Campbell-Walsh Urology, 11th Edition

PART VI

Male Genitalia

40

Surgery of the Penis and Urethra

Kurt A. McCammon; Jack M. Zuckerman; Gerald H. Jordan

Questions

  1. In terms of tissue transfer, which of the following statements concerning grafts is TRUE?
  2. The process of take is less than 48 hours.
  3. A graft is tissue that is excised from a donor site and reestablishes its blood supply by revascularization.
  4. During imbibition, the first phase of take, the graft exists above body temperature.
  5. Conditions of take are a reflection of only the graft host bed.
  6. Split-thickness skin grafts are less prone to contraction compared with full-thickness grafts.
  7. With regard to the microanatomy of grafts, using skin as a model, which of the following statements is TRUE?
  8. The intradermal plexus is at the interface of the superficial and deep dermis.
  9. The subdermal plexus is carried at the juncture of the deep dermis and the underlying tissue.
  10. The lymphatics are most richly distributed in the adventitial dermis.
  11. The adventitial dermis, because of its collagen content, accounts for the majority of the physical characteristics.
  12. Genital and extragenital skin behaves similarly when used in genitourinary reconstruction.
  13. With regard to the grafts used most commonly in genitourinary reconstructive surgery, which of the following statements is TRUE?
  14. Full-thickness skin is an optimal replacement for the tunica albuginea of the corpora cavernosa.
  15. Bladder epithelial graft is fastidious because of the nature of the superficial lamina.
  16. Buccal mucosa graft is thought to have a panlaminar plexus.
  17. Tunica vaginalis graft has proved to be a very reliable one for single-stage urethral reconstruction.
  18. Buccal mucosa grafts should not be thinned because it will adversely affect the physical and vascular properties of the graft.
  19. With regard to the anatomy of the penile shaft, which of the following statements is TRUE?
  20. Throughout most of the length of the penis, the septum is a true competent septum.
  21. The erectile tissues of the normal corpora cavernosa are separated from the tunica by the space of Smith.
  22. The dorsal arteries of the penis are carried in an envelope fashion in the dartos fascia.
  23. The Buck fascia is loosely areolar and lies immediately beneath the skin.
  24. The Buck fascia attenuates on the ventrum, lateral to the corpus spongiosum.
  25. According to consensus, the urethra should be divided into six entities. Which of the following statements is most accurate?
  26. The fossa navicularis is that portion of the urethra that is most dorsally displaced with regard to the surrounding spongy erectile tissue.
  27. The bulbous urethral portion is invested by the thickest portion of the corpora spongiosum.
  28. The bulbous urethral at its proximal extent is part of the posterior urethra.
  29. The membranous urethra is invested by the most proximal aspect of the corpus spongiosum.
  30. The membranous urethra, throughout its length is surrounded by the external rhabdosphincter.
  31. With regard to the arterial vascularization of the deep structures of the penis, which of the following statements is TRUE?
  32. The circumflex cavernosal arteries are uniform in number and distribution.
  33. The arteries to the bulb arborize into the spongy erectile tissue of the glans.
  34. The common penile artery represents the end continuation of the superficial external pudendal artery.
  35. The common penile artery divides to become the cavernosal artery and the dorsal arteries, after branching off the circumflex cavernosal arteries.
  36. The blood supply of the deep structures of the penis is derived from the common penile artery, which is the continuation of the internal pudendal artery after it branches off its perineal branch and the posterior scrotal arteries.
  37. With regard to the innervation to the penis, which of the following statements is TRUE?
  38. The cavernosal nerves are purely parasympathetic and are the extensions of the nervi erigentes.
  39. The pudendal nerves accompany the dorsal artery of the penis and the dorsal vein of the penis as they run through the obturator foramen.
  40. The dorsal nerve arises in the Alcock canal as a branch of the pudendal nerve.
  41. The dorsal nerves throughout their course are prominent, large nerve bundles.
  42. The skin of the shaft of the penis is innervated by a branch of the femoral nerve.
  43. Which of the following statements regarding lichen sclerosus (LS) is FALSE?
  44. Lichen sclerosus is the preferred term for what was previously known as balanitis xerotica obliterans.
  45. LS is the most common cause of meatal stenosis.
  46. There is a strong association with an infectious etiology for the development of LS.
  47. Circumcision may be curative if only foreskin is involved with LS.
  48. Topical steroids may help stabilize the inflammatory process early in the disease course.
  49. Each of the following statements regarding complications associated with lichen sclerosus are true, EXCEPT:
  50. Urethral stricture may develop secondary to iatrogenic injury from repeat instrumentation.
  51. Genital or extragenital skin may be used for urethral reconstruction for LS-associated urethral strictures.
  52. Meatal stenosis and high-pressure voiding with subsequent urinary extravasation into the glands of Littre may result in urethral stricture formation.
  53. Squamous cell carcinoma may develop in patients with a long history of LS.
  54. Patients under consideration for meatal reconstruction with LS must undergo retrograde urethrography to rule out proximal strictures before surgery.
  55. Urethrocutaneous fistulae may develop secondary to all of the following, EXCEPT:
  56. complication following hypospadias repair or other urethral surgery.
