Left ureteropelvic junction obstruction.
Left ureteropelvic junction obstruction.
General endotracheal anesthesia.
DESCRIPTION: The patient was brought to the operating room and underwent general anesthesia. He was placed in the dorsal lithotomy position. He was prepared and draped in the usual manner. The 9.5 pediatric cystoscope was placed in the bladder and a #3 ureteral catheter was placed through the torquing channel. A left retrograde ureteropyelogram was obtained. This showed a clear obstruction at the junction of the left ureteropelvic junction. The cystoscope and stent were then removed.
The patient was then placed in the left-flank-up position. An incision was made off the tip of the 12th rib with a #15 blade. Bleeding was controlled utilizing electrocautery. The muscle fibers were all incised in the flank with electrocautery. Two Richardson retractors were placed. Gerota's fascia was opened in a vertical fashion and the kidney was delivered. The ureter was found in the retroperitoneal space and dissected out to the level of the renal pelvis. There was clear obstruction and kinking at the level of the ureteropelvic junction. Markings sutures were placed in the ureter and the renal pelvis with 6-0 Vicryl. The obstructive segment was excised and the tenth renal pelvis was then decompressed. An oblique anastomosis was then effected between the upper ureter which had been spatulated and the renal pelvis. This was accomplished with two sutures of 6-0 Vicryl at the apices and then running sutures on the anterior and posterior wall with 6-0 Vicryl. Prior to completing the anterior anastomosis, a 10-French Malecot catheter was used as a nephrostomy tube and brought with the nephrostomy needle through the substance of the kidney and was brought out through the flank, and it was sewn to the flank with 4-0 Prolene. The anterior aspect of the anastomosis was then completed after a #3 pediatric feeding tube was placed through the anastomosis and� to be watertight. The kidney was returned to the renal space. Gerota's fascia was left open in the caudad portion. A Penrose drain was placed through a stab wound and brought down to the inferior portion below the anastomosis. This was sewn to the skin with 4-0 nylon. The muscle layers were then closed with running 3-0 Vicryl. The subcutaneous layer was closed with 4-0 Vicryl and the skin was closed with a running subcuticular 3-0 Prolene suture. There were no intraoperative complication. The patient was discharged to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSES: INTRINSIC URETHRAL SPHINCTER DEFICIENCY.
1. INTRINSIC URETHRAL SPHINCTER DEFICIENCY.
2. INADEQUATE BLADDER EMPTYING.
TITLE OF SURGERY:
1. CADAVERIC FASCIAL PUBOVAGINAL SLING.
3. INSERTION OF SUPRAPUBIC CATHETER.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
ESTIMATED BLOOD LOSS: 500 CC.
FLUID REPLACEMENT: 3400 CC CRYSTALLOID.
URINE OUTPUT: 150 CC.
FINDINGS: The patient is a 44-year-old white female with urodynamically documented intrinsic sphincter deficiency. Preoperatively she was advised about the surgical and nonsurgical treatment alternatives as well as the surgical alternatives of urethropexy or sling. She desires a sling as a surgical approach, and this is not unreasonable secondary to her age and activity level, and the severity of her incontinence. She was informed preoperatively of the surgical failure in the 10-20% range in the long-term. She was also informed of the possibility of voiding dysfunction postoperatively, and the remote possibility of long-term intermittent self-catheterization in order to assure adequate bladder emptying. The possibility of urge incontinence was also discussed. Other risks of the procedure including but not limited to death, anesthesia complications, need for blood transfusion, infection, and damage to surrounding structures including fistula formation, were also discussed. We discussed sling material and my recommendation was cadaveric fascia. We discussed the fact that this is human tissue and does carry with it a minimal but present risk of infectious complications including HIV and hepatitis, although this is felt to be minimal.
FINDINGS: A mobile uterovesical junction with minimal other pelvic organ prolapse. The surgery was technically challenging secondary to the patient's habitus.
DESCRIPTION OF PROCEDURE: Following the successful administration of general anesthesia, the patient was placed in the dorsal lithotomy position using Allen Universal stirrups. She was prepped and draped in the usual sterile fashion. A scalpel was used to create a transverse suprapubic incision. This was carried down through the subcutaneous fat to the rectus fascia. Hemostasis was assured with cautery.
