Presentation on theme: "Surgery of the Penis and Urethra Ch.Reading By: Dr. Ali AL-Amiri R2 Academic Day."— Presentation transcript:
Surgery of the Penis and Urethra Ch.Reading By: Dr. Ali AL-Amiri R2 Academic Day
PRINCIPLES OF RECONSTRUCTIVE SURGERY The term tissue transfer implies the movement of tissue for purposes of reconstruction All tissue has physical characteristics: – extensibility – inherent tension – viscoelastic 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
PRINCIPLES 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 take Take requires approximately 96 hours and occurs in two phases – The initial phase, imbibition, requires about 48 hours – second phase, inosculation, also requires about 48 hours and is the phase in which true microcirculation is reestablished
Graft Split-thickness : – carries the epidermis and also exposes the superficial dermal (intradermal or intralaminar) plexus – physical characteristics are not carried, which accounts for the tendency of split-thickness units to be brittle and less durable – favorable vascular characteristics Full-thickness : – Carries superficial dermis and deep dermis or deep lamina – Carries characteristics attributable to that layer – fastidious vascular characteristics – does not contract
Graft The grafts that have been successfully used for primary urethral reconstruction are the full-thickness – skin graft – bladder epithelial graft ( good vascular characteristics) – oral mucosal graft (optimal vascular characteristics) – rectal mucosal graft
Flap Flap: implies that the tissue is excised and transferred with the blood supply either preserved or surgically reestablished at the recipient site Classification vascularity ( random vs axial ) – Random : without a defined cuticular vascular territory – Axial : defined vessel in the base of the flap Peninsula:vascular continuity and the cutaneous continuity of flap base are intact Island: 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
Generalities of Reconstructive Surgical Techniques Reconstructive surgery is performed with all efforts aimed at minimizing tissue injury and promoting healing – Adequate visualization, Surgical loupes, headlight In penile cases such as reconstruction of the fossa navicularis bipolar cautery is used exclusively Sharp scissors that cut with minimal collateral trauma are essential choice of suture – urethral surgery, absorbable suture is the rule – flap or graft repair, 4-0 to 6-0 suture is usually adequate
Reiter Syndrome classic triad of arthritis, conjunctivitis, and urethritis Urethral involvement is usually mild, self-limited, and a minor portion of the disease 10% - 20% of patients have a called circinate balanitis, is diagnostic of Reiter syndrome – shallow, painless ulcer with gray borders mild and self-limited, no treatment is necessary In severe cases: perineal urethrostomy and excise the entire distal urethra may be performed
Lichen Sclerosus (Balanitis Xerotica Obliterans) chronic inflammatory disorder of the skin of uknown origin The peak ages – women are bimodal (before puberty and postmenopausal) – 30 to 50 years ( all ages ) most common cause of meatal stenosis LS appears as a whitish plaque that may involve the prepuce, glans penis, urethral meatus, and fossa navicularis If only the foreskin is involved, circumcision may be curative Diagnosis is made through biopsy
Lichen Sclerosus (Balanitis Xerotica Obliterans) cause of LS has not been defined, but suggested to be an autoimmune disease Treatment : combination of topical steroids and antibiotics may help stabilize the inflammatory process Conservative therapy may be warranted in patients whose meatus can easily be maintained at 14 F – intermittent catheterization with lubrication of the catheter and meatal dilator may be adequate treatment
Lichen Sclerosus (Balanitis Xerotica Obliterans) In young patients with severe meatal stenosis, surgery is indicated Because LS is a disease of genital skin, better tissue for reconstruction is the oral mucosa In severe urethral stricture disease – completely reconstructed the urethra – simply performed a perineal urethrostomy
Urethrocutaneous Fistula Urethral fistulas may be a complication of – urethral surgery – secondary to periurethral infection associated with inflammatory strictures Treatment of a urethral fistula must be directed defect the underlying process After urethral surgery – early fistula is the result of poor local healing, possibly secondary to hematoma, infection, or tension with closure aggressive local care and continued urinary diversion may close fistula
Urethrocutaneous Fistula Closure of fistula after surgery: If small : – button of skin is removed from around the fistula – edges are cut flush with the urethral wall. – The urethra is closed with small (6-0 or 7-0) absorbable suture If large : – local flaps will be required.
