines would be discussed with you much like any other medicine that you receive from a physician.

Preparation

Any of the three treatments can be performed in an office setting. Cryotherapy, small fulgurations, excisional biopsy of small lesions, and even cystoscopy (putting a scope in the urethra) with fulguration of small intraurethral lesions can be done in the office. For office-based treatments there is no particular preparation. *If your surgery is being done in the office, however, we suggest that you eat lightly no closer than one hour prior to your procedure.

If you are scheduled for a laser procedure in the hospital, a large volume fulguration, or a large excisional biopsy in the hospital using some form of anesthesia, you will be asked not to eat or drink anything after midnight on the evening prior to your procedure. You may brush your teeth in the morning but not swallow the water.

If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The procedure time varies considerably based on the location, size, and extent of the lesions. The type of anesthesia used will again depend on these same factors. Not all procedures require anesthesia. Local anesthesia, sedation, and rarely general anesthesia (complete sleep) may be used according to the suggestion of your surgeon as well as on your preference. We typically reserve general anesthesia for cases of high volume perianal (around the anus) condyloma or significant intraurethral (in the tube through which you urinate) condyloma. When there are just a few lesions, they may be individually numbered with a tiny injection of local anesthetic. This is true for fulguration, laser ablation, or excision.

In most instances, we are confident that a specific appearing lesion represents condyloma by looking at it. If the lesion appears atypical, we may perform an excisional biopsy of the lesion. In these cases, the area is cut away with a surrounding margin of what appears to be normal tissue. If the lesion is large, it may require a few sutures to close it. With small excisions, we may treat the base with laser or fulguration to kill possible virus left behind. An antibiotic ointment may then be applied to the area. A dressing is rarely, if ever, required. This sample will be sent to the pathologists (doctors who examine tissue specimens) who examine it under the microscope to confirm the tissue type.

When performing fulguration, an electric current (termed an electrocautery) is used to burn the lesion itself while making every effort to leave surrounding tissue untreated. The same is true for laser treatment. Again, antibiotic ointment may be applied to the areas.

For intraurethral lesions, the cystoscope is placed in the urethra and the lesion is biopsied or simply laser ablated. In very rare instances of high volume intraurethral condyloma, we may elect to leave a catheter in your bladder for one or two nights. This is to ensure that you do not go into urinary retention (inability to urinate) from the inflammation in the urethra.

Post Procedure

After fulguration or laser ablation, you may feel some minor discomfort over the treated areas. It is described as a stinging feeling much like a minor burn. Many patients have no pain whatsoever.

If your procedure was performed in the hospital, you will be in the recovery room for a short time before being sent home. If the procedure was performed in the office with mild sedation, we will observe you for a while. In either of these instances, you must have someone to take you home. If only local anesthetic was used, we may let you drive after a period of observation.

Areas that were treated will appear red and occasionally black. Over the next day or so, small scabs will form. Do not attempt to remove these scabs.

We may provide you with a prescription for pain medication but you certainly may take an over-the-counter medication to which you are not allergic. We may also ask you to apply antibiotic ointment to the treated areas a few times per day for just a few days. If a deep excision was performed, we may place you on a course of oral antibiotics. You may shower whenever you desire. If sutures were placed, you may shower, but please avoid bathing or swimming for a couple of days unless otherwise instructed to take warm baths. The sutures we use are usually self-dissolving, and therefore just fall out on their own within 1-2 weeks after surgery.

Expectations of Outcome

As mentioned previously, the available therapies are intended to destroy the existing lesions and should not be considered a “cure” of HPV. It is possible to develop new lesions during treatment or at any time in the future.

Until completion of your treatment, you should abstain from sexual contact to reduce the risk of HPV transmission to other non-infected individuals. You and your partners must realize, however, that HPV transmission is still possible even if no lesions are present. In other words, the virus may still be present.

Following treatment with the topical therapies, it may take weeks to months for lesions to completely disappear.
For any of the treatments, but particularly with cauterization, cryotherapy, or laser ablation, it is quite possible that you will have small permanent scar where the lesion was treated. These scars are rarely skin deformities (like a wound scar), but rather are a white spot representing a loss of pigmentation where the treatment occurred. These areas are typically very small and barely noticeable. Every patient has a different tendency to form scars, and it is not possible to predict in whom a slightly more noticeable scar may form.

Women treated for condyloma, or even exposed to a partner who was treated for condyloma, must be extra diligent about having their regularly scheduled Pap smears. As mentioned, there is an increased incidence of cervical cancer with certain types of HPV.

Possible Complications of the Procedure ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may generate questions if you are still concerned.

Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Recurrence: Condyloma does have a propensity to return. This is not a complication, but more of an expectation.
  • Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection following excision biopsy would require partially opening the wound to allow proper drainage.
  • Scarring: All surgeries leave some degree of a scar. As mentioned, fulguration, cryotherapy, or laser ablation often leave a white scar.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery.

Although very rare following such procedures, it is still possible. In almost all instances, the pain disappears over time. If persistent, further evaluation would be necessary.

  • Hematoma: This complication will very rarely occur if an excisional biopsy was performed. Even when all noticeable bleeding is stopped, it is possible for a small vessel to have a delayed bleed under the sutures. The collection of this blood under the skin is termed a hematoma. Intervention is very rarely necessary and it almost always resolves over time…much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
  • Urethral Stricture: This complication may be seen following procedures treating intraurethral condyloma. Following any intraurethral procedure (from the cystoscopyalone or more commonly from the laser fulguration), it is possible to develop a stricture (occlusive scar tissue) anywhere in the urethra. If it is significant and interferes with normal urination, a repeat scope procedure may be necessary to open the scar.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Excisional Biopsy of a Penile or Scrotal Lesion Excision of a Cyst or Abscess Drainage

Definition

Excision = to cut and remove

Biopsy = to take part of a tissue and have it analyzed

Penile = pertaining to the penis

Scrotal = the scrotum is the skin sac covering the testicles

Lesion = abnormal appearing or feeling tissue

Cyst = a collection of debris enclosed in a tissue capsule (can be infected)Abscess = an infected site walled off by tissue

Lumps on the penis or scrotum may be benign (not cancerous), malignant (cancerous), or infectious. Although we can often differentiate them by their location, appearance, and rate of growth, we may sometimes recommend excision and further microscopic examination by a trained pathologist. Alternatively, they may be excised for cosmetic reasons or because they are causing discomfort.

Cysts are far more common on the scrotum than on the penis. They are usually benign. Abscesses are more common on the scrotum as well. An abscess is usually a surgical emergency and should usually be drained. This is especially true in diabetic patients, those chronically on steroids, and patients with other disorders of the immune system.

Preparation

A small abscess can be drained in the office. If it is large or complex, we may send you to the hospital and perform the procedure in an operating room. If we are sending you to the hospital, do not eat or drink anything because you may need anesthesia.

*If your surgery is being done in the office, we suggest that you eat lightly no closer than one hour prior to your procedure.

If you are scheduled for an elective procedure in the hospital with anesthesia, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure may not be performed if you are currently taking or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc…”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

If you are having an excision of a large scrotal lesion, we will insist that you have a good quality scrotal support (jock strap) or pair of jockey shorts ready at home. You will need to wear it for a few days after surgery. If a large scrotal abscess was drained, you should stop on the way home to purchase a scrotal support. It helps to reduce discomfort and swelling.

Procedure

To review the basics of what we discussed in the office: These procedures are usually short, but vary in time based on the size, location or complexity of the lesion. The type of incision varies according to the particular procedure.

In cases of abscess, the infection is usually incised and the infection drained. The area may be thoroughly irrigated, and when present, any necrotic (dead or dying) tissue is then removed. The area may then be packed with sterile gauze. Closing an abscess cavity almost ensures its recurrence, and so the incision is left open to drain.

With lesions or small masses, the area is cut away from the normal tissue so as not to disturb the edges of the lesion. When a lesion or mass is suspicious, we make sure that we excise it entirely with a margin of healthy surrounding tissue. The specimen will be sent to the pathologist for microscopic analysis. If the lesion was on the penis, a dressing may be applied.

If a cyst, we try to remove the entire capsule in order to prevent its recurrence. Simple drainage of a cyst may not be effective because the capsule may refill. The specimen will be sent to the pathologist for analysis. We then close the incision and may apply an antibiotic ointment.

Post Procedure

You will be in the recovery room for a short time before being sent home. If done in the office, we will observe you for a while. You must have someone to take you home if you received sedation or anesthesia. If your procedure was done only with local anesthetic injection, we may just observe you for a short while before you are allowed to drive. You may have discomfort over the incision. If your procedure was on the scrotum, there may be no dressing directly adherent to the incision and so the stitches (if placed) may be visible. If on the penis, a gauze dressing may be wrapped around the area. Occasionally there is some bloodstaining on the stitches, and this is normal. If you see active blood oozing, please contact us. You will remove the dressing the following morning and take a shower. Some surgeons may ask you to avoid baths and others may ask you to take warm baths a couple of times per day depending on the circumstances. *If you had an abscess drained, we often will ask you to start taking warm, soapy baths twice a day immediately. We ask that you refrain from very strenuous activity until your follow-up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. If a lesion was excised, we may ask you to apply ice compresses as directed to help reduce swelling in the first several hours. We encourage you to take the following day off of work and perhaps more if your occupation requires strenuous activity or heavy lifting. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days; longer is rare. We may provide you with a prescription for pain medication but you certainly may take an over-the-counter medication to which you are not allergic. In cases of abscess and in a few ofthe other lesions, we may also give you a prescription for an antibiotic. The sutures we use are usually self-dissolving, and therefore just fall out on their own within 1-2 weeks after surgery.
*Following excision of a penile lesion, you may not engage in any sexual activity until otherwise instructed.

Expectations of Outcome

If the lesion removed was anything but a cyst or abscess, it will take up to a week to get a report back from the pathologist. In many cases, no other treatments are necessary. Lesions on the scrotum usually heal very quickly and without noticeable scars. Lesions on the glans penis(top or head of the penis) usually have more swelling and bleeding. Abscess cavities, with proper wound care, slowly close on their own over the next few days to weeks.

Possible Complications of the Procedure ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may generate questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Recurrence or Persistence: Rarely, a cyst or abscess can return. This is unusual with a formal excision or proper drainage, but more common after a simple needle drainage procedure.
  • Hematoma: This is when a small blood vessel continues to ooze or bleed under the suture line after the procedure is over. The result is greater swelling and bruising. Drainage is rarely necessary and it almost always resolves over time…much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
  • Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection would require partially opening the wound to allow proper drainage.
  • Scarring: All surgeries leave some degree of a scar. Scars resulting from infection leave more noticeable scars.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery.

