Vasectomy

Definition

Vasectomy refers to voluntary or “elective” surgical sterilization in men. In certain states, there is a mandatory waiting period from the time that you sign consent. In other states, you may have the procedure at any time after signing an informed consent. The waiting period is for your own protection to ensure that you and anyone else involved in the decision have thought about this carefully. In states that do not have a waiting period, you should take a little time to ensure that this decision is right for you. Vasectomy may be reversible, but it considered a permanent form of sterilization. Reversal is technically difficult, has a moderate to low success rate, and is quite costly.

The vas deferens are small tubes that transport sperm from each testicle to the urethra where the sperm combines with the remainder of the contents (made in other glands) of ejaculation. After vasectomy, the ejaculate fluid should appear unchanged in amount and consistency to the naked eye, but it will contain no sperm. Only under a microscope is the change perceptible. The sensation of orgasm and ejaculation are unaffected, and the operation does not affect libido (sex-drive) or erections.

Preparation

We ask that you purchase a scrotal support (jock strap) and bring it that day. You should have ice ready at home. The procedure cannot be done if you are currently on, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners”).We will have reviewed all of your current medications with you during the consultation, but please tell us if anything has changed since your previous visit. The most common of these medications are aspirin and all related pain reliever 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, mention it anyway so that we may ensure it is not a blood thinner. Lastly, you will be asked to shave the hair of your scrotum (as instructed) either that day or the day prior to the procedure.

Procedure

A vasectomy typically takes less than 30 minutes. Variations in time will depend on your particular anatomy. When performed in a hospital or surgical center, it is possible to have an anesthesiologist give you heavy sedation. In this regard, you would be asleep and have no awareness of the procedure. A small amount of medication will be injected intravenously (in the vein) to make you sleepy. Your position will be supine (flat on your back), possibly with your legs in stirrups (holsters), much like a woman during a gynecological examination.

Local anesthesia (numbing medicine) is injected into the area of the scrotum where the procedure is performed. Although you might feel some pressure during the procedure, you will not experience any pain.

In most instances, very small incisions (one centimeter or less) are made on the left and right side of the scrotum respectively. Some surgeons prefer one incision in the middle of the scrotum. Each vas deferens is located, separated from surrounding tissue, and divided. According to the surgeon’s preference, a short segment of the tube can be removed as well. The ends are then either tied with suture or secured with a small clip. Sometimes a surgeon will cauterize (electrically burn) the lumen (center hole through which the sperm flow) as well. The ends of the vas are placed back into the scrotal sac and the incisions are closed. The suture material used on the skin is self-dissolving and will just fall out on their own after 1-2 weeks. It is not necessary to place a dressing over the incision sites, but placing a clean gauze or pad against the scrotum will help to keep your underwear or scrotal support clean.

Post Procedure

After the vasectomy, you will have one to three small sutures on each side or just in the midline as previously discussed. They will dissolve over the following 1-2 weeks and need not be removed. Every patient has some degree of swelling, and it is not possible to predict who might have minimal versus significant swelling. It is very important that you apply ice to the area as soon as you return home for several hours as instructed and wear a scrotal support (or jockey shorts) for several days. 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 patient shave almost no discomfort while others are somewhat uncomfortable for a few days to a week. Severe pain is unlikely but possible. 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. Just like variation in swelling, the scrotum and surrounding areas can have a variation of bruising. This will typically resolve with time. You may shower the following day. Some surgeons will ask that you not take tub baths for a few days while others will recommend warm baths a couple of times per day.

Expectations of Outcome

The effects of a vasectomy at resulting in sterilization are not immediate. Despite a successful procedure, you are not considered sterile until two semen analyses (under the microscope) demonstrate no evidence of sperm. Do not make the assumption that you are sterile just because time has elapsed or because the first semen analysis demonstrated no sperm. You must wait for us to tell you, following the second semen analysis, that it is safe for you to have unprotected intercourse. Sometimes, it can take months for you to clear all of the sperm out of your tracts. Please make sure to keep all follow up appointments as they are scheduled. While rare, a vasectomy can fail. We will have discussed the possible explanations for this.

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 generate questions if you are still concerned. We think it is important that every patient be made aware of all possible outcomes. “An educated patient is the best patient.”

  • Failure: As mentioned, a vasectomy may fail. This is rare and probably only occurs1-2% of the time by national average. In immediate failure, the patient never has a semen analysis that demonstrates “no sperm”.
  • A delayed failure would mean that at one time, there were no, or few sperm but subsequently there were increased sperm again in the ejaculate. There are different reasons for each. Failure requires that the procedure be repeated.
  • Inability to Complete: There are rare instances when a patient’s anatomy makes it impossible to continue with an intended procedure (in the office) without causing too much discomfort or compromising the success or safety of the procedure. In this instance, we would stop and recommend that the procedure be rescheduled to be done in a different setting (i.e. in the hospital) with anesthesia.
  • 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. Intervention (opening the incision to evacuate the blood ) is very rarely necessary and it almost always resolves over time with compresses…much like any bad bruising or swelling. If this happens, i tis usually in the first day after the procedure.
  • Sperm Granuloma: A local blowout of sperm in the scrotal cavity may result in a painful swollen nodule. Usually pain resolves over time, but in rare instances may require surgery.
  • Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are all that is necessary. Opening the wound to drain the infection may be necessary if more conservative measures fail.
  • Hydrocele: Fluid may accumulate around the testicle. If this results in a lot of swelling or pain, surgery may need to be considered.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery. This is rare and would tend to disappear with time. If persistent, further evaluation may be necessary.
  • Testicular Ischemia/Loss: This is quite unlikely but could theoretically occur. If the testicle has inadequate blood supply, it would shrink and lose ability to function. While most urologists have never experienced this complication or know of any urologist that has, it is theoretically possible.
  • Prostate Cancer: Most recent medical research suggests minimal associated risk between vasectomy and prostate cancer.

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.

Definition

Varicocele = enlarged vein (veins are blood vessels that carry blood toward the heart)

Ectomy = removal of

Varicocelectomy refers to surgical removal or ligation (dividing and securing or sealing the ends) of veins in the spermatic cord. The spermatic cord is the name for the combination of structures that travel from the testicle, up the groin region, and into other areas of theabdomen or pelvis. The cord is wrapped in layers of tissue called fascia. Within the cord on each side are the:

  • Vas deferens: This is the spaghetti-like tube that transports sperm from the testicle to the urethra (tube through which you urinate and ejaculate semen).
  • Arteries: These are the blood vessels that transport blood to the testicle and surrounding structures. The main artery is the testicular (gonadal) artery.
  • Veins: These are blood vessels that transport used blood back in the direction of the heart.
  • Nerves: There are small nerve fibers that supply sensation or reflex action to this area.
  • Lymphatics: These are small vessels that drain tissue (lymph) fluid that surrounds the testicle.

For unknown reasons, the veins may become dilated (too large), and this is termed avaricocele. A varicocele may interfere with normal sperm production and consequently fertility(ability to produce normal sperm). Much like varicose veins in the legs, these veins can be visible to the naked eye. There is a grading system that we as urologists use to classify these veins, although size does not necessarily correlate with how problematic their presence may be. In other words, a larger varicocele does not necessarily indicate worse infertility.

While there are different theories as to why varicoceles may be associated with infertility, the “increased temperature” theory is most widely accepted. Your body temperature is 98.6degrees. The testicles hang low in the scrotal sac so that they can exist at just over 96 degrees(2 degrees lower); the temperature at which normal spermatogenesis (the production of sperm)can successfully occur. When a varicocele is present, there is more blood (traveling in the dilated veins) pooled around the testicles at any given time. The result is that the testicles are warmer than they should be to function properly. Consequently, spermatogenesis may be impaired.

Varicoceles are sometimes discovered by the patient, by the physician, or accidentally because you have a scrotal or testicular ultrasound (sonogram) test done for another reason. In the younger patient, these are common scenarios.
In married men, the most common reason to evaluate for a varicocele is infertility. In other words, a couple has long been unsuccessful at achieving pregnancy.