  57. recurrence following fistula repair as a result of distal obstruction and high-pressure voiding.
  58. extravasation of infected urine and periurethral abscess formation.
  59. complication of genital herpes simplex viral infection.
  60. early fistula following urethral surgery may result from hematoma, infection, or tension with the closure.
  61. With regard to urethral meatal stenosis in childhood, which of the following statements is TRUE?
  62. Meatal stenosis is a frequent complication of phimosis
  63. Meatal stenosis is frequently associated with upper tract changes, and all patients should be evaluated with ultrasonography and voiding cystourethrography
  64. When ammoniacal meatitis is noted, often a short course of meatal dilation and steroid cream application will resolve the problem.
  65. When meatal stenosis is present, usually a dorsally based YV advancement flap repair is preferred
  66. Meatal stenosis in childhood is frequently associated with concomitant lichen sclerosus
  67. When treating a patient with penile amputation, which of the following statements is TRUE?
  68. Replantation is not a consideration in self-inflicted injury, because most of these patients are chronically psychotic and will eventually try to amputate the penis again
  69. If the distal part of the penis is not available, even if the amputation involves mostly skin with much of the shaft preserved, it is recommended that the remaining shaft be buried in the scrotum
  70. In the case of amputation associated with avulsion, debridement to undivided tissue must precede penile replantation
  71. The classic technique for replantation involves coaptation of the dorsal nerve, the deep dorsal vein, and the cavernosal arteries
  72. The McRoberts technique of macroreplantation is not the preferred method of management for these patients, but when the situation warrants it, it is very successful
  73. All of the following statements regarding circumcision are true, EXCEPT:
  74. Circumcision may be performed in the neonatal period in newborns born with a distal hypospadias, but not in those with proximal hypospadias.
  75. Young boys with recurrent urinary tract infections (UTIs) should be considered for circumcision.
  76. The most common complication following newborn circumcision is bleeding.
  77. Circumcision has been shown to reduce the risk of human immunodeficiency virus (HIV) transmission in heterosexual men.
  78. Small skin dehiscence following circumcision may be managed conservatively with local wound care and healing by secondary intention.
  79. Concerning genital lymphedema, which of the following statements is TRUE?
  80. Reconstruction for lymphedema that is the consequence of the indirect effects of radiation is best accomplished with excision of the tissues and coverage with split-thickness skin grafts (STSGs).
  81. In reconstruction for lymphedema, it is essential to maintain the parietal tunica vaginalis of the testes intact with grafting over that location.
  82. When considering reconstruction for lymphedema, full-thickness skin grafts (FTSGs) are preferable because of the distribution of the lymphatics in the superficial (adventitial) dermis.
  83. In the case of genital lymphedema, it is not unusual for the immune response of the tissues to be altered and for patients to have significant involvement with genital papillomas.
  84. Not unusually, in cases where the genital lymphedema is localized, the midline of the scrotum can be preserved for reconstruction.
  85. Which of the following statements is most accurate concerning anterior urethral stricture disease?
  86. It causes limitation of the urethral lumen because of the bulk of the scar.
  87. It most often is limited to the urethral epithelium.
  88. It implies a scarring process, usually involving both the epithelium and the underlying spongy erectile tissue of the corpora cavernosa.
  89. It causes limitation of the urethral lumen because of contraction and noncompliance of the scar.
  90. It is a metaplastic process of the urethral epithelium.
  91. Which of the following statements concerning pelvic fracture urethral injury is TRUE?
  92. It involves the tissues of the epithelium as well as the underlying erectile tissues of the corpora cavernosa.
  93. It involves the tissues of the epithelium as well as the underlying erectile tissue of the corpus spongiosum.
  94. It is not a true stricture but rather fibrosis that results from distraction of the urethra.
  95. The stricture process can often be occult because of the unpredictable involvement of the urethral tissues.
  96. The defect is usually predictably proximal to the external sphincter at the junction of the prostatic urethra with the membranous urethra.
  97. In determining the anatomy of the stricture, all of the following provide useful information EXCEPT:
  98. magnetic resonance imaging (MRI).
  99. high-resolution ultrasonography.
  100. contrast studies.
  101. urethroscopy.
  102. calibration with bougie à boule.
  103. With regard to planning of reconstruction for urethral stricture, which of the following statements is TRUE?
  104. Even if a patient does not have retention, placement of a suprapubic tube may help define strictured areas.
  105. Tightly stenotic areas should be dilated to pass endoscopes proximally.
  106. The effects of hydrodilation are manifested most immediately distal to the area of narrowest stenosis.
  107. Calibration of strictured areas to 16 Fr or greater reliably predicts the potential for segments to contract.
  108. Sonourethrogram by itself accurately predicts depth of spongiofibrosis.
  109. With regard to direct visual internal urethrotomy, which of the following statements is TRUE?
  110. Strictures are best incised at the 12-o-clock position.
  111. Deep incision of the corpus spongiosum has been shown to optimize long-term results.
  112. In optimally selected patients, long-term success of internal urethrotomy is approximately 90%.
  113. Internal urethrotomy should be the first procedure considered for any stricture of the anterior urethra.
  114. It can be associated with erectile dysfunction.
  115. Concerning anterior urethral reconstruction, which of the following statements is TRUE?
  116. Excision and primary anastomosis reconstruction are severely limited and useful only for very proximal strictures 1 to 2 cm in length.
