Miko24
Guru
The patient was brought to the operating room and transferred to the operating room table. Anesthesia was initiated without complication.
The patient was positioned into High dorsal lithotomy. All pressure points were padded. Pre-procedure timeout was performed with all team members confirming correct patient, correct procedure and (laterality non-applicable) .
Begin the procedure by placing a traction stitch through the glans. The urethral meatus was calibrated with bougies was noted to be quite tight through the area of prior hypospadias repair. 4 oh tacking sutures were placed in the lateral aspect aspects of the glans. And a ventral extended meatotomy was performed until normal caliber urethra was encountered. The urethral mucosa was then approximated to the glans epithelium with running 5-0 PDS bilaterally. Was then calibrated with a 20 French bougie without resistance.
We then turned our attention to the perineum and the perineal midline was marked out and approximately 7 cm incision was made. Skin was divided with a scalpel Colles' fashion perineal fat was divided with electrocautery. The bulbospongiosus muscle was then encountered the distal aspect of it was divided in the midline and the proximal aspect was bluntly lifted off the ventral surface of the urethra. The perineal Bookwalter retractor was then set up. The distal fascia surrounding the urethra distal to the bulbospongiosus muscle was then incised. The entire penis was then encircled reaching up into the scrotum a Penrose was placed behind to delivered into the operative field. The left lateral side of the urethra was raised sharply off of the ventral surface of the corporal bodies. A 18 French ureteral catheter was passed retrograde into the area of narrowing was encountered. A dorsal urethrotomy was made with a scalpel. Tacking sutures were placed in the lateral aspects of the urethra. The urethrotomy was carried proximally until normal caliber urethra was encountered this ended up being approximately 5 cm. Tacking sutures were placed along the way. Once was felt to be normal caliber urethra was encountered it was calibrated with 22 French bougie's without resistance. Further proximally to the bladder neck there was what felt to be a small lip but it did not provide resistance to the 22 French. Thus we elected to not cut back any further. Flexible cystoscope was navigated through the urethra automate into the bladder that area of lip that just noted was visualized several centimeters from our urethrotomy but it did not provide resistance the scope and would have significantly extended the urethrotomy so elected to leave it alone.
Next we turned our attention to the mouth. The patient's mouth was prepped with Betadine. Tacking sutures were placed on the lips to provide exposure. Stensen's duct was identified on the left side of the mouth. A 5 cm x 1.5 cm buccal mucosa graft was marked out. And then was hydrodissected with quarter percent Marcaine and epinephrine. Scalpel was used to incise the buccal mucosa and then was sharply raised off the buccinator muscle using super cut scissors. Bipolar cautery was used to achieve hemostasis of the donor site. 3-0 chromic was used to close the mouth mucosa. The graft was taken to the back table and defatted. We then returned to the perineal incision and the proximal and distal extents of the urethrotomy were matched up with the graft and the graft was secured in place with 4-0 Vicryl's proximally distally. Then laterally and then quilted in the middle. The right aspect of the ureterotomy was approximated to the buccal mucosal graft using 5-0 PDS run from the proximal distal extents of the ureterotomy and tied in the middle. At this point 18 French Foley catheter was passed through the urethra into the operative field and then passed into the bladder. The left aspect of the urethrotomy was then closed with a running 5-0 PDS again proximally distally and tied in the middle. The balloon on the catheter was inflated the catheter was able to slide backs. The Penrose holding the penile structures in the field was removed. The bulbospongiosus muscle was reapproximated with 3-0 Vicryl. Perineal fat was reapproximated and the scrotal cavity was read to find with Vicryl suture. Colles' fascia was closed with a running 3-0 Vicryl. Skin was closed with interrupted 4-0 Vicryl. Sterile dressing was applied. The existing suprapubic tube was removed at the end of the case and dressing applied. The mouth was inspected 1 more time there was no evidence of bleeding and the previously placed Ray-Tec was removed.
