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TENSION-FREE VAGINAL TAPE SUBURETHRAL SLING

PREOPERATIVE DIAGNOSES:
1. Genuine stress incontinence.
2. Urethral hypermobility.   

POSTOPERATIVE DIAGNOSES:
1. Genuine stress incontinence.
2. Urethral hypermobility.   

OPERATION: Tension-free vaginal tape suburethral sling. 

ANESTHESIA: Local with IV sedation.

ESTIMATED BLOOD LOSS: 25 ml.

COMPLICATIONS: None.

PROCEDURE: The patient was brought to the operating room and placed in a low lithotomy position in Allen stirrups and prepped and draped in the usual fashion. She was given intravenous sedation and the bladder was decompressed.  We then used 90 ml of 1/8% Marcaine to infiltrate suprapubically and transvaginally.

I made a 1 cm longitudinal skin incision under the midurethra and dissected 3 cm underneath the vaginal mucosa bilaterally to create tunnels for the TVT needles. I then diverted the urethra off to the right with a rigid guidewire while introducing the TVT needle through the incision into the left tunnel and through the urogenital diaphragm, space of Retzius, rectus fascia, and out through a stab incision 2 cm left of midline. The urethra was diverted off to the left and needle passage repeated on the right side.

Urethrocystoscopy was done with a 70-degree lens to verify no perforation or trauma to the urothelium with the bladder full at 500 ml and then the needles were pulled out and cut off. I now did stress testing at this volume while performing Credé maneuver and brought the tape up just to the point where leakage slowed down significantly but was still slightly present and there was still a 0.25 to 0.50 cm of space between the tape and the posterior urethra. At this level of tension, I held countertraction transvaginally while peeling the plastic sheath off the tape suprapubically. The tape was cut beneath skin level. Mastisol and Steri-Strips were applied. The vaginal incision was closed with a running interlocking suture of 2-0 Vicryl. Hemostasis was excellent. All counts were reported to me as correct at the end of the procedure. She was brought to recovery in stable condition. She will be discharged once she is ambulating, tolerating liquids, and shows us her voiding pattern. She has an appointment in the office in a couple of weeks and knows to call or come in sooner if she has any questions or problems.

COLPORRHAPHY/VAGINAL VAULT SUSPENSION

PREOPERATIVE DIAGNOSES:
1. Recurrent genuine stress incontinence.
2. Urethral hypermobility.
3. Third-degree enterocele.
4. Third-degree vaginal vault prolapse.

POSTOPERATIVE DIAGNOSES:
1. Genuine stress incontinence.
2. Urethral hypermobility.
3. Third-degree vaginal vault prolapse.
4. No evidence for enterocele.
5. Second-degree cystocele.
6. Second-degree rectocele.

OPERATION:
1. Sacrospinous vaginal vault suspension.
2. Anterior colporrhaphy.
3. Tension-free vaginal tapes suburethral sling.
4. Posterior colporrhaphy with perineorrhaphy.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 300 ml.

COMPLICATIONS: None.

PROCEDURE: The patient was brought to the operating room and placed in a dorsal supine position and given general anesthesia. She was then re-placed in a lithotomy position and Gold post stirrups and prepped and draped in the usual fashion. I then placed a marking stitch for the vaginal apex. I then infiltrated underneath the vaginal mucosa with a dilute 1:5 Pitressin solution. I made an inverted T-incision just above the marking stitch and undermined and transected the anterior vaginal wall in the midline up to the level of the bladder neck. Although, it did not appear so in the office, this entire vaginal anterior wall came out very easily. I then undermined the underlying endopelvic connective tissue away from the overlying vaginal mucosa, back to the pubic rami on either side, and posteriorly up underneath the cystocele to get to the vaginal vault. Diligent search for enterocele found no evidence for it. I dissected back to the right ischial spine and sacrospinous ligament. I isolated the ligament with Breisky retractors and placed 2 sutures of 2-0 Gore-Tex through the ligament, a first through the middle-third, the second through the medial-third, using the Miya hook. The top portion of each Gore-Tex suture was fixed in a figure-of-eight fashion to the corresponding undersurface of vaginal mucosa, and what would be the new vaginal apex, and tied to itself to form a pulley stitch for later on in the case.

