Presentation on theme: "Chapter 33 Surgery of the Penis and Urethra continued"— Presentation transcript:
1 Chapter 33 Surgery of the Penis and Urethra continued C FitzgeraldGCH Uro 1
2 Overview Distraction injuries of the urethra Posterior urethral reconstructionVesicourethral distractionVesicourethralrectal fistula repairRepair of congenital curvatures of the penisPhallus reconstruction/transsexualism
3 Distraction Injuries of the Urethra Membranous urethra (junction of membranous bulbous urethra)Blunt trauma; straddle injuryPelvic fracture (10%)Prepubescent prostatic urethra disruptionEndoscopic 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 EvaluationDepthDensityLengthLocationContrast studiesCystogramVoiding cystogram, RG urethrogramEndoscopy+ Antegrade endoscopy+ MRIDepth 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
6 Posterior Urethral Reconstruction Pre-op endoscopy r/o stonesEvaluate bladder neck (reconstruct + scar)Exaggerated dorsal lithotomy positionAdvance 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.
10 Posterior Urethral Reconstruction Post Op managementSP cystotomy diversionsmall urethral catheter stentBedrest hoursDC with anitcholinergics/abxVoiding trial in 2-4 weeksAntegrade contrast; evaluate for extravasation, PVRCx, if successful remove SP in 5-7 daysFollow upFlexible endoscopy 6 and 12 moPostop RG studies avoided, use flexible endoscopyAddress post operative incontinenceOff 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) compromiseWorst outcomes BL complete obstruction of the internal pudendal artery, reconstitution UNI/BL gd outcomesEvaluate with duplex USNormal; uni or BL pudendal integrity; gd reconstruct candidatesLimited flow increased risk of BL obstruction with/without reconstitution. erectile dysfunction, + ischemia risk. Require pudenal arteriography
13 Repairing Distraction Injuries of the Urethra in Children PerinealorPosterior, 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 Risksradical prostatectomy, obesity, small, thick bladderEvaluateAntegrade endoscopyRG urthrographyInitial management; often suprapubic cystostomyRRP can result in an obliterating distraction defect or severe anastomotic stenosis
15 Vesicourethral distraction TreatmentGoal: functional reconstructionOther optionsEndoscopic (laser, cold knife)Continent catheterizable bladderDiversionActual treatment option depends on patinet size, comorbidties, degree of stenosis, length of stenosis/distraction defect
16 Functional reconstruction Vesicourethral distraction Position; low lithotomy; 2 surgeonsAbd-perineal combined approachLow midline incision, expose bladder, dissect from lateral walls, mobilize beneath pubisOpen peritoneum and develop retrovesical spacePerineal incision (posterior triangle); dissect along anterior rectal wall until prior anastomosis site identifiedDissect region of distraction defect off rectumResect fibrosis, marsupialize bladder epithelium through a vesicostomyPrimary anastomoses of the bladder to the membranous urethraSutures in urethral stump, stenting catheterOmental flap at site of anastomosisSeat anastomoses
18 Post op; Vesicourethral distraction D/C to homeurethral catheter stentsuprapubic catheterReevaluation 4-6 weeksFill antegradeRemove urethral catheterComplicationsIncontinence, fistula, restenosisDC 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 fistulaRadical prostatectomy; + radiation/brachyMost smallRepair ApproachTransperinealTransanal-sphinctericPosteriorRepairsFunctional reconstruction; bladder to membranous urethraDiversion w/ileal conduitBladder augmentation with continent catheterizable channel+ colostomy or J pouch coloanal anastomosisOmental, peritoneal, rectus abdominis mm flapsJoint Gen surg, urology proceduresProblem 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 RisksRadiation, cryo, brachyVesicourethral distractnFistulas with large granulated cavitiesSalvage prostatectomy with rectosigmoid resectionComplicationsRefistulizationIncontinence (common)ColitisSepsis
