16 DOT ‘Nesbitt’ Plication

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Correction of penile chordee / curvature.

Why is it done?

  • To treat an acquired deviation of an erect penis.
  • Usually occurs in males 55-65 years of age.
  • Can be associated with previous penile trauma, usually no associated history.
  • A dorsal (up) curvature is more common than a ventral (down) one. Can also deviate to the side.
  • Pain is usually the presenting symptom with a gradually worsening curvature.
  • The curvature may be so bad that penetration becomes impossible.
  • Associated with the connective tissue disorder: Dupuytren’s Contracture, which is an auto-immune disease.
  • Worse cases may require a penile prosthesis.

Pre-requirements

  • An informed consent is required from the patient/ parents.
  • Patients are informed that this may shorten the penis to the length of the shorter side of the penis, usually 2-3 cm.
  • In patients who wish to preserve penile length, a lengthening technique using buccal mucosa may be indicated and will be referred to a colleague.
  • Patients may not eat or drink from 6-8 hours prior to surgery according to age.
  • Any anti-coagulants such as Warfarin or Aspirin must be stopped 7 days prior to surgery. Clexane injections may be substituted.
  • Be prepared for an overnight stay.

How is it done?

  • This procedure is done under general anesthetic.
  • Supine position.
  • The foreskin is loosened proximal to the glans with a circumferential incision and the whole penile skin is retracted to the base of the penis.
  • An artificial erection will be induced by injecting a sterile saline solution into the penile corpora cavernosa with a tourniquet around the base.
  • Non-dissolvable sutures will be placed on the sides opposite to the diseased areas in an attempt to pull the erect penis into a straight alignment.
  • Occasionally a circumcision may result due to complications with this technique, yet foreskin preservation is attempted.
  • If there is a dorsal curvature, ventral sutures are laced and the penis pulled in upright position, therefore sutures are always placed on the opposite site avoiding vital structures such as.
  • An indwelling catheter will be inserted until you are awake.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anesthetic is injected at the base of the penis as a penile block thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is a common complication.
  • A hematoma (blood collection under the skin) may form and needs to be reviewed by Dr Schoeman as soon as possible. Bruising is normal.
  • Sutures may tear loose with vigorous use of erect penis, and the procedure may then require revision.
  • An infection of the wound may occur and requires immediate attention.
  • Necrosis of the foreskin and some penile skin can occur in rare circumstances. This may require skin-grafting.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • The catheter will be removed as soon as you are awake, or if there are concerns, the following morning.
  • On discharge, a prescription may be issued for patients to collect.
  • Patients should schedule a follow-up appointment with Dr Schoeman 2 weeks after the procedure.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 6 weeks.
  • The suture-line will be hard and indurated for at least 8-10 weeks.
  • Sick leave will be granted for 10 days.
  • Please direct all further queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

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Wes 16 Dot Nesbitt Plication

Artificial Urinary Male Sphincter – AUS

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Why is it done?

  • Male Stress incontinence/ Incontinence
  • Usually after a TURP/TUVP, Radical Prostatectomy in 2% of cases as pre-described complication of surgery

How is it done?

  • ·This procedure is done under a spinal /general anesthetic, as decided by the anesthetist.
  • The legs will be elevated into the lithotomy position.
  • A 7cm incision is made on the perineum space between scrotum and anus).  Or penoscrotal junction. You will also have a small suprapubic incision.
  • The silicone inflatable cuff is placed around the upper end of the corpora cavernosa of the penis under the muscle.
  • The reservoir is placed behind the pubic bone
  • The access port is placed in the scrotum; make sure it is on the side of your dominant hand.
  • The cuff will only be activated 6 weeks after the surgery
  • The wounds are closed with dissolvable sutures and/or skin glue.
  • A local anesthetic is given for pain relief.
  • A urinary catheter is placed for 24hrs.
  • The catheter will be removed early the next morning.
  • Prophylactic antibiotics will be given to prevent infection.

 

Complications

  • Any anesthetic has its risks, and the anesthetist will explain all such risks.
  • Complications: hemorrhaging, requiring blood transfusion <1%.
  • Patients will wake up with a catheter in the urethra and bladder. This will remain in the bladder for 24 hrs.
  • Pelvic pain for 10-14 days may occur, making it difficult to sit.
  • You will be incontinent until the cuff is activated
  • This may be less effective in irradiated patients

NB! Each person is unique and for this reason, symptoms may vary

 

What next?

