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 performed to surgically repair a long urethral stricture or one that has failed all prior attempts to correct. This procedure is best used for strictures greater than 1-2 cm in length. If the stricture is less than 2 cm long then an open urethroplasty using a primary anastomosis technique is best used. In this procedure, the urethra is exposed and the area that is strictured is incised and opened and some other tissue is laid or sutured onto this defect to make it a larger diameter tube. The tissue laid onto the defect could be buccal mucosa, penile foreskin, penile shaft skin or scrotal skin that has had its hair removed. (Our practice most commonly uses buccal mucosa). A catheter is left in place for three weeks to allow healing.
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:
As injury to the bowel is unlikely in this procedure, you will have the simplest form of a bowel preparation, described below.
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 with stricture disease of the urethra.
Alternatives:
Options include prolonged urethral dilation with clean intermittent catheterization (CIC), direct vision internal urethrotomy, laser ablation of stricture, Urolume stent placement, open urethroplasty, or open graft urethroplasty.
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 urethral catheterization, urethral diverticulum, urethral abscess, recurrence of the stricture, future alternative procedures for failures, prolonged dysuria, penile pain and impotence. If penile skin or scrotal skin is used you may develop hair growth in the flap which may require removal secondary to recurrent urethritis and urinary tract infections. You may be required to have a circumcision if foreskin is used as the on-lay flap. If buccal mucosa is used then an ENT doctor will perform the procedure separately under the same anesthesia, complications include but are not limited to prolonged mouth healing, infection, pain swallowing, may need soft diet until healing is finished and prolonged cheek pain. Your ENT doctor will discuss this procedure more in depth separately.
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 On-Lay Urethroplasty. 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: Patient is a male with a bulbous urethral stricture.Sample Procedure Dictation:
The patient was given spinal/general anesthesia, placed in the Lithotomy position and then prepped and draped in the usual standard sterile manner. The urethra was then injected with methylene blue to color the strictured area. A midline perineal incision from just below the scrotum to just above the anus was made through the skin. The subcutaneous tissues were sequentially dissected with bovie coagulation until the bulbocavernosus muscle and the Corpus Spongiosum was noted. The Bougie dilators were used to identify the level of the stricture and allow palpation to correctly identify the urethral location. The bulbocavernosus muscle was divided in the midline to expose the spongiosum. Lateral dissection to isolate the spongiosum was accomplished without difficulty. Posterior dissection was also performed to fully isolate the spongiosum and urethra. This was then secured with a 1/2 inch penrose drain. The level of the stricture was again determined using the Bougie dilators. The entire strictured area was incised the entire length of the stricture and into normal tissue over the Bougie dilator. Both ends of the open urethra were sounded to 30 French with the Bougie dilators to make sure that entire stricture and fibrotic spongiosum tissue was divided. The urethra was then covered with an On-Lay graft from the buccal mucosa harvested by the ENT surgeons. The defect was closed with interrupted 3-0 vicryl sutures over an 18 French Foley catheter. The closure was completed without leaving redundant on-Lay graft material. The excess tissue was excised. All bleeders were bovie coagulated and the wound was irrigated and inspected for bleeding. A 10 mm Jackson-Pratt drain was placed near the primary closure site, brought through a separate stab wound through the skin and placed under bulb suction. This was secured with 30- Nylon suture to the skin. The perineal incision was closed in three layers with 2-0 vicryl sutures. The wound was copiously irrigated with normal saline prior to subcuticular skin closure with 4-0 monocryl. The wounds were bandaged. The perineal bandage was secured with an athletic supporter. 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.
Activity
Diet
Medication
Catheter and Wound Care
Bowel Movements
When to Contact your Doctor
Contacting Your Physician
Dr. Bauer can be contacted by calling the number listed at the top of the 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.