I then reduced the central cystocele and brought the connective tissue from the sides together, across the midline, with 3 mattress sutures of 0 PDS. Urethral cystoscopy was performed with a 70-degree lens to verify no perforation or trauma to the urothelium and that blue dye was coming out of both ureteral orifices without difficulty.

The bladder was then decompressed. I then trimmed excess fascial mucosa and closed the bottom half of the vaginal incision with a running interlocking suture of 2-0 Vicryl. I then tied down the sacrospinous tissues to directly appose the undersurface of vaginal mucosa to the ligament and tied these down and then cut those tissues. Before I closed the rest of the vaginal incision, I went ahead with the sling procedure.

I diverted the urethra off to the right with a rigid guidewire while introducing the TVT needle through the incision, underneath the left pubic ramus, and up through the urogenital diaphragms, space of Retzius, rectus fascia, and out through the stab incision, 2 cm left of midline. The urethra was diverted off to the left, and needle passage repeated on the right side. I really did not feel that much scar tissue going through the retropubic space. A urethral cystoscopy was performed with 70-degree lens after each needle passed to verify no perforation or trauma to the urothelium with the bladder full, and then the needles were pulled out and cut off. At a volume of 400 ml now, I did stress testing while performing Crede maneuver and pulled it out just to the point where leakage started to slow down, but it was still somewhat present, but there was still a 0.25 cm of space between the tape and the posterior urethra. At this level of tension, I held countertraction transvaginally while peeling the plastic sheath off the tapes suprapubically. The tape was cut beneath skin level. Mastisol and Steri-Strips were applied. I finished closing the rest of the anterior vaginal incision with the same running interlocking suture of 2-0 Vicryl now. Hemostasis was good and all counts were reported to me as correct at the end of this part of the procedure.

I turned my attention to the posterior compartment, where I had originally been intending to do a simple perineorrhaphy. But now, I was clear that she had a good second-degree rectocele. I infiltrated underneath the vaginal mucosa with a dilute Pitressin solution. I excised a small portion of perineum and vaginal mucosa sharply, and undermined the mucosa back to the pubic rami on either side and anteriorly up above the rectocele. The central rectocele was reduced and I brought the connective tissue from the sides together with multiple mattress sutures of 0 PDS. The perineal body was rebuilt with 0 PDS. The vaginal mucosa was closed with a running interlocking suture of 2-0 Vicryl, and the perineum with a subcuticular suture of the same. Foley was in the bladder. Packed the vagina. Rectal exam was negative. She tolerated it well and was brought to recovery in stable condition. All counts were reported to me as correct at the end of the procedure.

 

 

RADICAL PROSTATECTOMY

PREOPERATIVE DIAGNOSIS: Prostate cancer.   

POSTOPERATIVE DIAGNOSIS: Prostate cancer. 

OPERATION: Robotic radical prostatectomy. 

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Estimated blood loss was 450 ml.

INTRAVENOUS FLUIDS: The patient received 200 ml of crystalloid.

INDICATIONS: This is a 60-year-old male noted to have elevated PSA. Biopsy was notable for adenocarcinoma, a Gleason sum of 6. Postbiopsy course was notable for urosepsis. The patient was treated with intravenous antibiotics. The patient was counseled in regard to his prostate cancer. Options of expectant management, radiation therapy via either seed implantation or external beam, cryotherapy, and radical prostatectomy either open or robotic were discussed at length.

Risks and benefits of each of which were outlined in detail. The patient was desirous of robotic radical prostatectomy. Risks and benefits of the procedure include but are not limited to bleeding, infection, injury to adjacent organs, DVT, pulmonary embolism, CVA, myocardial infarction, death, rectal injury, incontinence, impotence were discussed at length with the patient who was desirous of proceeding.

FINDINGS AT PROCEDURE: Inflamed prostate, clinically confined.

