John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions
Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.
This procedure is completed to remove lymph nodes in the posterior abdomen region near the great vessels suspected to contain microscopic amounts of testicular cancer. The diagnosis was determined previously by an operation that removes the testicle and spermatic cord called a radical orchiectomy. The operation is done through a midline incision in the abdomen from above the belly button down to the pubic bone. The entire small and large intestines need to be mobilized to gain access to the lymph node region. Since patients are usually very young, they tolerate the procedure will and recover very quickly.
Your pre-operative appointments
Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.
Change In Health Status
Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.
Pre-Operative Medication Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:
Your operation occurs near the bowels so your preparation involves an intermediate-level bowel prep, as follows.
Pre-Operative Diet Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:
Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.
Pre-Operative Cleaning Instructions (bathing and showering instructions)
Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:
On The Day Of Surgery
The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.
After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.
Time To Arrive For Your Surgery
During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.
ARRIVAL TIME:
WHERE TO ARRIVE:
The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.
Indications:
Patient is a male diagnosed with a symptomatic or asymptomatic testicular mass on physical exam and testicular ultrasound confirmation was obtained. CXR and tumor markers were drawn pre-op (B-HCG, AFP and LFT�s). Patient has undergone a previous radical orchiectomy and pathology revealed a non-seminomatous germ cell testicular tumor. CT of the abdomen/pelvis was obtained with no evidence of detectable lymph nodes or less than 2cm in diameter. Repeat tumor markers are undetectable or decaying at a rate consistent with the half-life decay of B-HCG(1.5 days) and AFP(5 days). Discussed were semen banking for future fertility.
Alternatives:
Alternative is observation with monthly CXR and tumor markers for two years and then q 2 months X 1year, Q 4 months X 1 year and then Q 6 months X 1 year then Q 1year for the rest of your life, laparoscopic PLND in experienced hands and chemotherapy if any lymph nodes are noted on CT scan of Abdomen or pelvis.
Risks/Complications:
The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.
The specific risks of this procedure include, but are not limited to: prolonged wound drainage, possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal skin, possible tumor seeding and possible positive microscopic nodal metastasis which would require two cycles of chemotherapy (PEB), loss of seminal emission, infertility, may need to use artificial reproductive techniques with banked frozen sperm for biological children, lymphoceole, lower extremity edema, major vascular injury, possible resection of vena cava and aortic graft/prosthetic placement if vessels are incased with tumor, If incidental large lymph nodes are noted during surgery and crossover of disease is highly probable the template would be expanded to a complete bilateral lymph node dissection, injury to bowel, vascular supply to bowel, kidney, pancreas, spleen, liver, gonadal artery and possible atrophy or loss of remaining testicle.
You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.
To view the actual printable form for this surgery, click here: Counseling Note for Retroperitoneal Lymph Node Dissection. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.
Indications: Male patient with history of non-seminomatous Germ Cell Testicular Tumor (NSGCTT).Sample Procedure Dictation:
Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 24 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the above the umbilicus to the symphysis pubis coagulating all bleeders as they where encountered. The rectus fascia was divided the length of the incision, the pre-peritoneal space was identified, and the peritoneum was entered taking care to avoid any injury to the bowel. We then placed a Buckwalter self-retaining retractor to expose the abdominal cavity. The spermatic cord was the dissected free of the inguinal canal. The entire cord and the suture left from the previous radical orchiectomy were removed. The small bowel was then retracted from the field with moist sponges and the White Line of Tolt was identified and incised along the lateral colonic gutters. This was carried superiorly to allow adequate exposure great vessels, ureters and the kidneys. The small bowel and colon were reflected from the field with moist sponges. These were inspected periodically to assure normal bowel integrity. The ureters were noted bilaterally. The modified template on the Left / Right side was then sequentially dissected and excised. The template included the lymph node region bounded by the middle of the Aorta medially, ureter laterally, junction of ureter and iliac vessels inferiorly and the renal vessels superiorly. A nerve sparing technique was performed to increase the probability of retaining emission of semen. The template was sent for permanent pathological review. Care was taken to avoid injury to the aorta, vena cava, renal vessels and the inferior messenteric artery during the case. The area was copiously irrigated and all bleeders were coagulated or clipped. The intestines were then replaced into the abdomen. The white line of Tolt was re-approximated bilaterally with running 2-0 vicryl sutures. The bowel was noted to be normal color and consistency. The fascia was then closed in a running fashion with running interrupted #2 Prolene sutures. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The Foley catheter was securely tapped. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR). The patient arrived to the RR in stable condition and without complications.
To the family and friends of patients undergoing surgery.
SCHEDULED STARTING TIME OF SURGERY:ESTIMATED LENGTH OF SURGERY:
You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.
The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.
We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.
Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.
General Instructions
Special Instructions for Endoscopic Procedures
Circumcisions, Penile or Scrotal Surgeries
Special Instructions for Patients with Catheters
Contacting Your Physician
Dr. Bauer can be contacted by calling the number at the top of this page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.
Frequently Asked Questions after surgery
This section is under construction.