Материал: Oxford American Handbook of Urology ( PDFDrive )

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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.

620 CHAPTER 16 Urological surgery and equipment

Hydrocele and epididymal cyst removal

Hydrocele repair (removal)

Indications include primary (idiopathic) hydrocele repair; this is not indicated for secondary hydrocele repair.

Anesthesia: local or general

Techniques

•Lord’s plication technique—for small to medium-sized hydroceles (minimal interference with surrounding scrotal tissues, which minimizes risk of postoperative hematoma)

•Jaboulay procedure—for large hydroceles. Excision of hydrocele sac

Hydrocele aspiration

Strict attention to asepsis is vital, since introduction of infection into a closed space could lead to abscess formation. Avoid superficial blood vessels (if you hit them, a large hematoma can result).

Postoperative care involves nothing specific.

Postoperative complications and their management

•Scrotal swelling, which resolves spontaneously

•Hematoma formation. If it is large, surgical drainage is best performed, as spontaneous resolution may take many weeks. It can be difficult

to identify the bleeding vessel. Leave a small drain to prevent reaccumulation of the hematoma.

•Hydrocele recurrence

Epididymal cyst removal (spermatocelectomy)

•Avoid in young men who wish to maintain fertility, since epididymal obstruction can occur.

•An alternative to surgical removal is aspiration, though recurrence is usual.

Procedure-specific consent form—recommended discussion of adverse events

Hydrocele removal

Occasional

•Recurrence of fluid collection can occur.

•Collection of blood around the testes which resolves slowly or requires surgical removal

•Possible infection of incision or testis requiring further treatment

Alternative therapy

•Observation

•Removal of fluid with a needle

HYDROCELE AND EPIDIDYMAL CYST REMOVAL 621

Epididymal cyst removal

Occasional

•Recurrence of fluid collection can occur

•Collection of blood around the testes which resolves slowly or requires surgical removal

•Possible infection of incision or testis requiring further treatment.

Rare

• Scarring can damage the epididymis, causing infertility

Alternative therapy includes observation; removal of fluid with a needle.