Presentation on theme: "Surgery of the Penis and Urethra Ch.Reading"— Presentation transcript:
1Surgery of the Penis and Urethra Ch.Reading By: Dr. Ali AL-AmiriR2Academic Day
2PRINCIPLES OF RECONSTRUCTIVE SURGERY The term tissue transfer implies the movement of tissue for purposes of reconstructionAll tissue has physical characteristics:extensibilityinherent tensionviscoelastic properties of stress relaxation and creep.physical characteristics of a transferred unit are primarily a function of the helical arrangement of collagen along with the elastin crosslinkages
3PRINCIPLES OF RECONSTRUCTIVE SURGERY Type of tissue transfer:A – Graft : that tissue has been excised and transferred to a graft host bed , where a new blood supply develops by a process termed takeTake requires approximately 96 hours and occurs in two phasesThe initial phase, imbibition, requires about 48 hourssecond phase, inosculation, also requires about 48 hours and is the phase in which true microcirculation is reestablished
4Graft Split-thickness : Full-thickness : carries the epidermis and also exposes the superficial dermal (intradermal or intralaminar) plexusphysical characteristics are not carried, which accounts for the tendency of split-thickness units to be brittle and less durablefavorable vascular characteristicsFull-thickness :Carries superficial dermis and deep dermis or deep laminaCarries characteristics attributable to that layerfastidious vascular characteristicsdoes not contract
5GraftThe grafts that have been successfully used for primary urethral reconstruction are the full-thicknessskin graftbladder epithelial graft ( good vascular characteristics)oral mucosal graft (optimal vascular characteristics)rectal mucosal graft
6FlapFlap: implies that the tissue is excised and transferred with the blood supply either preserved or surgically reestablished at the recipient siteClassificationvascularity ( random vs axial )Random : without a defined cuticular vascular territoryAxial : defined vessel in the base of the flapPeninsula:vascular continuity and the cutaneous continuity of flap base are intactIsland: The vascular pedicle is intact; the cuticular continuity has been divided.Microvascular free-transfer:The free-flap cuticular and vascular connections are interrupted at the base of the flap
8Generalities of Reconstructive Surgical Techniques Reconstructive surgery is performed with all efforts aimed at minimizing tissue injury and promoting healingAdequate visualization, Surgical loupes , headlightIn penile cases such as reconstruction of the fossa navicularis bipolar cautery is used exclusivelySharp scissors that cut with minimal collateral trauma are essentialchoice of sutureurethral surgery, absorbable suture is the ruleflap or graft repair, 4-0 to 6-0 suture is usually adequate
10Reiter Syndromeclassic triad of arthritis, conjunctivitis, and urethritisUrethral involvement is usually mild, self-limited, and a minor portion of the disease10% - 20% of patients have a called circinate balanitis, is diagnostic of Reiter syndromeshallow, painless ulcer with gray bordersmild and self-limited, no treatment is necessaryIn severe cases: perineal urethrostomy and excise the entire distal urethra may be performed
11Lichen Sclerosus (Balanitis Xerotica Obliterans) chronic inflammatory disorder of the skin of uknown originThe peak ageswomen are bimodal (before puberty and postmenopausal)30 to 50 years ( all ages )most common cause of meatal stenosisLS appears as a whitish plaque that may involve the prepuce, glans penis, urethral meatus, and fossa navicularisIf only the foreskin is involved, circumcision may be curativeDiagnosis is made through biopsy
12Lichen Sclerosus (Balanitis Xerotica Obliterans) cause of LS has not been defined , but suggested to be an autoimmune diseaseTreatment :combination of topical steroids and antibiotics may help stabilize the inflammatory processConservative therapy may be warranted in patients whose meatus can easily be maintained at 14 Fintermittent catheterization with lubrication of the catheter and meatal dilator may be adequate treatment
14Lichen Sclerosus (Balanitis Xerotica Obliterans) In young patients with severe meatal stenosis, surgery is indicatedBecause LS is a disease of genital skin, better tissue for reconstruction is the oral mucosaIn severe urethral stricture diseasecompletely reconstructed the urethrasimply performed a perineal urethrostomy
15Urethrocutaneous Fistula Urethral fistulas may be a complication ofurethral surgerysecondary to periurethral infection associated with inflammatory stricturesTreatment of a urethral fistula must be directed defect the underlying processAfter urethral surgeryearly fistula is the result of poor local healing, possibly secondary to hematoma, infection, or tension with closureaggressive local care and continued urinary diversion may close fistula
16Urethrocutaneous Fistula Closure of fistula after surgery:If small :button of skin is removed from around the fistulaedges are cut flush with the urethral wall.The urethra is closed with small (6-0 or 7-0) absorbable sutureIf large :local flaps will be required.
