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2. medicine
3. surgery

Chapter 33
Surgery of the Penis and Urethra
continued
C Fitzgerald
GCH Uro 1
Overview
 Distraction injuries of the urethra
 Posterior urethral reconstruction
 Vesicourethral distraction
 Vesicourethralrectal fistula repair
 Repair of congenital curvatures of the penis
 Phallus reconstruction/transsexualism
Distraction Injuries of the Urethra
 Membranous urethra (junction of membranous bulbous




urethra)
Blunt trauma; straddle injury
Pelvic fracture (10%)
Prepubescent prostatic urethra disruption
Endoscopic stabilization with aligning catheter
(Kielb 2001)
Distraction Injuries of the Urethra
 Evaluation
 Depth
 Density
 Length
 Location
Contrast studies
 Cystogram
 Voiding cystogram, RG
urethrogram
Endoscopy
 + Antegrade endoscopy
 + MRI
Posterior Urethral Reconstruction
Goal:Primary anastomosis
>90% success rates
 Time frame 4-6 months
 Perineal approach
 Avoid abdominal perineal
and transpubic
 Avoid pubectomy
 Erection/pelvis
destabilization
 Penile shortening
 + Chronic pain syndrome
 Classic:




Perineal approach
Primary reconstruction
Spatulated anastomosis
Prox ant urethraapical
prostatic urethra
 Others:
 Endoscopic “cut-for-light”
(Levine & Wessells 2001)
Posterior Urethral Reconstruction
 Pre-op endoscopy r/o stones
 Evaluate bladder neck (reconstruct + scar)
 Exaggerated dorsal lithotomy position
 Advance rigid scope through bladder neck to perineum/area
of obliteration (+ vesicostomy)
Figure 33-44 Diagram of a perineal repair of a membranous urethral stricture. A λ incision extends from the midline of the scrotum to the ischial tuberosities. A, Colles' fascia has been opened to expose
the midline fusion of the ischiocavernosus muscles and the tunica of the corpus spongiosum distal to the edge of the muscles. B, The scissors are introduced to develop the space between the muscle and the bulb
of the urethra. C, An incision is made in the midline with the scissors, exposing the length of the bulb. D, The ischiocavernosus muscle is retracted to expose the full length of the bulb. E, The self-retaining
retractor is placed to expose the inferior fascia of the genitourinary diaphragm. The bulb of the corpus spongiosum (bulbospongiosum) can now be mobilized to gain access to the fibrosed area of the urethra. F,
The fibrosed urethra is incised, freeing the bulb. G, The anterior urethra is opened to make an adequate lumen. H, The Haygrove staff has been passed through the suprapubic cystostomy. Resection of the
fibrotic distraction defect has allowed it to pass into the perineum.
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Figure 33-45 Division of the triangular ligament and development of the intracrural space. When the prostatic urethra is displaced and the arc that the urethra must traverse needs to be shortened, that length
can be shortened by incision of the triangular ligament (A). B, Incision and mobilization of the perichondrium and periosteum of the symphysis pubis to allow placement of retractors without trauma to the
erectile bodies. Lateral displacement of the crura will expose the dorsal vein of the penis; after careful identification, the vein can be ligated and divided. C, Completion of the dissection affords additional
exposure for resection of the fibrosis that surrounds the apex of the prostate and the proximal end of the disrupted urethra. (A to C, from Jordan GH: Reconstruction of the meatus-fossa navicularis using flap
techniques. In Schreiter F, ed: Plastic-Reconstructive Surgery in Urology. Stuttgart, Georg Thieme, 1999:338-344.)
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Figure 33-46 Infrapubectomy. If the prostate is elevated behind the symphysis pubis (A), the inferior aspect of the symphysis is resected with a Kerrison rongeur. As much of the bone can be removed as
necessary (B) to afford a simple approximation of the ends of the urethra (C).
