www.flinturology.com
Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190
Email: jbauer@flinturology.com
[map]
|
|
John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
|
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 correct stress urinary incontinence in men after prostate surgery for benign tumors (BPH) and prostate cancer. This procedure places a cadaveric sling reinforced with Marlex mesh around the urethra and then ties it up over the rectus muscle using non-absorbable suture. The pressure to push urine out is adjusted to 100cm of water pressure resistance, enough for daily activities. A trocar suprapubic tube is placed for one week to allow bladder drainage and voiding trials. A newer procedure is also available that does a similar maneuver but attaches the sling around the urethra and to the pubic bone using six titanium bone anchors. This procedure tightens the sling to 60 cm of water pressure and does not need a suprapubic tube placement.
Rather than using cadaveric tissue, you own tissue could be harvested from your body; however, the harvest is usually the part that the patient complains of most after the operation is completed. The cadaveric tissues used today extremely safe and are treated to remove all possible infectious agents. It is actually cleaner than you own tissue. With over 5 years experience and over 25,000 cases there has been no case of HIV transmission.
An alternative to these procedures is the AUS-800 urinary sphincter prosthesis. This procedure places a silicone cuff prosthesis around the urethra, a small pump in the scrotum and a reservoir in the abdomen to prevent leakage of urine. The device functions by keeping fluid in the urethral cuff, which acts to close the urethra with 60-70 cm of water pressure (good enough for daily activity). When the patient wishes to urinate, he simply presses on the pump 3-4 times and the fluid is moved from the cuff to the reservoir so that urination can proceed. After about two minutes, the fluid automatically re-fills the cuff. The AUS-800 can be placed after a failed male sling operation as a second attempt to control leakage and vice versa.
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 with stress urinary incontinence from previous prostate surgery for benign and malignant conditions or has an incompetent sphincter secondary to neurological disease. Urodynamic studies have confirmed the presence of Type III stress urinary incontinence with a low valsalva leak point pressure. The procedure requires the placement of a suprapubic cystotomy tube under cystoscopic guidance for urinary drainage.
Alternatives:
Alternatives include watchful waiting, Kegel exercises, behavioral/biofeedback/electrical stimulation therapy, injection of urethral bulking agents and an artificial urinary sphincter (AUS-800).
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: persistent incontinence, late failure of the sling with resultant incontinence, further therapy with bulking agents or AUS-800, if bone anchors are used then chronic pain or infection that may require removal of the anchors, chronic penile pain, numbness or hyperasthetic scrotal/perineal skin, the procedure uses non-absorbable mesh that can be infected in the future, will require prophylactic antibiotics before other surgical and dental procedures to avoid possible seeding of the mesh with bacteria, if the mesh does get infected then long- term antibiotics or removal of the mesh may be necessary. This procedure is a relatively new procedure and does not have any long term data regarding the results. Current results show 50% dry rate, total 87% dry or improved rate (~ 2 pads/day) at 6 months. A cystoscopy will be required for placement of a trocar cystotomy tube and to make sure that sutures where not inadvertently placed through the bladder, the trocar may pass through intestines and once diagnosed requiring further surgical procedures to correct the bowel injury possibly including a bowel diversion and external appliance for an extended period of time. Reconnection of the bowel segments will then be required at a later date.
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 Male Sling. 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?.
There are two types of surgeries in this category, Male Bone Anchor Sling and Male Rectus Urethral Sling.