17Urethrocutaneous Fistula Fistulas associated with inflammatory strictures develop secondary to high-pressure voiding of infected urinemultiple tracts develop called (watering pot perineum)Repair requiressuprapubic drainagetreatment of the infection requires incision and drainage of any abscessesWe widely excise the fistula tractsFlap reconstruction can be usedwait 4 to 6 months before repairing the underlying stricturefistula or periurethral abscess may be the hallmark symptom of urethral carcinoma
18Paraphimosis, Balanitis, and Phimosis Paraphimosis: painful swelling of the foreskin distal to a phimotic ring, occurs if the foreskin remains retracted for a prolonged timegentle steady pressure must be applied to the foreskin to decrease the swellingIf it reduced : elective dorsal slit or circumcision laterIf failed emergency dorsal slit or circumcisionBalanitis: inflammation of the glans, can occur as a result of poor hygiene, from failure to retract and clean under the foreskinTx : local care and antibiotic ointmentPhimosis: inability to retract the foreskin, can result from repeated episodes of balanitisTx : circumcision
19Urethral Meatal Stenosis Meatal stenosis in a boy appears to be a consequence of circumcisionMeatal stenosis occurs in adults after inflammation, specific or nonspecific urethral infection, and traumaTxventral urethral meatotomynecessary to place sutures to approximate the urethral mucosal edge to control bleeding.three sutures: one at the apex and one on either side
20CircumcisionIt is important not to circumcise any boy with a penile abnormality (e.g., hypospadias, chordee) that may require the foreskin during repair.Indication for circumcision in the young boyrecurrent UTI thought to be associated with the redundant preputial skinMonopolar electrocautery should be avoided in a neonatal circumcision
22URETHRAL 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 lumenposterior urethral “strictures” are not included in the common definition of urethral strictureobliterative process has resulted in fibrosis and is generally the effect of distraction in that area caused by either trauma or radical prostatectomyBy consensus of the WHO conference, the term stricture is limited to the anterior urethra.
23The anatomy of anterior urethral strictures includes, in most cases, underlying spongiofibrosis. A, Mucosal fold. B, Irisconstriction. C, Full-thickness involvement with minimal fibrosis in the spongy tissue. D, Full-thickness spongiofibrosis. E, Inflammation andfibrosis involving tissues outside the corpus spongiosum. F, Complex stricture complicated by a fistula.
