John J. Bauer, M.D. 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]

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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.

Spermatic cord lysis is a procedure that is a last ditch effort to help control the pain associated with the chronic myofascial pain disorders, such as chronic epididymitis and chronic orchitis. (For more information on these pain syndromes, please go to the links provided.) This procedure attempts to disconnect all nervous innervation to the epididymis and testicle by skeletonizing the spermatic cord of all tissues except the blood supply to these scrotal structures. If the pain experienced by the patient is specifically localized to one of these structures, there is a higher chance that the procedure will be successful. Despite this localization, the overall success of this procedure is less than 50%. If the pain is localized to the epididymis then an epididymectomy would be attempted first to control this chronic pain syndrome. The longer the patient has experienced these pain syndromes the less likely the surgery will be successful.

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:

1. One Week Prior to Surgery:
   - STOP all aspirin and all aspirin-containing medicines (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles to make certain aspirin is not contained. See additional list at Blood Thinners.

2. Two Days Prior to Surgery:
   - STOP all nonsteroidal anti-inflammatory medications (e.g., etodolac [Lodine], fenoprofen [Nalfon], ibuprofen [Advil, Motrin, Nuprin], ketorolac [Toradol], maproxen [Aleve], meclofenarnate [Meclomen], mefenamic acid [Ponstel], naproxen [Anaprox, Naprosyn].

3. Day Before Your Surgery:
   Start the pre-operative Bowel Prep (cleansing procedure) appropriate for this surgery, as described below.

   Your operation occurs near the bowels so your preparation involves an intermediate-level bowel prep, as follows.

   • 2-Bottles of Magnesium Citrate
   • 2-Fleets Enemas or Neomycin Enemas
     • Night before
     • Morning of the surgery

4. On the Morning of your Surgery:
   • DO NOT TAKE digitalis medicines (e.g., Crystodigin, Digoxin, Lanoxin).
   • DO NOT TAKE oral antidiabetes medicines (e.g., chlorpropamide [Diabinese], glyburide [DiaBeta, Glynase, Micronase], glypizide [Glucotrol], tolazamide [Tolinase], tolbutamide [Orinase].
   • DO TAKE one-half of your usual morning. INSULIN dose. DO NOT TAKE your morning INSULIN dose if you are driving a great distance the morning of surgery or if your surgery is scheduled for the afternoon.
   • DO TAKE, with a small sip of water, ALL of your other usual morning doses of regularly prescribed medicines. Use your asthma inhalers and bring them with you to the hospital.

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:

1. Eight hours before the Scheduled Start of your Surgery:
   DO NOT EAT any solid foods, including juices with pulp (e.g., orange juice, nectars), lozenges, candy, chewing gum, and mints. DO NOT DRINK full liquid, such as milk, cream, and jello. You may continue to drink up to eight ounces of clear liquids until SIX hours before the scheduled start of your surgery. Clear liquids include Water, clear juices (e.g., apple, grape), black tea and black coffee.
2. Six hours before the Scheduled Start of your Surgery:
   DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
3. Exceptions:
   DO NOT TAKE anything by mouth for eight hours, except for your usual medicines, if you are pregnant, morbidly obese, or are diagnosed with diabetes, renal failure, or stomach acid reflux with heartburn.

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:

1. Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
2. Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
3. Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
4. Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

On The Day Of Surgery

• Take your medicines as instructed above.
• You may brush your teeth; rinse your mouth, but do not swallow the water.
• Leave all jewelry (including wedding and all other rings) and valuables (including money and credit cards) at home.
• If you wear contact lenses, glasses or hearing aids, please bring a case or container, and solution for contacts, to protect them while you are in surgery.
• Wear a minimum amount of makeup, and no mascara. Please remove the nail polish from both index fingers.
• Please bring a copy of your current medical problem list from you primary care physician (family medicine/internist).
• Minors (anyone less than 18 years old) must be accompanied by a parent or legal guardian to sign the operative consent fount

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 symptomatic testicular or epididymal pain. This pain has been chronic and unremitting in character. All conservative therapies have been attempted without success.

Alternatives:

Options include but are not limited to: observation, oral analgesics, repeat trial of long-term antibiotics, repeated cord blocks, TENS therapy (nerve stimulation therapy), epididymectomy and orchiectomy.