Typically, the pain disappears over time. If persistent, further evaluation would be necessary.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Extracorporeal Shock Wave Lithotripsy (SWL)

Definition

Extracorporeal = “outside of the body

Shock Wave = “using waves of a specific type of energy

Litho = “stone”

Tripsy = “breakage or fragmentation”

Urinary tract stones are either located in the kidney, in the ureter (the tube that attaches the kidney to the bladder) or in the bladder itself. SWL may be used to fragment stones that are inthe kidney or in certain parts of the ureter. The success rate of breakage depends on the size of the stone, the location within the kidney or ureter, the composition or make-up of your particular stone, and the number and energy level of the shocks employed. The second part ofsuccess is whether or not the fragments pass out of your system. This will depend on the original location of the stone, the size of the fragments, and on the particular anatomy of your urinary tract.

There are different types of SWL machines throughout the world. They use different types of energy and have different powers. Regardless, they all have the same goal of fragmenting a stone employing non-invasive technology. This is NOT a form of laser technology. Lasers are only used to fragment stones with the minimally invasive procedures in which scopes are inserted into the urinary system.

Preparation

It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time. In order to assist us with visualizing your stone, we may ask you to clean out your intestines and colon the night before. You should plan a very light dinner (perhaps around 5-6:00 p.m.) the evening prior and avoid vegetables or other foods that typically cause gas. Approximately one hour after, you should take a laxative(available over the counter). Depending on your particular digestion, it will “clean you out.”You may drink for the rest of the evening, but do not eat. Not all patients will be asked to take a laxative, although the light dinner and the avoidance of gas-producing foods is usually a good idea.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter).

Please refer to the attached list and tell us if you took any of these within the past 10 days.

If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

*If you are a patient with high blood pressure (hypertension) and your pressure has been poorly controlled recently, please let us know as it is important that your primary care physician get your pressure back to normal prior to this procedure.

*Patients who are being treated for abnormal heart rhythm (i.e. atrial fibrillation or patients with pacemakers) can have this procedure, but it is important that we know so that we may communicate with your cardiologist and possibly make special preparations with the SWL machine and with the anesthesiologist.

Procedure

You will be placed lying on your back (or less commonly face-down on your stomach) and the stone will be localized with real-time x-rays (fluoroscopy) and/or ultrasound technology. Some machines necessitate that you be partially submerged in a water bath and others do not. Once we are satisfied that your stone can be accurately targeted with the shock waves, you will be given light sedation by the anesthesiologist. Rarely, some patients may require general anesthesia. Shock waves are aimed precisely at the stone. The maximum energy level used and the number of shocks administered will depend on how your stone responds to the shocks. There is, however, a maximum level at which point we will terminate the procedure. In addition, for safety reasons, your heart rate and rhythm may dictate the way in which we administer the shocks. At the end of the procedure, we often have an idea as to its success, but we too, are sometimes fooled. A stone that appears well-fragmented during the procedure can often be found to be unchanged on the follow-up x-rays weeks later. Alternatively, a stone that appeared unchanged during the procedure is sometimes not seen at all on follow-up x-rays due to successful fragmentation and passage.

At the termination of the shock waves, you are easily awakened and observed in the recovery room until the sedation has completely worn off. Almost all SWL procedures are done on an ambulatory basis, and it is quite rare that a patient needs to be admitted.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged. It is uncommon for a patient to be admitted to the hospital afterward, but certain circumstances could make admission necessary.

It is common and even expected to have some discomfort in your back on the treated side. Over the next day or two, your urine may appear dark or amber which represents the presence of blood. You may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. It is rare for the blood to not disappear within a day or two. You may also notice stone fragments passing in the urine, and this is the desired result. Because they are small, a patient typically does not feel them as they pass in the urine but they can be visible as sand or very small pebbles.

Expectations of Outcome

The intent of SWL is to completely fragment the stone and have all pieces pass out in the urine. Unfortunately, this is not always the case. Sometimes, the stone does not break at all, or there is incomplete fragmentation and only part of the stone breaks.

In this regard, we may suggest another SWL at a later date. Sometimes the stone fragments quite well, but the pieces never leave the kidney. This is most common with stones that are in the lower half of the kidney. The combination of the sharp angle and gravity holding them in the lower half make it less likely that they move into the ureter.

Occasionally, and more common to larger stones, a large fragment can get caught in the ureter and temporarily block the kidney. In this situation, we may elect to observe (if you are comfortable and the fragment is of a size that may permit spontaneous passage) or we may recommend placement of a stent.If necessary, we might recommend a ureteroscopy procedure (putting a small telescope into the ureter) to further fragment and/or remove the large piece.

Possible Complications of the Procedure All surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Urinary Tract Infection or Urosepsis: Not all SWL procedures require antibiotics. Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. Pyelonephritis (kidney infection) is also possible following SWL and is more likely to cause symptoms of severe back pain, fevers, chills, nausea, and vomiting. If the infection enters the bloodstream, you might feel very ill as well. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.
  • *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
  • Ureteral Blood Clots: Rarely, small blood vessels in the kidney can rupture and cause bleeding in the urine. If clots form, they can block the urine flow down the ureter. Treatment is usually observation or placement of a stent.
  • Hematoma: Occasionally, small blood vessels can rupture and cause significant bleeding around the kidney (hematoma). The majority of the time, the treatment is observation because the bleeding stops itself and is eventually reabsorbed by surrounding tissue. In some circumstances, a minimally invasive procedure(angiography) is done by special radiologist physicians to stop the blood vessel. A need for open surgery with possible removal of the kidney (nephrectomy) due to bleeding is unusual.
  • *Hematoma and bleeding are far more common in patients with poorly controlled high blood pressure or in patients on blood thinners who neglected to tell their physician that they were on such medications (either chronically or within 10 days of the procedure).
  • Loss of Kidney Function: There is bruising to the kidney from this procedure. Like other organs in the body, the kidney heals itself with time. It is possible for a part or even the entire kidney to lose function following SWL. This can result from the shocks to the kidney or from local or diffuse bleeding.
  • Chronic Pain: While quite unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always apparent.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Hydrocelectomy

Definition

Hydro = water

Cele = balloon-like

Hydrocelectomy refers to surgical removal of a fluid balloon around the testicle (or in the scrotal sac). It is normal to have a very thin layer of fluid directly surrounding the testicle. This fluid is constantly produced and drained so that it does not accumulate. In an adult, the tissue responsible for draining the fluid becomes blocked and so fluid begins to accumulate and the scrotum enlarges over time.

In babies and young children, the cause is usually different. In this instance the hydrocele is usually due to a persistent or previous abnormal communication between the scrotum and the abdominal (peritoneal) cavity that once allowed or continues to allow fluid into the scrotum.

Hydroceles are most often discovered by a patient. They may not change for years but then suddenly grow larger and more cumbersome. Other than patient discomfort or cosmetic reasons, there is rarely a medical need to operate on a hydrocele. Usually the physician can diagnose a hydrocele by physical examination, and sometimes it is confirmed by ultrasound examination. In adolescents or young adults with a new hydrocele, we may suggest an ultrasound because testicular cancer can sometimes present with a hydrocele.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc…”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

We will insist that you have a good quality scrotal support (jock strap) or a good pair of jockey shorts ready at home. You will need to wear them for a couple of weeks after surgery. Support helps to reduce discomfort and swelling.

Procedure

To review the basics of what we discussed in the office: The procedure takes less than one hour depending on an individual’s anatomy and whether a prior hydrocele or other procedure has been performed in the scrotum. An incision is made in the midline or across the involved side of the scrotum. Dissection is then performed down to the hydrocele sac. The sac is freed from surrounding tissue, opened and drained of its fluid. The sac is then turned inside-out and the edges sewn together or it is completely cut away. The testicle and adjacent structures are inspected to ensure that everything else appears normal. We then close the incision.

If your hydrocele is very large, we may elect to place a small drainage tube through the scrotal skin to help minimize the swelling. If we do so, we will have you return to the office in the next day or two to remove the drain.

Post Procedure

You will be in the recovery room for a short time before being sent home. You may have discomfort over the incisions and possibly in the groin and scrotum. There may be a scrotal support with some gauze underneath. There may be no dressing directly adherent to the incision and so the stitches may be visible. Sometimes, you will notice a white glue-like substance over the incision. Occasionally there is small blood staining on the gauze or skin, and this is normal. If the dressing becomes soaked, or you see active blood oozing, please contact us. You may shower the day after surgery, but no baths or swimming. Some surgeons may recommend warm baths a couple of times per day a few days after your surgery. We ask that you refrain from any strenuous activity until your follow-up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. We may recommend that you apply ice compresses to the scrotum when you return home. We strongly encourage you to take the following day off of work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 24 hours, it is to your advantage to minimize activity and spend a lot of time lying down. The more swelling you prevent in the first two days, the better off you are. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days. We may provide you with a prescription for pain medication but you certainly may take an over-the-counter medication to which you are not allergic. Upon your follow-up in the office, we will examine you. The sutures we use are self-dissolving, and therefore just fall out on their own within 2-3 weeks after surgery.

Expectations of Outcome

It is important for you to realize that the effects of the procedure can take days, weeks, or even more than a month to be fully realized. The tissues within the scrotum always swell and usually feel quite firm to the touch after swelling begins. This is expected, and you should not feel as though your surgery was unsuccessful.
Hydroceles very rarely recur because the tissue that caused it is either gone or turned inside-out.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation.

While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may generate questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Recurrence or Persistence: A hydrocele may return. As mentioned, this is fairly unusual with a formal hydrocelectomy, but common after a simple needle drainage procedure.
  • Hematoma: This is when a small blood vessel continues to ooze or bleed after the procedure is over. The result is greater swelling and bruising. It usually resolves overtime with compresses…much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
  • Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection would require partially opening the wound to allow proper drainage.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has been operated on. Typically, the pain disappears over time. If persistent, further evaluation would be necessary.
  • Testicular Ischemia/Loss: This is quite unlikely from the operation itself, but could occur.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Hydrodistention of the Bladder & Biopsy

Definition

Hydro = water

Distention = to stretch by filling

Biopsy = to take a sample of tissue for analysis by a pathologist

This procedure can be both diagnostic (helping to make a diagnosis) as well as therapeutic(resulting in treatment or relief). In short, your bladder will be filled with water so that we can examine the inner bladder wall appearance after it has been distended. One or a few small biopsies may also be taken from the wall of the bladder.

The purpose of this procedure is to help diagnose a condition known as interstitial cystitis(IC). This condition may present with one or a combination of pelvic pain, urinary frequency and nocturia (getting up at night to urinate), and urgency (strong sensation or urge to urinate).Although far more common in women, we are now realizing that some men, once thought to have chronic prostatitis (inflammation of the prostate) or prostadynia (chronic pelvic pain),may have IC. This disease complex in both women and men is not fully understood, and has been categorized as “chronic pelvic pain syndrome” or CPPS.

