DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Stress urinary incontinence secondary to intrinsic sphincter insufficiency.
POSTOPERATIVE DIAGNOSIS: Stress urinary incontinence secondary to intrinsic sphincter insufficiency.
OPERATION PERFORMED: Tegress periurethral implant.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This patient is a (XX)-year-old male who is nine years status post radial prostatectomy for carcinoma of the prostate. He developed a bladder neck postoperatively and underwent a transurethral incision of his bladder neck approximately seven to eight years ago. The patient was rendered constantly incontinent as a result. Hemodynamic assessment was consistent with intrinsic sphincter deficiency. After discussing treatment options, the patient agreed to proceed with a Tegress periurethral implant. The risks of bleeding, infection and urinary retention were reviewed with the patient.
FINDINGS AND DESCRIPTION OF OPERATION: After the patient had obtained adequate general anesthesia, he was placed in the dorsal lithotomy position. The genitals were prepped with Betadine and draped with sterile drapes. Cytoscopy demonstrated an open bladder neck and sphincter area. With the scope in the proximal urethra, the needle was placed at 9 o’clock on the right side of the sphincter and advanced to the appropriate distance. The implant site was approximately 1 to 2 cm distal to the bladder neck. A total of 1 mL of Tegress was injected over 1 minute and 2 minute period was observed prior to removing the needle to allow the Tegress to form.
Attention was then turned to the left side of the bladder neck. The scope was withdrawn approximately 2 cm, and a site approximately 1.5 to 2 cm distal to the bladder neck was chosen. Once again, a 1 cm implant of Tegress over 1 minute was carried out with a 2 minute wait before removing the needle.
The bladder was then irrigated, and the cystoscope was removed. The patient tolerated the procedure well and was transported to the recovery room in satisfactory condition.
