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.
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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: )
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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).
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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.
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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.
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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.
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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.
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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