Interstitial cystitis is thought to be due to a breakdown of a specialized protective coating lining the inner wall of the bladder. In the absence of this glycosaminoglycan (GAG) layer, the urine can leak in between the cells and cause irritation, inflammation, and pain. A careful history, physical examination, and urine tests are very important in excluding other problems that may present with similar symptoms. If there is a strong suspicion of IC, we may then suggest this procedure.

When we distend the bladder, we look for specific changes in the wall that we can see through a small telescope termed a cystoscope. A biopsy may be taken to rule out abnormalities in the bladder. Because patients with IC usually have a small capacity bladder (one that holds only small volumes), distention of the bladder can temporarily, and rarely permanently alleviate some of the urinary frequency and even some of the pain.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your procedure. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc…”).

The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past seven days.

If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during thepre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: A hydrodistention is done under general anesthesia (complete sleep). It can also be done with a spinal. The actual procedure usually takes less than 30 minutes. You will be placed lying down on your back with your legs gently elevated in holsters (called stirrups). The cystoscope (which has continuous fluid running through it) is inserted into the urethra and into the bladder. We examine the bladder to evaluate the walls prior to distention. Fluid is then run through the scope until the bladder is distended to a specifically calculated pressure. Once filled, we allow the fluid to remain in the bladder for a specific time. The bladder is then drained. After drainage, we begin to slowly fill the bladder again while examining the bladder to look for specific abnormalities in the appearance of the walls. With the bladder minimally full, we may then take one or a few biopsies. The biopsy areas may then be cauterized (burned) so that they do not bleed. The bladder is carefully inspected once again and emptied. The scope is removed and the procedure is over.

Post Procedure

You will be in the recovery room for a short time before being discharged home. You may feel a strong sense of urgency to urinate even though your bladder is empty. It is also common to feel pressure in the pelvis. Patients may have no blood in the urine, mild blood, or even a significant amount of blood or small clots. It is rare for the blood to not disappear within a few days. You will be discharged home with your usual medications, possibly a short antibiotic course (if indicated) and perhaps a pain medication. You may take an over-the-counter pain medication (to which you are not allergic) instead of the prescription pill if your discomfort is only mild or moderate.

Expectations of Outcome

As mentioned earlier, this procedure is both diagnostic and perhaps therapeutic. We can tell you what we observed visually in the bladder when we see you in the recovery area, but it will take up to a week before we have the results of the biopsy (if taken).

With regard to your symptoms, anything is possible after this procedure. You may feel a sense of relief (that can persist for days, weeks, or even months; longer), you may notice no change, or your symptoms can be made more severe from the trauma to the bladder. In these instances, the increase is almost always temporary, and the symptoms dissipate over the next fibroglandular elements days. They may return to your baseline or you may notice significant relief.

Many patients who have this procedure done with noticeable symptomatic relief will usually elect to have it repeated in the future. A biopsy is not necessary in repeat procedures because the diagnosis may already have been established.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned.

Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Hematuria/Clot Retention: As we distend the bladder, blood vessels in the bladder wall are stretched and can tear. We expect this finding in those who are found to have IC. In these patients, we almost always note some minor oozing of blood. As mentioned, the blood almost always disappears within a few days. Rarely, some of the veins can continue to ooze or a scab of a biopsied area can fall off and cause recurrent hematuria (blood in the urine). In most cases, we can observe, and the bleeding eventually stops. If clots form, it can block the flow of urine and we may consequently need to irrigate out the clots through a catheter. In unusual circumstances, we may have to return to the operating room to put the scope back inside and remove the clots and possibly cauterize the vessels.
  • Urinary Tract Infection or Urosepsis (Bloodstream Infection): Following any procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection often presents with urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This scenario is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.

*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.

  • Urinary Retention: In men, pressure from the scope can occasionally cause swelling in large and/or obstructing prostates. It may block the flow of urine and cause “retention.” In most circumstances, it resolves with a catheter over the next few days. Less commonly are medications or a prostate procedure required.
  • Perforation: The wall of the bladder can be perforated during the distention and less commonly from the superficial biopsy. In most cases, all we need to do is leave the catheter in for an extra few days to allow self-healing. If the perforation occurs in a specific area of the bladder, we may need to perform a formal bladder repair through an incision in the abdomen, or place a drainage tube in the lower abdomen to evacuate this fluid.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office.

Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Image Guided Radiation Therapy (IGRT) - Placement of Fiducial Markers

What is IGRT?

IGRT is Image-Guided Radiation Therapy—a method of using images taken immediately before treatment to use extreme accuracy to target a tumor.  Accurate targeting is essential to resolve daily tumor location changes due to internal organ motion and body position variation on the treatment couch.  IGRT increases radiation to the tumor and spares normal surrounding tissue.

Why use implanted markers?

To assist with IGRT, three tiny implanted markers become visible landmarks for tumor location on pre-treatment images.  They provide a permanent method for quick and accurate daily tumor alignment.

Implanted Markers

Implanted markers are typically, pure gold rods-crosscut to prevent movement—that permanently remain in the prostate.  Non-metallic markers are also used on occasion.
Note:  Gold markers do not contain iron and do not set off metal detectors.

Implant procedure

The 10 minute office procedure under ultrasound guidance is very similar to a prostate biopsy or other image-guided techniques, and only slightly uncomfortable.  Typically, three markers are placed in the prostate.

CT scan

After marker implantation, the radiation oncologist and planning team obtain a CT scan and create the unique treatment plan.

Daily image guidance

Each day, just before treatment, images are taken to confirm the exact tumor location.
IGRT images are obtained by the treatment machine itself (port films), electronic portal imaging devices (EPID images), real-time low-energy systems (kV x-rays) or computed radiography.

Implanted markers show up clearly on all image types, providing internal landmarks for tumor position.
Using localization software, the radiation therapist registers the markers on the pretreatment images and calculates the exact couch moves for high accuracy tumor alignment.

Summary

IGRT uses implanted markers, pre-treatment images, and localization software to provide advanced tumor targeting accuracy for radiotherapy.  IGRT increases radiation to the tumor and spares normal surrounding tissue.

Please contact your physician or nurse to discuss your treatment and review any questions you might have about your care.

Insertion of Artificial Urethral Sphincter (AUS)

Definition

Artificial = synthetic

Urethra = tube from the bladder through which you urinate Sphincter = a ring-shaped valve that prevents flow

The indication for this operation is to correct urinary incontinence (the involuntary loss of urine). The procedure is usually performed in males. Although there are different types of urinary incontinence , an AUS is placed as a last resort for stress incontinence (loss of urine with coughing, sneezing, lifting, etc.) or total incontinence (the constant dripping or leakage of urine).

In the male, urinary continence is basically maintained by the bladder neck, an internal sphincter and an external sphincter. The internal sphincter is closest to the bladder (near the neck of the bladder). You cannot control its activity, and it is therefore referred to as an “involuntary” sphincter. The external sphincter is just below the region of the prostate. It is called a “voluntary” sphincter because you can control its closure should you need to do so. The prostate only minimally contributes to urinary continence. The bladder neck can close tightly enough to prevent dripping. Some prostate procedures prevent the bladder neck from closing.

When all of the sphincters have been injured or malfunction, there may be chronic loss or dripping of urine. Common causes include:

  • a prostate procedure done through a small telescope (endoscopic) in which the sphincter is inadvertently injured (i.e. TURP)
  • an open procedure on the prostate such as radical prostatectomy for cancer or suprapubic prostatectomy for benign enlargement
  • effects of past radiation treatments; most commonly for prostate cancer
  • history of severe trauma to the urethra such as in a motor vehicle accident
  • history of urethral surgery to remove strictures (scars in the urethra) if the bladder neck had previously been unable to close

The basic concept of an AUS is that it performs the job of a sphincter. It resembles a tiny inner-tube that is wrapped around a short segment of your urethra. When a pump is squeezed, it deflates the inner-tube and allows the urethra to open. Urine will then drain from the bladder. The inner-tube then automatically regains its fluid so that it once again squeezes the urethra shut. Depending on the volume of fluid in the bladder, it may take more than one “squeeze cycle” to fully empty.

In most instances, we may have tried medications, offered more simple options, or attempted less invasive maneuvers prior to offering placement of an AUS. Although this is a fine option, and one that is usually effective, it does require that the patient have a certain degree of manual dexterity and full understanding of the potential problems.

*It is important that you realize the need for you to properly work the sphincter once implanted.

Preparation

*It is probably to your advantage not to strain to have a bowel movement in the week after the procedure. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas, and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you are known to have problems with constipation, you should consider taking an enema the evening before the surgery.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

The duration of the operation varies for every patient, reflecting the differences in each patient’s anatomy, and whether there is scarring in the area of surgery. In general, an AUS procedure takes 2-3 hours.

The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preference as well as that of your surgeon. General anesthesia(complete sleep) or a spinal are acceptable. Your position on the table will be supine (flat on your back), or in lithotomy position (supine with your legs gently elevated in holsters called stirrups).

The first part of the operation involves placing a catheter down the urethra (tube through which you urinate) and into the bladder. This allows us to feel the urethra during surgery. In many instances, the entire procedure will be done through an incision in the suprapubic area(lower abdomen). It may be up and down or from left to right. In these cases, the sphincter will be placed around the neck of the bladder (the portion in which the bladder becomes the urethra). In other circumstances an incision would also be made in the perineum (the area between the scrotum and the anus). This approach is used when the surgeon wishes to place the sphincter on a more distal (further from the bladder) portion of the urethra. This approach might also be preferable when there is significant scarring in the pelvis from prior surgeries or trauma. Some surgeons will use only an incision in the perineum for some cases. After the sphincter is placed around the selected portion of the urethra, the other two parts of the mechanism are placed in their respective positions. The reservoir (cylinder that holds the fluid) is placed alongside the bladder. The pump (portion that you will squeeze to pen the sphincter)will be placed in the scrotum (male patients) or in the labia majora (female patients). All three portions are connected by tubing in such a way that there is no air in the system.

Throughout the procedure, the operative field is irrigated with antibiotic solutions. After the device is implanted, the areas are irrigated one again and the incisions are sewn closed. Sterile bandages are then applied.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. Sometimes, this operation can be done on an ambulatory basis and so you will be sent home. As mentioned, you may have a urethral catheter draining your urine, and this catheter may give you a sensation that you need to urinate. Some surgeons prefer not to leave a catheter. The sphincter will not be inflated yet and so you will still be incontinent of urine. Depending on the choice of incisions, you may have sterile dressings on your suprapubic area and/or the perineum. You may feel some discomfort, but it is uncommon to have severe pain.

