SAS: Exam 1

Oral surgery considerations

• Intubation: per os, pharyngostomy, tracheostomy

  • Airway protection (aspiration): pack w/ gauze, Cuffed ET tube

  • 2º airway edema: Gentle tissue handling, Corticosteroids

• Incisions: blade/scissors, no electrocautery 

  • Expect extensive bleeding, delicate mucosa

• Sut: Interrupted, tension-free closure, Monofilament (PDS 3-0 or 4-0)

• Healing: rapid (3w)

  • Highly vascular, higher temp, phagocytic activity, early epithelial migration, higher metabolic rate, antimicrobial saliva

  • Dehiscence is common

    • Can be due to tension

    • Can be due to infection

• Antibiotics: low infection despite lots of bacti present

  • Ampicillin-sulbactam, Cefoxitin, Clindamycin

• Diet: Canned food only 4 wks, feeding tube, liquids

Oral Neoplasms

• Et:

  • Dogs: Acanthomatous epulis, melanoma, SCC, fibrosarcoma, papilloma

  • Cats: SCC, fibrosarcoma

• Dt: CT(extensive), FNA, Biopsy 

• Tx: Maxillectomy/mandibulectomy (CT first)

  • Consider eating ability, TMJ function, malocclusion, ulcerations

Tongue Disorders

• Et: melanoma (rare), SCC (rare), FB, burns, lacerations

• Tx: Sut, second intention healing, glossectomy 

  • dogs tolerate 75% removal of tongue, cats do NOT tolerate near-total

Cleft Palate

• Primary (premaxilla/lip) → aesthetic only

  • Et: congenital, intrauterine insult 25-28d 

    • unilateral, aesthetic, direct access between oral cavity and nasal cavity

  • Sig: young, brachycephalics

  • Cs: food caught in rostral nasal cavity

  • Tx: Sx repair at 5-6m : cosmetic only 

• Secondary (hard/soft palate)

  • Et: congenital (#1), intrauterine insult 25-28d, traumatic, midline

  • Sig: young, brachycephalics

  • Cs: milk from nose, coughing, gagging, sneezing, nasal discharge, poor growth

  • Tx: palatoplasty at 12-14w (short fasting time 4-6h)

    • Too early → friable tissue, poor anesthesia candidate

    • Too late → defect widens

Oronasal Fistula

• Acquired secondary cleft

• Et: dental dx, malocclusion, trauma, burns, neoplasia, surgery, radiation

• Cs: sneezing, unilateral discharge, difficulty eating, halitosis

• Dt: dental rads, probing

• Tx: debridement + double-layer closure w/ gingival or labial flaps

Sialocele (Salivary Mucocele)

• Et: trauma, sialoliths, FB, neoplasia, dental extraction, Sx

• Sig: GSD, Silky Terrier, Dachshund, Poodle

  • Main: Parotid, Mandibular, Sublingual, Zygomatic

• Cs: saliva collects in pseudocapsule, soft tissue swelling

  • Cervical (#1): soft, fluctuant, non-painful swelling ventral to mandible

  • Sublingual (ranula): swelling under tongue, halitosis, dysphagia, oral bleeding

  • Pharyngeal: intraoral swelling into pharynx, cough, dyspnea, stridor

  • Zygomatic: exophthalmos, 3rd eyelid protrusion, orbital swelling

• Dt: FNA w/ stringy fluid, non-degenerate neutrophils, macrophages

• Tx: Sx excision of both glands + duct (mandibular + sublingual), marsupialization (pharyngeal/ranula)

  • excellent prognosis, but recurrence and infection possible

  • Rx management unsuccessful

Esophagus surgical considerations

• Highest dehiscence risk

  • 3 tissue layers: No serosa: poor healing

  • Segmental blood supply

  • No omentum 

  • Constant motion

  • Tension at site

• Dog Anatomy: striated entire length

• Cat Anatomy: smooth in terminal ⅓ w/ involuntary contractions

  • Sphincters:

    • Upper Cricothyroid and thyropharyngeus muscles

    • Lower: Thickening of the muscularis layer, pressure, angle

Esophageal Foreign Body

• mucosa, submucosa, muscularis, and adventitia

• Cs: retching, regurg, drooling, pawing at mouth, dysphagia, gagging, inappetence