Any one, but more often a combination of physical examination, semen analysis, and ultrasound of the testicles will confirm the diagnosis. Because of your anatomy (the drainage patterns of the veins) the vast majority of varicoceles are on the left side. A few are on both sides, and rarely do we see a right side only presentation. Sometimes we can diagnose avaricocele just by looking. Other times we can only feel it. In some situations, it is only apparent on ultrasound examination. Sometimes, the testicle on that side may have been affected over time and is atrophied (shrunken) as a result. This finding may indicate a worse result for return to normal fertility following repair.

With varicoceles, any presentation is possible:

  • There may be a normal semen analysis and a normal size testicle with a large or small varicocele.
  • There may be an abnormal semen analysis and a small testicle with a small or large varicocele.

“In whom do we recommend that a varicocelectomy be performed?”

Not all varicoceles cause subfertility (diminished ability to impregnate) or infertility (complete inability to impregnate). In patients that do not want to have children or are finished having children, there is no need to have the procedure. In unusual instances, a large varicocele may cause discomfort, and we may suggest a repair in select patients. This would not be for fertility purposes. For the patients that present with a history of inability to impregnate that are then found to have a varicocele (with abnormal semen analysis), the answer is usually straightforward. In most of these patients, we would recommend a varicocelectomy. The first dilemma is in younger boys or adolescents. These patient are not yet attempting to have children, and so it is not yet known whether they have problems with fertility because of their varicocele. The second dilemma is in males old enough to father children (but who have not yet had any children) who currently have a normal semen analysis despite their varicocele. In either of these patients we cannot predict whose varicocele will eventually cause a problem. For that reason, we may suggest that the varicocele be repaired. The reason is twofold. Many physicians believe that permanent damage is occurring to the sperm-producing cells of the testicle even before the semen analysis is abnormal. The second reason is because your best chances to achieve normal fertility after the procedure is when it is performed before these men analysis is abnormal or the testicle has shrunken. Once you have any subfertility, your results are less likely to be as good after the procedure.

If after your consultation and this written explanation, you still have questions please let us know.

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: The procedure can take anywhere from 1-3 hours depending on an individual’s anatomy and whether one or two sides must be repaired. There are different types of incisions or approaches that can be used depending upon your anatomy and your surgeon’s preference. Regardless, they each involve a small incision near the groin area. The position of the incision may vary a bit depending on the type of procedure being done. The spermatic cord is identified and its contents examined. All of the veins in the actual cord or around the outside of the cord will be divided and the ends secured. In certain instances, it may be necessary to extend the procedure underneath the testicle to get to veins that are there. Once satisfied that all veins have been divided, inspection of other spermatic cord structures (the arteries, vas deferens, nerves, and lymphatic vessels) is again performed to ensure that they are normal and intact. The incision is then closed and your procedure is completed. Some surgeons may even tie off one of the arteries. Because there is more than one artery supplying the testicle, removal of one is unlikely to damage the testicle.

Some surgeons perform varicocelectomy laparoscopically. Laparoscopic surgery is performed by placing surgical instruments and a camera through small holes in the abdominal wall. The camera projects the surgery onto a television monitor. *If your child’s case is to be done in this fashion, you may also receive a written educational pamphlet on laparoscopic surgery so that you understand it better.

Post Procedure

You or your child will be in the recovery room for a short time before being sent home. You or your child may have discomfort over the incision site and adjacent areas. There will be a small bandage over the surgical area which is to remain until your follow up with us unless otherwise directed. Occasionally, there may be small blood staining on the bandage. If the dressing becomes soaked, or you see active blood oozing, please contact us immediately. You or your child may shower the day after surgery, but no bathing or swimming for 7-10 days(unless otherwise instructed). We ask that you or our child refrain from any strenuous activity until your follow up office visit. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. It is very important to apply ice compresses to the area as instructed. We strongly encourage you to take the following day off of work or school and perhaps more if going there requires strenuous activity or heavy lifting. In the first 24 hours it is to your advantage to minimize activity and rest in a lying down position. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days to weeks. Severe pain is unlikely but possible. We may provide a prescription for pain medication to alleviate most of the discomfort. Take this medication as prescribed and as needed. If any side effects occur, contact our office immediately.

Expectations of Outcome

In those patients that had abnormal semen parameters prior to surgery, there will be improvement in 60-80% following varicocelectomy. *It should be noted, however, that return to normal parameters does not guarantee normal fertility (an ability to successfully impregnate).It is estimated that about half of patients with improved parameters will be able to achieve pregnancy without assisted reproductive technology. Again, the initial size of the varicocele does not correlate with future fertility rates. In general, younger patients and those without testicular atrophy have a better prognosis for future fertility: basic principle “the longer the history of the varicocele before surgery, the worse the future fertility after surgery”.

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:

Failure: As mentioned, a varicocelectomy may fail to improve semen parameters or improve future fertility.

  • Recurrence or Persistence: Rarely, a varicocele can return due to engorgement of tiny veins that could not be seen during the operation. A patient may notice this soon after surgery or months later.
  • Hydrocele: This is perhaps the most commonly seen complication, occurring in10-15% of patients. This is a collection of fluid around the testicle. While some resolve without intervention, occasionally hydrocelectomy (surgical drainage of this fluid) maybe required.
  • Vas Ligation: This is very rare. If the vas deferens (tube that transports the sperm) is inadvertently divided, microscopic surgical repair would be performed. However the function of the vas deferens may be permanently damaged. the vas deferens may also become occluded (blocked) due to scarring or inflammation over time.
  • Hematoma: When a small blood vessel continues to ooze or bleed after the procedure is over, the area of collected blood is referred to as a hematoma. The human body normally re-absorbs this collection over a short period of time. A drainage procedure is rarely necessary.
  • Infection: Infection is possible following any surgical procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection may require drainage.
  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery. Although this is very rare, it is perhaps a bit more common with any procedure that involves the groin area (such as an inguinal hernia repair).Typically, the pain disappears over time, although some feeling of numbness may persist. If persistent, further evaluation may be necessary.
  • Paresthesia(s): As mentioned earlier, there are small nerves that run inside or directly alongside the spermatic cord. After varicocelectomy, it is possible to have areas of numbness on the scrotal sac or inner thigh area. Over time, the sensation usually returns. Less commonly, the area may stay numb forever.
  • Testicular Ischemia/Loss: Each testicle is supplied by blood vessels. If all vessels were unable to deliver blood to the testicle, the testicle on that side would decrease in size and lose function. This is quite rare.

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.

Definition

Ureter = the tube that transports urine from the kidney to the bladder

Reimplant = to disconnect and reconnect in a different area and in a different fashion

Trigone = the place in the bladder where the ureters enter

Ureteral reimplantation or subtrigonal injection are procedures that are performed to cure a condition known as vesicoureteral reflux (VUR). Reflux is when urine flows from the filled bladder back up toward the kidneys. Although this abnormal flow usually only occurs during bladder squeezing (urination or voiding), it may even occur during bladder filling in patients with more severe reflux. In people without VUR, once urine enters the bladder from the ureter, it is prevented from refluxing by a valve-like mechanism at the end of the ureter. It is not truly a “valve” but rather that the end of the ureter gets pinched in the muscular wall of the bladder while the bladder is squeezing.

The most common presentation of VUR is a febrile (with fever) urinary tract infection. During the evaluation, the VUR is detected by a voiding cystourethrogram (VCUG). This is the special contrast dye procedure (that your child already had) involving a catheterization of the urethra and bladder.

Reflux is graded on a scale of 1 to 5 (5 being the most severe). The grade is determined by the voiding cystourethrogram (VCUG). As a general rule, the higher the grade, the less likely it is that the VUR will disappear on its own without a procedure. All grades of reflux detected at a very young age (i.e. a newborn) are more likely to resolve without a procedure than when it is detected in an older child (i.e. a 3 year old). Grade does not correlate with repeated infections, however. All grades of reflux can cause infections that are equally harmful to the kidneys if a child is not maintained on antibiotics. Reflux can be one-sided, both sides, and be worse on one side than the other. Even in the absence of a symptomatic infection (one with fevers and/or pain, frequency, burning, urgency), persistent VUR of infected urine injures the kidneys over time. Therefore, once VUR is diagnosed, it is important that the child remain on antibiotics every day until the VUR disappears, is surgically corrected, or the physician determines that it will no longer be harmful to the kidneys.

