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C Fitzgerald GCH Uro 1 Chapter 33 Surgery of the Penis and Urethra continued Slide 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 Slide 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) Slide 4 Distraction Injuries of the Urethra Evaluation Depth Density Length Location Contrast studies Cystogram Voiding cystogram, RG urethrogram Endoscopy + Antegrade endoscopy + MRI Slide 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 ) Slide 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) Slide 7 Figure 33-44 Diagram of a perineal repair of a membranous urethral stricture. A 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 2009 11:49 PM) 2007 Elsevier Slide 8 Figure 33-45 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, 1999:338-344.) Downloaded from: Campbell-Walsh Urology (on 20 March 2009 11:49 PM) 2007 Elsevier Slide 9 Figure 33-46 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 2009 11:49 PM) 2007 Elsevier Slide 10 Posterior Urethral Reconstruction Post Op management SP cystotomy diversion small urethral catheter stent Bedrest 24-48 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 Slide 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 Slide 12 Figure 33-48 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 2009 11:49 PM) 2007 Elsevier Slide 13 Repairing Distraction Injuries of the Urethra in Children Perineal or Posterior, sagital transsphinteric approach (Mathews et al 1998 and Pena and Hong 2004) Slide 14 Vesicourethral distraction defects Risks radical prostatectomy, obesity, small, thick bladder Evaluate Antegrade endoscopy RG urthrography Initial management; often suprapubic cystostomy Slide 15 Vesicourethral distraction Treatment Goal: functional reconstruction Other options Endoscopic (laser, cold knife) Continent catheterizable bladder Diversion Slide 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 Slide 17 Figure 33-50 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 2009 11:49 PM) 2007 Elsevier Slide 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 Slide 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 Slide 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 Slide 21 Figure 33-51 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 2009 11:54 PM) 2007 Elsevier Slide 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) Slide 23 Congenital Curvatures of the Penis Dr CJ Devine and Horton Slide 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 Slide 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 Slide 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 Slide 27 Slide 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 Slide 29 Acquired curvature of the Penis Treatment Corporotomy with graft Mobilize Bucks fascia laterally Coporotomy location (laterally) requires little/no mobilization of neurovasccular structures Slide 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 Slide 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 Slide 32 Figure 33-53 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 2009 11:49 PM) 2007 Elsevier Slide 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 Slide 34 Phallic Reconstruction cont 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) Slide 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 Slide 36 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 Slide 37