ANATOMICAL ALIGNMENT FOR THE CORRECTION OF BURIED PENIS

Purpose

We report a straightforward surgical technique for the correction and anatomical alignment of the skin in patients with various degrees of buried penis.

Materials and Methods

A combined series of 74 patients 7 months to 10 years old who were treated for buried penis at 2 institutions during a 7-year period. Patients presented with various symptoms, including balanitis, urinary tract infection, painful voiding, ballooning of the foreskin and urinary retention. In 29 patients (38%) trapped penis was due to previous circumcision. In our estimation the major anatomical defect in buried penis is an insufficient attachment of the dartos fascia and penile skin to Buck's fascia. Our technique involves making a circumferential incision of the inner preputial skin layer proximal to the corona, unfurling it from the shaft skin and leaving a coronal collar of approximately 1 cm. The annular band that usually constricts the corpora on retraction of the penile skin is incised, and the remaining proximal penile skin and dartos fascia are dissected off Buck's fascia proximally to the base of the penis. The penile dermis is sutured to the lateral aspect of the tunica albuginea at the penopubic junction and mid shaft of the penis. This technique restores normal anatomical relationships with excellent cosmetic results and negligible complications.

Results

At a median 5-year followup cosmesis was excellent in all case. Two patients with micropenis who required revision responded to endocrine therapy.

Conclusions

Excellent cosmetic results were obtained in all cases using this surgical technique.     

One-Stage Anterior Urethroplasty

Purpose

A deficient urethral segment was replaced with penile skin during a 1-stage procedure in patients with a long, tight urethral stricture, multiple attempts at hypospadias repair or severe hypospadias and circumcision.

Materials and Methods

In 29 patients a pedicled circumferential strip of distal penile skin was used to construct a neourethral floor. The roof was formed by regeneration of the epithelium from the edges of the floor over Buck's fascia. In our series the urethra was reconstructed because of an anterior urethral stricture in 11 patients, multiple failed hypospadias repairs in 6 and severe hypospadias with circumcision in 12.

Results

A neourethra of sufficient caliber and length was constructed with minimal postoperative complications in all patients. There were 2 cases of urethrocutaneous fistula at the subcoronal region, 1 meatal stenosis, 1 persistent chordee and 1 small distal penile skin patch slough that required only prolonged dressings. Mean followup was 19 months.

Conclusion

Our urethroplasty technique can be used to correct various types of anterior urethral stricture or hypospadias associated with insufficient penile or preputial skin.     

SURGICAL REPAIR OF URETHRAL CIRCUMCISION INJURIES

Purpose

The 2 types of urethral injury that can occur during circumcision are urethrocutaneous fistula and urethral distortion secondary to partial glans amputation. We report the surgical repair of these rare injuries.

Materials and Methods

In 8 patients urethrocutaneous fistulas located on the distal penile shaft or at the coronal margin were managed by splitting the glans and using a Mathieu style skin flap in 4 or vascularized penile skin flap in 4 to bridge the urethral defect. Three patients underwent repair of a hypospadiac deviated urethra secondary to partial glans amputation by 1 cm. of urethral mobilization and repositioning the meatus into a terminal position within the remaining glans tissue.

Results

The 8 patients with urethrocutaneous fistulas voided via a terminal meatus without fistula recurrence at a mean followup of 3.2 years (range 1 to 6). The 3 patients with partial glans amputation and urethral deviation repaired by short urethral advancement had functionally acceptable results, defined as a normal urinary stream, although 1 required meatal dilation postoperatively.

Conclusions

The 2 types of urethral injuries that can occur during circumcision are a subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. The urethrocutaneous fistula can be successfully repaired by splitting the glans and forming a neourethra from a vascularized pedicle flap of penile skin. The abnormal urethra after partial glans amputation is more difficult to repair but repositioning the urethra in a more cosmetic location has restored function.     

Complications of Penile Lengthening and Augmentation Seen at 1 Referral Center

Purpose

Complications of the recent cosmetic technique of penile lengthening and girth enhancement are reviewed.

Materials and Methods

During a 16-month period 12 men presented with complications of penile augmentation performed elsewhere. All 12 patients had undergone release of the suspensory ligament and 10 had received autologous fat injection.