24EtiologyAny process that injures the urethral epithelium or the underlying corpus spongiosum to the point that healing results in a scar can cause an anterior urethral strictureTrauma ( straddle trauma - iatrogenic )inflammatory strictures ( gonorrhea –BXO )Congenital if it isnot an inflammatory strictureshort-length stricturenot associated with a history of or potential for urethral traumaMainly limited to infants before they attempt erect ambulation
25Diagnosis and Evaluation Patients often present withobstructive voiding symptomsUTI (prostatitis , epididymitis)urinary retention.For an appropriate treatment plan you should know :LocationLengthDepthDensity of the stricture (spongiofibrosis)
26The length and location The depth and density determined with radiography, urethroscopy, and ultrasonography.The depth and densitydetermined by P/Eappearance of the urethra in contrast-enhanced studiesthe amount of elasticity noted on urethroscopyThe depth and density of fibrosis are difficult to determine objectively
27Dynamic radiographic studies : retrograde injection of contrast material and while the patient is voidingIf the patient is not in steep lateral oblique position for retrograde urethrography, the length of the stricture will be underestimatedevaluate the urethra proximal and distal to the stricture with endoscopy during surgery to ensure that all the involved urethra is included in the reconstruction
31Treatment Dilation oldest and simplest treatment epithelial stricture without spongiofibrosis, it may be curativegoal is to stretch the scar without producing more scarringleast traumatic method is to use soft techniques over multiple treatment sessions.Safest is balloon-dilating catheters
32Internal Urethrotomyrefers to any procedure that opens the stricture by incising it transurethrallyincision through the scar to healthy tissueto allow the scar to expand and the lumen to heal enlargedUsually done by single incision at the 12-o’clock positioncross section of the corpus spongiosum, showed the thinnest portion of the anterior aspect is from 10-o’clock to 2-o’clock
33Internal Urethrotomy Complications: recurrence of stricture ( most common )Bleedingextravasation of irrigation fluid into the perispongiosal tissuescreation of a fistula (corpus spongiosum and the corpora cavernosa)The data show that strictures at the bulbous urethra that are less than 1.5 cm and not associated with dense, deep spongiofibrosis74% moderately long-term success rateF.cath to be kept for 3 to 7 days
34Internal UrethrotomyUrethral stents (removable or permanently implantable) after internal urethrotomy - UroLume ( permanent )6 months to 1 yearAvailable data show that the stent is best employed for relatively short strictures of the bulbous urethra associated with minimal spongiofibrosisComplications:perineal painMigration
35Internal Urethrotomy Lasers The ideal laser for urethral stricture diseasetotally vaporizes tissueexhibits negligible peripheral tissue destructionnot absorbed by watereasily propagated along a fiberAdvocates of the use of a contact laser suggest that it obliterates the scar by vaporization ( YAG)results with use of these fibers are no better than those with direct cold-knife visual internal urethrotomy
36Open Reconstruction Excision and Reanastomosis complete excision of the area of fibrosis, with a primary reanastomosis of the normal ends of the anterior urethraMost IMP technical points:area of fibrosis is totally excisedanastomosis is widely spatulated,large ovoid anastomosisanastomosis is tension free.Strictures of 1 to 2 cm are generally easily excised with reanastomosis
39Four grafts that have been successfully used for primary urethral reconstruction are the full-thickness skinthe bladder epithelialoral mucosal (buccal, labial, lingual)rectal mucosalGrafts have been most successfully employed in the area of the bulbous urethra
43FlapsA number of applications of genital skin islands, mobilized on either the dartos fascia of the penis or the tunica dartos of the scrotum, have been proposed for the repair of urethral stricture diseaseimportant considerations for the use of flaps:nature of the flap tissuevasculature of the flapmechanics of flap transferFor donor site consideration, it is most convenient to use the areas of redundant nonhirsute genital skin
48in a meta-analysis of graft onlay procedures compared with flap procedures, showed equivalent results for graft operations and flap procedures.
49PELVIC FRACTURE URETHRAL INJURIES Urethral injuries accompany about 10% of pelvic fracture injuriesDistraction injuries are for all intents unique to the membranous urethraMany injuries appear not to totally distract the entire circumference of the urethraplacement of an aligning catheter may allow the urethra to heal virtually unscarred or with an easily managed stenosis
50Repair It is desirable to proceed within 4 to 6 months after trauma The classic reconstruction consists of a spatulated anastomosis of the proximal anterior urethra to the apical prostatic urethraSeveral series support the concept that the bulk of pelvic fracture urethral injuries can be managed by the perineal approachAt the time of reconstructionendoscopy is performed through the meatus and again through the suprapubic tube sinusTo R/O vesicolithiasis
51RepairFor optimal exposure to the area of the membranous and apical prostaticn urethraexaggerated lithotomy position
52RepairA, Colles fascia has been opened to expose the midline fusion of the ischiocavernosus muscles and the tunica of the corpus spongiosum.B, The scissors are introduced to develop the space between the muscle and the bulb of the urethra
53RepairC, An incision is made in the midline with the scissors, exposing the length of the bulbD, The ischiocavernosus muscle is retracted to expose the full length of the bulbE, The self-retaining retractor is placed to expose the inferior fascia of the genitourinary diaphragm
54Repair 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
55When the prostatic urethra is displaced A , length can be shortened by incision of the triangular ligamentLateral displacement of the crura will expose the dorsal vein of the penis , the vein can be ligated and divided.C, Completion of the dissection affords additional exposure for resection of the fibrosis
57Postoperative Management Small soft silicone stenting catheter.Urine is diverted by way of the suprapubic cystostomyAfter the reconstruction, patients are initially kept at bed rest for 24 to 48Discharged with the SPC and stenting urethral catheter in placeDischarged on suppressive antibiotic.A voiding trial with contrast material is performed between 21 and 28 days postoperatively.