  • Patients will have a trial of void without catheter the next day. You will be incontinent until the device is activated in 6 weeks
  • Patients will be discharged as soon as they can completely empty the bladder.
  • Patients may initially suffer from urge incontinence, but this will improve within the next 6 weeks.
  • Allow 6 weeks for symptoms to stabilize.
  • Initial period of pelvic pain is expected.

 

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Wes AUS Male Sphincter

Copyright 2019 Dr Jo Schoeman

Burch Colposuspension

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  • Main incontinence surgery for ladies in the previous millennium. Making a resurgence in the post mesh-era.
  • Open retropubic vs robotic assisted procedure.
  • Lower success rates as the Sling procedure, and more invasive.

Indication:

  • Confirmed SUI
  • Hypermobile urethra

Procedure:

  • Robotic assisted procedure
  • Done under a GA
  • Sterile filed with BETADINE
  • 4 Robotic ports and 2 assistant ports placed
  • Abdomen insufflated with CO2
  • Head in Trendelenburg
  • Prophylactic antibiotics
  • An IDC placed
  • The retropubic space opened and the para-urethra vaginal wall is lifted and fixed to the pectineal line with 3 sutures on each side
  • Tension on these sutures to create a kink in the urethra
  • Vagina is inspected to exclude any sutures placed through the wall.
  • Abdomen is inspected for any bowel injuries
  • Drain is placed

Complications:

  • Wound infection
  • Ileus
  • Acute urine retention
  • May require self-catheterization
  • Return to theatre to release the tension

 

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Wes Burch Para-Urethral Repair – Open

Bladder Diverticulectomy – Robotic-assited

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Open excision of bladder diverticulum. Controversial procedure for the excision of a bladder diverticulum where there is bladder calculus and bladder function is compromised/

Why is it done?

  • This procedure is performed when all other treatment options are exhausted with recurrent symptoms.
  • Symptoms include: a weak stream, nightly urination, frequent urination, inability to urinate, sudden cut-off of stream, (LUTS), recurrent bladder infections, recurrent bladder calculi (stones).
  • Medication such as Flomaxtra, Urorec or Minipress etc. should always be given as a first resort.
  • Step-up therapy should have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar and can be used as a first line in these huge prostates.
  • A TURP may have been performed to dis-obstruct a huge prostate.
  • Neurogenic causes of bladder dysfunction should be excluded by means of a Urodynamic study.
  • Patient informed decision is vital.
  • It provides a quicker solution with more marked side-effects and risks.

How is it done?

  • Patients will receive a general anaesthesia, unless contra-indicated.
  • Prophylactic anti-biotics is given.
  • An indwelling catheter is placed, and the bladder is filled with saline.
  • Robotic access with 6 port placements.
  • The retropubic space of Retzuis is entered.
  • The bladder is opened anteriorly in the midline.
  • A Foleys catheter is placed in the diverticulum.
  • The bladder incision is extended to the diverticulum. Diverticulum is excised.
  • Special care is required for diverticula close to the ureters. Placement of ureteric catheters are done to prevent ureteric injury.
  • Bladder is closed in 2 layers over a 3-way irrigation catheter.
  • A drain is left for a couple of days.
  • You may have continuous Antibiotics over the next few days.

What next?

  • You will spend 2-3 nights in hospital.
  • You will have a catheter for 14 days.
  • A drain for 1 -2 days.
  • You will be discharged as soon as you are drain free, temperature free and have opened your bowels.
  • You may initially suffer from urge symptoms caused by the catheter.
  • There may be some blood in your urine. You can remedy this by drinking plenty of fluids until it clears.
  • A ward prescription will be issued on your discharge, for your own collection at any pharmacy.
  • A follow-up appointment will be scheduled for 2 weeks for a cystogram.
  • Should the cystogram confirm to urine leaks, your catheter will be removed.
  • A review appointment is scheduled 6 weeks later.
  • Don’t hesitate to ask Jo if you have any queries.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Side–effects

  • Rarely blood loss requiring blood transfusion.
  • Infection.
  • Prolonged hospital stays.
  • Urine leak requiring prolonged catheterization.
  • NB! Each person is unique and for this reason symptoms vary!

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Wes Bladder Diverticulectomy

Bladder Fistulectomy

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Why is it done?