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Posterior Urethral Reconstruction
Post Op management
 SP cystotomy diversion
 small urethral catheter stent
 Bedrest 24-48 hours
 DC with anitcholinergics/abx
 Voiding trial in 2-4 weeks
 Antegrade contrast; evaluate for extravasation, PVR
 Cx, if successful remove SP in 5-7 days
 Follow up
 Flexible endoscopy 6 and 12 mo
 Postop RG studies avoided, use flexible endoscopy
 Address post operative incontinence
Posterior Urethral Reconstruction
 Cure rates 90%
 Failures assc with ischemia/stenosis of proximal corp
spongiosum secondary to vascular pedicle (dorsal artery)
compromise
 Worst outcomes BL complete obstruction of the internal
pudendal artery, reconstitution UNI/BL gd outcomes
 Evaluate with duplex US
 Normal; uni or BL pudendal integrity; gd reconstruct
candidates
 Limited flow  increased risk of BL obstruction with/without
reconstitution. erectile dysfunction, + ischemia risk. Require
pudenal arteriography
Figure 33-48 Diagrammatic representation of the deep vasculature of the penis. A, In the normal situation, via the common penile artery, flow is directed to the tip of the penis with arborization into the spongy
erectile tissue of the glans penis. This provides retrograde flow into the corpus spongiosum. If the arteries of the bulb are intact, there is also antegrade arterial flow to the corpus spongiosum. B, With
interruption of the arteries to the bulb and mobilization of the corpus spongiosum, all flow to the corpus spongiosum is retrograde via the common penile arterial system. C, In the case of hypospadias, in which
the distal corpus spongiosum may have been interrupted, with proximal mobilization of the corpus spongiosum and therefore division of the arteries to the bulb, even if the common penile circulation is intact
to the tip of the penis, it may not adequately provide retrograde vascularity to the corpus spongiosum; hence, ischemic stenosis can ensue. D, In the case of injury to the common penile artery, with elevation of
the proximal corpus spongiosum and division of the arteries to the bulb, blood flow to the proximal corpus spongiosum may not be adequate, leading to ischemic necrosis or ischemic stenosis.
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Repairing Distraction Injuries of the
Urethra in Children
 Perineal
or
 Posterior, sagital transsphinteric approach
(Mathews et al 1998 and Pena and Hong 2004)
Vesicourethral distraction defects
Risks
 radical prostatectomy,
obesity, small, thick
bladder
Evaluate
 Antegrade endoscopy
 RG urthrography
Initial management; often
suprapubic cystostomy
Vesicourethral distraction
Treatment
Goal: functional reconstruction
Other options
 Endoscopic (laser, cold knife)
 Continent catheterizable bladder
 Diversion
Functional reconstruction Vesicourethral
distraction
 Position; low lithotomy; 2 surgeons
 Abd-perineal combined approach
Low midline incision, expose bladder, dissect from lateral walls, mobilize beneath pubis
 Open peritoneum and develop retrovesical space
Perineal incision (posterior triangle); dissect along anterior rectal wall until prior
anastomosis site identified
 Dissect region of distraction defect off rectum
 Resect fibrosis, marsupialize bladder epithelium through a vesicostomy
Primary anastomoses of the bladder to the membranous urethra
 Sutures in urethral stump, stenting catheter
 Omental flap at site of anastomosis
 Seat anastomoses
Figure 33-50 Reconstruction for vesicourethral distraction. Exposure is gained using an abdominal-perineal approach. The perineal dissection is through the posterior perineal triangle. The area of the
distraction defect is dissected from the rectum and then isolated. The area of fibrosis is resected. A primary anastomosis of the bladder to the membranous urethra is performed. Omentum is placed to surround
the reanastomosis.