22 Curvatures of the Penis Def: Relative asymmetry in one aspect of the erect penisCongenital or acquiredDorsal, lateral, ventral, complexSecondary to decreased TA compliance or erectile body shorteningEmbryologicallyEpithelial grooveDeepens then edges fuse into a tube proxdistalMesenchymal proliferatn corpus spongiosum, Bucks, dartosDHEA requiredGalloway 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 TYPEmeatusCurvatureurethradartosbucksCorpora spongiosumTunica alb of corporaITip of glansventralEpith urethra, fused to spongiAbnlIINlFibrous bandIIIInelasticIVyesShorteningHypercomplianceVRare, ventralShortHypocompliancew/erectionHypocomplianc w/erectionI, 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 penisInappropriate development of ventral penis, many worsen at pubertyVentral curvature + torsion, small or short penisDorsal - wrinkled; hooded preputial skin, high penoscrotal junctionVentral- inelastic (dysgenetic dartos, Bucks and/or tunica albuginea)Examine on stretch, pre-op digital erect photosPreoperative sexual and psychological counselingCongential 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 tissuesCorrect skin tetheringMobilize the spongiosumMidline ventral septotomy+ NVB dissection and dorsal plicationAttempt to avoid urethral division/reconstructionMidline 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), ComplexLarger than norm penisDigital photos reveal smooth curvatureCurve encompasses pendulous portion of the penile shaftWorsens as child enters pubertyProcedureDeglove penis above BucksArtificial erection; saline vs pharmacologic agentsMobilize and excise ventral fibrous tissues (dartos/Bucks)Mobilize spongiosum from cavernosum (glans to penoscrotal junction)Surgical correctionLengthen with graftORNesbitt: Shorten with excising TA elliptically and closinguse 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”DetumescenceEcchymosisDelayed presentationLateral shaft noduleLateral scarIndentation + curvatureErectile function usually normal, veno-occlusive dyfx not presentNo penile shorteningSubclinical;Disruption of the outer layer, + inner layer of the TA, Bucks or inner layer maintaining spongiosum integrityNo detumescence, bruising, at time of injury+ painful erections, nodule indentationTrauma during intercourse, audible snap Peyronies patinets more likely to have erectile dysfunction and shortening of the penis.
29 Acquired curvature of the Penis TreatmentCorporotomy with graftMobilize Buck’s fascia laterallyCoporotomy location (laterally) requires little/no mobilization of neurovasccular structures
30 Phallic Reconstruction 1936: Bogaraz (WWII)1944: Frunpkin; Soviet Union1948: Gilles and HarrisonProximal urethrostomy for voiding and tubed abdominal flaps; even “tube within a tube” with baculum placement for sexual relations until 19721972: Orticochea; gracilis musculocutaneous flap1973: Tubed groin flap1984: Forearm flap popularizedBaculum is the penis bone in lower mammels
31 Phallic Reconstruction: Forearm flap Forearm flap; fasciocutaneous free flap; bld supply Radial Artery1984: Chang and Hwang1988: Biemer1990: “the cricket bat”DisadvantagesDonor site scarCold intolerance of the handHirsute and urethral constructionPreopAllen test + arteriography; nondominant forearmSuprapubic cystostomyProcedureFlap 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
33 Upper lateral Arm FlapFasciocutaneous free flap for total phallic reconstruction or vascularized tissue to cover penile shaftRadial collateral AaLimited subcutaneous adiposityAmenable 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 graftMicrosurgical 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 anastomosisRigidity is achieved externally by an applied device or internallyGortex neocorpora can house prosthesis (1 year delay), anchored to ischial tuberosity and pubisNeoscrotum can house hydraulic pump or testicular prosthesisTrauma 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/supportTeam approachUrologistPlastic surgeonGynecologistTAH SBOUrethral lengthening with colpocleisis (possible)Ant vaginal wall random flap used for urethral lengtheningGracilis mm flap around urethral anastomosisThenPhallic reconstruction1 year delay before prosthesis consideredColpoclesis 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 HomeDistraction: Endoscopic stabilization and imaging, primary anastomosis without chordee, AVOID pubectomy destabilizingVesicourethral distraction: abd-perineal combined approach; rare diversionComplex fistulas risks: radiation, cryo, brachyCurvature : Secondary to decreased TA compliance or erectile body shortening, inelastic ventral anatomy (chart)QuestionsDr 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