Flexible Cystoscopy with Urethral Dilatation

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A diagnostic day procedure under local anesthetic, where a flexible cystoscope is placed in the bladder via the urethra

Why is it done?

To investigate:

  • Hematuria (blood in the urine)
  • Recurrent urinary tract infections
  • Space occupying lesions in the kidneys, ureters, bladder and urethra
  • Abnormal cells suggestive of urothelial carcinoma, on urine cytology
  • Possible urethral stricture

How is it done?

  • A cystoscopy is performed by placing a camera in the urethra with the help of a   lubricant jelly and saline
  • If a narrowing is found, a guidewire will be placed and urethra dilated
  • The bladder is then distended using the fluid
  • The inside of the bladder is viewed for pathology.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • Urine would have been sent for cytology prior to the procedure, to rule out the existence of cancer.
  • Antibiotics may be given to prevent infection

 

What to expect after the procedure?

  • An indwelling catheter will be placed for 3 days
  • Bladder infection ranging from a burning sensation to, fever, to puss (rare)
  • Blood stained urine
  • Lower abdominal discomfort which will persist for a few days
  • NB! Each person is unique and for this reason symptoms vary.

 

What next?

  • This all depends on what is found during the procedure. All the options will be discussed in detail.
  • With the removal of stents, the ureters have been dilated and will regain function (peristalsis) as soon as the stents are out. Thus slight pain can be expected in the first 24-48hrs.
  • Urethral strictures with an IDC will require a trial of void 3 days later
  • There may be some blood in the urine. This can be remedied by drinking plenty of   fluids until it clears.

Urethral Dilatation

  • If you have a urethral stricture, a guidewire will be placed and the narrowing dilated
  • There may be some hemorrhaging and you may need a catheter for 3 days
  • This will be removed at the hospital in 3 days or alternatively arrange for your GP to remove.
  • I will review in 6 –8 weeks

 

Wes Flexible Cystoscopy and Urethral Dilatation IDC

Exision of Urethral Caruncle Prolapsed Urethral Mucosa

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Why is it done?

  • Prolapsed urethral mucosa causing pain and bleeding
  • Occurs from childhood to old age

 

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.
  • This procedure is done with cystoscopy.
  • Your bladder and urethra are inspected with cystoscopy
  • The prolapsed mucosa will then be excised at the external meatus.
  • Dissolvable sutures will be placed for hemostasis
  • A catheter will be placed until you are awake for some compression.
  • Prophylactic antibiotics will be given to prevent infection.

Complications

Side–effects

  • Any anesthetic has its risks, and the anesthetist will explain all such risks.
  • Complications: hemorrhaging, and urine retention
  • Patients’ catheter will be removed the next morning.
  • If you cannot urinate after 2-3 attempts, a catheter may be inserted to empty your bladder.
  • You may be required to keep the catheter for a few days if you have persistent bleeding or urinary retention.
  • NB! Each person is unique and for this reason, symptoms may vary!

 

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Wes Urethral Caruncle – Prolapse Excision

Copyright 2019 Dr Jo Schoeman

Excision of Urethral Diverticulum – Female

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Why is it done?

  • Usually, an infected peri-urethral gland blocks and becomes infected
  • Causes a bulge which interferes with urination
  • Can mimic a vaginal prolapse
  • Usually, an MRI of the urethra delineates this beautifully.

How is it done?

  • This procedure is done under a general anaesthetic, as decided by the anaesthetist.
  • The legs will be elevated into the lithotomy position.
  • This procedure is done both cystoscopically and with an incision over the urethra.
  • The urethra is evaluated. endoscopically and a catheter placed
  • The vaginal mucosa will then be incised over the urethrocele.
  • A Fogarty catheter will be placed inside the diverticulum and the balloon inflated to delineate the borders of the diverticulum.
  • The diverticulum will be dissected out with injuring adjacent structures.
  • The neck will be tied off at the level of the adjoining urethra.
  • Dissolvable vaginal closure sutures will be placed for hemostasis
  • A cystoscopy confirms no injury to the urethra.
  • A catheter will be placed until you are awake for some compression.
  • Prophylactic antibiotics will be given to prevent infection.

