616 CHAPTER 16 Urological surgery and equipment

Optical urethrotomy

Indications

•Short (<1 cm) bulbar urethral strictures (longer and recurrent strictures are now best treated by open urethroplasty incorporating excision and/or grafts—usually buccal mucosa—or penile skin flaps)

Anesthesia

Use regional or general anesthetic.

Postoperative care

•Leave a catheter for 3–5 days (longer catheterization does not reduce long-term restricturing).

Common postoperative complications and their management

•Septicemia

•Restricturing is the most common long-term problem occurring after optical urethrotomy.

P rocedure-specific consent form—recommended discussion of adverse events

Common

•Mild burning on passing urine for short periods of time after operation

•Temporary insertion of a catheter

•Need for self-catheterization to keep the narrowing from closing down again

Occasional

•Infection of bladder, requiring antibiotics

•Permission for telescopic removal if stone is found, biopsy of bladder abnormality

•Recurrence of stricture necessitating further procedures or repeat incision

Rare

• Decrease in quality of erections, requiring treatment

Alternative therapy includes observation, urethral dilatation, and open (nontelescopic) repair of stricture.

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618 CHAPTER 16 Urological surgery and equipment

Circumcision

Indications

•Phimosis

•Recurrent paraphimosis

•Penile cancer confined to the foreskin

•Lesions on the foreskin of uncertain histological nature

Anesthesia

Local or general anesthetic can be used.

Postoperative care

A nonadhesive dressing may be applied to the end of the penis, but this is difficult to keep on for more than an hour or two and is unnecessary. Warn the patient that the penis may be bruised and swollen after the operation, but that this resolves spontaneously over a week or two.

Common postoperative complications and their management

You might think that circumcision is about as simple an operation as you can get, but it can cause both the patient (or, in the case of little boys, their parents) and you considerable concern if the cosmetic result is not what was expected, or if complications occur about which the patient was not warned.

As with any procedure, it should be performed with care and with the potential complications always in mind so that steps can be taken to avoid these. If complications do occur, manage them appropriately.

Hemorrhage

Most frequently this occurs from the frenular artery on the ventral surface of the penis. If local pressure does not stop the bleeding (and if it is from the frenular artery, it usually won’t), return the patient to the operating room and, either under ring-block local anesthesia or general anesthetic, suture ligature the bleeding vessel.

Be careful not to place the suture through the urethra!

Necrosis of the skin of the shaft of the penis

In most cases of suspected skin necrosis, there is none. Not infrequently, a crust of coagulated blood develops around the circumference of the penis after circumcision. As blood oxidizes it turns black and this appearance can be mistaken for necrosis of the end of the penis. Reassurance of the patient (and the referring doctor!) is all that is needed.

If necrosis has occurred because, for example, adrenaline was used in the local anesthetic, wait for the necrotic tissue to demarcate before assessing the extent of the problem. The penis has a superb blood supply and has remarkable healing characteristics.

Separation of the skin of the coronal sulcus from the shaft skin

If limited to a small area this will heal spontaneously. If a larger circumference of the wound has dehisced, resuture in the operating room.

Wound infection is rare.

CIRCUMCISION 619

Urethrocutaneous fistula is due to hemostatic sutures (placed to control bleeding from the frenular) passing through the urethra, the wound later breaking down.

Urethral damage is due to a stitch placed through the urethra as the frenular artery is suture ligatured.

Excessive removal of skin

Re-epithelialization can occur if the defect between the glans and shaft skin is not too great. If the defect is too great, the end result will be a buried penis—the glans retracts toward the skin at the base of the penis.

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of circumcision

•Bleeding of the wound occasionally needing a further procedure

•Infection of incision requiring further treatment

•Permanent altered sensation of the penis

•Persistence of absorbable stitches after 3–4 weeks, requiring removal

•Scar tenderness, rarely long-term

•You may not be completely cosmetically satisfied

•Occasional need for removal of excessive skin at a later date

•Permission for biopsy of abnormal area of glans if malignancy a concern

Alternative therapy includes drugs to relieve inflammation or leaving the penis uncircumcised.