• Dt: rads, esophagoscopy

• Tx: Endoscopic retrieval (#1), Push FB into stomach (gastrotomy), Esophagotomy

  • Comp: mediastinitis, pyothorax, pneumonia, sepsis, stricture, dehiscence

Esophageal Strictures

• Et: prior injury, silent anesthesia regurge, oral tablet injury

• Dt: contrast esophagram, endoscopy

Vascular Ring Anomalies

• Et: Persistent Right 4th Aortic Arch (PRAA), constriction at esophagus

• Sig: young, GSD, Irish Setter, Boston, Siamese, Persian

• Cs: solid food regurge, aspiration pneumonia(2ndary), failure to thrive, poor weight gain

• Dt: contrast esophagram (enlarged @ base), CT/angiogram

  • Check for cranial megaesophagus 

• Tx: Sx at 10-12w (lig arteriosum division)

  • Fair to good prognosis

  • the fibrous remnant of the fetal ductus arteriosus

Hiatal Hernia

• Et: stomach/abdominal esophagus through esophageal hiatus

• Congenital (Phrenicoesophageal ligament laxity) , trama, brachycephalic syndrome, laryngeal paralysis, chronic vomiting

• Sig: English bulldog, Shar Pei

• Cs: inappetence, dysphagia, regurgitation, vomiting, weight loss, dyspnea

• Dt: rads (may be normal), contrast gastroesophagram, fluoroscopy

• Tx: antacids, sucralfate, metoclopramide, low-fat diet, elevate feeding, herniorrhaphy, esophagopexy, left-sided fundus gastropexy

  • Comp: persistent regurg, aspiration pneumonia

    • Refer out for Sx

Surgical Considerations of the Stomach

• 4 layers

  • Serosa/muscularis (outer) + submucosa/mucosa (inner)

• Healing: good 

  • Lg blood supply, low bacti, acidic, rapid regen, omentum support

    • G+ antibiotics

• Layers: four (serosa/muscularis +submucosa/mucosa)

• Sut:

  • Avoid gastric spillage: suction, stay sutures 

  • identify the body → for incision

    • Midway between greater and lesser curvature

  • Closure: 2-layer closure (Leak test not req)

    • Inner mucosa + submucosa: simple continuous

    • Outer muscularis + serosa: inverting Cushing/Lembert

Gastric Surgical Procedures

• Gastrotomy: FB, gastric biopsy

  • Pack stomach w/ sponges and add stay sutures

  • ID body (between G+L curvatures) and use sharp insison

• Orogastric tube: GDV

  • Place mouth gag and lube Semi-rigid tube

  • Flex neck ventrally, pass slowly till 13th rib

• Trocarization: GDV

  • Puncture with 18 g needle at point of maximal tympany

  • Push opposite side of abdomen

• Gastric Derotation: GDV

  • Stand on left, ventral midline incision, should see omentum over stomach

  • Right hand on pylorus dorsally, left hand on fundus

  • push on fundus and pull pylorus left then ventral then right

• Insuasional Gastropexy: GDV

  • Inside right side of stomach (antrum) and right body wall (caudal 13^th rib)

Gastric Foreign Body

• Sig: history or suspicion of getting into things

• Cs: vomiting, anorexia, dehydration, depression

• Dt: contrast rads, US

• Tx: Emesis (#1), Endoscopy (#2), Gastrotomy

Gastric Dilatation-Volvulus (GDV)

• Et: pylorus moves R → ventral → L → dorsal

  • mucosal damage, sepsis, portal vein obx + hypertension, vena cava obx, poor cardiac output

• Sig: Deep-chested, Lg breeds, older, once-daily feeding, genetics, stress, exercise after eating

• Cs: Retching, pain, distended abdomen, hypersalivation, VPC, shock, splenic congestion (often corrects on its own), hypoxia, acidosis, death

• Dt: lactate trends, ECG (VPC), PT/PTT, RL rads w/ double bubble

• Tx: gastric decompress (Trocarization, OG tube), right gastropexy, de-rotation, tube feed, famotidine, pantoprazole, mu opioids, fluids, O2

  • ** Stand on left side, R hand pylorus, L hand on top of fundus - then rotate **

    • Tx arrythmias if: V tach >160-180. R on T, multifocal, pulse deficits

    • Emergency but good prognosis  

    • NO NSAIDS or medical management

Considerations for Small Intestinal Surgery

• Layers: all stuck together→mucosa, submucosa, muscularis, and serosa

  • Can resect < 70%

  • Ileum: antimesenteric artery

  • Duodenocolic ligament: anchors the duodenal flexure to colon

  • Proximal descending duodenum: common bile duct/pancreatic

• Bacti: lots, lavage if spillage

• Stabilization: fluids critical (#1)