Results

the chief complaint was poor cosmetic appearance (irregular residual fat nodules in 7 men, skin deformity and scarring in 4 and scrotalization in 4). Reoperation was necessary in 6 patients, wound complications occurred in 6 and sexual dysfunction was reported by 4. Only 1 patient reported a subjective increase in penile length.

Conclusions

Although a verifiable complication rate may never by available, the morbidity of elective penile lengthening and girth enhancement is noteworthy. These cosmetic techniques should be regarded as experimental.     

Coverage of circumferential penile shaft defects with the bipedicled scrotal flap: a case series

Background

Reconstruction of circumferential penile skin defects should address both cosmetic and functional concerns. Scrotal skin is an ideal replacement because its inherent elasticity allows erection. This characteristic also allows primary closure of the donor site. The purpose of this paper is to describe our use of a bipedicled scrotal flap and our modifications.

Methods

Five patients (age range, 19 to 76 years) over the last 7 years underwent reconstruction of circumferential defects with this technique. The underlying pathologic condition was siliconoma/paraffinoma (n?=?2), full-thickness burn (n=1), overly aggressive circumcision (n=1), and traumatic avulsion (n=1). Follow-up ranged from 2 to 6 years. A bipedicled flap was elevated from the scrotum and inset over either the dorsal or ventral aspect of the penile defect. Flap delay was carried out before final division at 3 weeks. The junction line on the penile shaft was designed as a Z-pattern which was off-center.

Results

Four patients healed uneventfully. One patient had flap tip necrosis due to insufficient delay, which resulted in mild ventral scarring. All were able to have normal erection.

Conclusions

We have used the bipedicled scrotal flap in a staged manner for circumferential penile defects. The advantages of this technique were reliable coverage with an inconspicuous donor site, provision of expansile skin allowing normal erection and preservation of the penile–scrotal junction. The disadvantages were multistaged procedure, skin mismatch because of rugosity, and hair growth. Level of Evidence: Level V, therapeutic study.     

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias

Aims and objectives

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias.

Materials and methods

All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty.

Results

Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52 %) children required a tunica albuginea plication for chordee correction. In total, 16 (17 %) patients developed 24 complications and 11 children (12 %) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus.

Conclusions

Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

     

Distal urethrectomy for localized penile squamous carcinoma in situ extending into the urethra: an updated series

Introduction

The presence of squamous carcinoma in situ (CIS) of the distal penis extending into the urethral meatus is generally considered a contraindication for glans-sparing procedures. Distal urethrectomy with subsequent reconstruction can provide an alternative approach toward urethral resection while providing penile preservation in select cases. Unfortunately, long-term oncologic outcomes with this approach are ill-defined.

Materials and methods

Between 1988 and 2012, five patients at Indiana University Medical Center underwent distal urethrectomy with reconstruction for penile squamous CIS extending into the urethral meatus. This cohort was retrospectively reviewed to evaluate functional and oncological outcomes.

Results

Of the five patients, four presented with glanular lesions and were initially managed with Mohs procedure in three cases, and local excision in one. The final patient presented with extensive urethral disease and was managed with primary urethrectomy. Reconstruction was performed with penile skin pedicle grafts in four patients and perineal urethrostomy in one. Final pathologic stage was T1 in one patient and Tis in the remaining four. Follow-up ranged from 6 to 96 months. One local recurrence was verified; however, it occurred outside the urethral area. This was confirmed in the pathologic analysis after the patient underwent a partial penectomy. Meatal dilation was necessary in two patients 12 and 7 months after the procedure.

Conclusion

Distal urethrectomy for penile squamous CIS extending into the urethral meatus is a valid alternative to achieve negative surgical margins while preserving a penile function. Oncologic outcomes appear acceptable but larger series are still warranted to confirm our findings.     

VAGINAL CONSTRUCTION IN CHILDREN

Purpose

We evaluated outcomes in 20 patients 1 to 21 years old who underwent vaginal construction between 1980 and 1996.

Materials and Methods

A total of 21 vaginal constructions was performed in 20 children using ileum in 13, sigmoid colon in 6, bladder mucosa from a diverticulum in 1 and scrotal skin in 1. The diagnoses included the Mayer-Rokitansky syndrome in 6 cases, micropenis in 5, cloacal exstrophy in 3, penile agenesis in 3, and testicular feminization, classic bladder exstrophy and true hermaphroditism in 1 each.