  117. Performance of the excision and primary anastomosis technique is facilitated by dissection of the corpus spongiosum to the level of the glans penis.
  118. Success requires total excision of the fibrosis with a widely spatulated anastomosis.
  119. Reconstruction is facilitated by development of the intracrural space with infrapubectomy.
  120. In cases of longer strictures, excision with partial anastomosis allowing one wall to granulate offers acceptable results.
  121. With regard to genital skin flap operations for anterior urethral reconstruction, which of the following statements is TRUE?
  122. Flap operations are best applied as individual techniques and require the surgeon to be intimately familiar with the individual steps of each technique.
  123. The operation can conceptually become one operation with multidimensional application.
  124. The operations are all based on mobilization of the extended Buck fascia.
  125. The operations require a comfortable understanding of the extended circumflex iliac superficial vascular pattern.
  126. They are of limited value in patients who have been previously circumcised.
  127. With regard to continence after reconstruction for pelvic fracture urethral distraction injuries, which of the following statements is TRUE?
  128. Location of the injury along the course of the membranous urethra is not associated with continence postoperatively.
  129. Continence can be accurately predicted by contrast studies.
  130. Continence is best predicted by the appearance of the bladder neck on endoscopy.
  131. Continence is best addressed after a procedure to reestablish urethral continuity is performed.
  132. Continence is best in patients with partial distraction injuries.
  133. In dealing with the entity of chordee without hypospadias, which of the following statements is TRUE?
  134. Correction of curvature is often achieved with mobilization of the corpus spongiosum alone.
  135. It often can be corrected with maneuvers that lengthen the foreshortened ventral skin.
  136. It is best straightened by an incision and grafting operation.
  137. Division of the urethra/corpus spongiosum is virtually always indicated.
  138. It is usually present with either ventral curvature or ventral curvature associated with torsion.
  139. With regard to acquired curvatures of the penis that are not Peyronie disease, which of the following statements is TRUE?
  140. Most are characterized by prominent dorsal scars.
  141. In most cases, global cavernosal veno-occlusive dysfunction (CVOD) is not a complicating factor.
  142. They are virtually never associated with "minimal" buckling trauma.
  143. Patients often have significant penile foreshortening.
  144. There is usually an association with either hypospadias or epispadias.
  145. All of the following are true regarding pelvic fracture urethral injuries (PFUI), EXCEPT:
  146. Pelvic fractures are associated with urethral injuries in about 10% of cases.
  147. PFUIs most commonly occur between the prostate and membranous urethra.
  148. In the prepubescent male, PFUI's are more likely to involve the prostatic urethra.
  149. A normal anterior urethral on retrograde urethrography nearly ensures an anastomotic repair of a PFUI is feasible.
  150. The appearance of the bladder neck on preoperative contrast studies does not accurately predict continence outcomes following anastomotic repair of PFUIs.
  151. In pelvic fracture urethral injuries, after excision of the traumatic scar, the distance between the two ends of healthy urethra can be minimized by all of the following, EXCEPT:
  152. mobilizing the corpus spongiosum off the corpora cavernosa up to the corona of the glans.
  153. excision of Buck fascia from the corpus spongiosum.
  154. dissection of the intracrural space down to the pubis.
  155. periosteal elevation and infrapubectomy.
  156. rerouting of the spongiosum above the crura of the corpora cavernosa.
  157. Which of the following patients should be considered for penile revascularization to prevent ischemic stenosis following PFUI repair?
  158. Men with erectile dysfunction (ED) following PFUI, but normal hemodynamics on penile duplex sonography
  159. Men with normal erectile function following PFUI
  160. Men following PFUI with ED and hemodynamics on penile duplex sonography suggesting venous leak
  161. Men with arteriogenic ED following PFUI who demonstrate bilateral occlusion of the internal pudendal arteries without reconstitution
  162. Men with arteriogenic ED following PFUI who demonstrate unilateral occlusion of the internal pudendal artery
  163. Which of the following statements regarding total phallic construction is FALSE?
  164. Phallic rigidity may be achieved in the neophallus by placement of a penile prosthesis before the return of tactile sensation of the phallus.
  165. Current techniques are accomplished with a variety of flap designs, which use microvascular free flap transfer.
  166. Urinary fistulae, although a common complication following phallic construction, are often resolved with conservative measures and do not routinely require operative repair.
  167. Complications following prosthesis placement into patients following total phallic construction are higher than those following placement into men with normal corporal anatomy.
  168. Penile tactile and erogenous sensation can be achieved following total phallic construction via coaptation of the flap cutaneous nerves to the dorsal penile/clitoral nerve, the pudendal nerve, or the ilioinguinal nerve.
  169. All of the following may be repaired with excision and primary anastomotic urethroplasty, EXCEPT:
  170. pelvic fracture urethral injury with a 3-cm gap demonstrated on preoperative urethrography.
