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Penis and Urethra Surgery: Difference between revisions

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=== Tissue Grafts ===
=== Tissue Grafts ===
[[File:Skin layers.png|alt=Anatomy of Skin Layers|thumb|600x600px|Anatomy of Skin Layers. Source: [[commons:File:Skin_layers.png|Wikipedia]]]]
==== Graft Anatomy ====
==== Graft Anatomy ====


* '''Superficial to deep:'''
* [[File:Skin layers.png|alt=Anatomy of Skin Layers|thumb|600x600px|Anatomy of Skin Layers. Source: [[commons:File:Skin_layers.png|Wikipedia]]]]'''Superficial to deep:'''
# '''Epidermal, or epithelial layer'''
# '''Epidermal, or epithelial layer'''
#* Acts as the barrier to the “outside”
#* Acts as the barrier to the “outside”
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===== Primary urethral reconstruction (5) =====
===== Primary urethral reconstruction (5) =====
# '''Skin grafts (full-thickness (FTSG) and split-thickness (STSG))'''
# '''<span style="color:#ff0000">Oral mucosal graft'''
#* '''<span style="color:#ff0000">Can be taken from (3):'''
#*#'''<span style="color:#ff0000">Cheek (buccal)'''
#*#'''<span style="color:#ff0000">Lip (labial)'''
#*#'''<span style="color:#ff0000">Undersurface of the tongue (lingual)'''
#* '''Buccal mucosa is thought to have a panlaminar plexus'''
#'''<span style="color:#ff0000">Bladder epithelial graft'''
#* Issues with desiccation and hypertrophic growth have limited its use in the distal urethra
#'''<span style="color:#ff0000">Rectal mucosa graft'''
#* Little is known about the characteristics of the rectal mucosal graft
#'''<span style="color:#ff0000">Skin grafts (full-thickness (FTSG) and split-thickness (STSG))'''
#* STSGs have been used for staged anterior urethral reconstruction
#* STSGs have been used for staged anterior urethral reconstruction
#* Extragenital FTSGs have an increased mass compared to genital FTSGs.
#* Extragenital FTSGs have an increased mass compared to genital FTSGs.
#** This increased mass makes the graft more fastidious, and the poor results reported with urethral reconstruction with extragenital FTSGs are probably due to poor or ischemic take.
#** This increased mass makes the graft more fastidious, and the poor results reported with urethral reconstruction with extragenital FTSGs are probably due to poor or ischemic take.
#** The posterior auricular graft (Wolfe graft) is an exception to the rule concerning extragenital skin.
#** The posterior auricular graft (Wolfe graft) is an exception to the rule concerning extragenital skin.
# '''Skin island flaps based on the dartos fascia or tunica dartos'''
# '''<span style="color:#ff0000">Skin island flaps based on the dartos fascia or tunica dartos'''
# '''Rectal mucosa graft'''
#* Little is known about the characteristics of the rectal mucosal graft
# '''Bladder epithelial graft'''
#* Issues with desiccation and hypertrophic growth have limited its use in the distal urethra.
# '''Oral mucosal graft'''
#* Can be taken from the cheek (buccal), the lip (labial), and the undersurface of the tongue (lingual);
#* '''Buccal mucosa is thought to have a panlaminar plexus'''
* The bladder epithelial graft and the oral mucosal graft have numerous vascular properties that make them desirable for urethral reconstruction.
* The bladder epithelial graft and the oral mucosal graft have numerous vascular properties that make them desirable for urethral reconstruction.
* '''Tunica vaginalis grafts have been tried for urethral reconstruction with uniformly poor results.'''
* '''Tunica vaginalis grafts have been tried for urethral reconstruction with uniformly poor results.'''


