Emmy Posted Thu 12th of March, 2020 15:37:27 PM
NEED ADVICE ON DX AND CPT FOR ALL SURGEONS SURGEONS: WHITE, MD; BAUER, MD; PETTY, MD; WALL, MD
PREOP DIAGNOSIS: Urethral stricture
POSTOP DIAGNOSIS: Urethral stricture
1. Anterior urethral reconstruction with buccal mucosa graft, ventral onlay
2. Buccal mucosa graft harvest
3. Cystourethroscopy with wire placement
4. Direct vision balloon dilation of membranous urethral stricture
5. Suprapubic tube placement
6. Complex foley catheter placement
DESCRIPTION OF PROCEDURE: The patient was prepped and raped in the usual sterile fashion in the lithotomy position. We introduced a flexible cystoscope. We passed a wire through the stricture into the bladder but met resistance proximally requiring a ureteral catheter and glide wire to transverse. We made a perineal incision. We divided the bulbospongious muscles and reflected them laterally using the Lone Star retractor. We engaged the structure using a size 22 bougie and the bougie probe. We opened the stricture in the ventral midline between traction sutures of 4-0 monocryl. The stricture began in the distal bulb under the lower scrotum and extended over a distance of 5 cm and extended to the area of the proximal bulbar urethra. We opened it throughout the length and then we were able to easily pass a 24 French probe without resistance in each direction. We did encounter a calcific area of dense resistance in the membranous area requiring a guidewire and eventually at 24 Fr 10 cm UroMax balloon was required to access the bladder.
We have harvested a 7x2cm graft from the left cheek. We defatted the back of the graft. We cauterized the edge of the donor site and closed loosely with 3-0 chromic sutures. We had placed 2-0 silk traction sutures in the commissure of the mouth and hydrodissected with lidocaine and epinephrine. We tailored the graft to fit the defect. We then sewed it into place in the ventral position using 4-0 running PDS suture. We scoped the bladder prior to completing the repair. Because of the density of the membranous stricture we elected to place a suprapubic tube using the 16 Fr peel-away trochar at a point two finger breadths above the pubic symphysis. These were no stones, tumors or other lesions, although he had turbid looking urine consistent with a low grade infection. We close the wound in multiple layers of 2-0 moncryl and 3-0 monocryl. We placed fibrillar hemostatic material around the urethroplasty repair site. He tolerated the procedure well, was taken to recovery awak, alert and in good condition with clear urine.
FINDINGS: a 5cm bulbar urethral stricture and a dense calcific subcentimeter membranous stricture
ATTESTATION: I was present for and supervised all parts of this procedure (White, MD).