PROCEDURE: The patient was taken electively to the operating room after undergoing preoperative cardiology clearance. He was positioned on the table in the supine position. Preoperatively he received 1 g of Ancef IV. After general endotracheal anesthetic as well as placement of orogastric tube, the patient was positioned on the table with his legs in stirrups, dropped as steep off the table as possible, with all pressure points padded. Bean bag deflated, taped securely to the table, and placed in a steep Trendelenburg. The patient’s abdomen and genitalia were then prepped with Betadine and draped as a sterile field. Foley catheter was placed and balloon was inflated with 15 ml of saline.

A 1-cm incision was then made just lateral to the umbilicus on the left-hand side and the peritoneal cavity was entered. A 12-mm laparoscopic port was placed. Laparoscopy was performed. The sigmoid colon was noted to be somewhat adherent to the pelvic sidewall. No other adhesions were noted.

The two 8-mm robotic ports were now placed approximately 16 cm from the symphysis pubis and approximately 9 cm from the midline, 1 fingerbreadth below the umbilicus. This was done under direct vision. A 12-mm port was then placed on the right side, superior to the iliac crest and above the robotic port. A 5-mm port was also placed superior and to the right of midline from the periumbilical port. Lastly, a 5-mm port was placed on the left-hand side above the iliac crest. All ports were placed under direct vision utilizing step technique with great care to avoid injury to any organs.

The robot was now brought into position and docked. It should be noted that a rectal bougie had been placed beforehand.

Utilizing electrocautery, the sigmoid colon which was adherent to the pelvic sidewall was now meticulously mobilized and any adhesions were lysed.

We now turned our attention to just above the bladder, and the midline attachments were taken down and the bladder was now dropped and the retropubic space was entered. Meticulous dissection was now done to mobilize the bladder laterally to the vas deferens bilaterally. Defatting was done over the bladder. Superficial dorsal vein was cauterized and transected. The endopelvic fascia was identified. Utilizing Potts scissors the endopelvic fascia was opened bilaterally up and down fashion and mobilization of the prostate was done meticulously. The puboprostatic ligaments were both taken down with electrocautery.

We turned our attention to the dorsal venous complex. Utilizing a 0 Vicryl, the dorsal venous complex was ligated times 2. Backbleeding was controlled to the prostate with a 0 Vicryl. Backbleeding was controlled to the bladder with a 0 Vicryl.

We now turned our attention to separation of the bladder from the prostate anteriorly. This was done with electrocautery and the bladder was separated and the bladder neck was identified. The Foley catheter was now visualized and was pulled into the field. The posterior bladder neck was now visualized and was transected with electrocautery. We now proceeded posteriorly with electrocautery to further separate the prostate from the bladder neck. Having performed this, the ampulla to the vas deferens as well as seminal vesicles now came into the field. It should be noted previously, that when taking down the endopelvic fascia, the endopelvic fascia was very thickened and woody and indurated likely secondary to previous inflammation, hence it was very sticky and this was a prolonged dissection, much longer than the usual to take down the endopelvic fascia, perhaps double the time.

We now turned our attention to the ampulla of the vas deferens as well as seminal vesicles. Once again, these were extremely inflamed and a great amount of stickiness was noted. We were able to dissect up the ampulla to vas deferens; however, they were very sticky and adherent. This was a very difficult dissection and the seminal vesicles eventually after a prolonged time, was to be dissected free. The rectal fat was now identified and utilizing endoscopic Potts scissors, the seminal vesicles and ampulla to the vas deferens were able to be elevated up off the rectum and dissection was carried forward to the apex of the prostate.

We now returned to the prostatic pedicles, which were isolated with a Maryland dissector and clipped with locking Weck clips and transected. This was a much longer than normal prolonged dissection.

We now turned our attention to the left side, and once again prostate was able to be mobilized. The neurovascular bundle was able to be maneuvered off of the prostate and the veil of Aphrodite was able to be created. The prostate was now fully mobilized. The dorsal venous complex was now dissected free and transected with electrocautery. The urethra was identified. The apex was meticulously dissected and the anterior followed by posterior ureter was transected. The rectal urethralis was identified. It was very thick and secondary to inflammation prolonged meticulous dissection was done and rectal urethralis was transected. Prostate had not been removed in its entirety and was placed in a lap sac.