The following morning, the catheter will be removed (if present), and you will be discharged home with instructions for follow-up in our office. If you were sent home with a catheter, you will either return to our office to have it removed or be instructed on how to remove it yourself. Other than your regular medications, you may be given a prescription for an antibiotic and a pain medication. Other medications are rarely necessary but depend on your particular needs.

At home, it is important that you really take it easy for a few days. We strongly encourage you to take one week off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 48 hours, it is to your advantage to minimize activity and to often rest in a sitting reclined or lying down position. Periodic walking is encouraged. If you had an incision in the perineum, you may notice some swelling and bruising in this region. It is helpful to apply ice compresses to the perineum as instructed. You should not remove any dressings unless instructed to do so. You may shower the day after your surgery, but no baths or swimming until instructed to do so. Some surgeons will instruct you to take warm baths a couple of times per day a few days after your surgery.

Expectations of Outcome

Most patients are quite satisfied with the results of the procedure. It is important to realize that the sphincter is in a “deactivated” mode after the surgery. You will not be using it until we “activate” it (inflate the inner-tube) many weeks later. The reason that we wait is to allow adequate time for tissue healing around all of the parts.

You cannot engage in any form of sexual activity until we tell you that you may. This is typically for several weeks.

Once activated, it may take practice before you are adept at locating the pump in the scrotum or labia and properly inflating and deflating the sphincter.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Infection: Infection is the most worrisome complication of any surgery in which an artificial device has been implanted. Despite all precautionary measures, infection can occur. It can be a urinary tract infection (presenting with urinary frequency, urgency, and burning) that most often responds to a course of antibiotics. Infection in the surgical site may be more serious. It could present with redness, swelling, fevers, chills, whitish to yellowish drainage, or persistent pain. Those at greatest risk are patients with diabetes. If antibiotics and local wound care are unsuccessful, part of, or the entire device will need to be removed. In this instance, it is best to wait several weeks before re-implanting a new one. If an infection enters the blood stream, you may feel very ill. This type of infection often presents with any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. Often, the patient needs a short hospitalization for intravenous antibiotics, fluids, and observation. This is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.
  • *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
  • Mechanical Failure: Like any other mechanical device, it is possible for the parts to malfunction. It can be early, or more commonly years later from chronic use. In this instance, the prosthesis can often be removed and replaced in the same operation. In other instances, there may be too much scarring around the urethra.
  • Urethral Injury: The urethra is the tube through which you urinate. While dissecting around the urethra (in order to place the sphincter) it is possible to make a hole in it. This injury may end the procedure. If so, a catheter would remain in the urethra for one to two weeks to allow healing. The AUS placement would have to be rescheduled.
  • Blood Loss/Transfusion: Blood loss from this procedure is usually minimal to moderate. If blood loss is more significant, transfusion may be necessary.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
  • Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery or trauma. The cause is not always apparent. While this usually resolves with time, persistent pain may warrant treatment by a specialist or rarely removal of the prosthesis.
  • Erosion: If the sphincter is forcibly pressing up against the urethral tissue over an extended period, it can slowly erode through the urethra even in the absence of infection. Part of or the entire device may need to be removed.
  • We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Insertion of Penile Prosthesis

Definition

Sexual dysfunction is the inability to participate in sexual activity. It can be secondary to anxiety or emotional disorders, or the loss of libido (sex drive). The most common reason for sexual dysfunction is erectile dysfunction (ED). ED is inability to have adequate erections. In this country, the most common cause of ED is long-term smoking. A close second is the presence of diabetes. Long-standing hypertension (high blood pressure), history of atherosclerosis (“hardening of the arteries”), uncontrolled high-cholesterol, history of penile or perineal (area between the scrotum an the anus) trauma, and deficiency in male hormones(testosterone), may all be causes in and of themselves. Very often, patients have a combination of reasons.

After a thorough evaluation, the options for treatments will be presented based on the contributing factors. Often, a patient may try many treatment options before he has success. The most common reason a treatment is discontinued is simply because it did not work. Other reasons include side-effects, cost of the treatment, and complaints that it is inconvenient, cumbersome or lacks spontaneity.

*When all other options have been exhausted, a urologist may suggest insertion of a penile prosthesis. We always emphasize that this is a last resort because once inserted, a patient can never go back to other treatment options. In other words, the surgery changes the anatomy of the penis in such a way that the prior treatment options are usually no longer effective.

There are several types of prosthesis manufactured by different companies. We basically separate them into two main categories: semi-rigid vs. inflatable (commonly referred to as “the pump”). A semi-rigid prosthesis is one that consists only of two malleable rods that are inserted into the penis. They are always rigid and thus the penis always appears to be erect. An inflatable device is more complicated. The penis can be in a flaccid (non-erect) state and can then be inflated using a small squeeze pump that is implanted in the scrotum (skin sac that covers the testicles). Regardless of the type, they both serve to stiffen the corporal cavernosal bodies (corpora cavernosum). These are the two (one left and one right) cylinder-like portions of the inner penis that accept and subsequently entrap blood and become stiff during an erection. They have a lumen (center cavity) much like a pipe, and these are the spaces into which the cylinders of the prosthesis are placed.

SEMI-RIGID Advantages: Shorter surgery; fewer complications; lower incidence of mechanical failure; easier to use. Disadvantages: Less natural in appearance and feel; always erect

It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time.

It is probably to your advantage not to strain to have a bowel movement in the week after the procedure. It may be uncomfortable while you are healing. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should administer an enema before bed the night before your procedure.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

The duration of the operation varies for every patient, reflecting the type of prosthesis implanted and differences in each patient’s anatomy. In general, a semi-rigid takes 1-2 hours, while an inflatable can take 2-3 hours.

Your position on the table will be supine (flat on your back) or in the lithotomy position (on your back with your legs elevated in holsters called stirrups). The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) or a spine are acceptable.

The first part of the operation involves placing a catheter down the urethra (tube through which you urinate) and into the bladder. This allows us to easily palpate the urethra during surgery. In addition, it is easier for you overnight to not have to urinate.

If an inflatable device is being placed, the incision may be on the very lower aspect of the abdomen called the suprapubic region. It will extend down toward the penis. The pump device will be placed in the scrotum, and the inflatable cylinders will be placed within the center cavity of the corpora cavernosa. In order to do so, we gently enlarge the lumen of the cavernosum with dilators (spreading instruments).

In most instances, there is a reservoir cylinder that stores the fluid that will be placed behind the pubic bone of the pelvis. All of the parts are connected by air-tight tubing.

Less commonly, a two-piece device has no separate fluid reservoir, and so all of the fluid is stored in the pump in the scrotum. When there is no reservoir, an incision on the lower abdomen is not always used.

When a semi-rigid device is being implanted, there is no pump and no reservoir. There are only the cylinders. The approach to the cavernosum (i.e. the skin incision) can be similar to that of the inflatable device (just a bit lower and called “infrapubic”). It can be anywhere on the penis itself, or even where the penis and scrotal sac meet (penoscrotal). Your anatomy combined with the preference of the surgeon will determine the location of the incision.

Throughout the procedure, the operative field is irrigated with antibiotic solutions. After the device is implanted, the areas are irrigated once again and the incisions are closed. Sterile dressings are then applied. Blood loss during this procedure is usually small.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. In some instances, this may be done as an ambulatory surgery. As mentioned, you will have a urethral catheter draining your urine, and this catheter may give you a constant sensation that you need to urinate. Depending on the choice of prosthesis, you may have sterile dressings on your suprapubic area or loosely wrapped around the penis. There may be ice compresses on the penis itself. You may feel pain and pain medication will be prescribed as needed.

The following morning, the catheter may be removed, and you will be discharged with instructions for follow-up in our office. If done on an ambulatory basis, you may be asked to come to the office the following day for catheter removal. It may slightly burn or sting the first few times that you urinate on your own. Other than your regular medications it is customary for us to give you an antibiotic and a pain medication. Other medications are rarely necessary but depend on your particular needs.

At home, it is important that you take it easy for a few days. We strongly encourage you to take one week off from work and perhaps more if your occupation requires strenuous activity or heavy lifting. In the first 48 hours, it is to your advantage to minimize activity and to often rest in a sitting reclined or lying down position. Try to keep the penis pointing up on your abdomen while lying down. You should not lay face down on your abdomen. Periodic walking is encouraged. You should continue applying ice compresses to the penis as directed. You may notice that while the swelling diminishes over the first week, the bruising (black and blue) may increase.

Depending on the location of your bandage, it may have been removed in the hospital or we will have given you instructions otherwise. Your surgeon will have discussed bathing with you. Some physicians ask that you only shower (no baths) in the first few days while others may request that you take warm baths by the second or third day. If your wound has no bandage, we may instruct you to apply an antibiotic ointment to the area a few times per day.

Expectations of Outcome

Most patients are quite satisfied with the results of the procedure. It is important to realize that the swelling will not fully resolve for up to six weeks. You cannot engage in any form of sexual activity until we tell you that you may. This is often for six weeks or until you are fully healed.

With the inflatable device, it may take a little practice before you are adept at locating the pump in the scrotum or properly inflating and deflating the cylinders. We may ask you to inflate and deflate the cylinders once or a few times per day when at home. You will be instructed on how to do this. The erection produced by a prosthesis should be rigid enough for sexual activity, but may not have the same girth or even length as your natural erection. In addition, the glans penis (head) may remain soft or floppy at the tip of the erection.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Infection: Infection is the most worrisome complication of any surgery in which an artificial device has been implanted. Despite all precautions, infection can arise. It could present with redness, swelling, fevers, chills, whitish to yellowish drainage, or persistent pain. Those at greatest risk are patients with diabetes. If antibiotics and warm soaks do not work, to clear the infection part of (as with inflatable prosthesis) or the entire device will need to be removed. In this instance, we may wait several weeks or longer before re-implanting a new one. Sometimes the infection may result in scarring or inflammation making placement of a new prosthesis difficult. If the infection enters the bloodstream, you may feel very ill. This is termed “sepsis.” This type of infection often presents with any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. A septic patient may need a short hospitalization for intravenous antibiotics, fluids and observation. This scenario is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.

*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.