53410 or 53415 with 15240
The patient was positioned into High dorsal lithotomy. All pressure points were padded. Pre-procedure timeout was performed with all team members confirming correct patient, correct procedure and (laterality non-applicable) .
Begin the procedure by placing a traction stitch through the glans. The urethral meatus was calibrated with bougies was noted to be quite tight through the area of prior hypospadias repair. 4 oh tacking sutures were placed in the lateral aspect aspects of the glans. And a ventral extended meatotomy was performed until normal caliber urethra was encountered. The urethral mucosa was then approximated to the glans epithelium with running 5-0 PDS bilaterally. Was then calibrated with a 20 French bougie without resistance.
We then turned our attention to the perineum and the perineal midline was marked out and approximately 7 cm incision was made. Skin was divided with a scalpel Colles' fashion perineal fat was divided with electrocautery. The bulbospongiosus muscle was then encountered the distal aspect of it was divided in the midline and the proximal aspect was bluntly lifted off the ventral surface of the urethra. The perineal Bookwalter retractor was then set up. The distal fascia surrounding the urethra distal to the bulbospongiosus muscle was then incised. The entire penis was then encircled reaching up into the scrotum a Penrose was placed behind to delivered into the operative field. The left lateral side of the urethra was raised sharply off of the ventral surface of the corporal bodies. A 18 French ureteral catheter was passed retrograde into the area of narrowing was encountered. A dorsal urethrotomy was made with a scalpel. Tacking sutures were placed in the lateral aspects of the urethra. The urethrotomy was carried proximally until normal caliber urethra was encountered this ended up being approximately 5 cm. Tacking sutures were placed along the way. Once was felt to be normal caliber urethra was encountered it was calibrated with 22 French bougie's without resistance. Further proximally to the bladder neck there was what felt to be a small lip but it did not provide resistance to the 22 French. Thus we elected to not cut back any further. Flexible cystoscope was navigated through the urethra automate into the bladder that area of lip that just noted was visualized several centimeters from our urethrotomy but it did not provide resistance the scope and would have significantly extended the urethrotomy so elected to leave it alone.
Next we turned our attention to the mouth. The patient's mouth was prepped with Betadine. Tacking sutures were placed on the lips to provide exposure. Stensen's duct was identified on the left side of the mouth. A 5 cm x 1.5 cm buccal mucosa graft was marked out. And then was hydrodissected with quarter percent Marcaine and epinephrine. Scalpel was used to incise the buccal mucosa and then was sharply raised off the buccinator muscle using super cut scissors. Bipolar cautery was used to achieve hemostasis of the donor site. 3-0 chromic was used to close the mouth mucosa. The graft was taken to the back table and defatted. We then returned to the perineal incision and the proximal and distal extents of the urethrotomy were matched up with the graft and the graft was secured in place with 4-0 Vicryl's proximally distally. Then laterally and then quilted in the middle. The right aspect of the ureterotomy was approximated to the buccal mucosal graft using 5-0 PDS run from the proximal distal extents of the ureterotomy and tied in the middle. At this point 18 French Foley catheter was passed through the urethra into the operative field and then passed into the bladder. The left aspect of the urethrotomy was then closed with a running 5-0 PDS again proximally distally and tied in the middle. The balloon on the catheter was inflated the catheter was able to slide backs. The Penrose holding the penile structures in the field was removed. The bulbospongiosus muscle was reapproximated with 3-0 Vicryl. Perineal fat was reapproximated and the scrotal cavity was read to find with Vicryl suture. Colles' fascia was closed with a running 3-0 Vicryl. Skin was closed with interrupted 4-0 Vicryl. Sterile dressing was applied. The existing suprapubic tube was removed at the end of the case and dressing applied. The mouth was inspected 1 more time there was no evidence of bleeding and the previously placed Ray-Tec was removed.
53410 or 53415 with 15240