  171. straddle injury resulting in a 1-cm bulbar urethral stricture.
  172. iatrogenic urethral trauma during a transurethral resection resulting in a 1-cm bulbar urethral stricture.
  173. idiopathic proximal 1-cm bulbar urethral stricture in a patient with a history of a prior hypospadias repair.
  174. perineal trauma resulting in a 2-cm proximal bulbar urethral stricture.

Answers

  1. b. A graft is tissue that is excised from a donor site and reestablishes its blood supply by revascularization.The term graft implies 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. During that phase, the graft survives by "drinking" nutrients from the adjacent graft host bed, and the temperature of the graft is less than the core body temperature. The second phase, inosculation, also requires about 48 hours and is the phase in which true microcirculation is reestablished in the graft. During that phase, the temperature of the graft rises to core body temperature. The process of take is influenced by both the nature of the grafted tissue and the conditions of the graft host bed. Processes that interfere with the vascularity of the graft host bed thus interfere with graft take.
  2. b. The subdermal plexus is carried at the juncture of the deep dermis and the underlying tissue.The epidermal, or epithelial layer, is a covering, the barrier to the "outside," and is adjacent to the superficial dermis, or superficial lamina. At approximately that interface is the superficial plexus. In the case of skin, the plexus is the intradermal plexus. There are some lymphatics in the superficial dermal or tunica layer. On the undersurface of the deep dermal layer or deep lamina is the deep plexus. In the case of skin, this is the subdermal plexus. The deep dermis contains most of the lymphatics and greater collagen content than found in the superficial dermal layer. The deep or reticular dermis is generally thought to account for the physical characteristics of the tissue. There is a difference between genital full-thickness skin (penile and preputial skin grafts) and extragenital full-thickness skin. This is probably a reflection of the increased mass of the graft in extragenital skin grafts. This increased mass makes the graft more fastidious, and the poor results reported with urethral reconstruction with extragenital full-thickness skin grafts are probably due to poor or ischemic take.
  3. c. Buccal mucosa graft is thought to have a panlaminar plexus.In the bladder epithelial graft, there is a superficial and a deep plexus; however, many more perforators connect the plexuses. Thus bladder epithelial grafts tend to have more favorable vascular characteristics. In the case of the oral mucosal grafts, there is a panlaminar plexus. Thus the oral mucosal graft can be thinned somewhat, provided a sufficient amount of deep lamina is carried to preserve the physical characteristics. The oral mucosal grafts are thought to have optimal vascular characteristics. The thinned graft diminishes the total graft mass while preserving the physical characteristics and not adversely affecting the vascular characteristics. Tunica vaginalis grafts have been tried for urethral reconstruction with uniformly poor results. The dermal graft (not full thickness skin) has been used for years to augment the tunica albuginea of the corpora cavernosa.
  4. b. The erectile tissues of the normal corpora cavernosa are separated from the tunica by the space of SmithThe corpora cavernosa are not separate structures but constitute a single space with free communication through an incompetent midline septum, composed of multiple strands of elastic tissue similar to that making up the tunica albuginea.The erectile tissue is separated from the tunica albuginea by a thin layer of areolar connective tissue that was described by Smith. The Buck fascia is directly abutted to the tunica albuginea of the corpora cavernosa. The Buck fascia surrounds the adventitia of the corpora spongiosum in envelope fashion, and the dorsal neurovascular structures are contained in envelope fashion between the superficial and deep laminar of the Buck fascia on the dorsum. The Buck fascia is thus "devoted" to the deep structures. The dartos fascia is loosely areolar and lies immediately beneath the skin. It is in that fascial layer that the arborizations of the superficial external pudendal vessels and the posterior scrotal vessels are carried.
  5. b. The bulbous urethral portion is invested by the thickest portion of the corpora spongiosum. The fossa navicularis is contained within the spongy erectile tissue of the glans penis and terminates at the junction of the urethral epithelium with the skin of the glans. The bulbous urethra is covered by the midline fusion of the ischiocavernosus musculature and is invested by the bulbospongiosum of the proximal corpus spongiosum. It becomes larger and lies closer to the dorsal aspect of the corpus spongiosum, exiting from its dorsal surface before the posterior attachment of the bulbospongiosum to the perineal body. The membranous urethra is the portion that traverses the perineal pouch and is partially surrounded by the external urethral sphincter. This segment of the urethra is unmatched to fixed structures, has the distinction of being the only portion of the male urethra that is not invested by another structure, and is lined with a delicate transitional epithelium.
  6. e. The blood supply of the deep structures of the penis is derived from the common penile artery, which is the continuation of the internal pudendal artery after it branches off its perineal branch and the posterior scrotal arteries.The common penile artery is the continuation of the internal pudendal artery giving off perineal posterior scrotal branches. From that point onward, it is termed the common penile artery. As it nears the urethral bulb, the artery divides into its three terminal branches as follows: (1) the bulbourethral arteries, which enter the proximal corpus spongiosum; (2) the dorsal artery, which travels along the dorsum of the penis contained in envelope fashion between the superficial and deep lamina of the Buck fascia; and (3) the cavernosal arteries, usually a single artery, which arise and penetrate the corpora cavernosa at the hilum and run the length of the penile shaft. The circumflex cavernosal arteries are given off at varying locations along the dorsal artery, but their distribution is neither uniform nor dependable.
