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Chapter 33 Surgery of the Penis and Urethra continued

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1 Chapter 33 Surgery of the Penis and Urethra continued
C Fitzgerald GCH Uro 1

2 Overview Distraction injuries of the urethra
Posterior urethral reconstruction Vesicourethral distraction Vesicourethralrectal fistula repair Repair of congenital curvatures of the penis Phallus reconstruction/transsexualism

3 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) Usually in, secondary to… associated with 10% of pelvic fractures. In the pre, extension into the prostatic urethra possible, NOT post pubecsent.

4 Distraction Injuries of the Urethra
Evaluation Depth Density Length Location Contrast studies Cystogram Voiding cystogram, RG urethrogram Endoscopy + Antegrade endoscopy + MRI Depth and density of fibrosis are predictable but shold be factored in. Endoscopy above and below with imaging is very important to determine length and location of the ends to be anastomosed. Eval most distraction injuries short, but length should be determined as precisely as possible. Location is important for pre op discussions about surgical risk including incontinence. Imaging begins with a cystogram to outline the bladder and possibly gain some information about the posterior urethra. Visualization of the bladder neck and proximal urethra is imperative. Voiding cystogram with RUG can outliine the distraction defect. Mmore often then not however the patinet cannot relax to void and Antegrade endoscopy with simultaneous RUG may be required to outline the urethral defect. Rarely complicated cases may require MRI to locate urethral lengths in double distraction or complex fracture involvement

5 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)

6 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) PREop endoscopy to r/o vesciolithiasis. Discuss risks of incontinence with patients who have clear bladder neck injuries. Previously believed any with bladder neck injury resulting in scar incarceration would be incontinent post operatively; many of these patients are however proven to have more then adequate continence after reconstruction. Use the exag DL position and attempt a perineal cut-down if rigid cystoscope palpable along perineum; otherwise create a vesicisotomy to reliably advance an instrument through the bladder neck and into the posterior urethra. Limits risk of microanastomoses of ant urethra and false passages.

7 Make initial inverted y incision and dissection in region anterior to the transverse perineal musculature (in the ant perineal triangle) carried down to the ishiocavernous musculature and the uninvested portion of the corpus spongiosum. MM dissected off the corpus spongiosum. Then the bulbospongiosum is detached from the triangular ligament and the corpora cavernosa and then the perineal body. It is important to mobilize the corpus spongiosum to create a tension-free anastomosis. Figure 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. Downloaded from: Campbell-Walsh Urology (on 20 March :49 PM) © 2007 Elsevier

8 Division of the triangluar ligament is carried out, careful identification and ligation f the dorsal vein Figure 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: ) Downloaded from: Campbell-Walsh Urology (on 20 March :49 PM) © 2007 Elsevier

9 Develop intracural space
Develop intracural space . A hargrove staff is passed antegrade into the posterior urethra and after the fibrotic tissues are removed passed through normal urethral epithelium at the anastomotic site. Identifying the anastomosis site above the penoscrotal junction limits the risk of debilitating Chordee. Figure 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). Downloaded from: Campbell-Walsh Urology (on 20 March :49 PM) © 2007 Elsevier

10 Posterior Urethral Reconstruction
Post Op management SP cystotomy diversion small urethral catheter stent Bedrest 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 Off anticholinergic for 24 hours begfore voiding trial. Antegrade contrast. CX urine. Remove urethral foley, allow pt to void spontaneously. If no extravasation or elevated PVR dc without urethral catheter. Remove SP after success 5-7 days. Treat urine colonization if present.

11 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

12 Figure 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. Downloaded from: Campbell-Walsh Urology (on 20 March :49 PM) © 2007 Elsevier

13 Repairing Distraction Injuries of the Urethra in Children
Perineal or Posterior, sagital transsphinteric approach (Mathews et al 1998 and Pena and Hong 2004) Probaly the best way to learn more about this approach is to discuss it during your pediatric rotations

14 Vesicourethral distraction defects
Risks radical prostatectomy, obesity, small, thick bladder Evaluate Antegrade endoscopy RG urthrography Initial management; often suprapubic cystostomy RRP can result in an obliterating distraction defect or severe anastomotic stenosis

15 Vesicourethral distraction
Treatment Goal: functional reconstruction Other options Endoscopic (laser, cold knife) Continent catheterizable bladder Diversion Actual treatment option depends on patinet size, comorbidties, degree of stenosis, length of stenosis/distraction defect