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Post op; Vesicourethral distraction
 D/C to home
 urethral catheter stent
 suprapubic catheter
 Reevaluation 4-6 weeks
 Fill antegrade
 Remove urethral catheter
 Complications
 Incontinence, fistula, restenosis
Complex Fistulas of the Posterior
Urethra
 Vesico/urethrorectal fistula
Repairs
 Radical prostatectomy; +
 Functional reconstruction;
radiation/brachy
 Most small
 Repair Approach
 Transperineal
 Transanal-sphincteric
 Posterior
bladder to membranous urethra
• Diversion w/ileal conduit
• Bladder augmentation with
continent catheterizable
channel
• + colostomy or J pouch
coloanal anastomosis
• Omental, peritoneal, rectus
abdominis mm flaps
•
Joint Gen surg, urology procedures
Complex Fistulas of the Posterior
Urethra
Risks
 Radiation, cryo, brachy
 Vesicourethral distractn
 Fistulas with large
granulated cavities
 Salvage prostatectomy with
rectosigmoid resection
Complications
• Refistulization
• Incontinence (common)
• Colitis
• Sepsis
Figure 33-51 Diagram illustrat-ing a complex fistula between the prostatic urethra and the rectum. Simple fistulas can be addressed through a transperineal or transanal-transsphincteric posterior approach with
great facility. However, complex cases associated with radiotherapy or large granulated cavities require a different approach. A combined abdominal-perineal exposure with repair of the fistulas as possible and
interposition of omentum, rectus abdominis muscle flap, and peritoneal urachal flap have been used.
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Curvatures of the Penis
 Def: Relative asymmetry in one
aspect of the erect penis
 Congenital or acquired
 Dorsal, lateral, ventral, complex
 Secondary to decreased TA
compliance or erectile body
shortening
Embryologically
 Epithelial grooveDeepens
then edges fuse into a tube
proxdistal
 Mesenchymal proliferatn
corpus spongiosum, Bucks,
dartos
 DHEA required
 Galloway et al suggest
deficiency of growth factors in
the ventral penile skin with
hypospadius; inconclusive 5
alpha redcutase defiency (CJ
Devine Jr and Pepe 1991)
Congenital Curvatures of the Penis
Dr CJ Devine and Horton
meatus
Curvature
urethra
dartos
bucks
Corpora
spongiosum
I
Tip of glans
ventral
Epith urethra,
fused to spongi
Abnl
Abnl
Abnl
II
Tip of glans
ventral
Nl
Fibrous
band
Fibrous
band
Nl
III
Tip of glans
ventral
Nl
Inelastic
Nl
Nl
IV
Tip of glans
yes
Nl
Nl
Nl
Nl
TYPE
Tunica alb of
corpora
Inelastic
Shortening
Hypercompliance
V
Tip of glans
Rare, ventral
Short
Hypocompliance
w/erection
Nl
Nl
Short
Hypocomplianc
w/erection
Nl
Chordee without hypospadius
Type I, II, III (V)
 Meatus at the tip of the glans penis
 Inappropriate development of ventral penis, many worsen at
puberty
 Ventral curvature + torsion, small or short penis
 Dorsal - wrinkled; hooded preputial skin, high penoscrotal
junction
 Ventral- inelastic (dysgenetic dartos, Bucks and/or tunica
albuginea)
 Examine on stretch, pre-op digital erect photos
 Preoperative sexual and psychological counseling
Procedure for repair
Single step-wise operation
 Ventral dissection of
dysgenetic tissues
 Correct skin tethering
 Mobilize the spongiosum
 Midline ventral septotomy
 + NVB dissection and dorsal
plication
 Attempt to avoid urethral
division/reconstruction
Congenital curvature of the Penis (IV)
 Ventral, Lateral (*left more




common), Dorsal (rare),
Complex
Larger than norm penis
Digital photos reveal smooth
curvature
Curve encompasses
pendulous portion of the
penile shaft
Worsens as child enters
puberty
Procedure
 Deglove penis above Bucks
 Artificial erection; saline vs
pharmacologic agents
 Mobilize and excise ventral
fibrous tissues (dartos/Bucks)
 Mobilize spongiosum from
cavernosum (glans to
penoscrotal junction)
 Surgical correction
 Lengthen with graft
OR
 Nesbitt: Shorten with excising TA
elliptically and closing
Acquired curvature of the Penis
Fracture (acute)
 Buckling trauma “snap”
 Detumescence
 Ecchymosis
Delayed presentation
 Lateral shaft nodule
 Lateral scar