Urethrocutaneous Fistula Fistulas associated with inflammatory strictures develop secondary to high-pressure voiding of infected urine – multiple tracts develop called (watering pot perineum) Repair requires – suprapubic drainage – treatment of the infection requires incision and drainage of any abscesses – We widely excise the fistula tracts – Flap reconstruction can be used – wait 4 to 6 months before repairing the underlying stricture fistula or periurethral abscess may be the hallmark symptom of urethral carcinoma
Paraphimosis, Balanitis, and Phimosis Paraphimosis: painful swelling of the foreskin distal to a phimotic ring, occurs if the foreskin remains retracted for a prolonged time – gentle steady pressure must be applied to the foreskin to decrease the swelling – If it reduced : elective dorsal slit or circumcision later – If failed emergency dorsal slit or circumcision Balanitis: inflammation of the glans, can occur as a result of poor hygiene, from failure to retract and clean under the foreskin – Tx : local care and antibiotic ointment Phimosis: inability to retract the foreskin, can result from repeated episodes of balanitis – Tx : circumcision
Urethral Meatal Stenosis Meatal stenosis in a boy appears to be a consequence of circumcision Meatal stenosis occurs in adults after inflammation, specific or nonspecific urethral infection, and trauma Tx – ventral urethral meatotomy – necessary to place sutures to approximate the urethral mucosal edge to control bleeding. – three sutures: one at the apex and one on either side
Circumcision It 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 boy – recurrent UTI thought to be associated with the redundant preputial skin Monopolar electrocautery should be avoided in a neonatal circumcision
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 – obliterative process has resulted in fibrosis and is generally the effect of distraction in that area caused by either trauma or radical prostatectomy By consensus of the WHO conference, the term stricture is limited to the anterior urethra.
The anatomy of anterior urethral strictures includes, in most cases, underlying spongiofibrosis. A, Mucosal fold. B, Iris constriction. C, Full-thickness involvement with minimal fibrosis in the spongy tissue. D, Full-thickness spongiofibrosis. E, Inflammation and fibrosis involving tissues outside the corpus spongiosum. F, Complex stricture complicated by a fistula.
Etiology Any 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 stricture – Trauma ( straddle trauma - iatrogenic ) – inflammatory strictures ( gonorrhea –BXO ) – Congenital if it is not an inflammatory stricture short-length stricture not associated with a history of or potential for urethral trauma Mainly limited to infants before they attempt erect ambulation
Diagnosis and Evaluation Patients often present with – obstructive voiding symptoms – UTI (prostatitis, epididymitis) – urinary retention. For an appropriate treatment plan you should know : – Location – Length – Depth – Density of the stricture (spongiofibrosis)
The length and location – determined with radiography, urethroscopy, and ultrasonography. The depth and density – determined by P/E – appearance of the urethra in contrast-enhanced studies – the amount of elasticity noted on urethroscopy The depth and density of fibrosis are difficult to determine objectively
Dynamic radiographic studies : – retrograde injection of contrast material and while the patient is voiding – If the patient is not in steep lateral oblique position for retrograde urethrography, the length of the stricture will be underestimated evaluate the urethra proximal and distal to the stricture with endoscopy during surgery to ensure that all the involved urethra is included in the reconstruction
Treatment Dilation oldest and simplest treatment epithelial stricture without spongiofibrosis, it may be curative goal is to stretch the scar without producing more scarring least traumatic method is to use soft techniques over multiple treatment sessions. – Safest is balloon-dilating catheters
Internal Urethrotomy refers to any procedure that opens the stricture by incising it transurethrally incision through the scar to healthy tissue – to allow the scar to expand and the lumen to heal enlarged Usually done by single incision at the 12-o’clock position – cross section of the corpus spongiosum, showed the thinnest portion of the anterior aspect is from 10-o’clock to 2-o’clock
Internal Urethrotomy Complications: – recurrence of stricture ( most common ) – Bleeding – extravasation of irrigation fluid into the perispongiosal tissues – creation 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 spongiofibrosis – 74% moderately long-term success rate F.cath to be kept for 3 to 7 days
Internal Urethrotomy Urethral stents (removable or permanently implantable) after internal urethrotomy - UroLume ( permanent ) – 6 months to 1 year – Available data show that the stent is best employed for relatively short strictures of the bulbous urethra associated with minimal spongiofibrosis Complications: – perineal pain – Migration
Internal Urethrotomy Lasers The ideal laser for urethral stricture disease – totally vaporizes tissue – exhibits negligible peripheral tissue destruction – not absorbed by water – easily propagated along a fiber Advocates 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
Open Reconstruction Excision and Reanastomosis complete excision of the area of fibrosis, with a primary reanastomosis of the normal ends of the anterior urethra Most IMP technical points: – area of fibrosis is totally excised – anastomosis is widely spatulated, – large ovoid anastomosis – anastomosis is tension free. Strictures of 1 to 2 cm are generally easily excised with reanastomosis
Excision and Reanastomosis
Four grafts that have been successfully used for primary urethral reconstruction are the – full-thickness skin – the bladder epithelial – oral mucosal (buccal, labial, lingual) – rectal mucosal Grafts have been most successfully employed in the area of the bulbous urethra
Flaps A 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 disease important considerations for the use of flaps: – nature of the flap tissue – vasculature of the flap – mechanics of flap transfer For donor site consideration, it is most convenient to use the areas of redundant nonhirsute genital skin
in a meta-analysis of graft onlay procedures compared with flap procedures, showed equivalent results for graft operations and flap procedures.