Attention was turned to the anterior vaginal wall. A Foley catheter was placed to aid in identification of the urethra and uterovesical junction. The vaginal epithelium underlying the urethra was injected with 1% Xylocaine with epinephrine and incised with a scalpel. Sharp dissection was used to mobilize the vaginal epithelium off the underlying fascia. This was taken up to the Space of Retzius. The Space of Retzius was then entered sharply bilaterally. Hemostasis was assured with a combination of cautery and interrupted figure-of-eight sutures of 2-0 Vicryl.
The sling material was then prepared with packing on either side of the dissection. A strip of cadaveric fascia was incised for its width, approximately 2.5-3.0 cm. Two strips were taken from the one piece of cadaveric fascia that was available. This was overlapped over approximately 6 cm and tacked at each of the corners with interrupted sutures of CV-2 Gore-Tex. One side was colored so as to not twist the sling during placement. The pack was removed. Bleeding was minimal from the dissection sites.
At this point, using a finger from above and uterine packing forceps from below, the uterine packing forceps were placed first through the left and then through the right aspects of the dissected area in the Space of Retzius. This was placed to the fascia which was incised with a scalpel. The cadaveric fascia was brought down through the right incision and a suture was brought down through the left, which was attached to the other end of the cadaveric fascial sling, and was brought up to the fascia on that side as well. These ends were held with hemostats.
A series of four interrupted sutures of 2-0 PDS were then used to tack the sling at the UVJ and down the urethra to minimize the risk of the sling rolling under the urethra. These were tacked to the fascia and tied down where they were placed. The sling was under minimal tension under the urethra. In fact, a tonsil clamp could easily be slid between the fascia and the urethra.
Attention was turned above and the sling arms were tacked using a series of four sutures of CV-2 Gore-Tex on either side. Generous purchases of the cadaveric fascia were taken. This was tacked in the anterior rectus fascia. After these were all tied down, attention was again turned below. The sling was well positioned but not under any tension from the urethra. The subcutaneous tissue was frequently and copiously lavaged with antibiotic-containing solution from the VitalView suction device as was the vaginal aspect of the incision.
At this point, the fat was closed over the sling arms with a running-locking suture of 2-0 Vicryl. The bladder was then inspected with a cystoscope. The urethra was normal. There was no evidence of any trauma to the urethra or bladder. The urine was clear. Both ureters were identified and found to be functioning normally, spilling indigo carmine dye which had been previously given by the anesthesiologist. The bladder was then distended with 400 cc D-10. A suprapubic catheter was inserted through a separate stab wound in the anterior abdominal wall and inserted under direct visualization. This was affixed by inflating the balloon.
The skin was then closed from above with staples after hemostasis was assured in the subcutaneous tissue. The subcu was lavaged again with antibiotic-containing solution. The vaginal epithelium was closed with 2-0 Vicryl in a running-locking fashion. One small tear of the vaginal epithelium on the distal aspect of the incision on the left was sutured with an additional figure-of-eight suture of 2-0 Vicryl. Hemostasis was assured. The vagina was packed. The suprapubic tube was draining well. The patient was then taken to the recovery room in stable condition with the IV infusing well and the suprapubic tube draining well.
Undescended right testis.
Undescended right testis.
General mask anesthesia.
DESCRIPTION: With the patient in the supine position after a suitable level of general mask anesthesia had been obtained, the penis and genitalia were prepared and draped in the usual manner. A transverse incision was made in the suprapubic skin fold on the right with a #15 blade. Bleeding was controlled with electrocautery. The subcutaneous tissues were incised and the testis was noted just emerging from the external inguinal ring. The external oblique fascia was opened with a #15 blade and Metzenbaum scissors. The testis was grasped and freed up from the surrounding fibers. This was freed up to the level of the internal inguinal ring. The hernia sac was then opened and the hernia sac dissected up to the level of the internal ring wh ere it was twisted and transfixed with 4-0 Vicryl. With this maneuver, quite adequate testis length was obtained.
Dr. X then returned to the operating room, rescrubbed and regowned and joined the operation. The testis was brought down to the subcutaneous dartos pouch created in the manner of Latimer in the scrotum. The testis was brought into the pouch and 3-0 silk suture was placed in the connective tissue of the testis, brought out through the scrotal wall and tied over a cotton pledget. The scrotal incision which had been made with a #15 blade was then closed with a 5-0 Vicryl. Careful search for bleeding was undertaken. None was seen in the scrotum or in the groin. The external oblique fascia was then closed with running 4-0 Vicryl. The subcutaneous tissue was closed with 4-0 Vicryl. The skin was closed with running subcuticular 3-0 Prolene suture. There were no intraoperative complications. The child was discharged from the operating room in satisfactory condition.