  • Mechanical Failure: Like any other device, it is possible for the parts to malfunction. It can be early, or years later. In this instance, the malfunctioning prosthesis can usually be removed and a new one replaced in the same operation.
  • Urethral Injury: The urethra is the tube through which you urinate. While dilating the corpora cavernosum, it is possible for the dilators to perforate through the wall of the corpora cavernosum and puncture the urethra. This injury usually ends the procedure. In most instances, the catheter would remain in for a week to ten days to allow healing. The prosthesis placement would have to be rescheduled. Injuries to the urethra can result in stricture formation (scar tissue that narrows the urethra). Strictures can interfere with urination, and may require surgical correction.
  • Urinary Tract Infection: We usually administer intravenous antibiotics once you enter the operating room. Nevertheless, any operation can lead to infections, especially when a catheter has been inserted. It may be a simple urinary tract infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate.
  • This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you could become more ill (see above).
  • Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery. Sometimes, a prosthesis may just feel uncomfortable. While this usually resolves with time, persistent pain may warrant removal of the prosthesis.
  • Erosion: If the cylinder is forcibly pressing up against tissue over an extended period, it can slowly erode through the tissue even in the absence of infection. The device would require removal.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations), you can develop a clot in a vein of your leg (DVT).Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Laparoscopy

This explanation of “laparoscopy” describes no specific operation. Rather, it is intended as a supplement to the Procedure Education Literature that you have received in the event that part or all of your procedure/surgery is going to be performed with laparoscopic technique. Throughout this pamphlet, we will refer to your “primary pamphlet” as the one describing your particular operation or procedure.

Definition

The surgical procedure that popularized laparoscopy is the cholecystectomy (removal of the gallbladder). Over the past decade, laparoscopy has become increasingly popular for urological surgeries as well. In pediatric urology, laparoscopy is most commonly used for performing an orchiopexy (bringing an undescended testicle into the scrotum). In adult urology, the most common laparoscopic operations are partial or total nephrectomy (removal of part or the entire kidney). Adrenalectomy (surgery to remove a small hormone-producing organ on top of the kidney), as well as lymphadenectomy (biopsy and/or removal of lymph nodes from the abdomen or pelvis) are sometimes performed laparoscopically. Some surgeons may perform incontinence surgeries in this fashion. Each year, there are an increasing number of radical prostatectomies (surgery performed to remove a cancerous prostate) performed in Europe and the United States.

As opposed to a laparotomy (open surgery through an incision), laparoscopy involves performing surgery through a few small holes in the abdomen. Through these holes, a camera and other instruments are placed, and the surgeons visualize the procedure on a television screen. With advances in camera optics (quality of the picture), laparoscopic instruments, and laparoscopic technique, many operations can be performed entirely or partially in this fashion.

The technique of hand-assisted laparoscopy uses a combination of laparoscopy with a short incision that allows just one hand to be placed in the abdomen. The advantage of this technique is that it allows the surgeon to make a smaller incision, and often, in an area that is less painful in the post-operative period. In urology, this technique is most commonly employed for a nephrectomy (removal of a kidney).

Preparation

As is often true with an open abdominal procedure, it may help the surgeon if your small intestine and colon are empty. You should avoid constipating foods (i.e. rice, bananas, red meat) for a few days prior to your procedure. Some surgeons may request that you clean out your intestines or colon the evening prior to your procedure. If asked to do so, you may receive instructions from your surgeon.

It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least 8 hours prior to the scheduled time.

Depending on the particular procedure, we may ask you to clean out your small intestine and colon the night before. * If we ask you to do so, instructions will be included in the primary literature pamphlet.

An empty gastrointestinal tract may facilitate the surgery and may also make you more comfortable in the postoperative period. You should plan a light lunch and early, very light dinner the day prior. For the remainder of the evening, it is important to continue to drink plenty of clear fluids, but you CANNOT eat. You may drink up until midnight but not after and not in the morning of your scheduled surgery.

If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc….”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

Laparoscopic procedures are performed under general anesthesia (complete sleep). The procedure differs from open surgery in that there will be anywhere from two to five less than one inch incisions placed on your abdomen instead of one larger incision. With hand-assisted laparoscopy, there will be one longer incision and fewer smaller incisions. After the camera is placed in an initial incision (usually near the bellybutton or navel), the abdominal cavity is inflated with a gas (carbon dioxide) to lift the abdominal wall away from the intra-abdominal or pelvic organs. This elevation provides the necessary space to perform and properly visualize the operation. The pressure of the gas in the abdominal or pelvic cavity is monitored. Small instruments are then placed (under camera vision) through other small carefully positioned incisions into the abdominal or pelvic cavity. The camera projects the picture onto a television screen. The remainder of the procedure is fairly identical to the steps described in the primary pamphlet. After the surgery is complete, the instruments are removed and each of the holes are usually sutured close. Sterile bandages are put over the small incision sites.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged or moved to a regular room (if you are being admitted). This will have been discussed with you prior. There will be small dressing over each of the small incision sites. If a longer incision was made (hand-assisted laparoscopy), it will be covered with a larger bandage. Otherwise, the “post procedure” expectations are the same as those in the primary pamphlet.

Expectations of Outcome

The purpose of laparoscopy is to help minimize post-operative pain, hospital stay, and overall recovery. In most instances, this is accomplished. In many, but not all surgeries, actual operative time is also reduced. However, in some operations, operative time may be the same or even greater as compared with an open operation.

In any laparoscopic surgery, your surgeon will have told you that there is a chance of “conversion” to an open procedure. This means that a laparoscopic procedure has to be changed to an open operation. The indication to do so may be one of two scenarios. The first is that there are findings (scarring, unexpected anatomy) that prevent the surgeon from completing the procedure effectively or safely. The second is that there is a problem during laparoscopy that the surgeon feels might be more effectively handled through a larger incision.

Conversion is a decision made by the surgeon that is in the patient’s best interest, and it should not be considered to be a complication. It simply means that your surgery will be completed in the open fashion.

Possible Complications of the Procedure

ALL surgical procedures (open or laparoscopic), regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. You should refer to the primary pamphlet describing your particular surgery for the complete list of complications. Some of those listed below are particular to laparoscopy, while others are already listed in your primary pamphlet. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned.

*Laparoscopic technology and instrumentation have evolved tremendously over the past decade. As you read below, bear in mind that complications particular to laparoscopy (subcutaneous emphysema, tension pneumoperitoneum and pneumothorax, pneumomediastinum, pneumopericardium and gas embolism) while possible, are not common.

  • Blood Loss/Transfusion: Significant blood loss is rare with laparoscopic procedures. Uncommonly, small or even large blood vessels can be injured during placement of the instruments into the abdominal cavity or during the dissection. Minor to moderate bleeding can usually be controlled through the laparoscope. More severe bleeding may require conversion to an open procedure. If severe bleeding occurs, transfusion could be necessary.
  • Organ Injury: During initial placement of the instruments or during any part of the dissection, any organ in the abdomen or pelvis (liver, spleen, colon, intestine, bladder, stomach, ureter, etc.) can be injured. Often, the problem can be treated through the laparoscope. In other instances, conversion to an open operation may be necessary. Treatment depends on the particular organ injured and the severity of the injury. These are described in your primary surgical pamphlet.
  • Subcutaneous Emphysema: In rare instances, the carbon dioxide gas (CO2) can enter the subcutaneous (below the skin) tissue plane. In the post-operative period, this may present with minor to severe swelling and bruising (depending on the amount of gas in the tissue). The gas eventually gets reabsorbed by the body and the swelling and bruising resolve with time.
  • Tension Pneumoperitoneum: The pressure of CO2 gas in the peritoneum(intra-abdominal space) is carefully monitored. Sometimes, the pressure can push upward on the chest cavity and cause problems with proper ventilation (breathing).This may result in blood pressure fluctuation and problems with the heart. In rare instances, high intra-abdominal pressures can result in a tension pneumothorax(collapse of the lung due to high surrounding pressures (see pneumothorax below).
  • Gas Embolism: This unusual problem results when CO2 gas enters into the blood vessels. The result can be changes in heart rhythm and blood pressure. While cardiac arrest (complete stop of the heart) is possible, it is highly unusual.
  • Pneumothorax (Collapse of the Lung): This can occur if one of the instruments enters the thoracic (chest) cavity. A chest tube (lung cavity drain) is sometimes placed that will be removed in a few days. There are rarely long-term complications as a result. Less commonly, the CO2 gas enters into the cavity outside of the heart and lung blood vessels (pneumomediastinum) or even directly around the heart (pneumopericardium). These rare complications can be life-threatening and require immediate attention in an intensive care setting.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office.
  • Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
  • Urinary Tract Infection or Urosepsis (Bloodstream Infection): Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.
  • Wound Infection: As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from any of the small incisions. Usually, these are easily managed with antibiotics. In some instances, an incision needs to be opened for adequate drainage. An abscess is an infection collection in the body. It can present with the same symptoms as sepsis and usually requires drainage.
  • *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
  • Ileus or Bowel Obstruction: Because we operate near the intestines, they can go into prolonged spasm (ileus), or they may become blocked. Treatment ranges from observation to other surgical procedures.
  • Hernia: Although small incisions are sutured closed, it is possible to develop a small hernia (tissue protrusion) in the wound. Treatment can be observation (if it is only acosmetic issue) or a surgery to repair the weak area of supportive tissue.
  • Lymphocele: A lymphocele is a collection of lymphatic fluid (tissue fluid that drains through the lymph nodes) that can rarely accumulate in patients that undergo removal of lymph nodes. It is possible for some of the fluid to persistently leak from tiny lymphatic channels. These collections can form in the abdomen or pelvis and may compress nerves(causing weakness in the leg) or blood vessels (increasing the risk of a deep vein thrombosis). Typically, the first sign of a pelvic lymphocele is ankle and foot swelling on the side of the lymphocele. Treatment ranges from observation (most often a self-limiting process) to a drainage procedure. The need for an open procedure is uncommon.
  • Chronic Pain: While quite unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Meatotomy

Definition

Meatus = the hole at the end of the urethra through which one urinates

Otomy = to make a hole or opening in

A meatotomy is performed for a condition referred to as meatal stenosis (tightening or narrowing). Although rare cases are discovered at the time of a circumcision or in an uncircumcised male, the vast majority present months or longer after circumcision. It is thought that the meatus, no longer covered by foreskin, is now exposed to irritation against a urine-soaked diaper, and consequently scars. Parents will notice that their baby’s urine shoots upward, or that it uncontrollably sprays in multiple directions. There is no effective medical treatment and so a procedure is needed to correct the condition.

Meatotomy is performed as an ambulatory procedure, usually under general anesthesia so that your child is not aware of the procedure. Some surgeons will also use a local injection of along-acting local anesthetic agent to minimize pain upon when the child awakens. This is rarely necessary, however. The recovery time is typically very short. This procedure can sometimes be done in the office with just local anesthesia.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to feed your child anything (including any liquids) after midnight on the evening prior to the surgery. If your child is on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. If safely avoidable, the procedure should no be performed if you child is on, or has recently been taking any medication that may interfere with his ability to clot his blood. This may not be of great concern for this procedure, however. The most common of these medications are aspirin-like compounds and all related pain relievers, fever reducers, or anti-inflammatory compounds(whether prescription or over-the-counter). Please refer to the attached list and tell us if he has taken any of these within the past 10 days. If his medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed any of the current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The procedure can take anywhere from 15-30 minutes. The tiny bit of skin that is partially covering the meatus is clamped (to interfere with blood supply) and then simply cut. We then look at the size of the opening to determine if it is large enough. In many instances, one or two very small sutures are placed on either side to help prevent a recurrence.