  7. c. The dorsal nerve arises in the Alcock canal as a branch of the pudendal nerve. The cavernosal nerves are a combination of the parasympathetic and visceral afferent fibers that constitute the autonomic nerves of the penis. These provide the nerve supply to the erectile apparatus. The pudendal nerves enter the perineum with the internal pudendal vessels through the lesser sciatic notch at the posterior border of the ischiorectal fossa. They run in the fibrofascial pudendal canal of Alcock to the edge of the urogenital diaphragm. Each dorsal nerve of the penis arises on Alcock canal as the first branch of the pudendal nerve. On the shaft, their fascicles fan out to supply proprioceptive and sensory nerve terminals in the tunica of the corpora cavernosa and sensory terminals in the skin. The skin of the penis is innervated by branches of the genitofemoral nerve.
  8. c. There is a strong association with an infectious etiology for the development of LS.The etiology of LS has not been well defined. Multiple potential infectious etiologies have been suggested, but recent studies have found no association. Other proposed etiologies include a Koebner phenomenon, autoimmune event, and genetic associations. The remaining answer choices are correct.
  9. b. Genital or extragenital skin may be used for urethral reconstruction for LS-associated urethral strictures. Most surgeons now believe that LS is a disease of genital skin. For this reason, genital skin is not appropriate for reconstruction in patients with LS. Although it is technically possible to use extragenital skin for reconstruction, oral mucosal grafting has emerged as a better tissue in patients with LS associated urethral strictures.Patients with meatal stenosis from LS not infrequently also have more proximal strictures and need a complete workup prior to surgery. Patients with long-standing LS should be monitored for potential development of squamous cell carcinoma, because this has been reported.
  10. d. Complication of genital herpes simplex viral infection.Genital HSV has not been reported to cause urethrocutaneous fistulae. Each of the remaining answers is a potential etiology for urethrocutaneous fistula formation.
  11. c. When ammoniacal meatitis is noted, often a short course of meatal dilation and steroid cream application will resolve the problem. Meatal stenosis in the male child appears to be a consequence of circumcision, which allows for ammoniacal meatitis.Children seen with ammoniacal meatitis are usually started with meatal dilation using steroid cream. Within a week, the process seems to settle down. Anecdotally, the fusion of the ventral meatus skin, which causes meatal stenosis, seems to be avoided. Because childhood meatal stenosis truly represents a fusion of the ventral urethral meatus, dividing the thin membrane of fusion is preferred. This leaves the child with a slit-shaped meatus.
  12. e. The McRoberts technique of macroreplantation is not the preferred method of management for these patients, but when the situation warrants it, it is very successful.Often the amputation is self-inflicted, usually during an acute psychotic break. This should not preclude replantation unless the patient adamantly refuses such treatment. Even then, with a court order and the agreement of two or more surgeons, replantation may be undertaken. If possible, microreplantation should be carried out. This technique consists of an anatomic approximation of the tunica albuginea of the corporal bodies, a spatulated two-layer anastomosis of the urethra. The dorsal nerves are coapted using an epineural technique unless the injury is distal, at which point a vesicular coaptation may be required. The dorsal vein is anastomosed, and the dorsal arteries are anastomosed. Anastomosis of the cavernosal arteries is not possible and should not be attempted. If the situation is such that microreplantation cannot be undertaken, then the technique described by McRoberts can be carried out. His series and other series show that a high degree of success can be expected after replantation without microvascular reanastomosis. In most patients, however, they will have numbness distal to the replant site. With microreplantation, it is not at all unusual for patients to have excellent sensation distal to the area of injury and to have resumption of normal erectile function.
    If the patient presents with the distal part having been disposed of or otherwise unavailable, then the wound should be closed. Often the penis will have been stretched during the amputation and an excess of skin will have been removed, leaving a good length intact with denuded penile shaft structures. In that case, the corporeal bodies would be closed, the urethral meatus must be spatulated, and the penis can be immediately covered with a split-thickness skin graft. If the injury occurs because of avulsion, replantation is not an option as the stretch injury to the spermatic vessels or vessels of the penis cause unpredictable damage to the endothelium.
  13. a. Circumcision may be performed in the neonatal period in newborns born with a distal hypospadias, but not in those with proximal hypospadias. Newborns with any concern for hypospadias (distal or proximal) should NOT undergo circumcision.It is essential to preserve the foreskin so that it may be used for the hypospadias repair if necessary. Circumcision has consistently been shown in well-conducted randomized controlled trials to reduce the risk of HIV acquisition in heterosexual men by 50% to 60%. Circumcision will reduce the risk for UTI in infants and should be considered in those with recurrent infections. Most skin dehiscence following circumcision can be managed conservatively and does not require operative intervention.