  • obstruction/ileus → fluid sequestration → hypovolemia, shock, death

• Rx: No NSAIDs, ampicillin + sulbactam

• Sut: leak test req

  • Monofilament, 3-0/4-0

  • submucosa (holding), start at mesenteric border w/ appositional patterns (simple interrupted or continuous)

    • dont go 360 w/ continuous pattern, if unequal diameter angle sut on sm side

Small Intestinal Foreign Body

• Common to anchor: pylorus (dog)

  • under tongue (cat)

    • Causes erosion into mesenteric border

• Cs: vomiting, depression, anorexia, diarrhea, pain, dehydration, palpable mass, string under tongue (C), weight loss

• Dt: rads (stacking/bunching SI, pneumoperitoneum), US

• Tx: gastroprotectants, Enterotomy (healthy bowel), R&A (damaged bowel), gastrotomy, (linear FB), fluids!!

Small Intestinal Surgery Procedures

• Enterotomy: FB, full tickness biopsy 

  • Full exploration and isolate bowel w/ sponges

  • Incise on antimesenteric surface

    • Aborad to FB (#1) > Orad to FB > Over FB

  • Leak test (22g needle) and wrap incision in omentum

• Resection & Anastomosis: resect devitalized bowl

  • Isolate diseased bowel

  • Ligate vessels and clamp

    • Carmalt (resected side, crushing), Doyen (remaining side, non-crushing)

  • Suture bowel, close mesenteric defect, omentalize

  • Can resect < 70%

  • Lavage!!! Lavage!!! Lavage !!!

  • Fish-mouth the smaller side: mix match sizes

Intussusception

• Et: Overlap of junctions of fixed & mobile bowel

• Intussusceptum = proximal loop; Intussuscipiens = distal loop

• Young: parasites, FB, viral enteritis

• Old: neoplasia, infiltrative bowel dz, FB

• Cs: diarrhea, anorexia, weight loss, pain

• Dt: palpable tubular mass, radiographs (ileus),US

• Tx: manual reduction (no adhesions), R&A (devitalized), SURGERY

Large Intestine Surgical Considerations

• Three segments: ascending, transverse, descending (longest part)  left side

• Cecum

  • True diverticulum

  • Cecocolic orifice

    • Ileocolic orifice

• Healing: poor, high collagenase activity, high bacti load, high dehiscence risk 

  • DON’T cut colon unless necessary

• Bld supply: vasa recti

• Sut: monofilament absorbable, taper needle

  • Always lavage, omentalize

• Rx: Cefoxitin, Ampicillin/sulbactam + enrofloxacin + metronidazole, epidural, opioids

  • No enemas, NSAIDs, steroids 

• Post-op: Fiber (increases motility & healing), high-carb, low-fat diet

Surgical Procedures within the Large Intestine

• Taper needle only

• Typhlectomy: impaction, perforation, inversion, neoplasia 

  • preserve ileocolic valve

• Colotomy: biopsy, FB removal

• Colectomy: megacolon, intussusception, ischemic injury, neoplasia, perforation

  • Subtotal: preserve ileocolic valve, better fecal consistency

  • Total: resect ileocolic valve and preform a typhlectomy

• Closed anal sacculectomy: neoplasia, medical management fail

  • Catheterize, lateral skin incision, dissect sac, avoid caudal rectal nerve, ligate duct

Neoplasia in the Rectum

• Perianal gland adenoma

  • Et: Benign, arises from circumanal glands, related to androgen concentrations

  • Sig: Older, intact males

  • Tx: Castration causes regression

• Adenomatous polyps

  • Et: Benign, intramural rectal mass, malignant transformation up to 50%

  • Tx: early Sx excision

Rectal Prolapse

• Et: parasites, enteritis, FB, dystocia, straining, genetic, sphincter laxity, prostatic dx, perineal hernia, recent butt sx

  • Incomplete: only rectal mucosa protrudes

  • Complete: all layers protrude

• Sig: Manx, younger

• Tx: cold saline, lubrication, sugar, purse-string anus over tube, Sx amp

Anal Sac Diseases

• Apocrine gland anal sac adenocarcinoma (AGASCA)

  • Et: Highly malignant, metastasis, sublumbar LN involvment  → 50% mets @ time of diagnosis 