We now turned our attention to the anastomosis which was performed with a 3-0 PDS utilizing both dyed and undyed suture in the standard running fashion. Lapra-Ty  was placed at the 50% mark on the anastomosis times 2. When we completed the anastomosis, a Lapra-Ty was placed and the catheter which had been placed was irrigated and no leak was noted. Hemostasis was appropriate throughout. A Blake drain was now advanced to the 12-mm port and out through the 5-mm port site and sewn in position. The previously placed lap sac was now brought out through the 12-mm midline port and the 12-mm lateral port was closed utilizing Carter-Thompson technique. All trocars were removed. The midline port was made approximately 1 cm larger to allow for removal of the specimen. The midline port was closed with #1 Vicryl interrupted fashion. Carter-Thompson technique had been used to close the 12-mm lateral port with a #1 Vicryl. The other ports were not closed. Skin was closed throughout.

Instrument, sponge, and needle counts were reported as correct. Estimated blood loss was 450 ml. The patient received 200 ml of crystalloid.

It should be noted that this procedure was prolonged by at least 50% of the time secondary to severe periprostatic inflammation from the patient’s previous severe urosepsis episode which resulted in likely secondary prostatitis. Consequent of this, the procedure was much more difficult than the standard laparoscopic robotic prostatectomy. Length of time for the procedure was lengthened by approximately 100%.

Renal Transplant

PREOPERATIVE DIAGNOSIS: Renal failure. 

POSTOPERATIVE DIAGNOSIS: Renal failure. 

OPERATION: Cadaveric renal transplant. 

ANESTHESIA: General endotracheal. 

INTRAOPERATIVE FINDINGS:  Positive stent placement with postop urine output.

ESTIMATED BLOOD LOSS:  300 ml.

INTRAVENOUS FLUIDS: 6 L IV fluids.

DRAINS:  JP drain next to the transplant kidney. 

COMPLICATIONS: None.

CONDITION:  Fair. 

INDICATIONS: The patient is a 56-year-old Caucasian female with a history of polycystic kidney disease.  She has been on hemodialysis.  The plan was to transplant a kidney to provide renal function.

PROCEDURE: The patient was brought to the operating room and laid supine on the table.  General endotracheal anesthesia was induced.  The abdomen and perineum were sterilely prepped and draped in the usual fashion. A sterile Foley catheter was placed into the bladder and the bladder itself had a small amount of urine which was sent off for cultures.  The blader itself was irrigated with antibiotic solution and then clamped with a Kelly clamp.  At this time, the kidney was being dissected with the bench work on a separate table in the operating room.  The patient was sterilely prepped and draped in the usual fashion.

A right lower quadrant hockey-stick-type incision was made with a scalpel and electrocautery was used to dissect down through the subcutaneous tissues, down through Scarpa’s fascia, and down through the external and internal oblique, as well as the transversalis muscles.  The external and internal obliques were opened using cautery all the way down to the midline.  Once these tissues were divided, hemostasis was controlled with electrocautery.  The peritoneum was retracted medially and cautery was used to dissect further down to the retroperitoneum.  There were 2 defects made in the peritoneum and these were closed with figure-of-eight 4-0 chromic suture.  The peritoneum was very thin but eventually the retroperitoneum was fully exposed.  There was a tortuous right external iliac artery and the right iliac vein appeared normal.  At this time a Bookwalter retractor was put into place.  The inferior epigastric arteries and veins were identified and tied doubly distally and once proximally and then cut.  The round ligament was identified and cut and tied with 2-0 silk suture as well.  At this time the iliac vessels were identified.  The overlying lymphatics were cut and tied with 3-0 silk suture and some of the lymphatics were then clipped with hemoclips as well.  Vessel loops were placed around the artery for good retraction and the artery was cleaned off further with sharp dissection.  The right external iliac vein was identified and the lymphatics were ligated with clips and ties as well and vessel loops were placed around the vein.  At this time systemic heparinization was begun by anesthesia.  The kidney was brought onto the field and the venous vein and artery were further dissected to fit for the anastomosis. 