Complications

Side–effects

  • Any anaesthetic has its risks, and the anaesthetist will explain all such risks.
  • Complications: hemorrhaging, and urine retention
  • Patients’ catheter will be removed the next morning
  • If you cannot urinate after 2-3 attempts, a catheter may be inserted to empty your bladder.
  • You may suffer temporary incontinence
  • You may suffer permanent incontinence as advised by Jo, depending on the extent of the diverticulum. Make sure you have discussed this with Jo.

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

 

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Wes Urethral Diverticulum Excision Female

Copyright 2019 Dr Jo Schoeman

Excision of Urethral Diverticulum – Male

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Why is it done?

  • Usually, an infected peri-urethral gland blocks and becomes infected, UTI symptoms
  • Causes a bulge which interferes with urination
  • Can mimic prostate enlargement LUTS
  • Dribbling after urination
  • Usually, a retrograde urethragram the urethra delineates this beautifully.

How is it done?

  • This procedure is done under a general anesthetic, as decided by the anesthetist.
  • The legs will be elevated into the lithotomy position.
  • This procedure is done both cystoscopically and with an incision over the urethra (Bulbous Spongiosum or Perineum)
  • The urethra is evaluated endoscopically and a catheter placed
  • If it is a small urethral diverticulum, it can be opened into the urethra endoscopically
  • If it has a narrow neck, then an external approach:
  • The penis or perineum will then be incised over the urethrocele.
  • A Fogarty catheter will be placed inside the diverticulum and the balloon inflated to delineate the borders of the diverticulum.
  • The diverticulum will be dissected out with injuring adjacent structures.
  • The neck will be tied off at the level of the adjoining urethra.
  • Dissolvable closure sutures will be placed for hemostasis
  • A cystoscopy confirms no injury to the urethra.
  • A catheter will be placed until you are awake for some compression.
  • Prophylactic antibiotics will be given to prevent infection.

Complications

Side–effects

  • Any anesthetic has its risks, and the anesthetist will explain all such risks.
  • Complications: hemorrhaging, and urine retention
  • Catheter will be left in for 10 days
  • Trial without catheter in day surgery
  • If you cannot urinate after 2-3 attempts, a catheter may be inserted to empty your bladder.
  • You may suffer temporary incontinence
  • You may suffer permanent incontinence as advised by Jo, depending on the location of the diverticulum. Make sure you have discussed this with Jo before the surgery.
  • NB! Each person is unique and for this reason, symptoms may vary!

 

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Wes Urethral Diverticulum Excision Male

Copyright 2019 Dr Jo Schoeman

Flexible Cystoscopy & Urethral Dilation

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A day procedure under local anaesthetic, where a flexible cystoscope is placed in the bladder via the urethra. Narrowing in the urethra is dilated.

Why is it done?

A cystoscopy is used to investigate:

  • Hematuria (blood in the urine)
  • Recurrent urinary tract infections
  • Dilatation of Urethral narrowing/ stricture
  • Abnormal cells suggestive of urothelial carcinoma, on urine cytology

Ideally a retrograde urethragram is used to diagnose this radiologically

 

Risk factors for strictures:

  • Straddle injuries
  • Catheterization or urethral instrumentation
  • Infections
  • Bypass cardiac surgery with long ischemic time

 

How is it done?

  • A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant jelly and saline
  • Usually, you can’t move past the narrowing
  • Then:

Urethral Dilatation

  • If you have a urethral stricture, a guidewire will be placed and the narrowing dilated
  • There may be some hemorrhaging and you may need a catheter for 3 days
  • This will be removed at the hospital in 3 days or alternatively arrange for your GP to remove.
  • I will review in 6 –8 weeks

Antibiotics may be given to prevent infection

Complications

What to expect after the procedure?

  • You may be sent home with an indwelling catheter for 3 days
  • Pain on initial passing of urine after it is removed
  • Bladder infection ranging from a burning sensation to, fever, to puss (rare)
  • Bloodstained urine
  • Lower abdominal discomfort which will persist for a few days
  • NB! Each person is unique and for this reason, symptoms vary.

 

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Wes Flexible Cystoscopy and Urethral Dilatation IDC

Copyright 2019 Dr. Jo Schoeman

Indwelling Urethral Catheter – IDC

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Non-invasive placement of a silicone tube which is secured inside the bladder and attached to a drainage bag on the outside, in order to drain an obstructed bladder (urinary retention)

Why is it done?