Subtrigonal injection surgery is a short, minimally-invasive ambulatory procedure. Formal reimplantation requires an incision on the lower abdomen and usually a one or two night stay in the hospital. Not all cases of VUR are appropriate for subtrigonal injection. Your surgeon will have discussed the pros and cons of each with you so that you fully understand why one procedure has been recommended over the other. There are no concrete rules. Your surgeon will explain why he or she believes your child is better off with one or another procedure.

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: Like any other procedures done on young children, these procedures are performed under general anesthesia (complete sleep).

Subtrigonal Injection: A small cystoscope (telescope) is passed through the urethra (tube through which urine leaves the bladder) and into the bladder. Each ureteral orifice (hole through which urine enters the bladder from the ureter) is identified. There are different substances available that are approved for injection. The material used will depend on each surgeon’s preference and experience. A small amount of the bulking agent is injected into a specific area near the ureteral orifice to help tighten the diameter of the hole. The amount injected will depend on the surgeon’s assessment at that time. Once injections are complete, the scope is removed and your child is awakened.

Formal Reimplantation: In this procedure, an incision is made from either left to right or up-and-down on the lower abdomen. The urinary bladder is opened and the ureteral orifices are examined. The ureters are detached from the bladder and then reimplanted (reattached or reinserted) into a newly made hole in such a manner as to prevent VUR. There are several variations with respect to the method and location of the new site for the ureter. They are all effective and depend on each surgeon’s experience and preference. Once the reimplantation is done, the bladder is sutured closed. The skin is then closed with absorbable (self-dissolving)sutures. Some surgeons will leave a little catheter (small plastic tube) coming out of the urethra for a few days so that the bladder is kept empty during the healing process. Other surgeons will leave no catheter. The incision is covered with a bandage and your child is awakened.

Post Procedure

Your child will be in the recovery room for a short time.

Following subtrigonal injection, your child will usually be discharged the same day. There are no real restrictions, although we ask that your child restrain from any strenuous activity or rough play (including gym or physical education) for a few days.

In the first few days, it is also possible that:

  • your child has a little stinging or burning with urination
  • your child has a sensation in the bladder that there is a need to urinate frequently or urgently
  • the urine may be clear or slightly blood-tinged

After formal reimplantation, most children are admitted for one night and discharged the following day. Depending on your child’s comfort level and ability to urinate well, he/she may require a second night of hospitalization. If a catheter is left in the urethra your child may complain of urgency (a constant sensation of a need to urinate). The surgery on the bladder itself may also cause a sense of urgency because the bladder is having spasms. These spasms typically last for only a few days. He/she may have discomfort over the incision. There will be a small bandage directly over the incision. Unless otherwise specified, the dressing is to remain on until office follow-up. Some blood staining may be seen on the dressing. If the dressing becomes soaked, or you see active blood oozing, please contact us. Your child may shower the day after surgery. Some surgeons will ask your child to stay out of a bath until follow-up, and others may suggest warm baths after the first few days. We ask that he/she refrain from any strenuous activity or rough play (including gym or physical education) until otherwise instructed. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days; longer is rare. For discomfort, you may administer any pediatric-dose over-the-counter medicine to which he/she is not allergic (Tylenol®, Advil® or other ibuprofen product). The urine may be clear or slightly blood-tinged for a few days. If bladder spasms are a problem for more than a day or so, we might prescribe a special type of medicine to minimize the spasms. Upon follow-up in the office, we will examine your child and once again review the necessary follow-up studies. The sutures we use are often self-dissolving, and therefore just fall out with time.

*Occasionally, constipation is a problem after open surgery. While it almost always resolves spontaneously or with medicine (laxative, suppository, etc.), you should contact your surgeon before anything is administered.

Expectations of Outcome

Surgical reimplantation is the “gold-standard,” and is very effective in curing all grades of VUR. Subtrigonal injection is not as effective stage for stage. Nevertheless, it is minimally invasive, has a short anesthesia time, and has a shorter recovery time. Many surgeons will not use subtrigonal injection for high grade reflux because of the high failure rate.
Either of these procedures may fail immediately. If surgical reimplantation is successful, it is quite unusual for VUR to recur in the future. Conversely, a subtrigonal injection that is successful initially can fail in the future due to absorption of some of the bulking agent into the tissue.

If subtrigonal injection fails, the options are to repeat the injections or to perform surgicalre implantation. If reimplantation fails, we may perform the injections and only repeat the surgery if the injections, too, fail.

Despite the success, most urologists will recommend keeping your child on antibiotic suppression for a while longer until follow-up demonstrates no persistence or recurrence of VUR. Each urologist varies a bit in how long he/she continues the antibiotic.

Children heal quickly and respond well to surgery. Even after surgical reimplantation, most children will be back to normal activity in about one week.

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:

  • Persistence or Recurrence: Despite the high success rates expected fro either of these procedures, it is possible that reflux may not go away or recur in the future. Recurrence or persistence is more common with the subtrigonal injection procedure for moderate to high grades of reflux.
  • Ureteral Obstruction/Anuria: Although unusual, it is possible for the reimplant to be “too effective.” In such cases, not only is urine not refluxing, it is not draining down from the kidney to the bladder. In other rare instances, the reimplant is perfect at the time of surgery but becomes scarred over time. In either of these situations, a second procedure or open surgery might be necessary. If both sides are affected, the child would not pass any urine at all, making the need for surgical correction immediate.
  • Contralateral Reflux: Occasionally, only one ureter is affected by VUR. Sometimes, when surgery is done on that side only, the other side can begin to reflux after the surgery. This is due to changes in the bladder and perhaps increases in pressure in the bladder following correction of reflux on the one side.
  • Bleeding: Significant blood loss is very rare during or following this operation. In unusual circumstances, a blood vessel in the bladder wall could begin to bleed after the surgery and cause significant hematuria (blood in the urine). A need for transfusion is unlikely.
  • Infection: Infection is possible following any procedure. A urinary tract infection can occur with either procedure and almost always responds to antibiotics. Following surgical reimplantation, the incision can become infected. This is usually detected early and responds to local wound care and antibiotics. It is quite unusual to have to drain the infection by removing sutures.
  • Urinary Retention: Sometimes after the bladder is cut open, it can fail to squeeze properly for a while. If this happens, a catheter may need to be placed in the bladder for a while to keep it drained until the function recovers. This almost always resolves with time.
  • Intraperitoneal Bowel Injury: There are certain reimplant procedures in which the ureter is passed behind and above the bladder to bring it to the new reimplant site. It is possible for the small intestine (and less commonly other organs) to be injured by one of the surgical instruments when creating the tunnel (passageway) behind the bladder.

Whether identified immediately (during the surgery) or in the immediate recovery period, a pediatric general surgeon may be consulted to repair the intestine. Again, this is a very rare complication.

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.

Definition

Urethra = the tube in the penis through which one urinates

Plasty = to cut and open or reconstruct to a new shape

This procedure is done to open up and remove a stricture (scar tissue that narrows a passageway) in the urethra. The most common reasons to have a stricture are:

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

Soft strictures and those scars that are very short may respond to simple office dilatation(gentle spreading with specialized instruments). Other strictures may need to undergo a more formal procedure to maximize results and reduce the incidence of recurrent scar formation. A minimally invasive procedure, termed an “internal optical urethrotomy (IOU)” can be done through a small telescope placed in the urethra. For strictures that have failed a prior IOU procedure, or for those that are too long to yield acceptable results from an IOU, an open operation might be suggested. Strictures can occur in different places throughout the length of the urethra. They may also range in length. Increased success of the procedure depends on the location of the stricture, shorter scar length, and fewer number of failed prior procedures. Re-do procedures have a higher failure rate.

The symptoms characteristic of a urethral stricture are those of an 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 split (sometimes called “forked”) stream
  • intermittence (urine stream that starts and stops)
  • sensation of incomplete emptying of the bladder after urination is complete

Other symptoms that may be present 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.