At this time clamps were placed proximally and distally on the external right iliac vein and a venotomy was made with a scalpel and Pott scissors.  The vein was irrigated with heparin saline solution and at this point the venous anastomosis was created using a 6-0 Prolene suture.  At this time clamps were placed on the vein itself of the transplant kidney and the iliac vein clamps were removed.  Next, clamps were placed proximally and distally on the right external iliac artery and an arteriotomy was made with a scalpel and Pott scissors and the artery was flushed with heparin saline solution.  The anastomosis was created with a running 6-0 Prolene suture.  At this time the clamps were removed, there was a bleeding point on the vein which was controlled with a figure-of-eight 6-0 Vicryl suture and a bleeding point on the artery as well at the anastomosis and this was controlled with a 6-0 figure-of-eight Prolene suture.  At this time there were several bleeding points on the capsule of the kidney and these were controlled with cautery but there was no other active bleeding.

At this time, the bladder was instilled with antibiotic solution.  The detrusor muscles were dissected off the mucosa with electrocautery.  The detrusor muscles were very atrophic and very thin walled bladder.  Stay sutures of silk were placed around the detrusor muscles.  The ureter for the transplant kidney was dissected.  The vessels were tied with silk suture and the ureter was trimmed to proper size.  A defect was made in the bladder mucosa and a stent was placed into the ureter and down into the bladder and the anastomosis with the ureter to the bladder mucosa was created with a running 6-0 Maxon suture.  The detrusor muscle was attempted to be closed over the ureter, but it was very difficult secondary to atrophic detrusor muscle.  So, at this time the wound was irrigated.  There was no other active bleeding.  A drain was tunneled through the right side of the incision and a JP drain was left next to the kidney itself.  The internal oblique and transversalis muscles were reapproximated with 0 Maxon suture.  The external oblique muscles were closed with 0 Maxon suture in interrupted simple fashion.  The Scarpa’s fascia was reapproximated with a 2-0 Vicryl suture.  The wound was irrigated and the skin was closed with staples.  A sterile dressing was applied.  A follow up x-ray showed no foreign body or needles and a chest x-ray showed no pneumothorax with a central line in the superior vena cava.  At this time the patient was extubated and sent to PACU in fair condition.  All needle and sponge counts were correct

TVT Suburethral Sling

PREOPERATIVE DIAGNOSIS:
1.  Fourth-degree cystocele.
2.  Third-degree uterine prolapse.
3.  Second-degree rectocele.
4.  Traction enterocele.
5.  Weakened pubocervical fascia.
6.  Potential genuine stress incontinence.
7.  Urethral hypermobility.  

POSTOPERATIVE DIAGNOSIS:
1.  Fourth-degree cystocele.
2.  Third-degree uterine prolapse.
3.  Second-degree rectocele.
4.  Traction enterocele.
5.  Weakened pubocervical fascia.
6.  Potential genuine stress incontinence.
7.  Urethral hypermobility.  
8.  Vaginal vault prolapse after the hysterectomy. 

OPERATION:
1.  Vaginal hysterectomy.
2.  Vaginal enterocele repair.
3.  Anterior colporrhaphy.
4.  A 4 x 7 cm dermal allograft placement in the anterior compartment. 
5.  Sacrospinous vaginal vault suspension. 
6.  Tension-free vaginal tape suburethral sling.
7.  Posterior colporrhaphy with perineorrhaphy. 

ANESTHESIA: Spinal.

ESTIMATED BLOOD LOSS: 500 ml.

COMPLICATIONS: None. 

PROCEDURE: The patient was brought to the operating room and placed in a sitting position and given spinal anesthesia.  She was then replaced in lithotomy position in gold post stirrups and prepped and draped in the usual fashion.  A marking stitch was placed through the vaginal apex and then I injected dilute 1:5 pitressin solution circumferentially around the cervix.  I then circumscribed the cervix sharply and gained entrance into the peritoneal cavity both anteriorly and posteriorly and then I clamped, cut, and suture ligated the uterosacral remnants, the cardinal ligaments, the uterine vessels, the broad ligaments, and finally the uteroovarian ligaments with delivery of the uterus and cervix.  The ovaries and tubes looked fine.  I had closed the enterocele defect with a single pursestring suture of 2-0 Gore-Tex bringing together the anterior tinea coli of the rectosigmoid, the lateral pelvic sidewall bilaterally, and the bladder reflection anteriorly.  This was tied and cut. 