  • This can be placed as an emergency for patients in acute urinary retention
    • Prostate obstruction
    • Urethral strictures
    • Blood clot obstruction caused by bleeding
    • Hematuria (bleeding)
    • Severe urinary tract infections
  • Commonly placed intra-operatively for long, non-urological surgical procedures to enable urine drainage and monitoring urine output.
  • Commonly placed at the end of a Urological procedure to enable urine drainage and to enable hemostasis (stopping bleeding)

 

How is it done?

  • This is done as a sterile procedure; therefore, the genital area will be cleaned with a non-abrasive disinfectant.
  • A sterile catheter will be used
  • A local anesthetic gel is placed in the urethra a few minutes prior to the placement of the catheter. This may initially sting for a few seconds until it numbs the mucosa.
  • An appropriate size catheter (14-18Fr) will be inserted
  • Urine should be aspirated with a syringe to confirm the correct position in the bladder.
  • An anchoring balloon will be inflated with 10cc of sterile water.
  • A drainage urine bag will be attached
  • The catheter will be secured to your leg. (check that this is always secured)

 

Complications

  • Urethra with resulting discomfort.
  • In the presence of urethral stricture, it may be impossible to pass the catheter, and a flexible cystoscopy with dilatation of the stricture may be required prior to placement.
  • If you had a large over-stretched bladder (urine retention) you may experience bleeding as the bladder empties, caused by the mucosal tears that have occurred.
  • Catheters that have been placed long term, may cause irritation and possibly attract infection. Permanent catheters are usually changed every 6-8 weeks.

 

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Wes Catheters Indwelling Catheter

Copyright 2019 Dr Jo Schoeman

Meatotomy

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Opening of a meatal stenosis (pinhole narrowing).

Why is it done?

  • To treat a narrowing in the tip of the urethra which has formed due to previous damage/injury to the urethra.
  • Where intermittent dilatation is not desired, as discussed with the patient.
  • Causes:
    • Circumcision in early childhood where the foreskin is still attached to the glans, usually neonatal circumcision
    • After bypass surgery where a drop in blood pressure has caused an area of low blood supply to the urethra.
    • trauma to the urethra (pelvic fractures/ urethral instrumentation).
    • and sexually transmitted diseases.
  • The procedure involves surgical refashioning of your meatus.

How is it done?

  • Usually done in male patients
  • Selected Female patients can be considered.
  • Patients will receive a general anesthetic.
  • Your meatus will be refashioned, in order to leave it patent without a narrowing.
  • An indwelling catheter is left till post-operative period.
  • Prophylactic antibiotics may be given to prevent infection.

What to expect after the procedure?

  • It may be slightly uncomfortable.
  • A catheter will be inserted in the urethra and bladder. This will remain in until you are awake.
  • Catheters can be very irritating and cause some discomfort.
  • Blood stained urine will be present.
  • Painful urination may persist for a few days.
  • NB! Each person is unique and for this reason symptoms may vary!

What next?

  • Patients will be sent home after a successful attempt at voiding.
  • You may experience some discomfort with every void, that will become less over the next few voids.
  • There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
  • On discharge a prescription may be issued for patients to collect.
  • Patients should schedule a follow-up appointment with Dr Schoeman within 6-8 weeks.
  • Should patients have any problems with urination, please contact the rooms for an earlier appointment.
  • Please don’t hesitate to direct any further 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 Meatotomy

One Stage Urethraplasty

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Primary excision and anastomosis of a short segment urethral stricture.

Why is it done?

  • To treat urethral strictures (narrowing) caused by trauma, infection, malignancy, etc. Shorter strictures less than 2 cm in length.

How is it done?

  • This procedure is done under general anesthetic.
  • Legs are placed in a lithotomy position.
  • A single incision is made on the midline raphe on the perineum (area between scrotum and anus).
  • The corpus spongiosum identified and exposed
  • Stricture located using urethral sounds
  • The stricture is excised with a spatulated anastomosis over an indwelling catheter
  • A long-term catheter will be inserted for 10 days.
  • A dressing is then applied, which should be removed after 72 hours.
  • A local anaesthetic is injected into the wound, thus giving post-operative pain relief for the next 4-6 hours.
  • A drain may also be left for 24-48 hours to prevent the collection of serous fluids.

What to expect after the procedure?