Male Bone Anchor Urethral Sling
Indications: Patient is a male with Stress Urinary Incontinence.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. With direct external pressure on the bladder, there was obvious urinary leakage. A cystoscope was then gently placed into the urethral meatus and the length of the urethra inspected. The bladder neck was open and the cystoscope was passed without difficulty. A general cystoscopy was performed. The veru montanum was in normal position and the lobes of the prostate where identified. The bladder neck and trigone were noted to be normal. The ureteral orifices were noted bilaterally to efflux clear urine. A systematic inspection of the bladder was completed. There were no obvious lesions. The bladder was drained and the scope was removed under direct vision. A 16 French Foley catheter was placed without difficulty
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 urethral catheter was palpated to correctly identify the urethra. Lateral dissection to the inferior pubic ramis and superiorly to the pubic symphysis was accomplished without difficulty. Three titanium bone anchors were placed into the left inferior pubic ramis. A patch of 4 X 7 cm cadaveric fascia was sutured into place with the pre-positioned bone anchors and the #1 Prolene sutures. Three additional titanium bone anchors were placed into the right inferior ramis opposite the left side and the sutures were brought through the cadaveric fascia with Mayo needles. The 16 French catheter was then removed from the bladder after draining it entirely, positioned in the Fossa Navicularis, and secured with 1-2 cc in the balloon. A bag of normal saline was placed at 60 cm above the patients bladder and the sutures were tied to provide a leak point pressure of 60 cm H20 pressure. This was checked multiple times. A 16 Fr Foley was placed without difficulty and left to gravity drainage. The catheter will be removed prior to discharge. 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 wound was bandaged and 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.
Male Rectus Urethral Sling
Indications: Patient is a male with Stress Urinary Incontinence.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. With direct external pressure on the bladder, there was obvious urinary leakage. A cystoscope was then gently placed into the urethral meatus and the length of the urethra inspected. The bladder neck was open and the cystoscope was passed without difficulty. A general cystoscopy was performed. The veru montanum was in normal position and the lobes of the prostate where identified. The bladder neck and trigone were noted to be normal. The ureteral orifices were noted bilaterally to efflux clear urine. A systematic inspection of the bladder was completed. There were no obvious lesions. Simultaneously, a small midline incision 1 cm above the pubis was made to expose the rectus fascia for placement of the Stamey suprapubic tube (SP). Under direct cystoscopic visualization the 16 Fr Stamey SP tube was placed in the anterior/dome of the bladder. The Stamey was brought out of the abdominal incision and secured with 3-0 nylon suture. The bladder was drained and the scope was removed under direct vision. A 16 French Foley catheter was placed without difficulty
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 urethral catheter was palpated to correctly identify the urethra. Lateral dissection to the inferior pubic ramis was accomplished without difficulty. The endopelvic fascia was entered bluntly with the Metzenbaum scissors. Using the index finger blunt dissection of the retropubic space was performed. The Stamey needles were passed through the rectus fascia and through the retropubic space with finger localization of the needle tip. The Stamey needles were brought through the endopelvic fascia opening previously made. A simultaneously prepared Marlex mesh reinforced cadaveric sling (4 X 7cm) with #1 Prolene sutures on each end was placed using the Stamey needles. The sutures were brought through the incision up through the rectus fascia. The sling was positioned at the level of the proximal bulbous urethra.
---------
The cadaveric sling was fashioned from a 4 X 7 cm Duraderm patch. A 2 X 7 cm Marlex mesh was placed between the cadaveric fascia, which was folded about the mesh length wise. The mesh was secured to the fascia with interrupted 2-0 vicryl sutures. The ends of the reinforced sling were then secured with #1 Prolene sutures using multiple throws to increase the strength. The cadaveric fascia and the mesh were pre-soaked in antibiotic solution prior to construction of the sling.
------------
We then placed a cystoscope to inspect the bladder to exclude penetration of the suture through the bladder wall. There was no evidence of suture in the lumen of the bladder. Pulling up on the sling was noted to pull up on the bladder neck and proximal urethra. A vesicle pressure lead attached to the transducer was placed into the lumen and then the cystoscope was removed. The bladder was filled with 300cc of normal saline and the sling was tied in place. The tension of the suture was determined by measuring 100 cm of H20 pressure before leakage occurred with direct external bladder pressure. After tying the sutures, the leak point pressure was again tested and noted to be 100cm H20 pressure. The abdominal incision was closed with staples after irrigating the wound with normal saline. 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 SP tube was secured and the placed to gravity drainage. 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.