===== Penile reconstruction =====
===== Penile reconstruction =====
* '''STSGs (preferred) and FTSGs and have been used for penile reconstruction.'''
* '''<span style="color:#ff0000">Split-thickness skin grafts (preferred) and full-thickness skin grafts and have been used for penile reconstruction.'''
** '''The highest probability of 100% graft take and best cosmetic results occur with penile skin reconstruction using an unmeshed thick''' (0.012 - 0.015 inch) '''STSG'''.
** '''The highest probability of 100% graft take and best cosmetic results occur with penile skin reconstruction using an unmeshed thick''' (0.012 - 0.015 inch) '''STSG'''.
*** Meshed or thinner STSGs have more of a tendency to contract which compromises penile functionality and cosmesis.
*** Meshed or thinner STSGs have more of a tendency to contract which compromises penile functionality and cosmesis.
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* In urethral surgery, absorbable suture is the rule. The needle should be tapered if possible
* In urethral surgery, absorbable suture is the rule. The needle should be tapered if possible
* '''Femoral neuropathy can occur after lithotomy procedures due to hip hyperabduction/hyperextension, or secondary to retractor injury with abdominal/pelvic procedures.'''
* '''Femoral neuropathy can occur after lithotomy procedures due to hip hyperabduction/hyperextension, or secondary to retractor injury with abdominal/pelvic procedures.'''
** The femoral nerve, the largest branch of the lumbar plexus, is formed within the psoas muscle from the fusion of the anterior divisions of L2-L4. It emerges between the psoas major and iliacus muscles just superior to the inguinal ligament and enters the thigh lateral to the external iliac artery.
** '''Femoral nerve'''
*** Sensory branches are the anterior and medial femoral cutaneous and long saphenous nerves.
***Largest branch of the lumbar plexus
**** Responsible for sensation of anterior thigh and medial leg
***Formed within the psoas muscle from the fusion of the anterior divisions of L2-L4
*** Motor supply is to the psoas, iliacus, quadriceps, pectineus, and sartorius muscles.
***Emerges between the psoas major and iliacus muscles just superior to the inguinal ligament and enters the thigh lateral to the external iliac artery
**** Responsible for knee extension.
*** '''Sensory branches are the anterior and medial femoral cutaneous and long saphenous nerves.'''
**** '''Responsible for sensation of anterior thigh and medial leg'''
*** '''Motor supply is to the psoas, iliacus, quadriceps, pectineus, and sartorius muscles.'''
**** '''Responsible for knee extension'''


== Urethral stricture disease ==
== Urethral stricture disease ==
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** Urethral anastomosis is widely spatulated, creating a large ovoid anastomosis
** Urethral anastomosis is widely spatulated, creating a large ovoid anastomosis
** Anastomosis is tension free
** Anastomosis is tension free
* '''Steps to gain urethral length:'''
* '''<span style="color:#ff0000">Position: lithotomy'''
*'''Steps to gain urethral length:'''
*# '''Vigorous mobilization of the corpus spongiosum'''
*# '''Vigorous mobilization of the corpus spongiosum'''
*# '''Development of the intracrural space and detachment of the bulbospongiosus from the perineal body'''
*# '''Development of the intracrural space and detachment of the bulbospongiosus from the perineal body'''
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====== Adverse Events ======
====== Adverse Events ======
* '''<span style="color:#ff0000">Sexual dysfunction</span>'''
* '''<span style="color:#ff0000">Intraoperative</span>'''
*# '''Permanent ejaculatory dysfunction</span>'''
*'''<span style="color:#ff0000">Post-operative</span>'''
*#* '''May occur in as high as 20% of men following urethroplasty.'''
**'''<span style="color:#ff0000">Late post-operative</span>'''
*#* Complaints are usually related to pooling of semen within the urethra and/or loss of force with ejaculation. The etiology is poorly defined but is presumed to be due to either tortuosity of the neourethra and/or dysfunction of the bulbocavernosal muscle.
***'''<span style="color:#ff0000">Sexual dysfunction</span>'''
*# '''<span style="color:#ff0000">Temporary erectile dysfunction</span>'''
***# '''<span style="color:#ff0000">Permanent ejaculatory dysfunction</span>'''
*#* Found in up to 20% of individuals undergoing an anterior urethroplasty.
***#* '''May occur in as high as 20% of men following urethroplasty.'''
*#** This incidence is similar between all types of anterior urethroplasties, e.g., excision and primary anastomosis, vascularized or graft urethroplasties.
***#* Complaints are usually related to pooling of semen within the urethra and/or loss of force with ejaculation. The etiology is poorly defined but is presumed to be due to either tortuosity of the neourethra and/or dysfunction of the bulbocavernosal muscle.
*#** The erectile dysfunction symptoms classically resolve 6 six months with < 3-4% of patients reporting a permanent alteration in their erectile capabilities.
***# '''<span style="color:#ff0000">Temporary erectile dysfunction</span>'''
*#*** Overall, the rate of erectile dysfunction after urethroplasty was ≈equal to the rate after circumcision.
***#* Found in up to 20% of individuals undergoing an anterior urethroplasty.
*#** Longer-segment reconstructions were associated with a higher risk of postoperative erectile dysfunction, although the patient’s erectile function improved over time in many cases.
***#** This incidence is similar between all types of anterior urethroplasties, e.g., excision and primary anastomosis, vascularized or graft urethroplasties.
*# '''<span style="color:#ff0000">New onset of penile curvature</span>'''
***#** The erectile dysfunction symptoms classically resolve 6 six months with < 3-4% of patients reporting a permanent alteration in their erectile capabilities.
*#* May occur usually following an overaggressive attempt at excision and primary anastomosis performed in the distal bulbar region.
***#*** Overall, the rate of erectile dysfunction after urethroplasty was ≈equal to the rate after circumcision.
*# '''<span style="color:#ff0000">Loss of libido and anorgasmia</span>'''
***#** Longer-segment reconstructions were associated with a higher risk of postoperative erectile dysfunction, although the patient’s erectile function improved over time in many cases.
*#* Very rare and are predominately due to a psychological component.
***# '''<span style="color:#ff0000">New onset of penile curvature</span>'''
***#* May occur usually following an overaggressive attempt at excision and primary anastomosis performed in the distal bulbar region.
***# '''<span style="color:#ff0000">Loss of libido and anorgasmia</span>'''
***#* Very rare and are predominately due to a psychological component.
 