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 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.

Procedure

To review the basics of what we discussed in the office: The actual procedure can take anywhere from one to several hours depending on the length, density, and location of the stricture. 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 a special x-ray (urethrogram). This is an x-ray of the urethra using an injection of contrast dye through a catheter. In very complex strictures, or those in which the urethra was actually divided (most commonly from a car accident in which there was a severe fracture of the pelvic bones), we may need to do the x-ray from two directions. In order to accomplish this, we would need to place a suprapubic catheter (SP tube) into the bladder through a tiny hole into the abdomen.

A urethroplasty is most commonly done through an incision in the perineum (the area between the scrotum and anus. In fewer instances, it may be done through an incision in the lower abdomen. Occasionally, combinations of the two incisions are used. Once the urethra is approached and separated from surrounding tissue, dead scar tissue is removed. With short strictures, the two healthy ends may be anastomosed (sewn together) without much manipulation. In other situations, there are numerous surgical maneuvers the surgeon can use to help bring the ends closer. This is important so that there is no tension on the edges that are sewn together. In rare instances, tissue may need to be harvested (taken from somewhere else on your body) to make up for a large gap between the ends. A catheter is placed across the repair and into the bladder. Once the urethral edges are repaired, the incisions are closed and a bandage is applied.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged home or admitted to the hospital. Your age and medical health, as well as the length of your procedure will determine whether or not you need to remain in the hospital.

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 dissipates within a couple of hours, but could last until the catheter is removed. *The catheter may remain for anywhere from 1-3 weeks (or longer).Some patients require medications to help relax the bladder while the catheter is still in. Your catheter will be attached to a bag. The urine will either be clear or minimally tinged with blood. If you are being discharged, the bag can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. We assure you that it is quite simple. You will also be given a large bag for overnight use that you will hang off the side of the bed. You should not use the leg bag overnight while sleeping.

There may be small blood staining on the bandage. If the dressing becomes soaked, however, or if you see active blood oozing under the bandage, please contact us immediately. We ask that you refrain from any strenuous activity until your follow-up office visit. Every patient has some degree of swelling and bruising. It is important to apply ice compresses intermittently to the incision area (behind the scrotum) for the first 12 hours. This may help reduce any of the expected swelling. When you sit, you may want to put a soft pillow down on the chair. 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.

We strongly encourage you to take approximately 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 lying down position. Periodic walking is encouraged. Some patients have almost no discomfort while others are somewhat uncomfortable for several days. Severe pain is unlikely but possible. We may provide you with a prescription for pain medication to alleviate most of the discomfort. An antibiotic prescription may also be given and should be taken until completion. If any side-effects occur, contact our office immediately.

Expectations of Outcome

Most 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 as well as a wider 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”

In rare instances, it may be difficult to control the urine for a couple of weeks. 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 may 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 several other physiological issues and also because the night-time ritual becomes somewhat habitual.

*Uncommonly, the stricture cannot be repaired. In instances where there was complete urethral separation, it may not be possible to bring the two ends together in a satisfactory manner. If there is too much tension on the repair, it is certainly doomed for failure. If this is the case, the suprapubic 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 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:

  • Wound Infection: As with any operation, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics and local wound care. In some instances, a small area of the superficial (upper layer) incision needs to be opened for adequate drainage. Infections are more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. 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.
  • Urinary Tract Infection or Urosepsis: It is possible for you to acquire a simple urinary tract infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This may not be readily apparent in the period that you have a catheter in place, as the catheter itself may cause these symptoms. The infection will usually resolve with a few days of antibiotics, and sepsis (infection in the bloodstream)is rare in this instance. *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 Urethral Stricture: A recurrence of the stricture can occur weeks, months, or even years after this sort of procedure. The chance of recurrence is proportional to the length of the stricture as well as the number of prior procedures that a patient had. In rare instances, however, even a first-time operated, short stricture can recur.
  • Urinary Incontinence: If your bladder was obstructed for years by a stricture, 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 even 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. Additionally, if the stricture involves the portion of the urethra where the continence sphincters are located, total incontinence (continuous dripping of urine) may result on a short term or even permanent basis.
  • Bleeding/Hematoma: When a small blood vessel continues to ooze or bleed after the procedure is over, the area of collected blood is referred to as a hematoma. The human body normally reabsorbs this collection over a short period of time. Intervention or surgical drainage is rarely 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.
  • Urinary Leak and Fistula: If the repair of the urethra heals poorly or comes apart, urine can leak from the area and come out through the incision. This abnormal connection is called a “fistula.” In most instances, this will heal by replacing the catheter. In other instances, the urine may need to be diverted out through a suprapubic tube (see above) for some time. An open repair may be necessary.
  • 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 a urethroplasty procedure. You may need to be taught to catheterize yourself after the procedure. Patients whose retention was more sudden and painful are quite likely to void after the procedure.
  • Injury from Suprapubic Tube: If a suprapubic tube is being placed (again when access to the urethra is needed from above), it can rarely puncture a structure adjacentto the bladder. Although rare in any instance, the small intestine is the most commonly involved organ. When recognized, a general surgeon may need to be consulted. Surgery on the small intestine may be necessary.
  • Erectile Dysfunction: Because the nerves stimulating erections run alongside certain portions of the urethra, they can be injured despite all attempts to void them during dissection. Following nerve injury, a patient may have partial or complete inability to achieve an erection. Often, the injury or infection that caused the stricture will also have already caused injury to these nerves as well. In that case, many patients will have partial or complete erectile dysfunction (impotence) prior to the surgery.

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.

Definition

Ureter = tube that connects your kidney to your bladder

Oscopy = procedure done through a scope as opposed to an incision

Stent = thin plastic tube that can be placed in the ureter

The ureter is a tube that connects each kidney with your urinary bladder. It is the most common site in which a kidney stone gets caught and consequently often causes severe pain. There are other reasons that a ureter may become blocked. There could be narrowing scar tissue inside the ureter (termed a stricture). There could be compression from outside the ureter due to a tumor or inflammatory response somewhere in the abdominal cavity or pelvis. There can be congential (something you are born with) defects in the ureter. The ureter can also be a site for tumors of the urinary tract. When there is a problem within the ureter, we can usually 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. This instrument is called a ureteroscope. The scope can usually be advanced all the way into the inside of the kidney. Ureteroscopy is performed under anesthesia so that you do not feel any discomfort, and because it is necessary that you are very still during the procedure.

Once in the ureter or in the kidney, we can break up a stone using different instruments. We can take biopsies as well. In addition, we can open up strictures (scar tissue) if the system is blocked. After any of these procedures, it may be necessary to leave a stent (plastic drainage tube) in the ureter for a few days to a few weeks (depending on your particular situation) 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. Sometimes, a thin string is attached to the end of the stent in the bladder, and this string is left hanging out of the urethra. The stent can then be removed by pulling on the string. In the absence of the string, the stent can be removed with a small scope in the office. Sometimes, we use injection of x-ray contrast up the ureter to help diagnose a problem or to help guide the path of theureteroscope. This special x-ray is called a retrograde pyelogram. Patients who are allergic to x-ray dye can usually have this procedure because the dye does not enter the bloodstream.

Preparation

There is no particular preparation for ureteroscopy. 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. 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 10days. 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 can take anywhere from 15 minutes to a couple of hours depending on the particulars of the case and the individual’s anatomy. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters called stirrups).
First, a scope is inserted into the bladder and the bladder is examined. The ureteral orifice(hole where the ureter enters the bladder) on the side of concern is then identified. Occasionally, a retrograde pyelogram (see above) is performed prior to the insertion of theureteroscope. Sometimes, one or more wires is/are placed into the ureter to help guide the passage of the scope. Then, the scope is inserted into the ureter and advanced to the area of concern. Depending on the location, size, and type of stone, the surgeon may elect to use one or a combination of instruments to break the stone and remove any significant fragments. If the fragments are very small, they may pass on their own over the next few days or following removal of the stent. Sometimes when some of the fragments are larger, the surgeon may elect to extract some of them from the ureter using any one of a number of available devices(grasping tools). If a stricture (scar tissue) is identified, it may be spread open with a balloon device or cut open with a small knife or laser. If abnormal tissue is identified, a biopsy can betaken and/or the tissue can be cauterized. This can be done with laser or other technology.