    • #1 anal sac tumor

  • Cs: hypercalcemia, PU/PD, anorexia, bladder stones, lethargy

    • Sublumbar LN Located: L7, colon ventrally displaced (when enlarged)

  • Tx: Closed anal sacculectomy + excision of affected LN

• Anal sacculitis

  • Et: obstruction and infection

  • Sig: toy breeds, seborrheic dermatitis

  • Cs: soft stool, perineal irritation, tenesmus, constipation, dyschezia

  • Tx: regular expression, antibiotics, warm compress

Closed anal sacculectomy

• Why: anal sacculitis, neoplasia

• Rx: anti-inflam and antibios pre-Sx

• How: 

  • Insert a foley urinary catheter (if needed) → infection, inflammation

  • Incise lateral aspect of anal sac and dissect sac from sphincter fibers

    • Avoid caudal rectal nerve

  • Ligate duct at orifice

Perineal Hernia

• Pelvic diaphragm: holds everything in

  • Coccygeus muscle

  • Levator ani muscle → pelvic floor

• Sacrotuberous lig: dogs only

• Et: abdominal contents herniate caudally

  • most common site due to levator ani atrophy → unilateral (dogs)

  • Cats: often bilateral

• Sig: Corgi, Boxer, Poodle, Bouvier, Pekingese, Boston, Sheepdog, DSH, 10y, male > female

• Cs: Perineal bulge, tenesmus, constipation, irregular stools

  • non-painful, incompletely reducible

  • Megacolon, perineal urethrostomy, trauma, perineal masses

    • Excess androgens and estrogens

• Dt: rectal exam, contrast rads, US

• Tx: Sx (#1), Palliative: stool softeners, enemas, fiber

  • castration + herniorrhaphy: internal obturator flap, coccygeus of anal sphincter and sacrotuberous lig

    • stabilize bladder entrapment w/ catheterization/cystocentesis before Sx

Pancreas surgical considerations

• Body: descending duodenum

• Left lobe: along greater curvature of stomach

• Right lobe: closely with duodenum

• Bld supply: Splenic a. (left limb), cranial pancreaticoduodenal a. (body, right limb, proximal), caudal pancreaticoduodenal a. (right limb, distal)

• Cats: 80% single pancreatic duct, fuses w/ bile duct before entering duodenum

• Dogs: Accessory pancreatic duct → minor, pancreatic duct → duodenal papilla (common duct)

Pancrease Surgical Techniques

• Biopsy: wedge, blunt dissection, guillotine, punch

  • Best site if diffuse = caudal/distal right limb

• Partial pancreatectomy: abscess, neoplasia, biopsy

  • Remove distal limbs only, 75–90% resectable

    • avoid body = risk of blood supply/duct damage

• Total pancreatectomy: very rare

  • Req duodenectomy, gastrojejunostomy, cholecystojejunostomy

  • Leads to loss of exocrine & endocrine fxn: req enzyme + insulin supp

Diseases of the pancrease

• Pseudocyst

  • Et: Sterile(fluid filled), often from pancreatitis

  • Tx: partial pancreatectomy, drain + omentalize(fills hole) (#1)

• Insulinoma

  • Cs: Severe hypoglycemia, seizures, metastasis

  • Tx: partial pancreatectomy, excise

    • metastasis 50% to liver and local lymph nodes: quickly

      • run a Insulin:glucose ratio - DX

• Abscess → sterile, very common 

  • Et: Rare, pancreatitis

  • Tx: excision, drain + omentalize, antibiotics

Surgical Techniques and Considerations of the Liver

• Bld Supply: Portal v. (80%) > Hepatic a. (20%)

• Biopsy: nonspecific path, high bile acids/ALP/ALT, storage dx, neoplasia

  • Guillotine: tie + excise distal

  • Punch: superficial, plug with gelfoam (vetsponge)

  • Laparoscopic: less invasive

• Partial lobectomy: neoplasia, abscess, AV fistula, focal dx 

• Total lobectomy: resect at hilus w/ blunt dissection, sutures, stapling device

Liver Shunts

• Et: genetic (single), acquired multiple (portal hypertension, cirrhosis)

  • Often seen with microvascular dysplasia, toxins circle systematically (ammonia)

• Sig: 

  • Single Congenital: toy breeds (Extrahepatic), Himalayans (Ex), → most common

    • Lg breeds (Intrahepatic)

  • Acquired multiple: older Lg breeds, cats

• Cs: seizures, head pressing, dull mentation, post-prandial dullness, copper-colored irises(cats), straining, ammonium biurate stones