== Pelvic Fracture Urethral Injuries ==


== Pelvic fracture urethral injuries ==
* '''See [[AUA: Male Urethral Stricture (2016)|AUA Urethral Stricture Guideline Notes]]'''


* '''See AUA Urethral Stricture Guideline Notes'''
=== Pathogenesis ===
* PFUIs are the result of blunt pelvic trauma and accompany ≈10% of pelvic fracture injuries
*PFUIs are the result of blunt pelvic trauma and accompany ≈10% of pelvic fracture injuries
** Although total disruption of the urethra is possible with a straddle injury, '''straddle injuries most commonly involve only the bulbar urethra'''
** Although total disruption of the urethra is possible with a straddle injury, '''straddle injuries most commonly involve only the bulbar urethra'''
** '''Distraction injuries are unique to the membranous urethra'''
** '''Distraction injuries are unique to the membranous urethra'''
*** '''The most frequent point of distraction is at the departure of the bulbous urethra from the membranous urethra'''
*** '''The most frequent point of distraction is at the departure of the bulbous urethra from the membranous urethra'''
* '''Diagnosis and Evaluation'''
 
** Important to define the precise anatomy of the pelvic fracture injury before treatment is undertaken
=== Diagnosis and Evaluation ===
** A '''cystogram''' outlines the bladder and provides information about rostral displacement of the proximal urethra'''.'''
* Important to define the precise anatomy of the pelvic fracture injury before treatment is undertaken
*** '''The appearance of the bladder neck on contrast studies or on antegrade endoscopy does not accurately predict the ultimate function of the bladder neck after urethral reconstruction'''
* '''<span style="color:#ff0000">Imaging'''
**** '''In the past, great reliance was placed on whether the bladder neck was closed or open on cystography.'''
**'''<span style="color:#ff0000">Cystogram'''
***** '''Lack of contrast in the prostatic urethra would suggest a competent, closed bladder neck whereas contrast in the prostatic urethra would suggest an incompetent, open bladder neck'''
***'''<span style="color:#ff0000">Provides information on (3):'''
****** '''A lack of contrast material in the posterior urethra gives some information, about the integrity of the bladder neck. However, contrast material may opacify the prostatic urethra when the bladder neck is more than adequately competent for continence'''
***#'''<span style="color:#ff0000">Rostral displacement of the proximal urethra'''
* '''Repair'''
***#'''<span style="color:#ff0000">Bladder outline'''
***#'''<span style="color:#ff0000">Bladder neck competency'''
***#*'''<span style="color:#ff0000">Contrast in the prostatic urethra suggests an incompetent, open bladder neck'''
***#*'''<span style="color:#ff0000">Lack of contrast in the prostatic urethra suggests a competent, closed bladder neck'''
***#**'''<span style="color:#ff0000">The appearance of the bladder neck on contrast studies or on antegrade endoscopy does not accurately predict the ultimate function of the bladder neck after urethral reconstruction'''
***#***'''Although a lack of contrast material in the posterior urethra gives some information about the integrity of the bladder neck, contrast material may opacify the prostatic urethra when the bladder neck is more than adequately competent for continence'''
***#***In the past, great reliance was placed on whether the bladder neck was closed or open on cystography.
***#***If truly incompetent, open bladder neck, consider continent stoma instead of urethroplasty
***#***'''Can obtain videourodynamics to determine bladder neck competency'''
 
=== Management ===
*'''Repair'''
** In most cases, PFUIs are not long, and the resultant obliteration is amenable to a technically straightforward mobilization of the corpus spongiosum with a primary anastomotic technique.
** In most cases, PFUIs are not long, and the resultant obliteration is amenable to a technically straightforward mobilization of the corpus spongiosum with a primary anastomotic technique.
*** '''Aggressive mobilization of the corpus spongiosum is performed with caution, because it is thought to have possible ill effects on retrograde blood supply, which in the pelvic fracture patient may be tenuous.'''
*** '''Aggressive mobilization of the corpus spongiosum is performed with caution, because it is thought to have possible ill effects on retrograde blood supply, which in the pelvic fracture patient may be tenuous.'''
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