elainehopf
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PREOPERATIVE DIAGNOSIS: Right groin mass/right inguinal lymphadenopathy.
POSTOPERATIVE DIAGNOSES: Right groin mass/right inguinal lymphadenopathy,
urethral stricture.
PROCEDURES:
1. Right inguinal lymphadenectomy/right groin mass removal.
2. Cystoscopy with urethral dilation.
3. Complex catheter placement over a wire.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 5 mL.
COMPLICATIONS: None.
FINDINGS:
1. Large 5.5 to 6 cm groin mass/lymphadenopathy.
2. Multiple urethral strictures in the proximal bulbar urethra.
3. No obvious tumor recurrence in the urethra.
DRAINS: 12-French urethral catheter.
SPECIMENS: Right groin mass/lymphadenopathy.
INDICATIONS FOR PROCEDURE: is a 64-year-old man with a history
of membranous urothelial carcinoma that is metastatic. He refuses surgery
and is currently undergoing chemotherapy.
DETAILS OF PROCEDURE: He was
placed in the supine position and prepped and draped in the usual fashion.
A time-out was done to confirm the correct patient, side, and procedure.
SCDs were placed and working prior to induction.
We then used a flexible cystoscope and identified a proximal bulbar
urethral stricture. There was no evidence of tumor recurrence in the
urethra. We tried passing a sensor wire through this stricture, but could
not do so. We therefore needed the use of a rigid ureteroscope, at which point
we were able to negotiate past the bulbar stricture. Beyond the stricture was
another short stricture, again we were able to negotiate past the stricture
with the rigid ureteroscope and at that point, we identified the prostatic
urethra and passed a wire into the bladder. Once the wire was coiled in the
bladder, we removed the rigid ureteroscope and dilated over the wire with a 10-
French Heyman dilator followed by a 12-French and then a 14-French. Given the
fact that he had evidence of urinary tract infection preoperatively, we decided
at that point to not dilate further to minimize risk of causing infected
urinary extravasation into the local tissues. Instead, we stopped at 14-
French and then placed a 12-French silicone catheter over a wire. This took a
moderate amount of effort, but we were eventually able to get into the bladder
without problems. We then put 10 mL of water into the balloon and got return
of clear urine that was slightly cloudy. At this point, we checked with
anesthesia and the patient had no fevers and continued to do well with normal
vital signs without need for any type of hemodynamic support. Therefore, we
decided to proceed with the right groin dissection. The patient was reprepped
and draped in the usual fashion. We then made about a 6 cm marking right on
top of the groin mass. We then cut through this with a knife and then
carefully went with electrocautery through the Camper's and Scarpa's fascia.
We then identified the mass and we were able to palpate this. We used gentle
blunt dissection to identify vessels and lymphatics. Lymphatics that were
attached to node were clipped and cut. We did this sequentially starting on
the lateral aspect and followed this superiorly and then medially and then
inferiorly. We did this systematically from superficial to deep layers and
eventually after clipping all the major lymphatics and vascular structures that
were feeding this groin mass, it was eventually freed up completely. We
irrigated the wound completely and there was no bleeding and no obvious
lymphatic leak. We then closed the tissue in multiple layers with 2-0 Vicryl.
Once this was done, we closed the skin with a 4-0 Biosyn. We then used Steri-
Strips. The mass itself was about 6 x 4 cm.
This was sent for final pathology.
At this point, we decided not to leave a drain as all lymphatics were
clipped and no skin flap was raised.