• Dt: low BUN/cholesterol/albumin; high liver enzymes and bile acids; US, CT

• Tx: Clavamox, lactulose, low protein diet, Keppra, Sx attenuation (ameroid ring, cellophane band)

  • Min. 2w medical tx even pre-Sx

  • Risk of portal hypertension, portal atresia w/ Sx

Extrahepatic Biliary Tract Obstruction

• Et: pancreatitis, neoplasia, mucocoele, cholelithiasis, cholangitis

• Cs: high bilirubin, hypotension, poor contractility, renal failure, coagulopathies, GI hemorrhage, intestinal bleeding

• Tx: Sx

  • extremely Critical patients

Surgical Techniques of the Gallbladder

• Cholecystotomy: open GB, remove stones

• Cholecystectomy: remove GB

• Cholecystoduodenostomy: reimplant GB to duodenum/jejunum 

  • if CBD diseased, GB healthy

Surgical Considerations of The Kidney and Urinary system

• Pre Op: Min database, UA, ensure urine production 1-2 ml/kg/hr

• Rx: penicillins, cephalosporins, enrofloxacin

  • NO: NSAIDs, aminoglycosides, tetracyclines, sulfonamides

• Sut: Monofilament, absorbable, full-thickness (simple interrupted/continuous)

  • Suture can be calculogenic

  • Avoid lumen occlusion/stricture

• Comp: Hypotension, pancreatitis, pancreatic duct cannulation, dehiscence, peritonitis, sepsis, DIC, choledochal dilation, re-obstruction

• Anatomy: Retroperitoneal, ureter exits at hilus, right kidney higher + left mobile

Kidney Surgical Considerations and Procedures

• Biopsy: done at the cortex, avoid medulla cause of hemorrhage

  • Open surgical (#1): best hemorrhage control

  • US: risk bleeding, monitor fluids

  • Laparoscopic: min invasive, good visualization

• Nephrotomy: explore pelvis, stone removal, hematuria, biopsy, partial nephrectomy

  • How: longitudinal incision in body, hemostasis critical, suture capsule

  • Comp: diminished renal function, urine leakage, stage if bilateral, temporary GFR reduction, renal failure 

• Nephrectomy: salvage; neoplasia, trauma, pyelonephritis, hydronephrosis, ureteral abnormality/trauma, ligation w/ OHE, ectopic ureter

  • How: confirm contralateral kidney GFR adequate pre-op

    • Free kidney from retroperitoneum

    • Double ligate renal a./v. (watch for multiple arteries)

    • Ligate ureter close and transect to bladder

Ureteral Surgical Procedures

• Subcutaneous ureteral bypass (SUB): Obstruction, cats 

  • Replaces ureterotomy, pyelolithotomy

  • Place catheter from renal pelvis to bladder apex

• Ureteral stent: for dogs w/ obstruction

• Neoureterostomy: Intramural ectopic uterus 

  • Do a cystotomy

  • Incise bladder mucosa into ureteral lumen

  • Create a new stoma then ligate distal portion of ureter

• Cystoscopic laser ablation: min invasive for Intramural ectopic uterus 

  • Insise between ectopic ureteral lumen and urethra/bladder

• Ureteroneocystostomy: Extramural ectopic ureter 

  • Ligate and transect distal ureter

  • Spatulate ureteral opening then reimplant ureter into bladder

Ureteral Obstruction

• Et: partial (stone, stricture), complete (stone, trauma, ligation, transection)

• Cs: lethargy, anorexia, hydronephrosis, azotemia

  • urination possible unless bilateral

• Dt: Rads + contrast, US

• Tx: SUB (C), Ureteral stent (D)

Ectopic Ureter

• Et: empties abnormally, unilateral urethra most common

  • Intramural: tunnels submucosally, exits urethra/vagina

  • Extramural: bypasses bladder completely

• Sig: young female, Husky, Golden, Lab, Newfie, Poodle, Bulldog

• Cs: incontinence, urine scald, recurrent UTIs

• Dt: azotemia, rads (stones), CT, cystoscopy (#1)

• Tx: neoureterostomy (I), laser ablation (I), ureteroneocystostomy (E)

  • Comp: incontancence

Renal Neoplasia

• Et: Primary tumors rare (malignant), renal tubular carcinoma (#1)