PELVIC FRACTURE URETHRAL INJURIES Urethral injuries accompany about 10% of pelvic fracture injuries Distraction injuries are for all intents unique to the membranous urethra Many injuries appear not to totally distract the entire circumference of the urethra – placement of an aligning catheter may allow the urethra to heal virtually unscarred or with an easily managed stenosis
Repair 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 urethra Several series support the concept that the bulk of pelvic fracture urethral injuries can be managed by the perineal approach At the time of reconstruction – endoscopy is performed through the meatus and again through the suprapubic tube sinus To R/O vesicolithiasis
Repair For optimal exposure to the area of the membranous and apical prostaticn urethra – exaggerated lithotomy position
Repair A, 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
Repair 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
Repair 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
When the prostatic urethra is displaced – A, length can be shortened by incision of the triangular ligament – Lateral 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
Postoperative Management Small soft silicone stenting catheter. Urine is diverted by way of the suprapubic cystostomy After the reconstruction, patients are initially kept at bed rest for 24 to 48 Discharged with the SPC and stenting urethral catheter in place Discharged on suppressive antibiotic. A voiding trial with contrast material is performed between 21 and 28 days postoperatively.
Postoperative Management Trial involves removing the urethral catheter, filling the patient’s bladder with contrast material, and instructing him to void – R/O extravasation – Patency of reanastomosis The patient is allowed to void through the urethra for 5 to 7 days, and the suprapubic catheter is then removed Approximately 6 months postoperatively, and again 1 year later, the patients are evaluated with flexible endoscopy The curative rates for reconstruction of posterior pelvic fracture urethral injuries are in the high 90% range.
CURVATURES OF THE PENIS
The 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 interchangeably prefer 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
Types 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 skin – element of hooded preputial skin – high insertion of the penoscrotal junction photographs are helpful in differentiating between chordee without hypospadias and congenital curvatures of the penis – erect penis equal to the size of the detumesced penis
Chordee without Hypospadias in Young Men: Corrective surgery is highly successful, and, in almost all cases, an effective penis has been straightened by excision of all the dysgenetic tissues from the ventral side of the penis.
Congenital Curvatures of the Penis: Patients can have ventral, lateral (which is most often to the left), or, unusually, dorsal curvature During surgery – artificial erection demonstrates the character of the curvature and the location of maximal curvature – fibrous tissue is mobilized and completely excised
Acquired Curvatures of the Penis Acquired curvatures of the penis inevitably follow trauma to the penis Acquired Curvatures of the Penis That Are Not Peyronie Disease: reveal a history of minimal lateral curvature of the penis clear 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
Subclinical 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 penis believed to be due to the disruption of the outer longitudinal layer of the tunica albuginea with intact inner circular layer These injuries are not associated with shortening of the penis TX : excise the scar and place a graft to replace the corporotomy defect caused by the scar excision
TOTAL PENILE RECONSTRUCTION In 1984, Chang and Hwang popularized the forearm flap, based on the radial artery, for phallic construction Today, forearm flaps are the most commonly employed method for total phallic construction and penile reconstruction.
patient’s left (usually nondominant) forearm. Laterally are the shaft skin islands medially is the urethral skin island distally is the intergral glans
urethral 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
skin island has been closed over the urethra, the dorsal skin islands are being collected appearance of the phallus after it is totally configured
TOTAL PENILE RECONSTRUCTION Disadvantages to the use of a forearm flap for phallic construction – obvious donor site deformity – Development of cold intolerance in the hand of the donor side – forearm skin is hirsute