  14. a. Reconstruction for lymphedema that is the consequence of the indirect effects of radiation is best accomplished with excision of the tissues and coverage with STSGs.Patients with lymphedema can readily undergo reconstruction. When the lymphedematous tissue has been excised, the testes will be free and, as in a degloving injury, they must be fixed in the midline in an anatomically correct position. The shaft of the penis should be covered with a STSG. If the scrotum cannot be closed, a meshed STSG is used to cover the testes, as described. Not uncommonly, these patients have hydroceles, the parietal tunica vaginalis must be excised, and grafting can be done directly onto the visceral tunica vaginalis of the testicles. Unlike the full-thickness skin flap (FTSF), split-thickness skin carries little of the reticular dermis and hence few of the lymphatic channels. Reaccumulation of lymphedema will occur within a FTSG and can recur in a thick STSG. In many cases of lymphedema limited to the genitalia, the posterior scrotal skin and the lateral scrotal skin are spared from the lymphedematous process. Thus, in some cases, primary closure after excision can be accomplished using these tissues. If grafting is required, using these tissues to blend the grafts into the groin and perineum technically is much easier. The lymphedematous process involves recurrent cellulitis, lymphedema, and the development of lymphangiectasia. Lymphangiectasia can look like genital papilloma; however, it is a very different process. If there is any question, biopsy can clarify the issue.
  15. d. It causes limitation of the urethral lumen because of contraction and noncompliance of the scar. The term urethral stricture refers to anterior urethral disease. By virtue of the Consensus Conference, obliterative processes of the membranous urethra, such as those associated with pelvic fracture, would be referred to as pelvic fracture urethral injury (PFUI), and other narrowing processes of the posterior urethra are correctly referred to as either contractures or stenoses. Thus the term urethral stricturedescribes a process that involves the urethral epithelium along with the spongy erectile tissue of the corpus spongiosum, and this is referred to as spongiofibrosis. In some cases, the scarring process can extend through the tissues of the corpus spongiosum and into the adjacent tissues. It is contraction of the scar that reduces the urethral lumen. Squamous metaplasia is often seen involving the urothelium of the urethra proximal to a narrow caliber urethral stricture.
  16. c. It is not a true stricture but rather fibrosis that results from distraction of the urethra. By virtue of the Consensus Conference, narrowing of the posterior urethra is not referred to as a stricture. Those obliterative processes associated with pelvic fracture are termed pelvic fracture urethral injury (PFUI). PFUI is an obliterative process of the posterior urethra that has resulted in fibrosis and is the defect of distraction of the urethra in that area. Although the distraction defect can be lengthy in some cases, the actual process involving the tissues of the urethra is usually confined.
  17. a. Magnetic resonance imaging (MRI).To devise an appropriate treatment plan, it is important to determine the location, length, depth, and density of the stricture (spongiofibrosis). The length and location of the stricture can be determined using radiographs, urethroscopy, and ultrasonography. The depth and density of the scar in the spongy tissue can be deduced from the physical examination, the appearance of the urethra in contrast studies, the amount of elasticity noted on urethroscopy, and the depth and density of fibrosis as evidenced by ultrasonographic evaluation of the urethra, although the absolute length of spongiofibrosis may not be evident on ultrasonographic evaluation. MRI has been suggested as useful in patients with pelvic fracture urethral distraction, particularly in cases in which the anatomy of the pelvis has become significantly distorted. With regard to anterior urethral stricture, however, MRI has not been useful, with the exception of those cases in which there is urethral carcinoma. In those cases, MRI can provide invaluable information concerning the spread of the tumor. Bougie à boule calibration can be very helpful.
  18. a. Even if a patient does not have retention, placement of a suprapubic tube may help define strictured areas. In selected patients, we have found it useful to place a suprapubic tube to defunctionalize the urethra. After 6 to 8 weeks, if there will be a constriction of an area that was hydrodilated with voiding, the tendency for that constriction to occur should become apparent. It is imperative, however, to completely evaluate the urethra proximal and distal to the stricture with endoscopy and bougienage during surgery, to ensure that all of the involved urethra is included in the reconstruction.Whereas hydraulic pressure generated by voiding may keep segments proximal to the stricture patent, unless these segments are included in the repair, they are at risk for contraction after obstruction of the narrow-caliber segment is relieved with reconstruction. For this reason, any abnormal areas of the urethra that are proximal to a narrow-caliber segment of the stricture must be treated with suspicion. If the lumen does not appear to demonstrate evidence of diminished compliance, then we presume that area to be uninvolved in active stricture disease. However, coning down of the urethra suggests its involvement in the scar. Use of a sonourethrogram is thought by some to accurately establish length of stricture but not the extent of spongiofibrosis.
  19. e. It can be associated with erectile dysfunction. Many surgeons have learned to perform internal urethrotomy by making a single incision at the 12-o'clock position. This location might be questioned, however, based on the location of the urethra within the corpus spongiosum. Distally, although the anterior aspect of the corpus spongiosum is thicker, a deep incision in the more distal aspects of the anterior urethra will certainly enter the corpora cavernosa, and these incisions have been associated with the creation of erectile dysfunction. The most common complication of internal urethrotomy is recurrence of stricture. Less commonly noted complications of internal urethrotomy include bleeding and extravasation of irrigation fluid into the perispongiosal tissues. One report that used the actuarial technique showed the curative success rate of internal urethrotomy to be 29% to 30% for all patients. Other evaluations have confirmed this success rate. However, a number of studies do show which strictures best respond to internal urethrotomy. These are strictures of the bulbous urethra that are less than 1.5 cm in length and are not associated with the dense or deep spongiofibrosis (i.e., straddle injuries).In those particular cases, long-term success has been shown to be 75% to 78%. For strictures outside the bulbous urethra, most studies do not show internal urethrotomy to have long-term success.
