Ryan P. Terlecki, MD, FACS, presented “Pitfalls in Perineal Surgery” during the 41st Annual Ralph E. Hopkins Urology Seminar on February 4, 2022, in Jackson Hole, Wyoming.
How to cite: Terlecki, Ryan P. “Pitfalls in Perineal Surgery.” February 4, 2022. Accessed Dec 2024. https://grandroundsinurology.com/pitfalls-in-perineal-surgery/
Pitfalls in Perineal Surgery – Summary
Ryan P. Terlecki, MD, FACS, Vice Chair and Associate Professor of Urology, Director of the Men’s Health Clinic, Director of Medical Student Education, and Fellowship Director for Reconstructive Urology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, discusses perineal surgery and key elements of preoperative planning to optimize the surgeon and patient experience while highlighting some intraoperative technical considerations to facilitate efficiency. He advises practitioners to choose patients commensurate with their own experience, to prioritize risk reduction, to under-promise and over-deliver, and to maintain technical poise. Dr. Terlecki addresses helping patients set expectations, which is dependent upon the patient’s preoperative level of suffering and upon the definition of success. He discusses patient preparation and the importance of doctors investing time to understand their patients as well as his own requirements, such as patients undergoing urine testing and suspending blood thinners preoperatively. He underlines the importance of clearly laying out the process—from start to finish—for the patient. He also warns of the “CURSED” patient—one who is compulsive-obsessive, unrealistic, revision-seeking, surgeon-shopping, entitled, and in denial. Dr. Terlecki then turns to optimizing the operating room through organization and aiming for what he calls “SWEET”; doing things the same way each and every time. He suggests video primers for support staff and an instrument and equipment checklist as well as pre-gaming with anesthesiologists and paying special attention to patient preparation. He addresses antibiotic stewardship before shifting to some technical items, highlighting the challenge of working in tight spaces during perineal surgery and the importance of surgeons freeing their hands and not struggling. Dr. Terlecki discusses the importance of illumination and magnification but advises surgeons to be mindful of ergonomics and equipment weight. Dr. Terlecki discusses considerations when doing artificial urinary sphincter (AUS) surgery, such as challenges when a patient has had a prior sling, before turning to combination cases (sling or AUS with inflatable penile prosthesis [IPP]). Here, he advises surgeons to accomplish the sling part of the operation first, noting that single-incision approaches are problematic and there are implications for the patient, the surgeon, and the hospital. Dr. Terlecki offers several items that allow for more efficient use of the surgeon’s time during urethroplasty. For example, surgeons should know whether the repair is an anastomotic repair or a substitution repair. He prefers scoping before and during the procedure to avoid a suboptimal incision site and addresses instruments that can be helpful throughout surgery. Dr. Terlecki then turns to the principles for urethral surgery, and poses a question for practitioners’ consideration: “If this was going perfectly, what would it look like?” He closes by citing Sir William Osler who advocated for equanimity, meaning the ability to calmly assess a situation, determine the best course of action and correction, and then to move forward. Dr. Terlecki discusses the importance of asking for help when needed, emphasizing that reaching out also helps build relationships and is a sign of excellence, not weakness.
About The 41st Annual Ralph E. Hopkins Urology Seminar:
The Ralph E. Hopkins Urology Seminar is a multi-day meeting focused on training urologists in the latest in assessing, diagnosing, and treating urologic conditions in the clinical setting. Updates are provided on urologic cancers, stone disease, urologic reconstruction, female urology, infertility, emerging surgical techniques, and general urology. Dr. Terlecki presented this lecture during the 41st iteration of the meeting on February 4th, 2022 in Jackson Hole, Wyoming.
For further educational activities from this conference, visit our collection page.
ABOUT THE AUTHOR
Ryan P. Terlecki, MD, FACS, is a reconstructive urologist for Atrium Health Wake Forest Baptist Medical Center, an academic Level 1 trauma center in Winston-Salem, North Carolina. Dr. Terlecki holds the rank of Professor and the title of Vice Chair of Research for the Department of Urology. In addition, Dr. Terlecki is Director of the Men’s Health Clinic, Director of Medical Student Education, and Fellowship Director for Reconstructive Urology. He holds a joint appointment in the Department of Obstetrics and Gynecology.
Dr. Terlecki earned his medical degree from Wayne State University School of Medicine and completed residency in general surgery and urology at Detroit Medical Center. Following his residency, Dr. Terlecki completed two separate fellowships in reconstructive surgery. He completed a fellowship at the University of Colorado’s Denver School of Medicine and at UT Southwestern Medical Center in Dallas, Texas.
Dr. Terlecki’s publications cover multiple areas of trauma and reconstruction and his research is focused primarily on models of wound healing and regeneration in the lower genitourinary system. Dr. Terlecki’s areas of expertise include urethral stricture disease, male sexual dysfunction, male incontinence, Peyronie’s disease, chronic testicular pain, hypogonadism, and infertility. He is a member of the Society of Genitourinary Reconstructive Surgeons (GURS), a member of the American Urological Association (AUA), and past president of the North Carolina Urological Association (NCUA).