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: complete breakdown of the repair, prolonged wound drainage, injury to spermatic vessels, testicle and vas deferens which may lead to loss of testicle or future infertility problems. Possible injury to the ilioinguinal nerve is also possible and could lead to anesthetic areas on the scrotal, penile and inguinal skin. This could also lead to separate chronic pain syndrome. It was repeatedly reinforced that this is a last radical effort to control the chronic pain that the patient is experiencing. He was made aware of the fact that this procedure may fail and that the pain may continue even after the spermatic cord has been skeletonized of all muscle and nerve tissue. Significant risk to the viability of the testicle is a potential outcome of this surgery.

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 Spermatic Cord Lysis (Skeletonization). 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 with chronic Epididimoorchitis.

Sample Procedure Dictation:

The patient was given spinal/general anesthesia, placed in the supine position and then prepped and draped in the usual standard sterile manner. An inguinal incision approximately 3 inches in length was made down to the Scarpa�s fascia. This layer was divided with the bovie and the external oblique fascia was identified. A small stab incision was made and then extended with the scissors to the external inguinal ring. The ilioinguinal nerve was identified and retracted from the field to prevent injury. The cord was isolated with a penrose drain and dissected free to the internal inguinal ring. The cremasteric muscle tissue was sequentially identified and excised along the entire cord from the internal ring deep into the scrotum. The cord was completely skeletonized with only the vas deferens and the vascular structures left intact. The artery was identified with use of intraoperative papaverine to prevent arterial spasm. The pulsations of the artery could be seen and this structure was preserved. The wound was then copiously irrigated with normal saline. The ilioinguinal nerve was placed into the inguinal canal and the external oblique fascia was closed with interrupted 2-0 vicryl sutures. The external inguinal ring was reconstructed to fit loosely about the spermatic cord. Scarpa�s fascia was closed with interrupted 2-0 vicryl and the skin was closed in a subcuticular fashion using running 4-0 monocryl suture. The wound was cleaned and dried. Xerofoam gauze was placed and the wound was bandaged. 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

1. Rest today.
2. Resume your regular diet. Some nausea after anesthesia is common.
3. Drink plenty of fluids . We recommend 24-32 oz. over your usual intake daily. Avoid tea, coffee (including decaf), carbonated products and alcoholic drinks.
4. You may experience some pain and burning when you urinate. There may be blood in your urine. This will get better over 1-3 days.
5. No sexual activity for 1 week unless instructed otherwise by your doctor.
6. Please call the urology office today to schedule your follow-up appointment.
7. Please start the medications prescribed by your doctor today. Please complete the entire prescription and do not share medications with others. If there is a problem taking or getting the medication, call us.
8. If a ureteral stent was placed, you may experience frequent urination, blood in the urine and occasional discomfort. This may continue until the stent is removed.

Special Instructions for Endoscopic Procedures

1. This may cause a burning sensation with urinating for 2-3 days.
2. You may pass blood in your urine over the next 3-5 days, progressively getting better.
3. You may have some bladder irritability, urgency, frequency and or incontinence. With most of the transurethral procedures, you will be discharged with Detrol to relax your bladder.

Circumcisions, Penile or Scrotal Surgeries

1. If you had a circumcision, remove Vaseline gauze dressing on the morning after surgery. You may need to soak in a warm (not hot) tub prior to removal. Apply Bacitracin or similar ointment to the wound three times a day.
2. All other dressing should be removed the second day after surgery unless otherwise directed. You may take showers daily once dressing is removed. No tub baths for 1 week unless otherwise directed.
3. Wear scrotal support with a jock strap or snug briefs for two weeks if you have had any testicular/scrotal surgery.
4. No sexual activity until you have seen the doctor.
5. Apply an ice pack to your groin for 24 hours.

Special Instructions for Patients with Catheters

1. If you have a catheter in place, wash around it gently with soap and water. Keep the catheter taped to your thigh or abdomen to avoid inadvertent jerking or pulling. Do not disconnect the catheter from the drainage bag unless directed by your doctor.
2. Some blood might be seen in the bag. This is normal. If the urine is very bloody, and the bag does not appear to be draining well, call our office.

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.