  • Bladder intestinal fistula is an abnormal communication between bladder and bowel.
  • Causes:
    • Previous surgery
    • Diverticular disease
    • Colonic cancers
    • Radiation
  • This procedure is performed when all other treatment options are exhausted with recurrent symptoms and persistent pneumaturia and fecal uria due to a colonic-vesical fistula
  • Symptoms include:
    • pneumaturia (air in urine),
    • fecal Uria (stool in Urine),
    • recurrent bladder infections.
  • This surgery is usually done with a colo-rectal surgeon and may involve a partial bowel resection, possibly a temporary loop ileo/colostomy (diversion of bowel with an external bag)

 

How is it done?

  • Patients will receive a general anaesthesia,  unless contra-indicated.
  • Prophylactic antibiotics are given.
  • An indwelling catheter is placed, and the bladder is filled with saline.
  • Open procedure or robotic assisted.
  • A lower midline incision is made, or robotic ports are placed
  • The retropubic space of Retzuis is entered
  • The bladder is resected away from the bowel.
  • The affected piece of bowel may be resected with either a temporary diversion of the bowel to a bag or a primary anastomosis depending on the colo-rectal surgeon’s findings
  • The affected part of the bladder may be resected. The bladder is closed in 2 layers over a 3-way irrigation catheter
  • Omentum will be placed between bladder and bowel where at all possible to limit recurrences
  • A drain is left for a couple of days
  • You may have continuous Antibiotics over the next few days.
  • You have a few days stay in ICU or high care facility

 

Complications

Side–effects

  • Rarely blood loss requiring a blood transfusion.
  • Infection/ sepsis
  • Prolonged hospital stays.
  • Urine leak requiring prolonged catheterization.
  • Bowel leak etc.
  • NB! Each person is unique and for this reason symptoms vary!

 

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Wes Bladder Fistulectomy

Copyright 2019 Dr. Jo Schoeman

Cauterization of Penile Condylomata

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Fulguration of penile condyloma, with penile block

Why is it done?

  • One of the non-medical treatment options for condylomas (genital warts)..

How is it done?

  • This procedure is done under local or general anaesthetic.
  • Supine position.
  • The foreskin may be the only affected area and therefore a circumcision is done.
  • Otherwise, the affected area is exposed and cleaned.
  • The affected lesions are cauterized, including the root of the wart.
  • Due to charring, and good hemostasis, no sutures are required.
  • Hemostatic dressings are placed.
  • Specimen is sent to a histopathologist.
  • An indwelling catheter may be inserted if the biopsy area involves the meatus of your urethra.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anesthetic is injected at the base of the penis as a penile block thus giving post-operative pain relief for the next 4-6 hours.

What to expect after the procedure?

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is an uncommon complication.
  • Eschar may loosen with vigorous use of erect penis and could lead to bleeding.
  • An infection of the wound may occur and requires immediate attention.
  • DANGER SIGNS: A wound that swells immediately, fever, and puss. Contact Dr Schoeman or the hospital immediately as this occurs in up to 15–20% of all cases.

What next?

  • Dressings should be kept dry for the initial 72 hours after surgery and soaked off in a bath thereafter.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • The catheter will be removed as soon as you are awake, or if there are concerns, the following morning.
  • Patients should schedule a follow-up appointment with Dr Schoeman 4-6 weeks after the procedure.
  • There will be signs of bruising for at least 10 days.
  • Refrain from using your erect penis for 6 weeks.
  • Sick leave will be granted for a few days.
  • Please direct all further queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL DIRECTLY WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Cauterization of Penile Condylomata

Caverject Intra-Cavernosal Injections

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Intra cavernous injections for erectile dysfunction, demonstrating and teaching self-administration.

Why is it done?

    • A treatment option for erectile dysfunction.
    • Usually when oral techniques have failed ie Viagra, Levitra and Cialis.
    • Or where the patient wishes to skip the oral phase for something more effective.
    • ED can occur from the age of 40.
    • Risk factors:
      • Older.
      • Overweight.
      • Diabetic,
      • Hypertensive,
      • Cardiac issues.
    • An alternative is a Vacuum Pump Device.
    • Worse cases may require a penile prosthesis.

How is it done?

  • This procedure is done at home.
  • You will be given a ‘hands-on’ instruction.
  • An effective dose will be determined.
  • A pre-made-up syringe with a determined dose is made ready prior to the injection.
  • The penis is pulled away from your body with the non-dominant hand.
  • The injection site is cleaned with an alcohol wipe.
  • Caverject is injected at the base of the corpora cavernosa at an angle of 45 degrees with the shaft. See hand-out.
  • Allow 5 minutes for an erection to be obtained.
  • The erection lasts approximately 20 minutes.