Sometimes a suture is needed to stop a small blood vessel from bleeding. In other instances, no sutures are placed. Sometimes an antibiotic ointment is then placed on the newly opened meatus. No dressings are necessary.

Post Procedure

When done in the hospital, your child will be in the recovery room for a short time before being sent home. He may have some discomfort, but typically not any severe pain. It is not uncommon to see small drops of blood drip from the area. Try to keep the surgical area dry for 24 hours. If your child is older (walking/running age), we ask that he refrain from any strenuous activity or rough play for two days. Some patients have almost no discomfort while others are somewhat uncomfortable for one to two days; longer is rare. Your child may cry the first few times he urinates. He may have a stinging or burning sensation from the urine hitting the recently cut tissue. For discomfort, he may have any pediatric-dose over-the-counter medicine to which he is not allergic (Tylenol®, Advil® or other ibuprofen product). Upon follow up in the office, we will examine the hole to ensure that it stayed open. The sutures (if any were placed) are self-dissolving, and do not require removal. In the first two to three days, you may be asked to spread antibiotic ointment (i.e. Bacitracin®) on the area to prevent the sutures or skin from sticking to diapers or undergarments. The ointment may also help to prevent recurrence. Some surgeons may ask you to put your son into a warm bath a couple of times a day. Some may ask you to gently spread the hole apart a few times a day for the first few days to help prevent the edges from sticking together.

Expectations of Outcome

You should notice that your child’s urine stream is no longer spraying or deflected upward. Again , he may have discomfort the first few times that he urinates. Encourage him not to hold the urine back. Sometimes, placing him into a warm tub to urinate will be helpful.

Most meatotomies do stay open. There is a small chance that the opening can scar down and need to be re-opened. We often make the meatus wider than is necessary for a successful outcome because we know and expect that a small length of the cut tissue will scar closed. There may be some swelling that may make the penis appear curved or wide. This swelling will disappear over the next one to two weeks.

The sutures (if placed) will break and fall out on their own in one to three weeks. If a suture breaks early (that day or within a couple of days), you need not be concerned. Chances are it has already served its purpose.

Possible Complications of the Procedure ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may generate questions if you are still concerned. Aside from anesthesia complications, it is important that parents be made aware of all possible outcomes which may include, but are not limited to:

  • Recurrent Meatal Stenosis: Again, despite a wide open meatus, some will re-close and perhaps require another procedure.
  • Infection: Infection is quite unusual following meatotomy, but is possible in any procedure. Usually, local wound care and antibiotics are sufficient.
  • Penile or Urethral Injury

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Open Pyeloplasty

This procedure is commonly performed in children, so this literature may be for you as parents rather than as a patient.

Definition

open = through an incision

pyelo = the pelvis of the kidney or the center part of the kidney where the ureter begins

plasty = to reconfigure or reshape

After urine is produced by the kidney, it drains into the center of the kidney called the collecting system. The individual passageways of the collecting system come together to form one large central area call the renal pelvis. The renal pelvis subsequently funnels urine into the ureter. The ureter is a thin tube that connects each kidney with the urinary bladder.

When there is a problem within the ureter or kidney, we can often approach it with a small telescope that is inserted through the urethra (tube through which you urinate), into your bladder, and then into the ureter. The scope can be advanced all the way into the renal pelvis or its branches. Another approach to the renal pelvis or ureter is through a small hole made in the back in the region of the kidney. This is referred to as percutaneous (through the skin)access to the kidney or ureter.

When there is an occlusion or blockage at the junction where the renal pelvis meets the actual ureters, we call this a ureteropelvic junction obstruction (UPJ obstruction). The exact cause of a UPJ obstruction is unknown but may be due to:

  • a blood vessel crossing this area and consequently compressing the region
  • a true area of scar tissue
  • an area of the ureter that is missing muscle components in its wall and therefore does not have proper peristalsis (contracting motion to move urine along)

*People are usually born with UPJ obstructions, but may also develop them later in life. Notall UPJ obstructions require correction. Sometimes they are discovered incidentally (while evaluating another problem) in older adults who have had no symptoms, and in whom the kidney has suffered minimal damage as a result. Alternatively, if a patient is found to have a very minimally or non-functioning kidney as a result of an undiscovered UPJ obstruction, then surgical correction may not be warranted. In other words, there may be no benefit to the procedure. Factors that dictate a need for treatment include:

  • pain or other symptoms due to the presence of obstruction
  • deterioration of a functioning kidney due to the obstruction
  • formation of stones or infections due to impaired urine flow
  • a younger patient in which there is greater uncertainty as to whether the kidney will ultimately lose function

When the UPJ obstruction is corrected through an endoscopic (through a scope) procedure, it is referred to as an endopyelotomy. It is not always practical or appropriate, however, to operate on the kidney or ureter through a scope. In these instances a pyeloplasty (open operation), may yield a better success rate or may be safer for the patient. Common reasons for an open operation include:

  • a failed prior endopyelotomy
  • a lengthy scar or UPJ obstruction that would not respond well to endopyelotomy
  • a UPJ obstruction in a child is more commonly treated with an open procedure
  • an anatomic abnormality where the ureter is attached to the renal pelvis in a high position (termed a high insertion)

After any of these procedures, it is usually necessary to leave a stent (plastic drainage tube) in the ureter for a few weeks to allow adequate drainage and resolution of inflammation of the tract. This tube is not visible on the outside of the body as one end is in the kidney, and the other in the bladder. The stent can be easily removed in the office without anesthesia. The amount of time that the stent remains in will depend on your particular situation.

Preparation

There is no particular preparation for this procedure. As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc…”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter).

Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The actual procedure will take a few hours and depends on the individual’s anatomy and the type of repair chosen by the surgeon. This operation is performed under general anesthesia (complete sleep).

The approach to the kidney may be through an incision in the back, the flank (side of the body), or on the abdomen. Your position on the tale will therefore vary with the chosen approach. In certain instances, it may be necessary to remove a rib in order to properly operate on the kidney. Depending on your anatomy and the type of incision used, we will decide whether we will have better exposure if a rib is removed. Subsequently, the ureteropelvic junction (UPJ) obstruction will then be identified. The length of the abnormal segment, as well as the point at which the ureter and renal pelvis connect will dictate how the remainder of the procedure is performed. Regardless, all variations include removing or excising the blocked or non-functioning segment and reconnecting the remainder of the ureter to the renal pelvis in anon-obstructing fashion. Before all of the sutures are placed, a stent may be placed in the ureter spanning the distance from the renal pelvis to the bladder. It will remain in for a few weeks.

Again, the stent is a small plastic tube that allows urine to adequately flow from the kidney to the bladder while the repair is healing. Sometimes, a stent is brought out through the side (i.e. through a small hole in the skin) to make removal easier. In certain cases, a drain may be placed on the outside of the kidney and brought out through a small second skin incision near the first. The purpose of this drain is to allow urine that leaks out of the kidney suture lines to exit the body. The use of a drain will depend on your particular case and the surgeon’s judgment. In small children and infants, the procedure is sometimes done without the use of either a stent or drain.

After the repair is complete, the deep tissue and skin incision are closed. A dressing will be applied over the wound.

Post Procedure

After the procedure, you will be in the recovery room until you are admitted to your room. The usual hospital stay can be as short as one night, but is more typically two. Occasionally, some patients may stay longer.

In the recovery room, you may have a catheter in your urethra that is attached to a bag. Its purpose is to keep the bladder empty. Because of this catheter, and the presence of the stent, you may have an urge to urinate even though your bladder is empty. You will have some discomfort over the area of the incision.

The following morning, the urethral catheter (one in the bladder) will probably be removed. The sense of urgency may remain, however, because of the stent. Although the stent is soft plastic, any degree of sensation from its presence is possible. You may have no sensation that the stent is there, or it can be somewhat bothersome at times. The symptoms can be any one or a combination of back or groin discomfort, urinary frequency, urgency or burning. If an external drain was placed, the time of its removal will depend on the amount of leaking from this drain.

Patients usually have minimal to no blood in the urine. When present, this usually disappears within a few days.

Expectations of Outcome

While our intent is to adequately open the UPJ obstruction, this is not always possible. Success of these procedures varies.

As previously mentioned, the stent will remain in the ureter for a few weeks. It is easily removed in the office.
Despite a properly performed procedure, an obstruction can persist or recur at any point in time. It is therefore imperative that you be followed up in our office at regular intervals.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you or your child might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You or your child may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. We also see infections more commonly in patients who already have a stent in place prior to this procedure.
  • Wound Infection: As with any incision, an infection can occur. This would present with unusual redness, swelling and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics. In some instances, as mall area of the superficial (upper layer) incision needs to be opened for adequate drainage. An abscess is an infection collection in the body. It can present with the same symptoms as sepsis and usually requires drainage.
  • *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
  • Urinoma: If there is leakage of urine across the repair, a urinoma (collection of urine) can form outside of the kidney or ureter. This urinoma is rarely of any consequence. If the leakage persists or becomes large, it can cause discomfort by placing pressure on adjacent structures. If a stent is in good position and providing good drainage down to the bladder, the leak will usually stop and the urinoma will disappear with time. If persistent or troublesome, a minimally invasive procedure to place a drain outside the ureter or kidney may be necessary. This is more common inpatients who have no external drain placed during surgery.
  • Blood Loss/Transfusion: Significant blood loss from this procedure is uncommon. Despite our understanding of the anatomy (specifically the location blood vessels), it is possible to cause an injury to a “crossing vessel” (one that courses across the area of the renal pelvis). Although its position is usually predictable, there are instances in which there are vessels in an unexpected position. Usually, bleeding can easily be controlled. A need for transfusion is rarely necessary.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg(calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
  • Hernia: A hernia (weakening of supportive tissue under the skin) is possible with any type of incision. The majority are only a cosmetic problem. Sometimes, repair is necessary.
  • Ileus or Bowel Obstruction: Because we operate near the intestines, they can go into prolonged spasm (ileus), or they may become blocked. Treatment ranges from observation to surgery (less commonly).
  • Injury to an Adjacent Organ: This type of complication is rare. This is more common in patients who have had prior surgeries in this area. During dissection, any of the following are possible and may be noticed immediately during the operation, or shortly after:
  • pneumothorax (partial or complete lung collapse) requiring temporary placement of a special chest tube for a few days
  • spleen (left side procedure) or liver (right side procedure) injury–treatment could range from observation to
  • angiogram (if significant bleeding), or even open surgery (a general surgeon may be asked to assist with this problem)
  • colon (large intestine) or bowel (small intestine) injury–treatment is usually open surgery (by a general surgeon) if the hole is significant (a general surgeon may be asked to assist with this problem).
  • Chronic Pain: Any surgery can be associated with chronic pain in the area of the incision. Although it is extremely rare, it is slightly more common in operations that involve an incision in the flank (side of the body).
  • Nephrectomy: In the overwhelming majority of cases, we will know if nephrectomy(kidney removal) is warranted, and we will have suggested this as the solution to the UPJ obstruction instead of an attempted repair. Although very uncommon, the look and feel of the kidney during surgery may be worse than was apparent through prior testing. In that regard, sometimes a patient is better off with the kidney removed than repaired. Another uncommon reason for removing a kidney is in patients who had other prior repairs with such significant scarring that the current repair is not possible.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Orchiopexy (Orchidopexy)

Definition

Orch = pertaining to the testicle

Pexy = fixation or attachment

In the developing male fetus, the testicles grow in the baby’s abdomen and drop down into the scrotal sac near the end of pregnancy. In some boys (more frequently in premature births), one or both of the testicles will not fully come down to the scrotal sac, and this is referred to as cryptorchidism. The undescended testicle can remain in the abdominal cavity, or further along its intended course in the inguinal canal (groin area between the abdomen and the scrotal sac).Its position, and whether it is palpable (able to be felt during physical examination) will determine the recommended treatment.

