location: Transition > Bottom Surgery > Revision Surgeries 2 & 3
This page picks up where Revision Surgery 1 written experience leaves off. I have included a couple entries that are also on that page for clarity and consistency.
Thursday, January 22, 2009 - 1 Year, 7 Months Post-op : 10.5 Months Post-1st-Revision
Big day for doctor's appointments and procedures! Over the holidays, I had continual bladder spasms and burning while urinating (similar symptoms to what I had experienced before) - I had a urine culture and sensitivity done by my PCP that came back negative (but was put on Macrobid just in case), and I had been taking Ditropan (oxybutinin) for a couple weeks with no real improvement. My urologist wanted me to come in for another Retrograde Urethrogram (RUG, #8 imaging study so far), which actually turned into a Voiding Cystourethrogram (VCUG, #9 imaging study so far) as it did back in April 2008, to check for strictures. As before, I outlined the path of urine/dye in yellow and marked the small diverticulum left from the previous fistula repair with a red arrow.
RUG #8 - 10.5 Months Post-1st-Revision
VCUG #9 - 10.5 Months Post-1st-Revision
Because they knew about the small diverticulum this time, they used floroscopy to guide the catheter around it, instead of getting stuck in it causing the pain I felt during the last RUG in April 2008. Luckily, the radiologist and my urologist said the urethra actually looks very good, with no evidence of strictures or narrowing. They said it has some redundant folds, but that is very common in reconstructed urethras. The fact that no strictures were seen was a huge relief. My urologist suggested it may have just been a transient bacterial or viral cystitis and to notify them if it happens again. Of course, it spontaneously resolved just days after the imaging tests. We also briefly talked about the upcoming surgery to fix the small external fistula, and he said that everything seemed in order to proceed with the revision.
Later that same day I had an appointment with my plastic surgeon to check in about the upcoming surgery to replace the testicular implants with tissue expanders. He said that the expansions will begin 2 weeks after the surgery, and 4-6 expansions (one per week) will probably be enough, depending on my skin's response to the expansions. The second surgery to replace the tissue expanders with new implants would then take place. He said to keep in mind that some recoil will take place after the second surgery, so it may be better to stretch a bit further than "just enough" to account for this. We also talked about doing another (minor) chest revision due to the scar tissue formed by the hematoma after the past revison surgery - he agreed to put in a drain this time to try to prevent another (third!) hematoma.
I also found out that my insurance approved both surgeries (replacement of implants with expanders and then subsequent re-placement of testicular implants) as well as the urethral fistula surgery.
Monday, January 26, 2009 - 1 Year, 7 Months Post-op : 10.5 Months Post-1st-Revision : 9 Days Pre-2nd-Revision
I had my pre-operative appointment for the (2nd total) revision surgery where my urologist will repair the external fistula on the shaft of the penis and the plastic surgeon will replace the testicular implants with tissue expanders. The plastic surgeon will also remove some remaining scar tissue and subcutaneous tissue from the right part of my chest. The total time of the operation was estimated to be 4-6 hours. The plastic surgeon wants me to stay overnight for one night, mostly because it will be easier to give me IV antibiotics while in the hospital.
Wednesday, February 4, 2009 - 1 Year, 7.5 Months Post-op : 10.5 Months Post-1st-Revision : Day of 2nd Revision
We arrived at the hospital around 7:00 am, met with an intake nurse, and was taken upstairs to the pre-op holding area. I met with the anesthesiologists who started an IV and the plastic surgeon. I didn't see the urologist before the surgery, because I had already met with a urology resident at my pre-operative appointment. They must not have given me the same pre-med medication as they did before my previous surgery, because I remember everything about being wheeled into the operating room, moving to the operating table, putting on the oxygen mask, and being asked repeatedly if I felt sleepy. Eventually the anesthetic kicked in and the next thing I remember is waking up in my in-patient room.
During the surgery (as it was explained to me), they made a small incision in the inguinal area (one incision on each side), then tunneled down into the scrotal sac where the implants were sitting. The implants were removed through these incisions, then tissue expanders were put in their place. There is a small tube from each tissue expander that leads to a port that was placed under the skin next to and just towards the midline of each incision. I have already scheduled six appointments, one per week, where they will put a needle into each port and inject saline to expand each side. My bandages post-op for this procedure were only two small non-stick coverings with steri-strips over the two incisions.