Results

Patients treated with intestinal vaginoplasty had excellent cosmetic results without excessive mucous production or the need for routine dilation. The bladder mucosa vagina achieved good results with periodic dilation. Loss of depth developed in the scrotal skin vagina and it was converted to an ileal vagina. Stenosis at the mucocutaneous junction in 1 patient with a sigmoid and 1 with an ileal vagina was treated with Y-V plasty.

Conclusions

Vaginal construction may be performed using isolated bowel segments with excellent results and minimal morbidity. We have found ileum to be the segment of choice in younger patients, while sigmoid colon is preferred for vaginal construction in adolescents. Vaginal construction with isolated bowel segments provides a cosmetic, self-lubricating neovagina with low rates of failure and revision, and without the need for routine dilation.     

Fluorescence-guided laser therapy for penile carcinoma and precancerous lesions: Long-term follow-up

Objectives and aims

Laser therapy for penile carcinoma is commonly used despite high recurrence rates of up to 48%. The aim of our study was to investigate the long-term recurrence rate of patients treated by fluorescence-guided laser therapy for penile carcinoma and its impact on oncologic outcome.

Patients and methods

Between 1999 and 2005, a total of 26 patients with premalignant carcinoma in situ (Tis) (n = 11) or invasive penile carcinoma (n = 15) were treated by fluorescence-guided laser therapy in our center. The mean follow-up was 71.1 months (range 41–104 months). Recurrence rate, time to recurrence, and impact on survival was investigated for Tis patients and penile carcinoma patients separately.

Results

No patient died tumor-associated recurrence during follow-up. No local progression of T stage was observed in patients with Tis tumor. In the group with invasive penile cancer, there were 4 (15.4%) local recurrences. However, 3 of them occurred after more than 3 years and, therefore, are more likely to be considered as “de novo” carcinoma. No intra- or perioperative side effects of photodynamic diagnosis (PDD) were observed.

Conclusions

Local recurrence rate of laser therapy can be reduced by fluorescence guidance without impairing cosmetic or functional results. The necessary equipment is available in many centers that perform PDD for urothelial bladder cancer. PDD, therefore, can be considered to be cost-effective and easy to perform. Prospective multi-center studies to directly compare recurrence rates between white light and fluorescence-guided laser therapy for penile carcinoma are required.     

An Innovative Wound Retractor/Protector for Prosthetic Urologic Surgery

Objective

We demonstrate an innovative use of a barrier surgical wound retractor/protector system for use in a variety of prosthetic urologic procedures (penile prosthetics, artificial urinary sphincters, male slings).

Materials and Methods

We demonstrate the use of a self-retaining ring wound retractor in a multitude of prosthetic urological procedures: insertion of an inflatable penile prosthesis through an infrapubic approach as well as penoscrotal approach, placement of a transperineal artificial urinary sphincter, and placement of a male urethral sling.

Results

The self-retaining ring wound retractor facilitated a more rapid setup and takedown, provided 360 degrees of atraumatic retraction as well as 360 degrees of wound protection, allowed for maximum exposure with a minimum incision size, significantly shortened the operating wound depth thus maximizing exposure, and isolated the surgical field minimizing prosthesis to skin contact.

Conclusion

Our experience shows that prosthetic urologic surgeries can be enhanced with the use of the self-retaining ring wound retractor as it provides better surgical exposure, lowers wound infection risks, sets up more quickly as a safer retraction system with substantial cost savings.Key Words: Reconstruction, Retractor, Prosthesis, Urinary incontinence, Erectile dysfunction     

Surgical Management of Adult Acquired Buried Penis

Purpose of Review

Adult acquired buried penis is a morbid condition characterized by complete entrapment of the phallus as a result of morbid obesity, post-surgical cicatrix formation, or primary genital lymphedema. Hygienic voiding is not possible and urinary dribbling is frequent with accompanying inflammation, skin breakdown, and infection from the chronic moisture. The end result is penile skin fibrosis resulting in permanent functional loss. Herein, we describe the etiology of adult acquired buried penis, advances in its surgical management, and quality of life outcomes with treatment.