16 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

17 Figure 33-50 Reconstruction for vesicourethral distraction
Figure 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. Downloaded from: Campbell-Walsh Urology (on 20 March :49 PM) © 2007 Elsevier

18 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 DC to home when ambulating, drains left laterally are removed. DC with catheter and sp. Reveval in 4-6 weeks for extravasation and patency. Post operative incontinence is possible due to external sphincter involvement. Artificial sphinctrs have been successfully place4d

19 Complex Fistulas of the Posterior Urethra
Vesico/urethrorectal fistula Radical prostatectomy; + radiation/brachy Most small Repair Approach Transperineal Transanal-sphincteric Posterior Repairs Functional reconstruction; 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 Problem magnified with radiation; diversions more common status post radiation; post raditaion colostomy reversals may result in colitis, possibility of refistulaization

20 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

21 Figure 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. Downloaded from: Campbell-Walsh Urology (on 20 March :54 PM) © 2007 Elsevier

22 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) Chorde used improperly to designate the tissues causing the curve” the chordee was resected” . Acquired secondary to intercourse rarely vigorous masturbation; before puberty CONGENITAL

23 Congenital Curvatures of the Penis Dr CJ Devine and Horton
TYPE meatus Curvature urethra dartos bucks Corpora spongiosum Tunica alb of corpora I Tip of glans ventral Epith urethra, fused to spongi Abnl II Nl Fibrous band III Inelastic IV yes Shortening Hypercompliance V Rare, ventral Short Hypocompliance w/erection Hypocomplianc w/erection I, II, III Chordee without hypospadius. Type IV penis normal size until erection rather large secondary to hypercompliance and asymmetrical expansion with erection worsens in puberty secondary to growth spurt

24 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 Congential curvature pt penis grow in length with erection the chordee without hypospadius DO NOT GAIN LENGTH with erection. Treatment of V is discussed with type I,II,III. Alos has a ventral bend. Rarely seen

25 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 Midline ventral septotomy to correct the inelasticity in the ventral corp cavernosum

26 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 use existing circumsision scar if presesnt to deglove from, The ventral fascial layers may appear thickenend. If so consider resection. Small intestinal mucosa graft if lenthening. Length is seldom a concern in these patients and plication is a very acceptable solution in these patients. ELEVATE BUCKS FASCIA WITH NVB intact like Dr Dabs taught us to.

27 Nesbitt bc larger than normal penis, if CHORDEE with out Hypospadius, lengthening procedure will be undertaken. Elevate NVB with Bucks fascia. Many small ellipses of Tunica ALBUGINEA carefukl not to damage underlying erectile bodies. few small instaed of one large ellipses, appose edges with prolene suture. Can plicate before making tunica incisions to determine placement . Use artificial erections intermittant to evaluate the final product. A MINIMAL degree of DORSAL flexion ACCEPTABLE secondary to changes as sutures dissolve.

28 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 Trauma during intercourse, audible snap Peyronies patinets more likely to have erectile dysfunction and shortening of the penis.

29 Acquired curvature of the Penis
Treatment Corporotomy with graft Mobilize Buck’s fascia laterally Coporotomy location (laterally) requires little/no mobilization of neurovasccular structures

30 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 Baculum is the penis bone in lower mammels

31 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

32 Figure 33-53 Variations of the forearm flap for phallic construction
Figure 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. Downloaded from: Campbell-Walsh Urology (on 20 March :49 PM) © 2007 Elsevier

33 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 Microsurgical free flaps are generally utilized. A fasciocutaneous Deep inf epigastric: medial braches of illiac, on dorsal aspect of rectus abdominus mm

34 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) Wait at least one year to obtain sensation noted in the flap; starts 3-4 mo. Creative use of flaps make for funtional, ascethetically pleasing outcomes

35 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 Colpoclesis closure or Surgical obliteration of vaginal lumen. Urethral lengthening is possible but not always advisable due to increased risk of complications. Sometimes a simple perinela urethrostomy is created. Recent article in Journal of Reconstructive and Aethetic Surgery presented a case study of island pedicled anterolateral thigh (ALT) flap. J Plast Reconstr Aesthet Surg Mar;62(3):e45-9. Epub 2008 May 2. Other pedicled flaps include the anterior abdomnal cutaneous flap

36 Complex fistulas risks: radiation, cryo, brachy
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

37 Neophallus made from an abdmoninal flap with a recently implanted inflatable penile prosthesis (AMS CX prosthesis) 20 cm prosthesis with 5 cm rear tip, malleable rod

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