Also during the surgery the urologist excised a small fistula on the shaft of the penis. The bandages for this was only a small non-stick covering and tegaderm surrounding the shaft. I also had an in-dwelling catheter.
I ate really well that night and felt well enough to get up and walk around a little. The hardest part about moving around was that every time I used my abdominal muscles in any way (trying to sit up, turn over, etc.) I felt shooting and ripping-like pain around the incision sites. They assured me it was normal and just to over do it. I had very minimal nausea (although they were giving me IV anti-nausea medication), and I slept fairly sound that night.
Thursday, February 5, 2009 - 1 Year, 7.5 Months Post-op : 10.5 Months Post-1st-Revision : 1 Day Post-2nd-Revision
I was discharged in the early afternoon after eating a full breakfast and walking around a little. I was sent home with Percocet (oxycodone and acetaminophen) for pain management and Cephalexin (Keflex, antibiotic) to take 4x per day for 7 days. I was instructed to treat myself like I had bilateral hernia surgery - to avoid lifting more than 10-15 lbs. for 3-4 weeks and no bending over. The car ride home was a little rough, mostly because I couldn't use my abdominal muscles to stabilize myself when we hit bumps. You really don't appreciate how and when you use your abdominal muscles until it hurts to do so. I now whole-heartedly sympathetize with people who have had C-sections - and actual muscles weren't even cut during my surgery!
Soon after we got home, I began to feel extreme nausea, which progressed to vomiting multiple times. I realized it was probably due to the Percocet (to which I've had bad reactions before) and immediately stopped taking it. We called the hospital and talked to the plastic surgeon resident on call, and he said that if it didn't get better by the next morning, I would have to go to the ER. The main concern was that I couldn't hold anything down, meaning I couldn't take the antibiotic that was very important due to having foreign bodies (expanders) put in.
Friday, February 6, 2009 - 1 Year, 7.5 Months Post-op : 10.5 Months Post-1st-Revision : 2 Days Post-2nd-Revision
I didn't feel any better in the morning, despite stopping the pain medication. So, we went back to the hospital and spent most of the day there. They put in another IV and gave me IV anti-nausea medication as well as the antibiotic I was supposed to have been taking orally. They also took two sets of abdominal x-rays and diagnosed constipation, a common sequela of surgery and pain medications. The threatened to re-admit me if the nausea couldn't be managed, but later on in the afternoon I was able to drink some apple juice and hold it down. I was released in the early evening and went back home to sleep. Luckily, after stopping the pain meds and returning home, things slowly began to improve.
Tuesday, February 10, 2009 - 1 Year, 7.5 Months Post-op : 10.5 Months Post-1st-Revision : 6 Days Post-2nd-Revision
I had my first post-op appointment with both the urologist and the plastic surgeon. My catheter was removed (yay!) and was allowed to urinate normally, with no sign of leakage from the stitched-up site on the shaft of the penis. I also gave a urine sample to check for any cystitis that may have developed from the catheterization, but that came back clean! I was instructed to put globs and globs of Bacitracin around the entire shaft 2-3x per day for 7 days and to come back in 3-4 weeks.
The post-op appointment with the plastic surgeon was mostly to take care of the chest surgery revision, but he did remove the dressings on the inguinal incisions and said they looked good.
Tuesday, February 17, 2009 - 1 Year, 8 Months Post-op : 11 Months Post-1st-Revision : 13 Days Post-2nd-Revision
I had my first tissue expansion appointment with the plastic surgeon. I was more scared than I expected, but I think that is because I was anxious about what it was going to feel like and the actual process of putting in the saline. They had given me EMLA cream (topical lidocaine and prilocaine) to apply 30-45 minutes before my appointment to help numb the skin. The entire process was quite simple, really. I laid on a table and they cleaned the areas of my skin over the ports, where I had applied the topical anesthetic cream. He inserted a small butterfly needle into the port (felt like a vaccination shot), drew back on the syringe plunger to make sure he was indeed in the right place (there is blue dye in the saline inside the expanders), then slowly began injecting saline into the expanders. The amount they were going to inject was determined by when I felt it stretching or painful in the stretching scrotal skin. When I told them it was beginning to hurt, they stopped injecting saline - and that was at 10 ml of saline injected. The process was repeated for the other side, again stopping at 10 ml. That was it.
