DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Urethral stricture.
POSTOPERATIVE DIAGNOSIS: Urethral stricture.
OPERATION PERFORMED: First stage Leadbetter urethroplasty.
SURGEON: John Doe, MD
ASSISTANT SURGEON: Jane Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: After the adequate induction of general anesthesia, the patient was placed in the exaggerated lithotomy position for first stage Leadbetter urethroplasty. Care was taken to place him well in the bariatric Allen stirrups. His calves were padded well and care was taken to protect the peroneal nerve. He was brought into position and maintained in position utilizing a bean bag. Eggcrate foam was placed immediately under him to protect the sacrum. Care was taken to be sure he was not suspended by his lower extremities. The extremities were bent less than 90 degrees at the knees. Once in position, the patient’s perineum and lower abdomen were prepped and draped in the usual fashion for first stage Leadbetter urethroplasty.
The perineum was entered with a Y-type incision with the largest portion being the flap created from the ischial tuberosities, up really into his posterior scrotal area. The incision was carried in the midline for a few centimeters further. The subcutaneous tissue was developed utilizing sharp dissection and Bovie. The bulbocavernosus muscle was identified and a plane was developed within this muscle to separate it from the corpora spongiosum.
As is usual, the muscle was fixed in the midline. Care was taken to sharply remove the muscle from the urethra. This line of development was continued down to the spongiosum, which was released from the perineal body. Care was taken to not dissect the bowel far laterally so as to preserve the arteries to the bulb.
At this point, a flexible ureteroscope was passed via his suprapubic cystostomy site. It was passed through the bladder neck and into the proximal urethra. It could be palpated for a short distance in the bulbar urethra. A 0.038 sensor wire was passed through the scope and this was able to negotiate the entire urethra. Utilizing the scope to identify the urethra, the urethra was sharply incised in a linear fashion quite proximally in the area where the scope was. Marking sutures were taken bilaterally.
Urethrotomy was continued proximally and distally for a total distance of about 3.5 to 4 cm. The proximal area was extended almost to the external urinary sphincter. The urethrotomy was bougied in the proximal area, easily allowed a 28-French bougie to enter the bladder. The distal urethra, at the end of our urethrotomy, would not allow an 8-French bougie to pass.
The bleeding from the spongy tissue was controlled with interrupted sutures of 5-0 PDS. The posterior-based flap was brought to the apex of our urethrotomy and care was taken to bring the skin down to the mucosa with interrupted 5-0 PDS. Because of his size, we were not able to bring a great deal of the flap down to the urethra, in all about 5 sutures were based on the posterior flap, but it was felt to be too much tension to place any further sutures.
The anterior and lateral aspects of the urethrotomy were closed to the posterior scrotal and perineal skin. This was easily done without tension, though the anastomosis was somewhat difficult because of his obesity and the degree of flabby tissue present. The two lateral extremes of the flap incision were closed with vertical mattress sutures of 3-0 Vicryl and posterior scrotal incision was similarly closed. A 16-French silicone catheter was placed via the urethrotomy. This was surrounded by Xeroform gauze and OpSite dressings were placed on the lateral aspects of our flap incision. The patient tolerated the procedure well. He was sent to the recovery room in satisfactory condition.
