twisted testicles

testicular torsion, to put it mildly, is a terrible condition. the testis twists around on its axis, cutting off its own blood supply. over and above the excruciating pain, if it is not operated within about six hours of it happening, well then you can pretty much kiss that testis goodbye. and to make things worse, it strikes young boys who have just entered puberty while they are awkward and unsure of themselves. it is seldom that they ask for help until long after it is all to late. at least that makes the operation easy... you simply cut out the necrotic testis, easy as pie. but at the operation, it is always important to remember that if the one testis has twisted, the other one tends to follow suit in due course, so, while chopping out the twisted testis, it is absolutely imperative that you suture the other testis to the scrotum so that it can't twist. of course if you omit this step, in all probability, in a few years time, the poor awkward teen is going to loose his second testis and this is really going to mess with his mojo, pretty much for the rest of his life.

but testicular torsion is not something that i deal with all that much. you see the condition falls into the realm of the urologists and if these humble creatures are to be found in your local hospital, then torsions go their way. however, even mighty urologists need to take time off. then us humble general surgeons step up and cut out on their behalf. recently i was put in this position and handled a testis torsion. but it reminded me of another one i dealt with a few years ago.

the patient, an eighteen year old young man, turned up at casualties about 20 minutes after developing excruciating pain in his right testicle. on examination it was clearly a torsion. but what i noticed immediately was the missing left testicle. i asked him about it.

as it turns out the patient had had a similar problem with the left testicle about a year previously. then, as was typical of young men of his age, he had waited a full day before he worked up the courage to go to hospital to seek help. of course the left testicle was already necrotic and had to be removed. the urologist tending to him at the time had done the right thing to the right testicle and fixed it to the scrotum so that it would not twist like its troublesome left counterpart. but still here i was faced with a patient with only one testicle and that one was twisted and in real danger of moving on to the hereafter (testicle heaven). also the urologist had previously operated the patient and, despite that, his remaining jewel was in danger. now that all the urologists were gone or on leave or dead or whatever, what chance did that poor nut have in my mere general surgeon hands? yet i felt the necessary urgency of the moment. one testicle is bad enough, but none??? unthinkable!!! i booked him for theater and demanded immediate theater time (something somewhat more scarce and valuable than fine gold in south africa).

surprisingly, soon i found myself (and the endangered testis) in theater. i opened the scrotum. the testis was twisted as i knew it would be, but, luckily, it was still viable. what was interesting was that the stitch that the urologist had placed a year or so earlier was still there. the testis had managed to rotate around the axis created between the stitch and its blood supply. this was clearly a testis hell bent of causing havoc and depriving its owner of full manhood. i was not about to let it do that.

i twisted the testicle back to its natural position, but somehow i needed to keep it there. one standard stitch by a urologist clearly had not been sufficient. luckily i was not a urologist. i would not be shown up by some young, single, upstart testicle, especially when my patient's very manhood rested on my actions. i fixed it and i fixed it good.

i replaced the urological stitch, then i placed four more stitches at the four points of the compass. i felt pretty sure that nothing would convince that testis to twist again. yet i still wasn't willing to take the chance of this young lad having to face life without all the questionable advantages of testosterone, so i felt compelled to do more. i used my cautery to burn multiple small scars into the surface of the testicle so that once i closed it in the scrotum, each little scar would attach to the scrotum, fixing it absolutely and permanently so that there would be and could be no question of any further gyrating and twisting. that testicle would do nothing without the scrotum knowing about it. i felt good. i had done my (or rather the urologist's) job and i had done it well. i had made a difference to a small testicle and his boy.

the next monday when the urologists had come streaming back from their no doubt deserved respite, they were quite eager to hear if i had handled anything for them. when i relayed the story of the stubbornly rotating testicle to the very one who had placed the first stitch a year or two previously, to no avail, apparently, i was not impressed when he questioned if i had sufficiently fixed the testis in place.

"are you sure that testicle won't rotate again?" he asked.

"no, i am not!" i replied, "but i can assure you if it tries to rotate again, it's going to take the whole patient with it, so look out for a guy walking down the streets doing a pirouette every so often and you'll know that's the guy i operated!"

the urologist

i sometimes reckon i'm quite the urologist. but i'm not. even when i was rotating through urology i would often visit the general surgery tea room. i missed my real work i suppose. but the guys seemed to know i liked hanging out with the urologists and sometimes raged me a bit. i remember the one senior registrar trying to give me a hard time the one day when i visited the general surgeons.

"hi bongi. how's urology going? have you played with any good penises today?" i couldn't let that slide.

"no, but then again i haven't been home yet." he was floored.

but i realised more recently that i'm not really a urologist. it was a gunshot in the state hospital. it was the usual type of thing requiring time systematically repairing the multiple holes in the small bowel. but this case had a little bit more than just small bowel injuries. the bladder was hit too. the medical officer felt that that was beyond his scope and asked me to handle it.

gunshot injuries to the bladder aren't all that difficult, but one thing to remember is that there are always two holes in the bladder and it's the hole at the back that can be slightly more challenging. i opened the bladder by simply extending the anterior hole left by the bullet. the exit wound was clearly visible, but there was a problem. the bullet had exited the bladder exactly where the left ureter (the pipe carrying urine from the kidney to the bladder) enters the bladder. it had pretty much shot the ureter off the bladder leaving it to leak urine from its frayed end into the area behind the bladder. i honestly had a moment when i wished i could call a urologist, but that option wasn't open to me. there was no urologist doing calls in the state hospital, so i would have to sort out the problem myself.