He said to expect it to be sore for a few days, but by the next week it should be nice and loose again so they can expand more. If it doesn't hurt too much, maybe they'll inject more next time. If it hurts a lot, they'll do less. There isn't one hard and fast rule about how much to inject and how often - it is determined by each patient's skin and its ability to withstand the stretching process.
The majority of the pain now is not in the scrotal sac where the tissue expanders are, but rather on the inside of my left leg around where the scar from the first revision is. Also, the pubic area is still swollen and sensitive to the touch, probably due to the tissue manipulation during the surgical process. Both of these areas right now are so sensitive that anything that even touches them (underwear, pants, etc.) is painful. I'm hoping this is just from the surgery itself and will resolve in time. The actual expansion process hasn't been that painful so far.
Tuesday, February 24, 2009 - 1 Year, 8 Months Post-op : 11.5 Months Post-1st-Revision : 20 Days Post-2nd-Revision
The second tissue expansion was intensly more painful than the first. After the first one, it was painful/confomfortable for maybe a couple hours - but this time, it was stabbing, cringing, give-me-pain-meds-NOW painful. Luckily, it was managed well with some Aleve and only lasted about a day. But boy that day was intense. As with the first time, 10 ml of saline was injected into each side.
Tuesday, March 3, 2009 - 1 Year, 8.5 Months Post-op : 11.5 Months Post-1st-Revision : 27 Days Post-2nd-Revision
The third tissue expansion went better than the second. I took some Aleve about an hour before going, then took one more right after I left, hoping to take advantage of the idea that pre-emptive analgesia results in better pain relief than if you wait to take pain meds until it hurts. It definitely seemed to work, because even though they put in the same amount (10 ml each side), it wasn't nearly as painful. It was definitely uncomfortable, especially on the left side (the left side was the one that did not drop properly), but it was also definitely not as intense.
My theory (which turned out to be wrong) as to why the the second expansion was so much more painful than the first was because maybe during the surgery they only put in 10 ml or so (the old implants were 18 ml each). Therefore, at the first expansion, the total would only have been about 20 ml (and no real stretching would have occured). Then, at the second expansion where 10 more mls were put in, that's when I started to really feel the expansion. So I asked my doctor how much was put in during surgery, and he said 20 ml in each! So, my theory was wrong - and maybe it wasn't as painful the first time because I was still very numb from the surgery. Anyway, that brings the total to 50 ml each side.
Tuesday, March 10, 2009 - 1 Year, 8.5 Months Post-op : 1 Year Post-1st-Revision : 34 Days Post-2nd-Revision
The fourth tissue expansion went very similarly to the third. Taking Aleve about an hour before going, then taking another one after leaving, was definitely key to managing the pain of the expansion. Another 10 mls were put into each expander, bringing the total to 60 ml each side. My doctor also mentioned that 70 mls each may give sufficient expansion to do the surgery with the goal of having one, joined scrotal sac without the implants riding too high.
Tuesday, March 17, 2009 - 1 Year, 9 Months Post-op : 1 Year Post-1st-Revision : 41 Days Post-2nd-Revision
The fifth tissue expansion was similar to the past few. Minimal pain with the pre- and post-Aleve. As usual, 10 mls were put into each side, making the total 70 ml each. The right expander is sitting much higher than the left, which is ironic becuase it was the left implant that had healed way too high and prompted these revisions/expansions. My doctor assured me it shouldn't be a problem to manipulate that skin to where it should be. Also, because I reached the 70 ml "goal," he said I could cancel my next two expansion appointments if I wanted. I'll most likely do just one more expansion, then cancel the last one.
Friday, March 27, 2009 - 1 Year, 9 Months Post-op : 1 Year Post-1st-Revision : 51 Days Post-2nd-Revision
I decided to have one more expansion, even though my plastic surgeon said he thought 70 mls each would be enough to create a joined-looking scrotum. Since one implant healed way too high the first time, I wanted to give it a good chance to prevent that from happeneing again. I'd really like both implants to sit below the penis itself, not next to it in any way. He also mentioned there will be some retraction of the skin over time so I figured one more expansion probably couldn't hurt. I've been tolerating it well, so might as well give it a go.
