Penoscrotal / urethrocutaneous fistula repair

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• fistula may come back and need another operation
• narrowing of the urethra or meatus
• a second hidden fistula may be found and repaired at the same time
• wound infection or breakdown
• swelling and bruising of the penis
• skin flap from the side or scrotum may be needed to cover the repair
• catheter for a short time, or none
• long-term catheter damage: the urethra may be too destroyed for local repair, and bladder neck closure with a suprapubic tube may be advised instead

Pre-operative details for this operation

1. Cause of fistulaAfter hypospadias repairLong-term urethral catheter / pressure ulcer (spinal cord injury or neurogenic bladder)After urethroplastyOther (state)for hypospadias: type of original repair (TIP, Mathieu, onlay, two-stage), date, centre
2. Time since fistula appearedafter hypospadias repair, at least 6 months is advised before repair
3. Spinal cord injury (if catheter-related)level and completeness; injury at T6 or above carries a risk of autonomic dysreflexia; present bladder drainage (urethral catheter, suprapubic catheter, intermittent catheterisation, sheath)
4. Work-up for a catheter-related fistularetrograde urethrogram with or without voiding cystourethrogram (extent and site of fistula); cystoscopy to exclude bladder cancer after a long-term catheter; urine culture to plan antibiotics; nutrition; perineal skin and pressure sores
5. Fistula siteGlansCoronal sulcusPenile shaftPenoscrotal junctionMultiple
6. Voidingstream from meatus vs fistula; straining; spraying
7. MeatusWideNarrow / stenosed
8. Previous fistula repairsnumber, what was used as cover
9. Circumcised / foreskin presentdecides which dartos flap is available

Anaesthesia and position

1. AnaesthesiaGeneralSpinalspinal injury at T6 or above: spinal removes the risk of autonomic dysreflexia; general gives some control of blood pressure
2. PositionSupine
3. MagnificationLoupes (magnification)Operating microscope
4. Urinary diversionNoneExisting suprapubic catheterSuprapubic catheter placed at this operationsize; in a man who needs a long-term catheter, a suprapubic catheter avoids further urethral damage

Operative findings

1. Distal obstruction excludedCatheter passed freely (size)CystoscopyRetrograde urethrogramNarrowing foundsize of catheter that passed
2. Number of fistulas on dye testdilute povidone-iodine injected into the meatus
3. Fistulasite, diameter in mm, length of tract, genu at urethral end
4. Urethra around the defectHealthy, repairable locallyEroded / large defect, not suitable for local repairif not repairable, record the reason and the plan
5. Surrounding tissueHealthy, well vascularisedScarred / thin skin
6. Available coverPreputial dartosVentral dartosTunica vaginalisExternal spermatic fasciaDe-epithelialised skin

Procedure (steps)

1. Distal obstruction excludedcatheter size, or cystoscopy / RGU findings
2. Fistula located and other fistulas excludeddilute povidone-iodine into meatus with proximal compression
3. IncisionCircumscribing incision around fistulaSubcoronal incisionOpening glans wings (glanular / coronal fistula)
4. Tract dissected to the urethraurethra separated widely from the overlying skin all around
5. Fistula tract and genu excisedback to healthy thin urethra
6. Urethral closureTransverse, running subcuticular invertingTwo continuous layersConnected to meatus and glans refashionedOnlay flap / graftsuture and size (e.g. 7-0 polyglactin 910); no PDS inside the urethra
7. Leak testNot doneSaline with proximal compression: no leak
8. Protective layer(s)one or two; tissue used; extends over the whole repair
9. Skin coverDirect closureRotation flap from lateral penile skinScrotal flapsuture used; suture lines not overlapping
10. If the urethra is not repairable locallyrecord the finding and the plan discussed (suprapubic drainage, bladder neck closure as a separate operation)

Closure, drains and dressing

1. Skin suturesmaterial and size (absorbable, fine)
2. Catheter / stentNoneSilicone catheter one size smaller than urethraSuprapubic cathetersize; planned duration
3. DressingNoneHydrocolloidSilicone foam

Specimens and implants

1. Excised fistula tractDiscardedSent for HPE
2. ImplantsNone

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Dischargesame day, or next day if a catheter is left
2. Catheterif left, keep draining; remove on day 1 or as written
3. Watch voidingstream from meatus; any leak from the repair site
4. Analgesiaweight-based dose as on the drug chart
5. Spinal cord injury patientsno traction on any catheter (absent genital sensation hides it); headache or high BP may be autonomic dysreflexia: check that the bladder is draining first
6. Wound carekeep clean; avoid pressure from dressings or tight clothes
7. Follow-upwound check; later review of stream and repair site

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery