Surgery of the Penis and Urethra

1. Surgery of the Penis and Urethra Campbell’s Chapter 33 By Peter Tran Garden City Hospital 4/22/2009

2. Objectives • Basic Principles of Reconstructive Surgery • Grafts/Flaps • Specific conditions requiring reconstructive repair • Penetrating trauma to the penis • Urethral stricture disease

3. Grafts/Flaps • The term tissue transfer implies the movement of tissue for purposes of reconstruction. • Can be as a graft or flap • The term graft implies that tissue has been excised and transferred to a graft host bed, Take requires 96 hours and occurs in two phases. • The initial phase, imbibition, takes about 48 hours. • The second phase, inosculation, also requires about 48 hours and is the phase in which true microcirculation is re-established in the graft.

4. Grafts/Flaps • If a graft is a split-thickness unit, that graft carries the epidermis and the part of the superficial dermis. • Tends to brittle and less durable • If a graft is a full-thickness unit, it carries the covering and the superficial dermis or lamina with all the characteristics attributable to that layer. It also carries the deep dermis or deep lamina. • fastidious in its vascular characteristics • Buccal mucosal grafts have optimal vascular characteristics

5. Grafts/Flaps

6. Grafts/Flaps

7. Grafts/Flaps • The term flap implies that the tissue is excised and transferred with the blood supply either preserved or surgically re-established at the recipient site. • Random Flaps • A flap without a defined cuticular vascular territory. • Axial Flaps • there is a defined vessel in the base of the flap • 3 types • direct cuticular axial flap • musculocutaneous flap • fasciocutaneous system

8. Grafts/Flaps Figure 33-2 Random flap. The arterial perforators have been interrupted, and flap survival depends on the intradermal and subdermal plexuses.

9. Grafts/Flaps Figure 33-3 Axial flaps. Large vessels enter the base of the flaps. Survival depends on these vessels and on the random distal vascularity. A, Peninsula flap. The vascular continuity and the cutaneous continuity in the flap base are intact. B, Island flap. The vascular pedicle is intact; the cuticular continuity has been divided. These axial vessels are unsupported (dangling). C, Microvascular "free" transfer flap. The free flap cuticular and vascular connections are interrupted at the base of the flap. Vascular continuity is reconstituted in the recipient area by a microsurgical anastomosis. (A to C, from Jordan GH, et al: Tissue transfer techniques for genitourinary reconstructive surgery. AUA Update Series 1988;7:lesson 10.)

10. Grafts/Flaps Figure 33-4 A, Musculocutaneous flap. Musculocutaneous perforators from the artery to a muscle vascularize the skin and overlying subcutaneous fat. They may be transferred as free flaps but are usually transferred locally, left attached to the vascular pedicle. B, Fasciocutaneous flap. Perforating blood vessels from rich plexuses on the superficial and deep aspects of the fascia connect to perforator vessels that communicate with the microvasculature of the overlying paddle. In genital reconstruction, these flaps are based on the dartos fascia of the penis or are free flaps from the forearm. (A and B, from Jordan GH, et al: Tissue transfer techniques for genitourinary reconstructive surgery. AUA Update Series 1988;7:lesson 10.)

11. Penile Anatomy Figure 33-6 Sagittal section of the pelvis. The urethra is subdivided into the following sections: 1, fossanavicularis; 2, pendulous or penile urethra; 3, bulbous urethra; 4, membranous urethra; 5, prostatic urethra; 6, bladder neck. By common usage, the divisions of the fossanavicularis, pendulous urethra, and bulbous urethra compose the anterior urethra; and the divisions of the membranous urethra, prostatic urethra, and bladder neck compose the posterior urethra. (Modified from Devine CJ Jr, Angermeier KW: Anatomy of the penis and male perineum. AUA Update Series 1994;8:11.)

12. Penile Anatomy • Five sphincters are recognized

13. Blood Supply to the Genital Skin Figure 33-9 Illustration of the vasculature to the genital skin. A, The superficial external pudendal vessels arborize to become the fascial blood supply contained in the dartos fascia of the penis. B, The scrotal artery is a terminal branch of the deep internal pudendal artery. This artery is thought to arborize in the tunica dartos of the scrotum and Colles' fascia of the perineum. The perineal artery continues lateral to the groin crease onto the thigh and extends toward the groin.

14. Venous Drainage of the Penis • The penis is drained by three venous systems: superficial, intermediate, and deep • The superficial veins contained in the dartos fascia on the dorsolateral aspects of the penis unite at its base to form a single superficial dorsal vein. The superficial dorsal vein usually drains into the left saphenous vein. • The intermediate system contains the deep dorsal and circumflex veins, lying within and beneath Buck's fascia. • The deep drainage system consists of the crural and cavernosal veins.

15. Venous Drainage of the Penis

16. Arterial Supply to the Penis

17. Specific Disease Processes • Urethral Hemangioma • Benign • management depends on the size and location of the lesion • Laser Tx • Reiter’s syndrome • Urethral involvement is usually mild, self-limited, and a minor portion of the disease. • No Tx needed. • Also known as circinatebalanitis • perinealurethrostomy and excise the entire distal urethra for severe disease

18. Specific Disease Processes • Lichen-Sclerosus(BXO) • most common cause of meatalstenosis • lichen sclerosus appears as a whitish plaque that may involve the prepuce, glans penis, urethral meatus, and fossanavicularis • Diagnosis is made through biopsy • For mild disease • Topical steroids and abx • For severe disease or young patients • RUG • staged buccal graft reconstruction, at least in the short to mid term, seems to provide superior durable results

19. LS/BXO

20. Urethrocutaneous Fistula • Urethral fistulas may be a complication of urethral surgery or develop secondary to periurethral infection associated with inflammatory strictures or treatment of a urethral growth. • Treatment of a urethral fistula must be directed not only to the defect but also to the underlying process that led to its development.

21. Urethrocutaneous Fistula • Tx • Conservative • Stenting/Catheter • If conservative measures fail, wait 6 months to allow complete resolution of the inflammatory process

22. Urethrocutaneous Fistula

23. MeatalStenosis • Meatalstenosis in a boy appears to be a consequence of circumcision that then allows subsequent meatitis from a wet diaper pressing for prolonged periods against the glans penis. • Tx • Meatotomy

24. Correction of Chordee • Chordee – penile curvature caused by tethered superficial tissue or scarred urethra.

25. Penile Amputation Injury • Amputation is the ultimate penetrating penile injury. • If the patient presents acutely with the amputated distal part of his penis, microvascularreplantation is the favored approach.

26. Degloving Injury of the Penis and Scrotum • Wounds should be dressed in sterile saline-soaked bandages. • A delay of approximately 24 hours is sufficient to define the extent of the damage. • Most degloving injuries can then be managed acutely with immediate reconstruction by the application of split-thickness skin grafts. • The shaft is covered with a sheet graft of split-thickness skin. • The testes are sutured together in the midline, fixed in their anatomically correct position, and covered with a meshed split-thickness skin graft.

27. Genital Burns • Ability to reconstruct the damage caused by genital burns often depends on how well the normal structures have been maintained after the acute injury. • Careful debridement is the rule in acute management of genital burns • Can’t replace corporal tissue. • Will typically need flaps/grafts performed under multiple stages

28. Urethral Stricture Disease • Urethral stricture refers to anterior urethral disease, or a scarring process involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis). • Contraction of this scar reduces the urethral lumen • posterior urethral "strictures" are not included in the common definition of urethral stricture • Posterior urethral stricture is an obliterative process in the posterior urethra that has resulted in fibrosis and is generally the effect of distraction in that area caused by either trauma or radical prostatectomy.

29. Urethral Stricture Disease • Etiology • Trauma/inflammation that results in scarring • GC, straddle injury, iatrogenic, LS-BXO • Diagnosis/Evaluation • Most patients present with obstructive voiding symptoms/UTI’s/retention. • Important to determine the location, length, depth, and density of the stricture (spongiofibrosis). • RUG (dynamic?)/cysto/US

30. Urethral Stricture Disease

31. Urethral Stricture Disease • Tx • Goals • Cure vs. conservative management? • Urethral dilation • Oldest and simplest • goal is to stretch the scar without causing further bleeding/scarring • Balloon dilation prefered • DVIU • The urethrotomy procedure involves incision through the scar to healthy tissue to allow the scar to expand (release of scar contracture) and the lumen to heal enlarged. • Competition between wound contraction and epithelialization. • Success rate low: 20-35%. • Better with stricture < 1.5cm and not associated with severe spongiofibrosis (75%) • Leaving indwelling catheter or on self-dilation program does not prevent recurrence.

32. Urethral Stricture Disease • Tx • Urethral Stents (removable/permanent) • Majority of experience from Europe and UK • Best used for short bulbar stricture with minimal spongiofibrosis. • Open surgery still offer better long-term results • Unique complications • Placed only in bulbar urethra. • Pain on sitting and intercourse, perineal pain. • Two or more overlapping stents can migrate, leaving a gap, where stricture recurrence can occur. • Not to be used in urethral distraction injuries or straddle injuries where significant fibrosis is present. • Lasers • Data shows mixed results

33. Urethral Stricture Disease • Excision and Reanastomosis • the most dependable technique of anterior urethral reconstruction is the complete excision of the area of fibrosis, with a primary reanastomosis of the normal ends of the anterior urethra. • Important points • the area of fibrosis is totally excised; the urethral anastomosis is widely spatulated, creating a large ovoid anastomosis; and the anastomosis is tension free. • success of this procedure relies on vigorous mobilization of the corpus spongiosum • The more proximal the stricture the more likely reanastomosis can be performed, otherwise tissue transfer is required.

34. Urethral Stricture Disease

35. Urethral Stricture Disease • Grafts • 4 types used for urethral reconstruction • FTSG, bladder epithelial, buccal mucosal, rectal mucosal

36. Urethral Stricture Disease

37. Urethral Stricture Disease • Use of flaps • mobilized on either the dartos fascia of the penis or the tunica dartos of the scrotum • 3 important points • the nature of the flap tissue, the vasculature of the flap, the mechanics of flap transfer, and use on non-hirsute skin

38. Urethral Stricture Disease Figure 33-33 A dorsal transverse island of penile skin applied to a stricture of the urethra. The flap has been elevated on the dartos fascia, and a lateral incision has been made into the urethra. The flap is secured in place (right). (From Jordan GH: Management of anterior urethral stricture disease. In Webster GD, ed: Problems in Urology. Philadelphia, JB Lippincott, 1987:217.)

39. Urethral Stricture Disease Figure 33-34 Penile longitudinal skin island. The incisions to be made to mobilize the flap are demonstrated in the inset. The heavy line is the primary incision made full thickness through the dartos fascia and superficial Buck's fascia lateral to the corpus spongiosum. A, Dissection elevates the dartos fascial flap well past the corpus spongiosum in the midline. B, A lateral urethrostomy placed to face the flap has opened the entire length of the stricture. C, The skin paddle of the flap has been developed by making the incision outlined by the dotted line (inset) and undermining the skin lateral to it. The medial edge of the flap has been fixed to the edge of the stricturotomy. D, The flap is inverted into the defect. E, A watertight subepithelial suture line has been completed with a running absorbable monofilament suture. The skin will be closed with subcutaneous sutures and interrupted cutaneous sutures. (A to E, from Jordan GH: Management of anterior urethral stricture disease. In Webster GD, ed: Problems in Urology. Philadelphia, JB Lippincott, 1987:214.)

40. Urethral Stricture Disease Figure 33-35 A ventral transverse skin island is elevated on the penile dartos fascia, inverted to the area of the perineum where flap onlay is accomplished. A, The skin island is elevated on the dartos fascia. B, The appearance of the flap transposed to the area of the perineum for onlay in a proximal bulbous urethral stricture.

41. Urethral Stricture Disease Figure 33-37 Ventral skin island for long bulbous stricture. The skin paddle of the flap is developed on the ventral midline of the penis and can be extended around the penile shaft at its distal end. A, The paddle of the flap has been incised and its pedicle elevated. This pedicle includes Buck's fascia and dartos fascia, denuding the tunica of the corpus spongiosum and the corpora cavernosa. The pedicle (the dartos fascia bilaterally) is based on the superficial external pudendal vessels and the internal pudendal vessels in the scrotum. Development of this pedicle allows the flap to be moved to any area of the urethra. B, The flap has been passed through a tunnel beneath the scrotum developed by dissection along the corpus spongiosum. A laterally placed urethrostomy has opened the urethral stricture. C, The deep edge of the flap is secured by the suture techniques previously described. D, Anastomosis of the flap has been completed. The pedicle can be seen extending beneath the scrotum. (A to D, from Jordan GH, McCraw JB: Tissue transfer techniques for genitourinary surgery, Part III. AUA Update Series 1988;7.)

42. Urethral Stricture Disease Figure 33-38 Illustration of reconstruction in a patient with a long anterior urethral stricture with a relatively short narrow-caliber section (technique of augmented anastomosis with circular skin island). A, A circular skin island is elevated on the dartos fascia. The patient is positioned flat on the table. B, The skin island onlay is begun, the rest of the flap is placed into the perineal dissection, and the penis is closed; the patient is then repositioned in the lithotomy position. C, The flap is retrieved through the perineal dissection. The narrow-caliber section is excised, and the urethra is spatulated on the dorsum. D, The onlay is completed, and the floor strip anastomosis is closed. E, Schematic of the surgery. (A to E, from Stack RS, Schlossberg SM, Jordan GH: Reconstruction of anterior urethral strictures by the technique of excision and primary anastomosis. Atlas UrolClin North Am 1997;5:11-21.)

43. Urethral Stricture Disease Figure 33-39 Collage of techniques for reconstruction of the fossanavicularis and meatus. A, Technique after Blandy in which a random penile skin island is advanced into a meatotomy defect. B, Technique after Cohney in which a transversely oriented random flap is advanced into the meatotomy defect. C, Technique after Brannen in which a midline random flap is advanced into the meatotomy defect. This technique was an attempt to improve the cosmetic result of prior procedures. D, Technique after De Sy in which a ventral longitudinal skin island is advanced into the meatotomy defect. The skin island is developed by deepithelialization of a portion of the longitudinal flap. (After Jordan GH: Management of anterior urethral stricture disease. ProblUrol 1987;1:199-225.)