  20. c. Success requires total excision of the fibrosis with a widely spatulated anastomosisIt has now been demonstrated with certainty that the most dependable technique of anterior urethral reconstruction is the complete excision of the area of fibrosis, with a primary reanastomosis of the normal ends of the anterior urethra. The best results are achieved when the following technical points are observed: (1) the area of the fibrosis is totally excised; (2) the urethral anastomosis is widely spatulated, creating a large ovoid anastomosis; (3) the anastomosis is tension free; (4) epithelial apposition is achieved.With vigorous mobilization, development of the intracrural space, and detachment of the bulbospongiosum from the perineal body, significant lengths of stricture can be excised and reanastomosed. For very proximal bulbous strictures, tension-free anastomosis can be facilitated by the dissection of the membranous urethra. As a rule, the closer the stricture is to the membranous urethra, the longer it can be and still be reconstructed by anastomotic techniques. The tenet that excision and primary anastomosis should be the goal for all bulbous strictures is one that is being further reinforced by current published series. Although guideline lengths of 1 to 2 cm are valuable for planning, most would agree that if excision and primary anastomosis is possible it should be done, and, with aggressive dissection and the maneuvers described earlier, often strictures much longer than the "guideline lengths" can be so reconstructed.
  21. b. The operation can conceptually become one operation with multidimensional application. 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 repair of urethral stricture disease. In the past, these flap operations were considered to be separate procedures. We suggest that all of these procedures are really different applications of a single concept, proposed by the microinjection studies of Quartey. Skin islands, as mentioned, can be viewed as passengers on fascial flaps, and the design of flaps for urethral reconstruction can be done parallel to the design of flaps for reconstruction in general. These procedures that use skin islands oriented on the penile dartos fascia have been also useful for reconstruction of the fossa navicularis. There are three important considerations for the use of flaps in urethral reconstruction: (1) the nature of the flap tissue, (2) the vasculature of the flap, and (3) the mechanics of flap transfer. The skin must be nonhirsute for urethral reconstruction. In addition, for donor site consideration, it is most convenient to use the areas of redundant nonhirsute genital skin. These skin islands can be reliably elevated even in patients who have been circumcised.
  22. d. Continence is best addressed after a procedure to reestablish urethral continuity is performed. We have found, and others have reported, that the competence of the bladder neck is difficult to accurately assess before the reestablishment of urethral continuity. Even in cases in which an obvious scar is noted to involve the bladder neck, follow-up of these patients after urethral reconstruction has found many patients with more than adequate continence. Still other patients are believed to have incontinence due to scar incarceration of the bladder neck. In our experience, however, this is an infrequent occurrence, and the appearance of the bladder neck by any modality available is not predictive of continence. It is currently our practice to reestablish the continuity of the urethra and, in cases in which there are concerns about continence, to forewarn the patient before the urethral reconstruction. Colopinto and others have not shown an association of ultimate continence as related to the location of the distraction injury.
  23. e. It is usually present with either ventral curvature or ventral curvature associated with torsionIn many cases, there are abnormalities of the ventral penile skin.In patients who have chordee without hypospadias, the photograph will reveal an erect penis commensurate with the size of the detumescent penis, whereas in the congenital curvature patient, the erect penis will be noticeably large. Because of their congenital anomaly, these patients often become relatively reclusive and have poor self and genital images and may benefit from sex therapy. Even in patients with obvious abnormalities of the corpus spongiosum (i.e., poor ventral fusion or frank bifid corpus spongiosum), wide mobilization usually reveals that it is not the corpus spongiosum that remains as the ventral limiting factor. In most patients, the penis will remain curved because of the inelasticity of the ventral aspect of the corpora cavernosa. If the epithelial tube has served as an adequate urethra (i.e., it is not stenotic), the morbidity of the urethral division and subsequent need for urethral reconstruction must be considered before undertaking such a procedure. In children, after mobilization and excision of the dysgenetic tissues, the residual chordee can usually be corrected by making a longitudinal incision with a sharp blade. If this maneuver is not sufficient, the dorsal neurovascular structures can be mobilized in concert with the Buck fascia and a small ellipse or ellipses of dorsal tunica albuginea excised and closed with watertight plicating sutures.