INDICATIONS FOR SURGERY:
This 64-year-old gentleman was recently found to have a PSA elevation to 4.1 which prompted a biopsy of the prostate, which then showed prostate cancer. A metastatic workup was negative for disease spread. He was counseled regarding treatment options and desired to undergo a radical prostatectomy. He was well informed regarding all risks, alternatives, and expectations, and provided his adequate informed consent prior to surgery.
Prostate cancer, stage T1c.
Prostate cancer, stage T1c.
Prostate with seminal vesicles and bilateral pelvic lymph nodes.
DESCRIPTION: The patient was brought to the operating room and regional anesthesia was achieved. He was placed supine on the operating table. His lower abdomen and genitalia were prepped and draped in a sterile manner. The operating room table was flexed. Routine antibiotic prophylaxis was provided. A 20-French Foley catheter was inserted per urethra at the beginning of the case and connected to straight drainage. A lower midline abdominal incision between the umbilicus and the symphy sis pubis was then made dividing the rectus abdominis muscle bellies. The Space of Retzius was entered. Routine bilateral pelvic lymph node dissections were performed. The lymph node packets were not thought to be suspicious for disease spread, and thus they were sent for final histopathologic diagnosis. Surgery continued. The fat overlying the endopelvic fascia was then removed. The endopelvic fascia was then incised bilaterally at reflections with the lateral pelvic side walls. The dorsal vein complex was isolated. This was oversewn initially with a running 3-0 Monocryl suture. Thereafter, the complex was divided distal to the apex. Monocryl suture was used to complete hemostasis.
Dissection of the prostate was then performed from the apex to the base of the prostate, preserving neovascular tissue bilaterally. At the base of the prostate, seminal vesicles were dissected free and the vas deferens were clipped and divided. The prostate was divided from the bladder neck circumferentially while avoiding injury to the ureters. The specimen was removed intact from the operative field. It was also sent for final histopathologic diagnosis. Hemostasis was achieved and irrigation perfor med. Reconstruction of the bladder neck was then performed. This was done in a standard tennis-racket-type closure using both 2-0 and 4-0 chromic suture which formed a handle and racket respectively. The mucosa of the bladder neck was everted and the r econstructed bladder neck measured approximately 22-French in size. Five separate 2-0 Monocryl sutures were originally placed within the urethral stump and were then used to complete an anastomosis with the reconstructed bladder neck. The anastomosis was completed over an 18-French Foley catheter reinserted per urethra. The reconstruction was shown to be watertight. The catheter was connected to straight drainage. Percutaneous drains were placed bilaterally with inward ports directed toward the obturator fossae. They were secured at the skin level with 3-0 nylon suture and connected to Hemovac suction. Irrigation was then performed. Closure was then performed at the fascial level with a #1 PDS suture and at the skin level with staples. A dry sterile dressing was applied. This completed the procedure. There were no apparent complications. At the conclusion of the procedure, all needle, sponge, and instrument counts were noted to be correct. Estimated blood loss was 1700 ml. Replacement consisted of 5.5 liters crystalloid and 2 U autologous blood. The patient was transferred to a stretcher and taken to the recovery room in satisfactory condition.
DESCRIPTION: The patient was taken to the operating room and after induction of anesthesia and the administration of intravenous antibiotics, he was prepared and draped in the usual relaxed dorsal lithotomy position.
The anterior urethra was sounded to 30-French, and then the Iglesias resectoscope was placed and cystopanendoscopy was performed with the results noted below. The urethra was within normal limits. The outlet nonocclusive bladder capacity was adequate.
The orifices were normal in position and morphology, and the left orifice was adjacent to a large fungating bladder carcinoma which was obviously necrotic. The tumor extended to the entire surface of the left lateral wall and was sequy resected into deep muscle using the Iglesias resectoscope. No other lesions were identified. A separate biopsy of the prostatic urethra was obtained. Electrocautery was used to achieve hemostasis. The chips were removed and the bladder was once again inspected and found to be free of evidence of injury, and the ureteral orifices were intact at the conclusion of the procedure. No evidence of perforation was identified. The scope was withdrawn and a 24-French 30-cc bag, three-way Foley catheter was placed to continuous bladder irrigation with clear efflux of urine noted. The patient was taken to the recovery room in stable condition, having tolerated the procedure well.