I now grasped the anterior cuff and infiltrated underneath the anterior mucosa with the dilute pitressin.  I then undermined and transected the anterior mucosa in the midline up to the level of the bladder neck and dissected away the underlying endopelvic connective tissue back to the pubic rami bilaterally exposing the massive central cystocele.  I dissected back to the right ischial spine, the sacrospinous ligament.  I isolated the ligament with Breisky retractors and placed 2 sutures of 2-0 Gore-Tex through the ligament using the Miya hook, the first through the middle third and the second through the medial third.  The top portion of each Gore-Tex suture was fixed in a figure-of-eight fashion to the corresponding undersurface of vaginal mucosa and what would be the new vaginal apex and tied to itself to form a pulley stitch to tie down later on in the case.  Excess vaginal mucosa was trimmed.  I now reduced the central cystocele and brought the connective tissue from the sides together with 3 mattress sutures of 0 PDS.  Urethrocystoscopy was performed with a 70-degree lens and verified that blue dye was coming into both ureteral orifices without difficulty.  The bladder was now decompressed.  She had fairly extensive paravaginal defect on the right and the tissue on the left really did not look that good either, so I augmented this entire compartment with a donor graft.  I took a 4 x 7 cm piece of Alloderm, folded this half to form a 4 x 3 cm piece and sewed this in place so that the 2 anterior corners were attached to the arcus tendineus fascia of the pelvis at a level just beneath that of the bladder neck and the posterior 2 corners further posterolaterally.  The posterior midline of the graft was attached to the enterocele Gore-Tex suture.  These were all tied and cut.  I now closed the bottom half of the vaginal incision with a running interlocking suture of 2-0 Vicryl and then I tied down the sacrospinous tissue to directly appose the undersurface of vaginal mucosa to the ligament and these were tied and cut. 

Before I finished closure of the anterior wall, I went ahead with the TVT procedure.  The urethra was diverted off to the right with the rigid guidewire.  I introduced the TVT needle through the incision underneath the left pubic ramus and through the urogenital diaphragm, space of Retzius, rectus fascia, and out through a stab incision 2 cm left of midline.  The urethra was diverted off to the left and needle passage repeated on the right side.  Urethrocystoscopy was performed with 70-degree lens again to a capacity of 600 ml and then when no perforation or trauma was noted anywhere, the needles were pulled out and cut off and I adjusted tension on the tape at this volume while performing Credé maneuver.  The tape was brought up just to the point where leakage was still present but had largely slowed down and there was still a 0.25 to 0.5 cm of space between the tape and the posterior urethra.  At this level of tension, I held countertraction transvaginally while peeling the plastic sheath off the tape suprapubically.  The tape was cut beneath skin level. Mastisol and Steri-Strips were applied.  I now finished closing the remainder of the vaginal incision with the same running interlocking suture of 2-0 Vicryl.  Hemostasis was good.  All counts were reported as correct at the end of this part of the procedure. 

Attention was now turned to the gaping introitus and rectocele.  I infiltrated here with a dilute pitressin and then I excised a portion of perineum and vaginal mucosa sharply. I noted immediately that I had created an incidental enterotomy in the distal rectal area that was about 2 cm long.  So, I closed this carefully with a running suture of 2-0 Vicryl.  I now dissected away the underlying endopelvic connective tissue back to the pubic rami and anteriorly up above the rectocele, the rectocele was reduced in the midline and I brought the connective tissue from the sides together with several mattress sutures of 0 PDS.  She had a distal size specific defect, which I closed with an anterior imbrication of the distal rectum with 0 PDS.  Peroneal body was rebuilt with 0 PDS.  The vaginal mucosa I now closed with a running interlocking suture of 2-0 Vicryl and the perineum with a subcuticular suture of the same.  She had adequate caliber and length now and a Foley was in the bladder draining free-flowing blue urine.  A pack in the vagina.  Rectal exam was negative.  She tolerated it well and was brought to recovery in stable condition.  All counts were reported as correct.