58Postoperative Management Trial involves removing the urethral catheter, filling the patient’s bladder with contrast material, and instructing him to voidR/O extravasationPatency of reanastomosisThe patient is allowed to void through the urethra for 5 to 7 days, and the suprapubic catheter is then removedApproximately 6 months postoperatively, and again 1 year later, the patients are evaluated with flexible endoscopyThe curative rates for reconstruction of posterior pelvic fracture urethral injuries are in the high 90% range.
60The term chordee means curvature Curvatures of the penis can be congenital or acquired.The terms congenital curvature of the penis and chordee without hypospadias have often been used interchangeablyprefer to reserve the term chordee without hypospadias for those patients in whom the meatus is properly located on the tip of th glans penis, yet a ventral curvature is associated with abnormalities of the ventral fascial tissues or corpus spongiosum, or both
61Types of Congenital Curvature of the Penis Chordee without Hypospadias in Young Men:present with either ventral curvature or ventral curvature associated with torsion (complex curvature)abnormalities of the ventral penile skinelement of hooded preputial skinhigh insertion of the penoscrotal junctionphotographs are helpful in differentiating between chordee without hypospadias and congenital curvatures of the peniserect penis equal to the size of the detumesced penis
62Chordee without Hypospadias in Young Men: Corrective surgery is highly successful, and, in almost all cases, an effectivepenis has been straightened by excision of all the dysgenetic tissues from the ventral side of the penis.
63Congenital Curvatures of the Penis: Patients can have ventral, lateral (which is most often to the left), or, unusually, dorsal curvatureDuring surgeryartificial erection demonstrates the character of the curvature and the location of maximal curvaturefibrous tissue is mobilized and completely excised
64Acquired Curvatures of the Penis Acquired curvatures of the penis inevitably follow trauma to the penisAcquired Curvatures of the Penis That Are Not Peyronie Disease:reveal a history of minimal lateral curvature of the penisclear memory of a lateral buckling injury that occurred during intercourse.In some cases, the patient remembers hearing a “snap” and notices immediate detumescence and significant ecchymosis of the penis
65Subclinical fracture of the penis Buckling trauma to the penis but without associated detumescence or ecchymosis.Painful erection for a period after the trauma,nodule developed in the lateral aspect of the penisbelieved to be due to the disruption of the outer longitudinal layer of the tunica albuginea with intact inner circular layerThese injuries are not associated with shortening of the penisTX : excise the scar and place a graft to replace the corporotomy defect caused by the scar excision
66TOTAL PENILE RECONSTRUCTION In 1984, Chang and Hwang popularized the forearm flap, based on the radial artery, for phallic constructionToday, forearm flaps are the most commonly employed method for total phallic construction and penile reconstruction.
67patient’s left (usually nondominant) forearm. Laterally are the shaft skin islandsmedially is the urethral skin islanddistally is the intergral glans
68urethral skin island has been tabularized to the level of the neomeatus The lateral shaft skin islands are now in the process of being tabularized over the tabularized urethra
69skin island has been closed over the urethra, the dorsal skin islands are being collectedappearance of the phallus after it is totally configured
70TOTAL PENILE RECONSTRUCTION Disadvantages to the use of a forearm flap for phallic constructionobvious donor site deformityDevelopment of cold intolerance in the hand of the donor sideforearm skin is hirsute