Recent Findings

Adult acquired buried penis is increasing in incidence as morbid obesity becomes more prevalent. Frequently comorbid conditions affect treatment including those affecting wound healing such a diabetes mellitus. Functional and cosmetic surgical outcomes are being published in greater volume in recent years leading to more refined treatment algorithms. Patient quality of life is greatly improved by definitive surgical management.

Summary

Adult acquired buried penis is a morbid condition that is increasing in incidence as obesity becomes more commonplace. Surgical management often necessitates surgical lipectomy of the suprapubic fat pad, scrotoplasty, and penile split thickness skin graft. Substantial quality of life improvements have been consistently reported after surgical treatment.

     

Successful penile reimplantation and systematic review of world literature

Introduction

There is paucity of case reports that describe successful non-microscopic penile reimplantation. We report a case of a self-inflicted penile amputation in an apparently normal patient with first psychotic break.

Buried penis: Classification surgical approach

Purpose

The purpose of this study was to describe morphological classification of congenital buried penis (BP) and present a versatile surgical approach for correction.

Materials and Methods

Sixty-one patients referred with BP were classified into 3 grades according to morphological findings: Grade 1—29 patients with Longer Inner Prepuce (LIP) only, Grade II—20 patients who presented with LIP associated with indrawn penis that required division of the fundiform and suspensory ligaments, and Grade III—12 patients who had in addition to the above, excess supra-pubic fat.

Operative Approach

A ventral midline penile incision extending from the tip of prepuce down to the penoscrotal junction was used in all patients. The operation was tailored according to the BP Grade. All patients underwent circumcision. Mean follow up was 3 years (range 1 to 10).

Results

All 61 patients had an abnormally long inner prepuce (LIP). Forty-seven patients had a short penile shaft. Early improvement was noted in all cases. Satisfactory results were achieved in all 29 patients in grade I and in 27 patients in grades II and III. Five children (Grades II and III) required further surgery (9%).

Conclusions

Congenital buried penis is a spectrum characterized by LIP and may include in addition; short penile shaft, abnormal attachment of fundiform, and suspensory ligaments and excess supra-pubic fat. Congenital Mega Prepuce (CMP) is a variant of Grade I BP, with LIP characterized by intermittent ballooning of the genital area.     

Totally extraperitoneal (TEP) bilateral hernioplasty using the Single Site® robotic da Vinci platform (DV-SS TEP): description of the technique and preliminary results

Purpose

Laparoendoscopic single site totally extraperitoneal (TEP) hernia repair showed to be a feasible alternative to conventional laparoscopic hernia repair; nevertheless single site surgery, with the loss of instruments triangulation can be a demanding procedure. To overcome those hurdles, the Single Site® (SS) platform of the da Vinci (DV) Si robotic system enables to perform surgical procedures through a 25-mm skin incision, with a stable 3D vision and restoring an adequate triangulation of the surgical instruments. We present in details the technique and the preliminary results of DV-SS TEP, to our knowledge the first cases reported in literature.

Methods

In March 2016, three consecutive male patients (mean age 46.6 years–mean BMI 25.3) with bilateral symptomatic inguinal hernia were submitted to DV-SS TEP in our institutions. Feasibility, codification of the technique, operative time and perioperative outcomes were recorded.

Results

All the procedures were completed as scheduled, with no conversion to other techniques. Mean operative time was 98.6 min, ranging between 155 and 55 min, reflecting the learning curve of the operating room team on this new procedure. No intraoperative or postoperative complications were experienced and all the patients were discharged within 24 h after surgery. Patients reported satisfactory postoperative course, with no recurrence of inguinal hernia and satisfaction in cosmetic result at 6-month follow-up.

Conclusions

DV-SS TEP inguinal hernia repair showed to be feasible and effective surgical option for bilateral groin hernia repair. Patients’ outcome was uneventful, with optimal cosmetic results. Further studies comparing this innovative technique to TEP or LESS TEP should be promoted.

     

Use of Free Grafts in Urethral Stricture Reconstruction

Purpose

The indications, contraindications and results of free graft urethroplasty are determined.

Materials and Methods

A retrospective review was done of 40 consecutive patients who underwent free graft urethroplasty with penile and preputial skin, buccal mucosa and bladder epithelium.

