1. Surgery of the Penis and Urethra Ch.Reading
By: Dr. Ali AL-Amiri R2
Academic Day

2. 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

3. 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

4. Graft Split-thickness : Full-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

5. 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

6. 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

8. 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

9. SELECTED PROCESSES

10. 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

11. 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

12. 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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. URETHRAL STRICTURE DISEASE

22. 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.

23. 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.

24. 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

25. 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)

26. The length and location The depth and density
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

27. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. Excision and Reanastomosis

39. 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

43. 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

44. Techniques

48. in a meta-analysis of graft onlay procedures compared with flap procedures, showed equivalent results for graft operations and flap procedures.

49. 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

50. 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

51. Repair
For optimal exposure to the area of the membranous and apical prostaticn urethra
exaggerated lithotomy position

52. 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

53. 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

54. 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

55. 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

57. 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.

58. 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.

59. CURVATURES OF THE PENIS

60. 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

61. 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

62. 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.

63. 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

64. 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

65. 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

66. 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.

67. patient’s left (usually nondominant) forearm.
Laterally are the shaft skin islands
medially is the urethral skin island
distally is the intergral glans

68. 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

69. skin island has been closed over the urethra,
the dorsal skin islands are being collected
appearance of the phallus after it is totally configured

70. 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

71. Thank you 