  • Metastasis to chest common

• Tx: ureteronephrectomy 

  • only if contralateral kidney fxn

Surgical Conciderations of the Bladder

• Healing: regains 100% strength in 14-21d, full re-epithelialization in 30d, 50% can be removed safely

  • avoid incisions near trigone

  • Urine sterile unless UTI

• Sut: Full-thickness, monofilament absorbable

  • Simple continuous or interrupted, 

  • single layer adequate, leak test req

• Catheter: Not for routine, use if concern for leakage/repair integrity

  • Retrograde male, normograde female 

  • Avoid bladder expression

• Rx: fluids >24h

Surgical Principles of the Bladder

• Leak test: saline infusion w/ 22g needle while occluding neck

• Cystotomy: calculi, neoplasia, biopsy, polyp removal, ectopic ureter repair, cystopexy

  • Exteriorize & isolate bladder, place stay sutures at apex/body 

  • Incise ventrally, suction urine and lavage 

• Partial Cystectomy: neoplasia, necrotic/traumatized bladder, lesions in apex/body

  • NOT for trigone issues 

• Cystopexy: perineal hernia, augment ureteral anastomosis

  • open or laparoscopic/lap-assisted

  • Bladder sutured to lateral body wall

• Tube Cystostomy

  • Temp: Unstable patients  w/ calculi obstruction, urethral trauma

    • Diverts urine until definitive procedure

  • Perm: neurogenic bladder, urethral obstruction, neoplasia

Uroabdomen

• Et: blunt trauma (HBC), gunshot, surgery dehiscence, necrotic neoplasia

• Cs: electrolyte imbalances, hyperkalemia, dehydration, hypovolemia, shock, uremia, death, abdominal distention

• Dt: HCBC/chem (infection, azotemia), rads (loss of serosal detail), abdominocentesis (fluid Cr & K > blood levels), contrast cystourethrogram

  • Creatinine, potassium – higher than peripheral blood

• Tx: ventral midline incision, ID defect, repair, lavage, drains, catheter

Bladder Neoplasia

• Et: TCC (#1)→ @ trigone, SCC, adenocarcinoma, hemangiosarcoma, fibrosarcoma, leiomyosarcoma, benign tumors

• Dt: rads, thoracic rads (mets), US, BRAF gene test, cystoscopy, traumatic catheterization

• Tx: NSAID, chemo, tube cystostomy, sx (best long term)

  • Mostly medical

Urethral Disorders

• Stones

  • Et: Bladder stones lodged in urethra

    • distal urethra, just proximal to os penis

  • Sig: Males > females

  • Tx: urohydropulsion, cystotomy

    • complete obstruction = EMERGENCY

• Urethral Trauma

  • Laceration: usually heal w/ urinary diversion (catheter ≥ 7d)

  • Transection: primary anastomosis, urethrostomy

• Urethral Prolapse

  • Et: excitement, chronic irritation, infection

  • Sig: Bulldogs

  • Cs: bleeding from urethra, visible prolapse

  • Tx: Urethral resection, Urethropexy, castrate

Urethral Surgery Procedures

• Urohydropulsion: urethral stones, avoid Urethrotomy

  • Confirm stone position with rads, then push into bladder

• Urethrotomy: stone retrieval, FB retrieval, biopsy, neoplasia

  • Sharp midline incision over obstruction 

  • Primary closure with apposition and place catheter 

• Urethrostomy: permanent stoma; Urethral obx, FIC, trauma, neoplasia, calculi

  • Perineal (C) or scrotal (D) incision, create stoma

  • Must dissect penis to bulbourethral glands (C) or stricture risk

  • Use a drain board to prevent urine scald, should fit hemostat box lock 

    • A drain board is necessary to prevent urine scald

• Urethral resection: urethral prolapse 

  • excise prolapsed mucosa, amputate, suture to skin

• Urethropexy: urethral prolapse 

  • reduce prolapse, place sutures proximally

Penile Disorders

• Hypospadias: 

  • Et: congenital, urethral opening ventral/caudal to normal 

  • Tx: preputial/urethral reconstruction

• Phimosis: 

  • Et: Congenital, trauma

  • Cs: inability to extrude penis, urine pooling, purulent discharge

  • Tx: enlarge preputial opening, new mucocutaneous junction

• Paraphimosis: 

  • Cs: penis remains extruded

  • Tx: reduce, preputial reconstruction, preputiotomy, phallopexy, partial penile amputation, castration

Penile Amputation

• Why: neoplasia, trauma, congenital anomalies

• How: scrotal urethrostomy + scrotal ablation