  • Any anaesthetic has its risks and the anaesthetist will explain all such risks.
  • You will be sent home with an Indwelling catheter for 7-10 days
  • Bleeding is a common complication.
  • A haematoma (blood collection under the skin) may form and needs to be reviewed by Dr Schoeman as soon as possible. Bruising is normal.
  • An infection of the wound may occur and requires immediate attention.
  • Erectile dysfunction (15%) may occur.
  • Re-stricturing (20-30%) may occur.
  • Owing to the area of the surgery the wound should be kept clean and dry.
  • DANGER SIGNS: A scrotum that swells immediately to the size of a football, fever, or puss. Please contact Dr Schoeman or the hospital immediately as this may occur in up to 15 % of all cases.

What next?

  • The dressing should be kept dry for the initial 72 hours after surgery and then soaked in a bath until it comes off easily.
  • The dressing may sometimes adhere to the wound causing slight bleeding on removal. Don’t panic, the bleeding will stop.
  • Arrangements will be made for the removal of the catheter after 7-10 days.
  • A urinating Urethragram will be arranged with radiology within 6 weeks to determine the final result of the surgery.
  • There will be signs of bruising for at least 10 days.
  • The suture-line will be hard and indurated for at least 8-10 weeks.
  • PLEASE CONTACT THE HOSPITAL DIRECT WITH ANY POST-OPERATIVE CONCERNS AND RETURN TO THE HOSPITAL IMMEDIATELY SHOULD THERE BE ANY SIGNS OF SEPSIS.

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Wes Urethraplasty One-Stage

Optic Urethrotomy

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Why is it done?

  • To treat a narrowing in the urethra which has formed due to previous damage/injury to the urethra.
  • Causes:
    • After bypass surgery where a drop in blood pressure has caused an area of low blood supply to the urethra;
    • Trauma to the urethra (pelvic fractures/ urethral instrumentation);
    • Sexually transmitted diseases.
  • The procedure entails cutting the stricture with a cold knife.

How is it done?

  • A urethroscopy is performed by placing a camera in the urethra, with the help of a lubricant jelly and an irrigate fluid, to identify the stricture.
  • A cold knife is then used to cut the stricture open.
  • The inside of the bladder is viewed for pathology.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • Prophylactic antibiotics may be given to prevent infection.
  • Indwelling catheter placed.

 

Complications

Side–effects

  • Patients will spend the night in the hospital.
  • Patients will be sent home with a catheter for 3 days after receiving thorough catheter care Instructions.
  • Arrangements will be made to remove the catheter on day 3.
  • There may be some blood in the urine. This can be remedied by drinking plenty of fluids until it clears.
  • Review at 6 weeks.
  • There is a >50% risk of recurrence and may need further treatment
    • Re-dilatation
    • Self-dilatation
    • Urethraplasty

 

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Wes Optic Urethrotomy

Copyright 2019 Dr Jo Schoeman

Perineostomy – Perineal Urostomy

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Opening of the posterior Urethra on the Perineum

Why is it done?

  • Seldom done
  • This procedure is performed when concentric extensive scarring in the urethra (strictures) causes Urinary Retention
  • A long history of strictures.
  • This is alternative to an invasive procedure where long periods of anesthetic are contra-indicated and extensive grafts may be required
  • Usually for chronically sick patients who cannot undergo surgery yet are active enough not to want a permanent catheter.
  • Patients who don’t want to / cannot do intermittent self-dilatation of these strictures
  • Don’t want a permanent Indwelling Catheter penile/Urethral cripple

 

How is it done?

  • Patients will receive a General Anesthetic.
  • Flexible cystoscopy is done through your urethra or suprapubic catheter site to find normal urethra (usually posterior urethra)
  • A urethral sound is placed/ catheter
  • A perineal incision is made.
  • The urethra is divided proximal (above) the stricture
  • The opening of the urethra is brought out and attached to the skin on the perineum (the area between scrotum and anus)
  • A catheter is placed
  • Prophylactic antibiotics will be given to prevent any infections.

 

Complications

  • Persistent pain in penile shaft
  • Pain in Perineum when seated
  • Scarring of the opening requiring dilatation
  • Possible infection
  • NB! Each person is unique and for this reason, symptoms vary!

 

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Wes Perineostomy

Copyright 2019 Dr Jo Schoeman