What next?

  • Once the correct the dose has been established.
  • You feel comfortable using the injections.
  • A repeat script will be issued.
  • Your GP will continue with the medication.
  • Dr Michael Gillman, Men’s Health Physician is a fantastic alternative.

Complications?

  • Dose too high for the individual.
  • Prolonged painful erection.
  • If erection lasts longer than 4-6 hours, it becomes an emergency, and you are required to visit your local Emergency Department.
  • This will be drained with a syringe.
  • A surgical bypass my be done with possible erectile dysfunction as complication.

 

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Wes Caverject Intra-Cavernosal Injections

Circumcision

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Surgical removal of foreskin with penile block for post-operative pain relief

Why is it done?

  • Religious reasons.
  • Health reasons.
  • Personal reasons.
  • Medical reasons:
    • Narrowing of foreskin -phimosis.
    • Foreskin stuck behind head of penis – paraphimosis.
    • Severe infection of the foreskin and head of penis -balanoposthitis.
    • Cancer of the foreskin – SCC.
    • Trauma.

How is it done?

  • This is done under general anesthetic or penile block.
  • A cut is made at the level of the glans penis, circumferentially around the penis, through the skin.
  • The foreskin is then retracted, and a second incision is made circumferentially around the base of the glans penis.
  • The skin between the 2 incisions is then surgically removed.
  • Dissolvable sutures are then placed between the 2 remaining edges.
  • A Jelonet and Bactroban dressing is then placed tightly around the penis, still allowing urine to pass through the end.
  • A local anesthetic is injected into the base of the penis thus giving post-operative pain relief for the next 4-6 hours.

Unfortunately, no infants younger than 12 months can be operated on in any of the private hospitals ONLY at Children’s Hospital.

 

What to expect after the procedure

  • Any anesthetic has its risks, and the anesthetist will explain such risks.
  • Bleeding is a common complication.
  • With any subsequent erections post operatively, the sutures may pull out causing an opening of the wound with subsequent bleeding.
  • An infection of the wound can occur if the dressings are left on too long.
  • If the dressing has been applied too tightly, or if there is any discomfort, please remove the dressing immediately. If some hemorrhaging re-occurs, REDO the dressing!
  • In very young patients, the foreskin may still be attached to the head of the penis, thus leaving a raw and red glans penis after surgery. Keep the affected area clean and apply ointment as prescribed.
  • NB! Each person is unique and for this reason symptoms may vary!

What next?

  • The dressing should be removed in a bath 48 hours after the procedure.
  • The dressing should be soaked until it comes off with ease.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic the bleeding will stop.
  • As soon as the dressing has been removed, Bactroban (or similar) ointment should be applied on the wound twice a day.
  • This may not be required if the foreskin was not adhered to the glans penis.
  • On discharge a prescription may be issued for the patient to collect.
  • A follow-up appointment should be scheduled to see Dr Schoeman within 2 weeks.
  • Please don’t hesitate to direct all pre-operative queries to Dr Schoeman’s rooms.
  • PLEASE CONTACT THE HOSPITAL WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

 

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Wes Circumcision

Colpocleisis

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Permanent closure of the vagina in the elderly who suffer from pelvic organ prolapse and who aren’t and never will be sexually active.

Why is it done?

  • The aim of surgery is to relieve the symptoms of vaginal bulge and / or laxity.
  • Improve bladder function.
  • Used where women are elderly and have no desire to be sexually active again.
  • Vaginal prolapse is a common condition causing symptoms such as a sensation of dragging or fullness in the vagina, and difficulty emptying the bowel or bladder and back ache.
  • About 1 in 10 women need surgery for prolapse of the uterus or vagina.

 

How is it done?

  • This procedure is done under a spinal / general anesthetic, as decided by the anesthetist.
  • A large portion of the vaginal mucosa is removed on the bladder and rectal side, from the vault to the introitus.
  • The edges of the front wall are sewn to the back wall, therefore occluding the whole urethra.
  • The side of the vagina is not occluded to allow drainage of fluids.
  • A catheter is placed into the bladder at the end of surgery.
  • The catheter is removed the next day

Complications?

There are also general risks associated with surgery:

  • Wound infection.
  • Urinary tract infection.
  • NO MORE VAGINAL INTERCOURSE.
  • Rarely – Bleeding requiring a blood transfusion and Deep vein thrombosis (clots) in the legs, Chest infection.

 

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Wes Colpocleisis