This sixth (and final!) tissue expansion was similar to the rest. Each side received 10 ml, putting the total at 80 ml each side. The next step is the 3rd (and *hopefully* final) surgery to replace the tissue expanders with permanent testicular prostheses, which is scheduled for April 6, 2009.
Monday, April 6, 2009 - 1 Year, 9.5 Months Post-op : 1 Year, 1 Month Post-1st-Revision : 2 Months Post-2nd-Revision : Day of 3rd Revision
Being an outpatient surgery, the procedure was scheduled for 1:00pm instead of early morning. The anesthesiologists started the IV, and I saw my plastic surgeon before they wheeled me into the operating room. During the surgery, they removed the tissue expanders on both sides, joined the two sides of the scrotum to make it one sac, and put in new, size small, testicular prostheses. They used the same inguinal incisions as the second revision surgery so no additional scars were created. The bandages were minimal, only steri-strips over the incisions. I woke up in the recovery area, and was discharged that evening.
Thursday, April 16, 2009 - 1 Year, 10 Months Post-op : 1 Year, 1.5 Months Post-1st-Revision : 2.5 Months Post-2nd-Revision : 10 Days Post-3rd-Revision
My first post-op appointment with the plastic surgeon went well. Both implants look like they are sitting pretty high, but my surgeon said he thinks they will drop over time. This certainly was the case after the original surgery in 2007, so I'm hoping that's true for this time as well...just that they both drop instead of just one. The right one seems higher than the left (was the opposite before surgery) so time will tell how they heal.
Thursday, May 14, 2009 - 1 Year, 11 Months Post-op : 1 Year, 2 Months Post-1st-Revision : 3 Months Post-2nd-Revision : 38 Days Post-3rd-Revision
Another post-op appointment with my surgeon went well. The right implant is now sitting much higher than the left, even higher than the left one was before this set of expansion surgeries. My surgeon said to keep pushing it the implant down to encourage it to heal in a more down position. The joined scrotum looks very nice, though I wish both implants were actually in the scrotum. My surgeon remains very positive about it dropping and ending up in the scrotum.
Thursday, September 10, 2009 - 2 Years, 3 Months Post-op : 1 Year, 6 Months Post-1st-Revision : 7 Months Post-2nd-Revision : 5 Months Post-3rd-Revision
The right implant still has not dropped properly, and it is definitely higher than the left one was pre-surgery (the higher of the two pre-expansion revision), and the right one now causes the same discomfort that the left one used to. I find this very disappointing. My surgeon was very surprised that it healed so high, because he said he really tacked it down and closed off the area above it so it wouldn't slip up. Even though the left implant is lower than the right one now, it is still very next-to the penis itself, not entirely below it as most testicles are. I had really hoped that after all the time and pain with expansions, that I would have ended up with a somewhat hanging scrotum with two testicles in it. The recommended plan of action is to repeat the entire two surgeries: one to put expanders back in, then another to replace the expanders with implants; although this time, we would expand the skin a lot to make sure there would be plenty. I really don't know if I'm up for all of that again at this time. However, if I were to pursue it, I would want to do it with the same surgeon as I already have an established relationship with him and the hospital.
Tuesday, January 19, 2010 - 2 Years, 7 Months Post-op : 1 Year, 10 Months Post-1st-Revision : 11.5 Months Post-2nd-Revision : 9.5 Months Post-3rd-Revision
I had another consult with my plastic surgeon who again agreed that re-doing the skin expansion and replacing the implants over another two surgeries was probably the best bet in terms of achieving a somewhat normal scrotum. As it stands, one of the implants sits almost completely above the penis itself, basically over the pubic bone. I don't think this is a satisfactory result. I decided to re-do the process of replacing the implants with tissue expanders, expanding the skin over a number of weeks, and then replacing the skin expanders with the implants. This time we decided that we will really overstretch the skin because it seems like my tissue there wants to recoil a lot. Hopefully I just won't end up with a huge saggy scrotum, but at least that wouldn't be as uncomfortable as one of the implants constantly over my pubic bone. Surgery was scheduled for early March 2010.
Please see Revision Surgeries 4 & 5 for the continuation of my written experience.