After the indicated procedure is complete, a stent may be inserted and the patient is awakened.

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 for your own safety.

It is common and even expected to have some discomfort while urinating. 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 in 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. As a result of the instrumentation, it is common to have discomfort in the back or groin region much like the pain from the stone. This, too, will gradually disappear.

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 very bothersome symptoms. The symptoms can be any one or a combination of back or groin discomfort (like still having a stone), 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.

Expectations of Outcome

It is important that you understand the possible outcomes of the procedure. While our intent is to fragment a stone into small pieces, this is not always possible. There are occasional instances in which the scope cannot be passed safely into the ureter. Common reasons include a very large prostate, scarring at the orifice (small entrance) of the ureter, or that the stone is impacted (embedded in the tissue and causing a lot of inflammation) in the orifice.

Sometimes the presence of a dense stricture prevents passage of the scope up the ureter. Not all strictures can be dilated or cut. In this case, we might just try to pass a stent to unblock the kidney. 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 break. The stone (or tumor in those cases in which ureteroscopy is being done for biopsy) may also be situated in an area that is not readily or safely approachable.

Sometimes a stone that is in the ureter is pushed back into the kidney by the water current(from the scope) or from the attempt to break it. If it cannot be accessed or adequately broken, a stent may be placed and a different type of procedure might be planned for another day.

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 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 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. *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.
  • Blood Clots in the Urine: Rarely, a small blood vessel can be cut in the ureter, in the bladder, or more commonly in the prostate in males. If the bleeding is significant, it can cause clots that can block the urine flow. A catheter may need to be inserted to flush out the clots. Significant blood loss is very rare as is need for transfusion.
  • Urinary Retention: Even in the absence of bleeding, the prostate in males can become swollen from the scopes pressing against it or less commonly secondary to infection. In this instance, a catheter would be placed and your doctor would discuss the next step. Patients at greater risk are those who already have difficulty urinating before the procedure due to BPH (benign prostatic hyperplasia). Ureteral Injury: Despite precautionary measures, the ureter may be injured from the scope or from the instruments used to break/remove your stone or take a biopsy. Usually, we will end the procedure, place a stent in the ureter if possible and allow the tissue to heal itself over the next week or two. A more severe injury (while very rare)may require placement of a nephrostomy tube (different type of tube placed through the back and into the kidney as a temporary means of kidney drainage). A complete ureteral avulsion (separation of the ureter from the bladder or kidney) is a very rare occurrence and requires open surgery through an incision to repair.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This would be quite unusual following a ureteroscopy procedure unless the operative time was long. Following any long procedure, and more commonly following those in which your legs are elevated 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.

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.

Definition

Transurethral = Through or across the urethra (tube through which urine exits bladder)

Resection = cutting away or removal. Some people refer to it as a “scraping.”Incision = making a cut in

In short, a special scope termed a “cystoscope” is placed in the penis and guided up into the part of the urethra that is the center portion of the prostate. This prostate tissue is systematically resected until all of the obstructing tissue is removed.

In cases where the prostate is small and perhaps the problem is the increased tone (see below),we can do a more limited procedure. This would be an “incision” rather than a full” resection.” In this regard, the procedure is termed TUIP instead of a TURP.

Most TURPs are performed to treat a condition termed “benign prostatic hyperplasia” (BPH).With progressive BPH, the prostate enlarges and obstructs the proper flow of urine from the bladder. Most often, the reduced flow represents a combination of prostate enlargement and tone (the prostate constricting down on the urethra as the urethra courses through the center of the prostate). Some patients with this condition may already have been on one or a combination of medications at increasing doses prior to needing a procedure. If the medications are no longer effective in alleviating symptoms, then a surgical procedure may be warranted. Sometimes, the medications are effective at high doses, but side-effects prohibit their use in a particular patient. In other instances, the symptoms are tolerable, but we have determined that the degree of obstruction is progressively damaging your bladder and even your kidneys. The characteristic symptoms are those of an obstructive urination pattern and are most commonly recognized as:

  • straining (need to push to begin urination)
  • hesitancy (delayed onset of urination following the urge to urinate)
  • slow or diminished force of stream
  • intermittence (urine stream that starts and stops)
  • a sensation of incomplete emptying of your bladder

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).

There are other types of procedures that are available for this condition, and these have been explained to you in your surgical consultation. The pros and cons of each with respect to your health and your particular prostate condition will have already been discussed. In the urologic literature, the TURP is still considered the “gold-standard” operation to which the results of all other procedures need be compared.

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.

*It is definitely to your advantage not to be constipated in the week after the procedure as straining may cause bleeding in the urine. 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 consider administering an enema one hour before bed the night before your procedure. enemas should not be used for a few weeks after this operation, however.

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.

Procedure

To review the basics of what we discussed in the office: The actual procedure can take anywhere from 20 to 90 minutes depending on the particulars of the case and the size of your prostate. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters call stirrups). The scope (which has continuous fluid running through it) is carefully inserted into the urethra and advanced into the bladder. We carefully examine the bladder to ensure that everything is within normal limits. The scope is then pulled back into the first part of the urethra termed the “prostatic urethra.” Next, a special electric knife or similar technology is used to scrape away the inner core of the prostate. Think of it like coring an apple. In the TUIP, incisions are made with a slightly different type of electric knife to allow the prostate to open its center channel. In some occasions, we can use a specific type of laser to do the same procedures. Other than being a different type of technology, it does not change the procedure. We will have already discussed the advantages and disadvantages of each technology with you prior to scheduling. Once the resection is complete, all of the prostate pieces (chips) are irrigated out of the bladder. They will be sent to the pathologist for examination under a microscope. A the end of the procedure, a catheter is placed in the bladder to allow proper healing of the prostate channel.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be admitted to a room. If you are having a TUIP as opposed to a TURP, there is a chance that you will be discharged home with or without a catheter.

It is normal for you to feel a strong sense of urgency to urinate. This is from the procedure and the presence of the catheter. In most patients, this dissipates within a couple of hours. Some patients require medications to help relax the bladder while the catheter is in. Your catheter may be attached to a large bag that runs fluid into your bladder (irrigation) to keep it washed out. Through a separate channel in the catheter, the fluid runs out into a drainage bag. This continuous bladder irrigation (CBI) is done to prevent blood clots from obstructing the catheter. Patients may have clear 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. The rate of the irrigation will be adjusted by the doctor or the nurses to a rate that keeps your urine on the clear side. Other patients may not require continuous irrigation and so there will not be any fluid running in. The urine will simply be draining out of the catheter and into a bag. In many patients, the catheter is removed the following morning and you are discharged home after you urinate on your own. In patients with larger prostates or in patients that still have moderate or significant blood in the urine, we may keep you in the hospital with the catheter for an extra day or so.

Plan to be out of work and avoid driving a car for a few weeks.

Expectations of Outcome

Most patients are very satisfied after the procedure. We typically hear phrases such as “I can urinate like a teenager again.” 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 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”

In some patients, it may be difficult to control the urine for a couple of weeks. 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 several other physiological issues and also because the night-time ritual becomes somewhat habitual.
Retrograde ejaculation is when the semen (during ejaculation) goes backward into the bladder instead of forward and out of the penis. This is expected to some degree in almost all patients. It may be that your semen volume is less, or absent altogether. *You will still have the sensation of orgasm, but you may not seen the semen. In this regard, you may be considered sterile.