If both testicles are undescended, we may have already recommended a trial of human chorionic gonadotropin (HCG) injections. This hormone therapy may cause the testicles to drop down further. HCG injections usually work better when both testicles are undescended.

Orchiopexy is not recommended for cosmetic reasons. Undescended testicles place your son at a much greater risk of developing testicular cancer in his lifetime compared to males with normally descended testicles. Cryptorchidism may also result in impaired spermatogenesis(ability to properly produce sperm) in the undescended and even the descended testicle. If left undescended, your child may be at risk for infertility. Also, torsion or twisting of the vascular spermatic cord on which the testicle dangles may result in loss of blood supply to and permanent damage to the testicle.

Orchiopexy is appropriately done as an “open” operation (involving small skin incisions) or as a “laparoscopic” operation (done through a scope with instruments inserted into the body through tiny incisions). Sometimes, laparoscopy is combined with an incision to maximize results. Rarely, with very high testicles, it is possible that the orchiopexy procedure is done in more than one operation (i.e. on two different dates). This is referred to as a “staged” operation.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to feed your child anything (including any liquids) after midnight on the evening prior to the surgery. If your child is on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if your child is on, or has recently been taking any medication that may interfere with his ability to clot his blood. The most common of these medications are aspirin-like compounds and all related pain relievers, fever reducers, or anti-inflammatory compounds(whether prescription or over-the-counter). Please refer to the attached list and tell us if he has taken any of these within the past 10 days.

If his medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed any of the current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The procedure can take up to two hours depending on an individual’s anatomy, the location of the testicle(s) and whether one or both sides require treatment.

As previously mentioned, undescended testicles are classified as palpable or non-palpable(depending on whether they can be felt on physical examination). Laparoscopy (putting the small telescope into the abdominal cavity) is often done to determine if a non-palpable testicle does indeed exist before any formal skin incisions are made to perform an orchiopexy. Many orchiopexy procedures may be done completely by laparoscopy depending on the location of the testicle and the surgeon’s experience in this area. In other instances, the laparoscopic portion may be used to move the testicle down to a point where it is easily approachable with an inguinal (lower abdomen near the groin) incision.

Laparoscopy: A camera (that is projected onto a television screen) and small instruments are placed through tiny holes in the abdomen. The abdomen is gently inflated with a type of gas to create a space that allows proper visualization. First, the testicle and the cord structures: the artery and vein (blood vessels) and the vas deferens (tube that transports the sperm) are identified. The remainder of the procedure is the same as in the open procedure. The cord is lengthened as much as possible to bring it down near, or into the scrotum. Once in position, it is fixed in place with sutures. Once the instruments are withdrawn, the small holes are all sutured closed and sterile bandages are applied.

Open Surgery: If the testicle is palpable, an open procedure or laparoscopy may be used. As mentioned, sometimes laparoscopy is employed first to locate and even partially bring the testicle down. Open surgery through a small incision may then be made to get the testicle into the scrotum. Sometimes, laparoscopy is not used regardless of the location of the testicle. The small incision is made across the inguinal region (groin area just above and off to the side of the penis or scrotal sac). Dissection is performed down to the testicle and cord. During the procedure, the testicle and cord structures are inspected to ensure that everything else appears within normal limits. Sometimes, the undescended testicle is smaller than the other testicle. In some instances, one of the arteries (vessels bringing blood to the testicle) must be sacrificed(purposely cut) to create a longer cord. The cord must be long enough to bring the testicle down to the scrotum without any tension. The testicle can usually survive because there are other small vessels bringing blood to the testicle. Once the testicle is in the scrotum, sutures are placed to fix the testicle in a pouch in the scrotum. To create the pouch, a small incision is made in the wall of the scrotal sac. The inguinal incision and the scrotal incision are then closed. The stitches may be buried underneath the skin and will therefore not require removal. A sterile bandage is then applied.

Post Procedure

Your child will be in the recovery room for a short time before being sent home. He may have discomfort over the incision(s) and possibly in the groin and scrotum. If laparoscopy was performed, there may be small bandages directly over any incision(s). If an incision was made, it may also be covered.

Bandages are to remain on until follow up in the office unless you have been specifically instructed to remove them earlier. It is common to see small blood staining on the bandages. If the dressing becomes soaked, or you see active blood oozing, please contact us.

He may shower the day after surgery. Your surgeon may ask you not to place your child in a bath. Sometimes your surgeon may instruct you to place him in a warm bath a few days after surgery. We ask that he refrain from any strenuous activity or rough play (including gym or physical education) until after his follow up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. In the first 24 hours, it is important to minimize his activity and have him spend a lot of time sitting or lying down. Some patients have almost no discomfort while others are some what uncomfortable for a few days; longer is rare. For discomfort, he may have any pediatric-dose over-the-counter medicine to which he is not allergic (Tylenol®, Advil® or other ibuprofen product). Upon follow up in the office, we will examine him. The sutures we use are usually self-dissolving, and therefore just dissolve with time.

Expectations of Outcome

The tissues within the scrotum and over the incision(s) may swell and appear bruised. This may be more dramatic one or two days after than on the first day. This is expected.

If the testicle was easily palpable prior to the operation, it is usually found to be a normal testicle (one that will survive and function). It will, however, remain small if it was found to be shrunken during surgery. In that regard, it may always have decreased function compared with the other.

It is also possible for a testicle to shrink after the operation. It is possible that the testicle loses its blood supply during the effort to lengthen the cord. This is not always apparent during the actual surgery.

With very high testicles that cannot be brought down during the operation, one of two choices must be made:

*If the testicle looks normal and significant progress is made, we can stage the operation. This means that we can return to the operating room months later (after some healing has occurred)and make an attempt to bring it down the remainder of the way.

*If the testicle appears abnormal (fairly shrunken), or if we have little success in getting it near the scrotum on the first procedure, we may decide to remove the testicle as opposed to stage the operation. The operation is only successful if the testicle is successfully brought into the scrotum. Leaving the testicle in the inguinal canal is still putting your child at risk.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Hematoma: This is when a small blood vessel continues to ooze or bleed after the procedure is over. The result is greater swelling and bruising. A drainage procedure is rarely necessary and it usually resolves over time with compresses…much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
  • Infection: Infection is possible in any procedure. Usually, warm compresses and antibiotics are sufficient. Occasionally, an infection would require partially opening the wound to allow proper drainage.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area exposed to surgery. Typically, the pain disappears over time. If persistent, further evaluation would be necessary.
  • Testicular Ischemia/Loss: Any time surgery is performed on a testicle, it is possible to injure the blood supply to the testicle. As a result, the testicle may not survive and shrink in size.
  • Vas Deferens Injury: The vas deferens is the small tube that transports sperm from the testicle to the urethra. During attempts to lengthen the cord it could be transected(cut). It would be repaired during the surgery if possible. Sometimes, it is repaired at a later date.
  • Nerve Injury: Sometimes the nerve that provides sensation to the groin and inner thigh may be injured resulting in numbness in these areas.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C

Pediatric Circumcision / Revision of Circumcision

Definition

Removal of the prepuce (foreskin) that covers the glans penis (head of the penis).

In a baby most circumcisions are performed within the first few days of life before the newborn is discharged home. In other instances, parents make a decision to have their son circumcised later in infancy or even during childhood. Some of the reasons include:

  1. Phimosis: This means that the opening of the foreskin has scarred down and the individual or parents cannot pull it back easily, or in some cases, at all. This may result in poor hygiene, and in extreme cases, interfere with urination.
  2. Urinary Tract Infection: When a young boy gets urinary tract infections, often circumcision is recommended when there is no other determined cause of the infections.
  3. Infection: The head of the penis or the foreskin itself may become repeatedly infected. Patients who have an initial infection are more likely to have problems with recurrent infections.
  4. Elective: In these cases, parents may tell the pediatrician or urologist that they wish to undergo circumcision for cosmetic or religious reasons.

Circumcision is performed as an outpatient procedure. Children are placed under general anesthesia so they are not aware of the procedure. In addition, some surgeons use a local injection of a long-acting local anesthetic agent to minimize pain when the child awakens. The recovery time is typically short.
Occasionally a newborn is circumcised but there is a problem with the healing process. In certain instances, there may be extra skin left behind. In other situations, some of the skin may form adhesions (skin bridges or scar tissue). Both scenarios may necessitate a “revision” of the circumcision. these procedures are fairly similar to a first-time circumcision with respect to preparation, procedure, recovery, and possible complications.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to feed your child anything (including any liquids) after midnight on the evening prior to the surgery. If your child is on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if your child is on, or has recently been taking any medication that may interfere with his ability to clot his blood. The most common of these medications are aspirin-like compounds and all related pain relievers, fever reducers, or anti-inflammatory compounds(whether prescription or over-the-counter). Please refer to the attached list and tell us if he has taken any of these within the past 10 days. If his medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed any of the current medications with you during the pre-operative/pre-procedure consultation.

You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The procedure usually takes less than one hour.
There are several methods to remove the foreskin. Each surgeon is comfortable with, and typically favors a specific approach. In the end, the result is the same.

Once the excess skin is completely removed, we examine the glans penis (the head) to ensure that the meatus (hole through which one urinates at the end of the penis) is of proper caliber(wide enough) and location. We also inspect the frenulum (web-like tissue on the undersurface of the penis that bridges the glans and the shaft) to ensure that it is not pulling on the glans. If this finding is apparent, we perform a frenulotomy (simple division of the skin bridge or frenulum). We then inspect the area where the skin was removed and ensure that there is no bleeding. The skin edges are sewn together, and may be coated with an antibiotic ointment. Next, we place a loose-fitting bandage around the penis. The dressing does not block the meatus, so it does not obstruct the flow of urine.