 Indentation + curvature
 Erectile function usually
normal, veno-occlusive dyfx
not present
 No penile shortening
Subclinical;
Disruption of the outer layer, + inner
layer of the TA, Bucks or inner layer
maintaining spongiosum integrity
 No detumescence, bruising,
at time of injury
 + painful erections, nodule
 indentation
Acquired curvature of the Penis
Treatment
 Corporotomy with graft
 Mobilize Buck’s fascia laterally
 Coporotomy location (laterally) requires little/no
mobilization of neurovasccular structures
Phallic Reconstruction
 1936: Bogaraz (WWII)
 1944: Frunpkin; Soviet Union
 1948: Gilles and Harrison
 Proximal urethrostomy for voiding and tubed abdominal flaps; even “tube
within a tube” with baculum placement for sexual relations until 1972
 1972: Orticochea; gracilis musculocutaneous flap
 1973: Tubed groin flap
 1984: Forearm flap popularized
Phallic Reconstruction: Forearm flap
Forearm flap; fasciocutaneous
free flap; bld supply Radial
Artery
 1984: Chang and Hwang
 1988: Biemer
 1990: “the cricket bat”
Disadvantages
 Donor site scar
 Cold intolerance of the hand
 Hirsute and urethral
construction
Preop
 Allen test + arteriography;
nondominant forearm
 Suprapubic cystostomy
Procedure
 Flap can be elevated on
superficial fascia including the
radial or ulnar aa (Biemer)
 Urethral tube centered around
artery or risk stenosis (Chang
Hwang)
 Transfer of cephalic, basilic and
antebrachial veins
Figure 33-53 Variations of the forearm flap for phallic construction. A, The Chang "Chinese" flap based on the radial artery. Notice that the skin island has two separate paddles. An ulnar "urethral" paddle is
separated from the shaft coverage paddle by a deepithelialized strip. B, The "cricket bat" modification of the radial forearm flap proposed by Farrow and Boyd. The urethral portion extends centered over the
artery. The shaft coverage portion is on the proximal forearm. The deepithelialized areas (crosshatched) add bulk to the glans. The urethral portion is flipped into the middle of the flap and tubularized. C,
Modification of the forearm flap as proposed by Biemer (1988). The urethral paddle is a midline strip separated by the two lateral paddles by a deepithelialized strip. The lateral paddles are tubularized, with the
urethral paddle tubularized in the center.
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Upper lateral Arm Flap
 Fasciocutaneous free flap for total phallic reconstruction or




vascularized tissue to cover penile shaft
Radial collateral Aa
Limited subcutaneous adiposity
Amenable to microneurosurgical coaptation: flap to recipient
nn (Dorsal nn of penis, pudendal nn, less common
ilioinguinal nn)
Recipient vasculature; deep inf epigastric aa, saphenous vv,
less commonly superficial femoral artery with saphenous
interposition graft
Phallic Reconstruction con’t
 Gracilis, dartos, Martius and tunica vaginalis flaps can be




used in male or the transgender patients to cover the urethral
anastomosis
Rigidity is achieved externally by an applied device or
internally
Gortex neocorpora can house prosthesis (1 year delay),
anchored to ischial tuberosity and pubis
Neoscrotum can house hydraulic pump or testicular
prosthesis
Trauma patients may require debridement and delayed
repairs (3-6 weeks)
Transsexualism
Harry Benjamin criteria
 Psychological
counseling/support
 Team approach
 Urologist
 Plastic surgeon
 Gynecologist
 TAH SBO
 Urethral lengthening with
colpocleisis (possible)
 Ant vaginal wall random flap
used for urethral lengthening
 Gracilis mm flap around
urethral anastomosis
Then
 Phallic reconstruction
 1 year delay before prosthesis
considered
Take Home
 Distraction: Endoscopic stabilization and imaging, primary
anastomosis without chordee, AVOID pubectomy
destabilizing
 Vesicourethral distraction: abd-perineal combined approach;
rare diversion
 Complex fistulas risks: radiation, cryo, brachy
 Curvature : Secondary to decreased TA compliance or erectile
body shortening, inelastic ventral anatomy (chart)
 Questions
 Dr Curtis Crane