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:

  • Hematuria: As we scrape the prostate tissue, small blood vessels (arteries and veins)may be cut and bleed. Throughout the entire procedure, we cauterize (burn) the vessels shut. At the end of the procedure, we carefully inspect the area to ensure that there is no significant bleeding. Rarely, a scab of a vessel we cauterized can fall off and cause delayed hematuria (blood in the urine). In most cases, we can observe and it will spontaneously stop. Sometimes we will manipulate the catheter to compress the vessel. In patients with continuous irrigation, we can increase the rate of irrigation dripping into the catheter to clear the urine. If clots form, it can block the catheter and we consequently will need to hand-irrigate the clots out. Very rarely, we have to return to the operating room to put the scope back inside the bladder and recauterize. If bleeding is prolonged during or after the operation, we would check your blood count. It is rare to need a a blood transfusion following a TURP.
  • 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 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 problem 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.
  • Urethral Stricture/Bladder Neck Contracture: A stricture is scar tissue that can form anywhere in the urethra following prolonged instrumentation. It typically occurs weeks to months (or even longer) after the procedure. Scar tissue can also form at the exit(neck) of the bladder, and this is termed a contracture. For either condition, it may be necessary to schedule another scope procedure to open the scar. These procedures can be done with a small blade, electric knife, or with a laser and they are quick and almost always an outpatient procedure. A scar at the tip of the urethra can sometimes be dilated (spread open) in the office. Sometimes, a stricture or contracture can recur in the future.
  • Urinary Incontinence: Bladders that are obstructed for years learn to over-compensate by squeezing with more force. The bladder, like any other muscle, thickens and gets stronger over those years of hard 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. In extremely rare instances, this may never resolve completely. In other very rare instances, the sphincter that allows you to voluntarily hold urine back can be damaged from the energy course. With severe injury to the sphincter, you can have total incontinence (inability to hold back urine). Again, this is very rare.
  • Urinary Retention: Sometimes, a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If urodynamics testing (special computerized testing of your bladder) demonstrates adequate ability of the bladder to squeeze, we may offer a procedure as a last resort to get you to empty your bladder.

It is possible, however, that even with a wide-open channel, the bladder is still un able to fully empty or empty at all. Sometimes it improves over time, and occasionally never. Patients at greatest risk are those who presented originally with severe blockage and huge volumes in the bladder, as well as diabetics in which the bladder may have already lost some ability to contract. Again, in cases that we are suspicious of this outcome, we probably will have performed a special test on your bladder (urodynamics) to help predict the outcome.

  • TUR Syndrome: If there is excessive absorption of irrigating fluid during the procedure, the blood can become somewhat diluted. The changes in the blood could affect the blood pressure, the heart, and in severe instances, the brain. With the newer fluid, more advanced equipment, and more efficient ways to treat even the suspicion of “too much absorbed fluid,” TUR syndrome is quite rare.
  • Perforation: The prostate capsule or even the bladder can be perforated. In most cases, all we need to do is leave the catheter in for an extra few days to allow self-healing. Other procedures are rarely necessary. Injuries to the ureteral orifices(holes where the kidney tubes come into the bladder) are also very rare. Sometimes ,we may need to place a temporary stent in place (a plastic tube that goes from the kidney to the bladder). If a stent cannot be placed, it may be necessary to put a temporary tube into the kidney through a hole in your back. It would be quite unusual to need an open operation to repair any of these problems.
  • Erectile Dysfunction: According to the literature, anywhere from 5-25% of patients complain of some degree of erectile dysfunction (ED or impotence) after a TURP. For the majority of these patients, the patient notes a change but does not complain of complete impotence. Most studies report ED numbers on the lower end of the spectrum. This problem has always been quite puzzling to urologists in that a sound “cause and effect relationship” has not been established. The most plausible explanation may be the transmission of the energy source through the entire thickness of the prostate and subsequently to the nerves controlling erections. Psychological and other pre-existing factors may play a role as well.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as TURP. 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 involvedwith 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.

Definition

Transurethral = Through the urethra (tube through which urine exits the bladder)

Resection = cutting away or removal (some people refer to it as a “scraping”)

In short, a special scope termed a “cystoscope” is placed in the urethra and guided up into the bladder. The bladder tumor is cut away completely, or in other circumstances, just biopsied for analysis by the pathologists.

Most TURBTs are performed for transitional cell carcinoma (TCC), the most common type of bladder cancer. There are, however, other far less common types of tumors. In most instances, a TURBT is performed with the intent of removing the entire mass. In cases where the tumor is very extensive, we might only try to sample as much tissue as we need to properly determine the type and extent of the cancer to decide on the next plan of action.

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.

*It is to your advantage not to strain to have a bowel movement in the week after the procedure as it may cause bleeding in the urine. Try to avoid constipating foods in the week before your procedure. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you might 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 can take anywhere from 15 to 90 minutes (sometimes longer) depending on the location and size of the tumor.

You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters call stirrups). The scope (which has continuous fluid running through it) is carefully inserted into the urethra and advanced into the bladder. We carefully examine the bladder to determine the extent of the tumor. Next, a special electric knife (termed a loop) is used to cut the tumor while simultaneously cauterizing (burning) the blood vessels. In some occasions, we use laser to assist in the procedure. Once the tumor is resected, we may take sample biopsies from uninvolved areas of the bladder or even from the inside of the urethra(prostate channel in men). After the resection is over, all of the tumor pieces (chips) are irrigated out of the bladder. In some cases (large tumors or apparently deep tumors), a catheter might be placed in the bladder to allow proper healing of the bladder wall.

Post Procedure

Depending on the size of the tumor, and the extent of the resection, you might either be discharged home or admitted to the hospital. Depending on the circumstances, we may discharge you home with a catheter for a few days. It is normal for you to feel a strong sense of urgency to urinate. This is from the trauma to the bladder wall and possibly the presence of the catheter. In most patients, this goes away within a couple of hours. Some patients require medications to help relax the bladder while it is healing or while the catheter is in place. 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 day or two. In most patients that are admitted, the catheter is removed the following morning and you are discharged home after you urinate on your own.

Expectations of Outcome

As previously mentioned, there are different reasons that a TURBT is performed. The most common scenario is that we intend to fully remove (scrape out) the tumor while simultaneously staging the tumor (determining how advanced or invasive the cancer is). In instances where the tumor is unable to be completely removed due to its size or location, we will sample as much as we need to properly stage the cancer, with the understanding that we may be recommending another form of treatment. There are instances in which we initially planned to resect the entire tumor, but realize during the procedure that this cannot be safely accomplished.

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:

  • Hematuria/Clot Retention/Transfusion: As we cut away the tumor, small blood vessels (arteries and veins) are cut and bleed. Throughout the entire procedure, we cauterize (burn) the vessels shut. At the end of the procedure, we carefully inspect the area to ensure that there is no significant bleeding. There are always some minor, insignificant vessels that slowly ooze. Rarely, a scab of a vessel we cauterized can falloff and cause significant hematuria (blood in the urine). In most cases, we only need to watch the patient, and the bleeding eventually stops. If clots form it can block the urethra or the catheter and we may need to irrigate the clots out. Rarely, we would have to return to the operating room to put the scope back inside the bladder and re-cauterize the blood vessels. If bleeding is prolonged during or after the operation, we may need to check your blood count. It is rare to need a blood transfusion following a TURBT. 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 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 problem 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.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as TURBT. 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.
  • Urethral Stricture/Bladder Neck Contracture: A stricture is scar tissue that can form anywhere in the urethra following prolonged instrumentation. It typically occurs weeks to months (or even longer) after the procedure. Scar tissue can also form at the exit(neck) of the bladder, and this is termed a contracture. For either condition, it may be necessary to schedule another procedure to open the scar. These procedures can be done with a small blade, electric knife, or with a laser and they are quick and almost always an outpatient procedure. A scar at the tip of the urethra can sometimes be dilated (spread open) in the office. Sometimes, a stricture or contracture can recur in the future.
  • Urinary Retention: In a male, pressure from the scope can occasionally cause inflammation in large and/or obstructing prostates. It may block the flow of urine and cause retention (inability to urinate or empty the bladder). In many circumstances, it resolves with a catheter over the next few days. Less commonly are medications or a prostate procedure required.
  • Perforation: If the cutting is deep, the wall of the bladder can be perforated. This is far more common in large tumors or those that are at an advanced stage (deeply invading the wall of the bladder). In most cases, we need to leave the catheter in for an extra few days to allow self-healing. If this happens early in the middle of the TURBT, we may stop the procedure, allow it to heal, and finish the procedure another day. Sometimes we may need to perform a bladder repair through an incision in the abdomen.
  • Ureteral Injury: On either side of the bladder is a small ureteral orifice. This is the hole through which the ureter (tube from the kidney) enters the bladder. If there is tumor at or near the orifice, it may be necessary to resect there. Within days to weeks, a scar could form over the orifice and block the kidney on that side. Sometimes we can unblock the tube by inserting a stent (small plastic tube) into the ureter through the scope. We may do this during the TURBT procedure if we realize that the orifice has been injured, or in a separate procedure if the problem arises later. In other instances, we may ask the interventional radiologist (radiology doctors that perform minimally invasive procedures) to place a temporary drainage tube into your kidney through a small needle stick in the back. If neither are successful, open abdominal surgery could be necessary to correct the blockage.
  • TUR Syndrome: This only occurs in very prolonged resections, and is rarely seen in this procedure. Because many blood vessels may be opened while cutting away the tumor, some of the irrigation fluid may enter the bloodstream and dilute the blood components. With the newer irrigant fluids that we use, TUR syndrome is very unlikely. Severe cases may cause heart or brain complications.