Post Procedure

Your child will be in the recovery room for a short time before being sent home. He may have some discomfort, but typically not any severe pain due to the administration of local anesthesia during the surgery. As mentioned, there will be a small dressing directly around the penis that covers the incision. Unless otherwise instructed by your surgeon, this dressing should be removed the following morning. Often we get phone calls that afternoon or evening that the bandage fell off prior to the following morning. If there is no significant bleeding, this is not a concern and you should not worry. Do not attempt to replace the bandage. It is not uncommon to see small blood staining under the bandages. If the bandage becomes soaked, or you see active blood oozing, please contact us. Sponge baths on other areas of the body are acceptable on the first day or so. Some surgeons will ask that you keep the surgical site dry for a few days longer while others may recommend warm baths a few days after the procedure. If your child is older (walking/running age), we ask that he refrain from any strenuous activity or rough play until after his follow up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. For this reason, the penis may appear slightly wider and/or discolored. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days; longer is rare. For discomfort, he may have a pediatric-dose over-the-counter medicine to which he is not allergic (Tylenol®, Advil® or other ibuprofen product). Upon follow up in the office, we will examine the surgical repair. The sutures we use are self-dissolving, and therefore just dissolve with time. They need not be removed.

Expectations of Outcome

Circumcisions typically heal quite well. There is usually some swelling that may make the penis appear curved or wide. This swelling will disappear over the next few weeks.

Your child will not have burning when he urinates. The only exception is if we have to perform a meatotomy (open the caliber of the hole through which he urinates). If this is the case, we will discuss this finding with you after the procedure.

The suture line may be visible for quite some time after the sutures dissolve and fall out. These markings usually fade with time as the child grows.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in the consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia, it is important that parents be made aware of all possible outcomes which may include, but are not limited to:

  • Meatal Stricture or Stenosis: Following circumcision, the meatus (hole at the very end of the urethra or tip of the penis) is now exposed to the diaper or undergarments. Chronic irritation may cause it to scar tighter. The result may be a slight obstruction to the free flow of urine. Often the urine stream is deflected upward and sprays. It may require a minor revision procedure such as dilatation or tiny incision.
  • Infection: Infection is possible following any procedure. Usually, warm compresses and antibiotics are sufficient. Occasionally, an infection would require partially opening the wound to allow proper drainage.
  • Hematoma: This is when a small blood vessel continues to ooze or bleed after the procedure is over. The result is greater swelling and bruising. A drainage procedure is rarely necessary and it usually resolves over time with compresses…much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
  • Suture Breakdown: If the penis is accidentally traumatized after the surgery, some or all of the sutures can tear. If soon after the circumcision, and if immediate attention is sought, sutures may be replaced in the operating room. In most instances, it is just a few sutures, and there is little that we need to do. In most cases, the circumcisions will still heal nicely.
  • Injury to the Glans (Head of) Penis: This is an extremely rare complication. When recognized, we will do what is indicated to repair the injury.
  • Penile Torsion or Chordee: During the procedure, the skin edges are aligned and subsequently sewn together. Nevertheless, there may be a slight torsion (rotation or twisting) to one side. If more skin is taken from one side than another, a chordee (bend of the penis to one side) could result. In either scenario, a revision procedure may be necessary. Penile torsion and chordee are conditions that babies may be born with and are both very uncommon following circumcision.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area exposed to surgery. Typically, the pain disappears over time. If persistent, further evaluation would be necessary.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office.

Alternative treatments, the purpose of the procedure/surgery, and the points in this hand out have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

Percutaneous Nephrolithotomy (PCNL)

Definition

Percutaneous = “through the skin”

Nephro = “kidney”

Lithotomy = “stone breakage and removal”

Essentially, a PCNL is just that…removing a kidney stone through a hole in your back. Before the invention of endoscopic (through a scope) procedures, very large kidney stones would be removed through an incision (open operation). While this is still sometimes performed, open operations for stones are now rarely necessary.

We attempt to remove most kidney stones with shock wave lithotripsy (SWL), which is anon-invasive procedure involving external shock waves. Other stones in the kidney or ureter(tube extending from the kidney to the bladder) can be successfully treated with ureteroscopy (a procedure in which a scope is passed from the urethra, into the bladder and up the ureter into the kidney). In this operation, no incisions are made in the skin.

When a stone is very large, moderately large and located in certain parts of the kidney, or have been unsuccessfully treated with the above mentioned procedures, a PCNL is commonly recommended.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc….”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: Some urologists place the initial tube into your kidney at the time of the procedure. Other urologists ask the interventional radiology team (physician radiologists that perform minimally invasive procedures) to place the initial tube the day prior to or the day of your procedure.

This initial tube (the nephrostomy tube) is called the “access” because it is the tube that will allow us access to the center of your kidney. If your tube is being placed the day prior, you will be admitted to the hospital overnight, and the PCNL will be performed the following day.

The actual procedure can take anywhere from one to three hours depending on stones (size, location and composition) as well as on your anatomy. Once under general anesthesia, you will be placed lying face down with cushions and supports. We dilate (spread open) the access tract up to the size of a nickel until we can fit our nephroscope (scope that goes into the kidney) inside. Using a combination of direct vision through the scope, as well as x-ray guidance, we advance the scope directly to the stone(s). Depending on the location, size and consistency of the stone, the surgeon may elect to use one or a combination of technologies or instruments to break the stone and remove any significant fragments. When we are finished removing as much stone as is safely possible, we place a tube (which is attached to a small drainage bag) in the tract. In some cases, we may also elect to place a stent (small plastic tube that does from the kidney all the way down to the bladder) in the ureter.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be sent to your room. Your back may be sore where we made the small hole for the scope and where you now have a tube. You may have a catheter in your bladder overnight. It is common to have a sense of urinary urgency (bladder spasms) from the catheter. Patients may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. The blood usually disappears within a few days. You may also notice stone fragments in the urine. Because they are small, a patient typically does not feel them as they pass in the urine.

Although the stent is soft plastic, any degree of sensation from its presence is possible. Some patients have no feeling, while on the other extreme, some have bothersome symptoms. The symptoms can be any one or a combination of back or groin discomfort, urinary frequency, urgency or burning. The symptoms may last only one day or persist for the duration of the presence of the stent. Most patients, however, have very mild symptoms that are tolerable.
In the next day or two, we may take an x-ray with dye injected into the tube in your back. If everything looks acceptable, we will remove the drainage tube in your back and send you home with detailed follow-up instructions. You will have a gauze dressing on your back that will need to be changed one or a few times over the 24-48 hours. Urine may leak from this hole for a few days, and then should stop on its own. If a stent was placed in your procedure, you will be discharged with that tube inside your kidney and ureter. Sometimes, we may leave the tube in the kidney when you go home. It will be connected to a drainage bag or have a cap in the end of it. We will remove it in the office as an outpatient or we may leave it in if another procedure is planned for the near future.

Expectations of Outcome

It is important that you understand the possible outcomes of the procedure. While our intent is to fragment the stone into small pieces, this is not always possible. There are occasional instances in which the scope cannot be passed safely into the kidney despite what appeared to be adequate access. We would not force the scope in as this could cause significant injury to the kidney or surrounding organs. In this instance, we would terminate the procedure, and the next step would be discussed in a follow-up consultation.

Another obstacle may be that the composition of the stone is too hard to fragment. Alternatively, part or all of the stone may be situated in an area that is not readily or safely approachable. Sometimes, small fragments of the stone can be pushed down into the ureter by the water current (from the scope) or from the attempt to break it. If it cannot be safely accessed or adequately broken, a stent may be placed and a different type of procedure (ureteroscopy or shock wave lithotripsy) might be planned for another day. In this regard, treatment for large or complex stones is sometimes referred to as a “staged procedure” because it is done in different stages. Lastly, open surgery could be necessary to fully remove the stone.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Blood Loss/Transfusion: Because the scope and the stone traumatize small blood vessels, there is always minor to moderate blood loss expected. In some instances, blood loss is more severe and could possibly necessitate a transfusion.
  • Renal Infarction/Loss of Kidney: Sometimes the scope or stone instruments can traumatize an important blood vessel supplying a portion of the kidney. If this occurs, part of the kidney could die. If there is a major vascular injury, it could necessitate an emergent procedure by the interventional radiologists to clot off the vessel. In an extreme situation, an open operation to correct the problem or even remove the kidney entirely may be the only way to control the bleeding.
  • Urine Leak: As described, this operation requires entering through a hole in the kidney. The tube(s) placed at the end of the case are there to allow healing of the hole. Typically, this hole closes after 1-3 days. Sometimes, there may be a leak for a longer period. While the vast majority of these leaks stop within a few days, persistent leaks may require additional minimally-invasive procedures or repeat minor operations (i.e. placement of a stent). This complication can present immediately (while in the hospital)or even weeks later.
  • Pneumothorax (Collapse of the Lung): The kidneys lie close to the chest cavity. Using any of the methods, it is possible to enter the lung cavity and cause collapse of the lung. It may be necessary to place a tube (lung cavity drain) in the side of the chest wall to allow the lung to re-inflate. The tube will usually be removed in a few days.
  • Liver or Spleen Injury: Kidneys that have had infections (those associated with scarring and inflammation) can sometimes be directly adjacent to or even adherent to surrounding organs–on the right, the liver, and on the left, the spleen. During placement of the initial catheter or scope into the kidney, either organ can be injured. The injury may be small and easily repaired. A significant injury can increase the incidence of transfusion. It is extremely rare for part of all of an organ to necessitate removal. Open surgery may be necessary for these repairs, and a general surgeon might be called to assist with this problem.
  • Injury to the Small Intestine or Colon: The kidneys lie in close proximity to portions of the small intestine and colon. If the scope inadvertently exits the kidney, it can cause injury to these structures. If immediately recognized, we would terminate the procedure immediately. An open abdominal operation (sometimes assisted by a general surgeon) would then be performed. A significant injury could necessitate a temporary colostomy.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
  • Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This scenario is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.
  • *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
  • Pain: Chronic pain, although unusual, may develop from the treated kidney and/or access tract.
  • Ureteral Injury: In an attempt to get the portion of the stone heading down the ureter, this delicate structure may be injured from the scope or from the instruments employed to break/remove your stone. The solution is typically to terminate the procedure, place a stent, and allow the tissue to heal itself over the next week or two. A complete separation of the ureter from the kidney (ureteral avulsion) is a very rare occurrence and requires open surgery through an incision to repair the injured organ. Strictures or scar tissue may develop, narrowing or completely blocking off the urine drainage through the ureter requiring treatment to allow adequate urine flow.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

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