Results

Of the 35 patients in whom adequate followup data were available the outcome was successful in 30 (86 percent). Success was unrelated to donor site, prior intervention or cause of stricture. Failure was attributed to placement of grafts onto the penile urethra and patient age.

Conclusions

For strictures in the bulbar urethra the success rate of free grafts was high. Failures occurred in patients in whom full thickness skin grafts were extended far onto the penile urethra.     

PENILE CIRCULAR FASCIOCUTANEOUS SKIN FLAP IN 1-STAGE RECONSTRUCTION OF COMPLEX ANTERIOR URETHRAL STRICTURES

Purpose

We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution.

Materials and Methods

We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years).

Results

The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning.

Conclusions

Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

The Dartos Flap as an Adjunct in Preventing Urethrocutaneous Fistulas in Repeat Hypospadias Surgery

Purpose

Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair.

Materials and Methods

The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995.

Results

Of 6 patients cosmesis was excellent in 84 percent, erections were straight in 100 percent, and urinary streams were of good quality and without fistula in 100 percent after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year.

Conclusions

The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.     

Organ‐preserving surgery for penile cancer: description of techniques and surgical outcomes

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Organ‐preserving surgeries for penile cancer have been described to reduce the morbidity associated with traditional operations. Patients derive better functional outcomes from penile‐preserving surgery, although local recurrence rates can be higher. Excellent results can be obtained at large‐volume centres. With close follow‐up, local recurrences can be identified and treated promptly (often with further local excision).

OBJECTIVE

• ? To describe the outcomes of organ‐preserving surgery for penile cancer at a UK tertiary referral centre.

PATIENTS AND METHODS

• ? Patients at Sunderland Hospital (UK) between 2001 and 2008 who had squamous cell tumours limited to the glans penis underwent penile‐preserving surgery including total glansectomy and glanuloplasty, partial glansectomy, glans relining and distal penectomy with glans reconstruction.
• ? Recurrence rates, cosmetic and functional outcomes were recorded.

RESULTS

• ? In all, 65 patients were identified with a median follow‐up of 40 months. Local recurrence was present in four patients (6%) despite 72% having intermediate or poorly differentiated tumours and 30% with T2 disease.
• ? Complications included partial graft loss (1.5%), graft contractures (4.5%) and meatal stenosis (7.5%).
• ? In all, 5% were deemed to have poor cosmetic outcome and 85% described good erections at 1 year after surgery.

CONCLUSION

• ? Penile‐preserving surgery can achieve good penile cancer control with minimal morbidity and reduced psychosexual side‐effects.

     

Reconstruction of the male external genitalia in diverse disease processes: Our reconstructive algorithm,techniques, and experience

BackgroundMale genital form and function may be rendered abnormal by a number of disease processes, with profound associated psychological and functional consequences. The aim of the study is to review our reconstructive experience with cases of genital loss or distortion due to nonmalignant diseases processes and atypical neoplasia.Materials and methodsA retrospective review of a prospectively maintained database was performed to identify reconstructive cases performed from 2018 to 2020 under the care of a single surgeon. Male patients 18 years or older with a disease diagnosis other than squamous cell carcinoma affecting genital form were included. Disease processes, patient factors, surgical techniques, and both functional and cosmetic outcomes were reviewed.ResultsFourteen cases were identified. The patients had a mean age of 52.2 years (range, 21–72 years). Acquired buried penis was present in 8 patients. Etiology of genital abnormality included balanitis xerotica obliterans (n = 6), excess skin loss at circumcision (n = 2), self-injection of petroleum jelly to penile shaft (n = 1), Fournier gangrene (n = 1), hidradenitis suppurativa (n = 1), extramammary Paget disease (n = 1), idiopathic lymphoedema (n = 1), and penoscrotal webbing (n = 1). Reconstructive techniques performed included penile debridement/shaft skin release, scrotectomy, suprapubic apronectomy, and division of penoscrotal webbing, in combination with split-thickness skin grafting where required. A penile implant was inserted in one patient. Reconstructive planning, techniques, and outcomes are described.ConclusionsA variety of reconstructive techniques in andrology can be used to improve the aesthetic and functional outcomes of multiple disease processes affecting the male external genitalia.