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.

Definition

Transurethral = through or across the urethra (tube through which urine exits bladder)

Incision = making a cut in

Resection = cutting away or removal (some people refer to it as a “scraping”)

Bladder Neck = the opening of the bladder where the urethra begins

This procedure is done to open up a BNC or bladder neck contracture (restricting scar tissue)at the neck of the bladder. The most common reasons to have a bladder neck contracture are:

  • a history of transurethral resection of the prostate, referred to as a TURP (prostate scraping procedure) or transurethral resection of a bladder tumor
  • a history of an open prostate operation such as radical prostatectomy (removal of the prostate for cancer treatment) or simple prostatectomy (removal of the center portion of a prostate that was too large for a TURP procedure)
  • a history of radiation and/or radioactive seed implantation for prostate cancer treatment

The symptoms characteristic of a bladder neck contracture 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
  • 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. 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 reliever 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 whether the procedure is an incision (typically shorter) or are section. Very dense (hard) and tight strictures may add some minimal time to the procedure. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters called stirrups). A special scope (which may have continuous fluid running through it) is carefully inserted up to the area of the BNC. In certain instances, we will insert a small wire through the tiny, scarred opening and into the bladder to act as a guide. This ensures that we open the scar in the proper place. The most common tool used to open a BNC is a small knife with an electric current. Certain types of laser may be used as well. In the TUIBN, incisions are made in certain areas to allow the scar to relax open. In a TURBN (more commonly done when prior radiation is the cause) the tissue may be cut or scraped away. Any blood vessels that are oozing may be cauterized (burned) closed. Once the channel is sufficiently open, we advance the scope into the bladder and carefully examine the bladder to ensure that everything is within normal limits. At the end of the procedure, a catheter is placed into the bladder to allow proper healing of the newly opened bladder neck channel.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged home. Less commonly, you may require admission to the hospital after this 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.

Expectations of Outcome

Most 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 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”

Sometimes, it may be difficult to control the urine for a couple of weeks. This is more common in patients who had scarring due to radical prostatectomy or radiation.

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 who were significantly obstructed for a prolonged period, these symptoms may never fully go away.

Nocturia (getting up at night to urinate) is typically the last symptom to go away. 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.

Retrograde ejaculation is when the semen (during ejaculation) goes backward into the bladder instead of forward and out of the penis. This is expected to some degree in almost all patients. It may be that your semen volume is less, or absent altogether. *You will still have the sensation of orgasm, but you may not see the semen. In this regard, you may be considered sterile.

*Uncommonly, the BNC cannot be opened. The two most common reasons are that it is too dense or too irregular to safely cut (more common in radiation patients). In these cases it maybe risky to cut the scar “blindly.” If this were the case, we would need to place a suprapubic catheter in your bladder. A suprapubic catheter is a small tube that is inserted into the bladder through a tiny puncture hole in the lower abdomen. It would be attached to a drainage bag. The tube will remain in place 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 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:

  • 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. If severe, it could require replacement of the catheter.
  • Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is 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 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 is more common in diabetics, patients on long-term steroids, or 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.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as TUIBN/TURBN. 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 Bladder Neck Contracture: A recurrence of the BNC can occur weeks, months, or even years after this sort of procedure. Each time the procedure is repeated, the incidence of recurrence is greater.
  • Urinary Incontinence: If your bladder was obstructed for years, 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 some cases, it may never completely go away. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel. This is more common in patients who have a BNC following radical prostatectomy or radiation treatment.
  • 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 a TUIBN/TURBN procedure. Patients whose retention was more sudden and painful are quite likely to void after the procedure.
  • Perforation: If the incision or cut is too deep, the bladder can be perforated. This finding may not change the course of the case. It heals within days over the catheter that is left in place. In this case, we may elect to leave the catheter in for a few extra days. Injuries to the ureteral orifices (holes where the kidney tubes come into the bladder) are exceedingly rare and are most often dealt with in the same fashion. Sometimes, we may need to place a temporary stent in place (a plastic tube that goes from the kidney to the bladder). It would be quite unusual to need an open operation(incision on the abdomen) or minimally invasive procedure to repair the bladder or ureteral orifices.
  • Erectile Dysfunction: According to the literature, 1-2% of patients complain of some erectile dysfunction (impotence) after almost any endoscopic procedure. There is no known explanation for its occurrence.

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.

Definition

A prostate biopsy is taking multiple small tissue samples from the prostate for evaluation by a pathologist (doctors who examine tissue under the microscope). We use ultrasound technology to accurately guide our biopsy needle. Prostate biopsies are not perfect in their ability to detect prostate cancer. At this point in time, however, there is no other method to differentiate benign tissue from malignant tissue in a patient with a suspicious PSA (prostate specific antigen) or digital rectal examination. It is possible that a very small (microscopic) area of cancer could be missed. We take samples that reflect each of the different zones of the prostate as well as the size of your prostate. In other words, we might take a few extra samples from a larger gland.

Preparation

The procedure cannot be done if you are currently on, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners”). We will have reviewed all of your current medications with you during the consultation, but please tell us if anything has changed since your previous visit. The most common of these medications are aspirin and all related pain reliever 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 you new medication is not on the list, mention it anyway so that we may ensure it is not a blood thinner.

You do not have to fast in order to have a prostate biopsy. It is recommended that you eat a very light breakfast (if your biopsy is in the morning) or a very light lunch (if your biopsy is in the afternoon). Try, however, to eat at least one hour before the biopsy. If you are diabetic, make sure you do not miss your regular meal.

You may be asked to take enemas. The first enema is usually administered one hour before bed the night before your biopsy; and the second should be administered 1-2 hours before you leave for your appointment with our office. Each physician has their own regimen, and they will let you know about the number of enemas and the times that they should be administered.

You will be given antibiotic tablets as well. They should be taken as directed by your urologist.

If possible, have a friend or family member come with you that day to keep you company and drive you home. While it is not absolutely necessary, we would prefer that you have someone accompany you. In some cases, a patient can unexpectedly feel light-headed or uncomfortable after any procedure. If you do not have anyone available, we may ask that you relax for awhile in our waiting room after the procedure until we feel it is appropriate for you to leave.

Procedure

To review the basics of what we discussed in the office: The actual procedure typically takes10-15 minutes. You will be placed lying down on your side on an examining table. Some urologists may use numbing medicine. It can be given by an injection around the nerves adjacent to the prostate or sometimes as a jelly pushed into the rectum. An ultrasound probe will be gently placed in your rectum. Although it is slightly uncomfortable, very few patients believe it is painful. We will then take the biopsies with a small needle. You will hear a click or snap sound for each biopsy and feel a little pinch. Again, while most admit it is uncomfortable, very few claim that it is actually painful. The amount of biopsy cores taken will depend on the decision of your urologist, your anatomy, and possibly on whether you have had a prostate biopsy done in the past.

