From
Dr. Lee Ponsky
Essential urology for general surgeons with Drs. Ponsky and Cherullo
With Dr. Lee Ponsky & Dr. Edward Cherullo · hosted by Dr. Todd Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Testicular torsion should be treated like appendicitis—it is never wrong to explore a scrotum in fear of torsion to fix it.
Testicular torsion classically appears at ages 10-11, 12-14, 15-16 when testicles grow during puberty; very rare when older or younger.
In very early torsion, ultrasound can still show arterial flow because the pathology is venous outflow obstruction first, then arterial inflow obstruction.
In very young children (1-2 years old), ultrasound may show false positive for torsion because the testicular artery is so small that no flow is identifiable.
Untwisting a torsed testicle is like opening a book—twist toward the ipsilateral thigh.
Fix the torsed testicle with non-absorbable fine suture, usually 5-0 Prolene, to dartos fascia to prevent re-torsion.
Pex the contralateral testicle because it may have the same anatomic abnormality that caused torsion on the first side.
Manual detorsion by twisting the testicle to the ipsilateral thigh can provide immediate relief and the surgeon will feel the testicle de-twist, but operative fixation is still required.
It is almost never wrong to order a scrotal ultrasound for testicular pain because it is the best test to ensure anatomically nothing is wrong and helps reassure the patient.
For chronic testicular pain with normal anatomy, treatment is scrotal support, sitz baths, and a 6-week anti-inflammatory taper starting at high dose, with 80% success rate.
Pneumaturia is a clear sign of colovesical fistula, though patients may not understand what is happening and need to be asked about it.
On cystoscopy for colovesical fistula, it is a minority of the time that you see an obvious large defect—often it is a pinhole and very difficult to identify.
The pathophysiology for colovesical fistula creation is almost always colorectal (chronic diverticulitis, colon cancer, inflammatory bowel disease)—very rarely is the primary pathology urologic.
Pinhole bladder defects from colovesical fistula do not require closure—patients do well without transmural abscesses or fistulization to staple lines.
Any permanent material in the urothelial tract (staples, Ethibond, Prolene) will collect urinary salts and start to form stones.
Bladder closure uses absorbable suture (2-0 or 3-0 Vicryl), closed in two layers in a watertight fashion, can be run or interrupted—bladder is very forgiving tissue.
After bladder repair, upsize Foley to 20 Fr for excellent drainage, leave a drain, and study the patient with cystogram on day 4-5 before discharge; with no leak, drain and catheter come out.
For postoperative urinary retention after straightforward abdominal surgery, recommend starting all patients on an alpha-blocker (tamsulosin or Rapaflo for quicker onset).
Trial-of-void involves filling the bladder through the catheter with 200-300 cc, removing the catheter, and measuring void—acceptable if less than 100 cc residual urine.
Postoperative urinary retention often unmasks underlying BPH or other lower urinary tract problems that patients were not aware of before surgery.
With blood at the meatus or pelvic fracture, do not instrument the urethra—get a retrograde urethrogram first to assess urethral integrity.
Urethral injury from pelvic trauma typically occurs at the point where the urethra enters the external sphincter (GU diaphragm) at the apex of the prostate.
Blind catheter placement with blood at meatus can convert a partial urethral tear (which might heal spontaneously) into a complete tear, with long-term sequelae including incontinence and impotence.
If a urology resident got blood at the meatus and did not get a retrograde urethrogram, 'we would kill them' because trying to advance a catheter without visualization could cause complete disruption.
Retrograde urethrogram requires fluoroscopy (C-arm), contrast material, Foley catheter placed just within the urethral meatus, patient obliqued if possible, inject contrast under fluoroscopic guidance to visualize entire urethra and contrast entering bladder.
If orthopedics will use hardware to plate the symphysis or fractured pelvis, try not to place suprapubic tubes because of infection risk to their hardware per literature.
For renal trauma, try to avoid surgical exploration unless forced—angioembolization is preferred for partial injury to save some kidney.
If patient is unstable and bleeding from renal trauma, control the hilum of the kidney (through root of mesentery if needed) and often this results in nephrectomy.
Urologic trauma, whether urologist present or not, is almost always managed non-surgically and supported by good level evidence.
Ureteral repair is not an emergency—it can be put on the back burner until other bleeding or issues are controlled.
For ureteral injury, dissect out both ends of the ureter and assess whether there could be multiple injuries or dissection of different portions.
Thermal ureteral injury requires excision of affected areas because of risk of delayed necrosis; non-thermal injury does not require excision.
The ureter has watershed blood supply—best at the upper ureter (near kidney) and lower ureter, worst in the mid-ureter.
For ureteral repair, spatulate the ends, use fine absorbable suture (not permanent to avoid urothelial stone formation), run or interrupt, place over a stent (usually 26 Fr double-J stent), and leave a drain.
Pass the double-J stent up to the kidney through the defect, pass the lower end to the bladder, confirm with X-ray or cystoscopy that proximal end is in kidney and distal end is in bladder.
To temporize ureteral injury without urologist: put a big clip on the end of the ureter and place percutaneous nephrostomy tube, or leave the divided ureter end open with a drain (less ideal because it creates inflammatory response).
If one ureter is divided, there is a chance the other ureter was also divided—not a rare occurrence in urologic literature—so always check the contralateral ureter.