one thing that is important when working with the ureter is to place a pipe in it to sort of stent it while it heals. the urologist have a nice pipe called a double j stent that they routinely use, but we had no such thing there that night. the other problem with a double j stent is that you need to do a cystoscopy to remove it at a later stage. although the visiting urologist could probably do that i didn't like the idea of placing something in the patient that i myself couldn't remove. i came up with a plan.

i dissected out the ureter above where it had been shot off, cleaned it up nicely and reimplanted it into the bladder over a thin tube we call a feeding tube (named after the fact that it is used to deliver food directly into a baby's stomach). this tube i then pulled out straight through the abdominal wall. when i wanted to remove it all i'd need to do would be to pull it out. the hole in the bladder would heal and all would be well. i was super impressed with my ability to think on my feet. the medical officer was also duly impressed. we closed up and i went home.

i was super keen to 'accidentally' run into my urologist friend the next day at the private hospital to tell him about my brilliant improvisation so i spent extra time on rounds wandering the corridors with the hope of seeing him. finally just by orchestrated chance i did run into him. i proudly told him about what i had done in the absence of a double j tube and how it meant i would be able to remove the tube easily in the ward later without the need of another anaesthetic. i was so impressed with myself.

"bongi, that is a well known technique which we sometimes use." my bubble was good and truly burst.

yep, i'm not a urologist. not only do i not know all their fancy techniques, but in the end i feel i must admit i have the fragile ego of a general surgeon.

running with the big dogs

on the topic of urologists, sometimes we actually do operate together. it happens seldom but it does happen. it is actually usually during these operations that i realise i no longer enjoy assisting so much. i think it has something to do with the surgical personality. you see we don't like to play second fiddle. it's a bit boring. having said that, when assisting the urologists, boring is what you want. the alternative can be quite terrifying. i mean there is usually a good reason that the urologists ask the big dogs to accompany them to theater.

i was senior registrar. one of the other firms had some sort of dispute with the urologists about a patient. you see after both disciplines reviewed the ct scan of the patient, the urologists felt it was clearly an inflamed gallbladder that was the problem and the surgical firm felt it was an inflamed kidney. neither one wanted to actually operate the guy. finally the boss intervened. he told the surgical registrar to take the guy to theater and call the urologists if necessary. the fact that the registrar in the relevant firm was a junior and could hardly take out a straight forward gallbladder didn't worry the boss too much. he simply instructed me to assist in the operation. not that i had a choice but i consented. however i decided i would be doing no assisting. if i had to be there then i was going to bloody well operate myself.

the gallbladder part of the operation was a walk in the park. it was completely normal and practically climbed out of the abdomen on its own. of course as soon as we saw that it was in fact the kidney that was inflamed we called for the urologists. things were looking up for me. i had it planned. as soon as the urologists arrived i was going to hit the road and leave the junior surgical registrar to assist. after all it wasn't even my patient. also, the boss wouldn't be looking for me for the rest of the day so i could catch a beer with a friend at the local tavern. i could already taste it.

the urologist registrar entered. he was a good friend of mine and as i took off my theater gown and gloves we exchanged a few laughs. but then their prof walked in. i was a bit surprised. they were obviously taking this kidney quite seriously. or at least more seriously than when they reviewed the ct scan. i stayed to see whether the prof was going to scrub in. he did. i should have left then but i sort of hung around for a while.

suddenly their prof looked up at me.

"aren't you a senior in the surgery department?" i considered lying. to say yes could only lead to trouble.

"yes." it led to trouble.

"well then scrub in. you can't go now. i need you here to look after the ivc." absolutely great!! i thought. now not only would i miss out on a beer but i would end up assisting anyway. again it wasn't really as if i had a choice, so quite soon i was scrubbed up and standing opposite the prof as he wrestled with the kidney. it was then that i realised why they had brought their prof along. the kidney seemed angry, very angry.

the inflammation and fibrosis around the kidney was immense. there were no normal anatomical planes but instead everything just adhered to everything else. one of those everythings was the ivc. i understood that the prof was worried about it. i was too.

finally he lifted the kidney out free of the patient. the urologists let off a whistle of congratulations but i remained silent as did the prof. you see i was watching his other hand which shot into the wound as the kidney came out to put pressure on the ivc amid a sudden torrent of blood. also as he passed the kidney off he didn't remove his hand from the wound. there was something under that hand and it was something that wasn't going to lie down without a fight. then coolly and calmly spake the prof.

"i think i have torn the ivc." he said it as if it wasn't a problem, as if it wasn't something that often was followed by the ending of life. i was amazed that he could be so calm when faced with such a calamity. and then i found out why. he looked at me.

"that's why you are here," he said, "it's your job to fix the ivc." he was calm when faced with such a calamity for the simple reason that he was not faced with such a calamity. i was. the realization set into my heart like a pick axe. i felt nauseous. i thought of that beer that i was busy not drinking because i was required to somehow perform a miracle on a patient that was never mine. but it didn't help to bemoan my position or to shy away from this immense responsibility that had been thrust upon me. i had to put my head down and fix it.

i fixed it. i remained calm on the outside and got to work and got the job done. but i think i shaved a few years off my life during that operation. when i was finished i was exhausted. i left the junior to close and finally went for that long overdue beer.