Post Procedure

After the procedure, you might feel a bit sore in the rectal or anal areas for a few hours. We rarely hear of problems beyond that, although patients with hemorrhoids might have discomfort a bit longer. It is very common to see some blood from the rectum, on the stool with the next bowel movement, or on the toilet paper, especially that day and rarely the next day. Again, this is more common in patients with hemorrhoids. A small amount of blood in the urine or some discoloration of the urine is rarely seen but not impossible. You may commonly see blood in your semen (ejaculation) for a few days and sometimes up to 4-6 weeks. It might be red or just discolor your semen brown.
You have no restrictions after the biopsy other than to take it easy that day. If possible, have a friend drive you home.

Expectations of Outcome

After the biopsy, the specimens are sent to a pathology laboratory for evaluation by a trained pathologist. We cannot give you any accurate information from the ultrasound appearance of the prostate or from the look of the tiny specimens that we remove with the needle. We understand that you are anxious to have the results and can only ask for your patience. We will call you as soon as they are available to us. It usually takes one week to get the results.

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:

  • Excessive Bleeding from the Anus: It is uncommon to require any treatment, and the majority of the time the bleeding stops on its own. This is far more common in patients with hemorrhoids.
  • Blood Clots in the Urine: The needle can enter the middle of the prostate where the urethra or the neck of the bladder are located and cause blood in the urine. If the bleeding is significant, it can cause clots that can block the urine flow. A catheter may need to be inserted to flush out the clots.
  • Urinary Retention: Even in the absence of bleeding, the prostate can become swollen from the biopsy or secondary to infection. In this instance, a catheter will be placed and your doctor will discuss the next step. Usually the problem resolves with time after the swelling goes down. Sometimes medications are given that may help to open the prostate channel. Patients at greater risk are those who already have difficulty urinating before the procedure due to BPH (Benign Prostatic Hyperplasia).
  • Urinary Tract Infection or Urosepsis: Although we give you antibiotics, it is 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 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 is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. Lastly, an abscess of the prostate, while quite rare, can develop. This is an infectious cavity that may respond to antibiotics alone or need surgical (needle) drainage. It can begin with urinary symptoms but also progress to the symptoms of bloodstream infections. Urinary retention is possible with an abscess.

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

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.

Definition

Penectomy = an operation in which part of or all of the penis is removed

Lymph Node = small glands throughout the entire body that drain abnormal substances cancer cells or infection) from the organs with which they are associated.

Dissection = surgery to separate two areas of tissue

The most common reason to perform a penectomy is in an attempt to cure a patient of penile cancer. In this instance, you may have already had a biopsy (smaller procedure in which a part of the lesion is removed to be analyzed by a pathologist). A biopsy may be performed to confirm the diagnosis of cancer, and may also help to “locally stage” the tumor. The local stage of a cancer is a determination as to whether a cancer is superficial (just on the surface and not deeply invading) or has already invaded deeper tissue layers. It is this stage and the location of the tumor on the penis that will determine whether a partial or total penectomy should be performed. The most common type of cancer is called “squamous cell carcinoma,” a skin cancer that only occurs in uncircumcised males. Penectomy for other types of cancer is far less common.

In instances of life-threatening infections involving the penis, part of or the entire penis may require amputation (removal).

Infections and cancers of the penis and scrotum (skin sac that covers the testicles) drain to lymph nodes that are located in the groin region. These are called “inguinal” nodes and are often palpable (able to be felt) when examining a patient. These lymph nodes then drain to deeper nodes in the body called “pelvic nodes”. In certain, more advanced cases of penile cancer, it may be necessary to remove these lymph nodes on one or both sides of the inguinal region (groin area). If necessary, this operation is usually performed at a later date (for reasons that are beyond the scope of this educational paper) and serves one or two purposes.*The first reason is to better “stage” the cancer. The stage of a cancer (not to be confused with the local stage) is a measurement as to whether the cancer has begun to spread away from the organ in which the cancer originated (in this case the penis). *The second reason is that if some cancer cells have spread to the lymph nodes, then removing them may help to cure or control further spread of these cells.

If only part of the penis is removed, it is often still possible for a male to urinate through the urethra (tube through which one urinates) while standing. If the remaining portion of the penis is too short, it may be necessary for a male to sit while urinating. In cases where the entire penis is amputated (removed), the urethra is surgically relocated to the perineum (area behind the scrotal sac and in front of the anus). This is termed a “perineal urethrostomy,” and once created, it is definitely necessary to sit in order to urinate.

Preparation

If you have any significant medical problems, we may send you for an updated general physical and note of “medical clearance” from your primary physician. This precautionary and for your own protection.

It is definitely 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.

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 is different for every patient, mostly reflecting a difference in whether partial or total penectomy is to be performed. The general range is less than two 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). A catheter is inserted into the urethra (tube through which you urinate) and into the bladder to help us identify the urethra during surgery. In a partial penectomy, the individual parts of the anatomy are all identified and divided at a point that leaves a planned width of normal tissue between the tumor and the remaining healthy tissue while attempting to spare as much penile length as possible. When we close the incision, we bring the new end of the urethra through an opening in the skin. In total penectomy, after the penis is removed, we bring the urethra to a new opening in the skin of the perineum. In either instance, the catheter may remain in place for 1-2 weeks (depending on the particular circumstances) to allow adequate time for the urethra to heal. Blood loss in either procedure is rarely enough to require a transfusion.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. Some patients may have this procedure done on an ambulatory basis and go home several hours after the procedure. As mentioned, you will have a urethral catheter draining your urine, and this catheter may give you a sensation that you need to urinate. This sensation typically disappears after a few days. You may also have boots on your legs that inflate and deflate (intermittent squeezing) to prevent the formation of blood clots in your veins(deep venous thrombosis or DVT). There will be a gauze dressing wrapped around the penis or behind the scrotum. A typical hospital stay for this operation is one and rarely two nights.

Upon discharge, you may have no dressing (bandage) on your incision and your catheter will be attached to a small bag that straps to one of your legs. Occasionally, the catheter is removed just prior to discharge. The catheter is easily concealed under your clothing and nobody knows it is there. You will get instructions while in the hospital on how to empty the bag and even switch it to a larger bag for overnight use when you are sleeping.

You will be discharged with instructions for follow-up in our office. Other than your regular medications, we may give you an antibiotic, a pain medication, and a stool softener so that you do not strain to have a bowel movement. Other medications are rarely necessary but depend on your particular needs.

It is normal to feel a bit tired for a few days after such an operation. We typically tell patients that they will be out of work for two weeks (anywhere from 3-4 weeks is possible) and that it may take longer before you truly feel like yourself.

Expectations of Outcome

As you may realize, all patients who have a total penectomy and most patients who have a partial penectomy will not be able to engage in sexual intercourse after this procedure.

Therefore, it is very normal for you to feel depressed after this procedure, more so than following other operations. It is important that you share your feelings with your family and closest friends, as they will be instrumental in helping you with this adjustment. Professional counseling can also be arranged upon request.

The pathology report should be available in a week, and at that time we will discuss the significance with you. Depending on the report, we may recommend the second procedure to remove the inguinal lymph nodes. In cases where the local stage is not as advanced, this decision will be based on whether your lymph nodes are enlarged.

If your inguinal lymph nodes were enlarged prior to the procedure, we will keep you on antibiotics for an extended time and re-examine the lymph nodes in six weeks. If the lymph nodes remain abnormally enlarged, we will usually recommend the procedure. At that time we will discuss whether the procedure is necessary on both sides, as well as the details of the surgery.

Recurrence of the cancer on the penis itself is uncommon.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with un foreseen 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, iti s important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • 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 in between the sutures. Usually, these are managed with antibiotics and local wound care. In some instances, a small area of the superficial (upper layer) incision needs to be opened for adequate drainage. Infections are more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. 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. Urinary Tract Infection or Urosepsis: It is possible for you to acquire a simple urinary tract infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This may not be readily apparent in the period that you have a catheter in place, as the catheter itself may cause these symptoms. The infection will usually resolve with a few days of antibiotics, and sepsis (infection in the bloodstream)is rare in this instance.
  • *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.
  • 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 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.
  • Death: The incidence of death during or shortly after the operation is less than 1%. It is usually a result of an unexpected cardiac (heart) event or a pulmonary (lung) event.

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.