  24. b. In most cases, global cavernosal veno-occlusive dysfunction (CVOD) is not a complicating factor. When a young man presents with an acquired curvature of the penis, one must always allow for the possibility of Peyronie disease. Occasionally, however, a patient or his initial-care physician will ignore the stigmata of the trauma (often described as "minimal" by patients), and the patient will present with a noticeable lateral scar that causes both indentation of the lateral aspect of the penis and, in some cases, curvature. Patients who had preexisting lateral curvature may actually notice that their penis has been straightened by the trauma, but they are disturbed by the concavity caused by the scar. The pathology of a subclinical fracture of the penis is believed to be due to either the disruption of the outer longitudinal layer of the tunica albuginea during the buckling trauma only or the disruption of both layers of the tunica albuginea during the buckling trauma but with preservation of Buck fascia. These patients usually have normal erectile function, and there is no association with concomitant global CVOD. However, the association of CVOD and trauma of the penis continues to be seen, and some patients, after fracture-type injuries of the penis, will have significant problems with erectile dysfunction. These injuries are not associated with shortening of the penis. It is the lack of erectile dysfunction and penile shortening that help distinguish these patients from those with Peyronie disease. Although foreshortening of the penis is not a characteristic of either the injury itself or the resulting scar in either of these injuries, these patients are not thought to be best treated by approaching the opposite aspect of the scar and excising an ellipse of the tunica. This would result in bilateral scars, which will cause bilateral indentation of the penis, and although the penis will have been straightened by the correction, most patients are upset by the cosmetic and functional result of a near-circumferential indentation of the penis. Curvatures associated with hypospadias or epispadias are not acquired curvatures.
  25. b. PFUIs most commonly occur between the prostate and membranous urethra.Pelvic fracture distraction injuries of the membranous urethra have been compared with plucking an apple (prostate) off its stem (the membranous urethra). This analogy implies that the injury most frequently occurs at the apex of the prostate. Experience shows that this is not the case, however, and the most frequent point of distraction is at the departure of the bulbous urethra from the membranous urethra. The distraction can, however, involve all or any portion of the membranous urethra between the departure of the bulbous urethra and the apex of the prostate. The remaining answer choices are correct.
  26. a. Mobilizing the corpus spongiosum off the corpora cavernosa up to the corona of the glans. 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.Meticulous detachment of the investment of Buck fascia from the corpus spongiosum increases the compliance of the corpus and limits the need for aggressive mobilization. It is important to try to avoid the creation of chordee during the repair of a distraction injury. To prevent chordee, the attachment cannot be carried beyond the area of the penoscrotal attachment. Development of the intracrural space, infrapubectomy, and, if needed, rerouting of the corpus spongiosum each shorten the course that the corpus spongiosum must traverse and allow reconstruction without attendant chordee.
  27. d. Men with arteriogenic ED following PFUI who demonstrate bilateral occlusion of the internal pudendal arteries without reconstitution.Patients with an intact pudendal artery on one side are often potent and reliably cured with reconstruction. Patients with only reconstituted vessels, either unilateral or bilateral, are rarely potent but reliably reconstructed. Those patients at risk for ischemic stenosis are only those with bilateral complete obstruction of the internal pudendal vessels without reconstitution. In such a patient, we now perform penile arterial revascularization to augment the vascularity and, with that accomplished, then proceed to urethral reconstruction. Patients without ED by definition have normal penile hemodynamics and do not require further investigation before repair of a PFUI.
  28. b. Current techniques are accomplished with a variety of flap designs, which use microvascular free flap transfer.Rigidity for intercourse in the patient with phallic construction is usually achieved by either an externally applied or a permanently implanted prosthesis. Prosthetic implantation is never undertaken until 1 year after phallic construction, because protective sensibility must be demonstrated in the flap. When the flap is transferred, it is, by definition, rendered insensate. At about 3 to 4 months after reconstruction, however, as nerve regeneration occurs, sensation becomes noticeable. In addition, before prosthetic implantation is undertaken, the urethra must be patent and proved to be durable.
  29. d. Idiopathic proximal 1-cm bulbar urethral stricture in a patient with a history of a prior hypospadias repair.Patients with a history of hypospadias can be expected to have altered or absent retrograde blood supply to the urethra through the normal arborization in the glans. In this situation, transecting techniques to repair urethral strictures should be avoided unless performed in a "vessel-sparing" fashion to avoid the risk of ischemic urethral stenosis. Inlay or onlay graft or flap techniques may be used in these patients, as these do not disrupt the proximal blood supply to the urethra. The remaining scenarios can be reliably repaired with anastomotic urethroplasty.

Chapter review

  1. A meshed split-thickness graft that is applied to the genitalia should not be expanded but rather placed on the recipient site without expansion to allow collections from beneath the graft to escape.
  2. Split-thickness grafts may contain some lymphatics; however, full-thickness grafts have a full complement of lymphatics.
  3. Split-thickness grafts are more likely to take (become vascularized) but tend to contract and become brittle when mature, whereas full-thickness grafts have more difficulty becoming vascularized but are less likely to contract and are more durable when mature.
  4. Tunica vaginalis grafts result in aneurysmal dilatation when they are used for large defects.
  5. The superficial dorsal penile vein usually drains to the left sapohenous vein; the deep dorsal and circumflex veins lying beneath the Buck fascia drain to the periprostatic plexus.
  6. The Buck fascia is adjacent to the deep structures of the penis; the dartos fascia is next to the skin.
  7. Lichen sclerosus is a disease of the skin and may involve large portions of the genital skin; therefore, using the genital skin for reconstruction may result in recurrence of the disease. Oral mucosal grafting has emerged as a better tissue in patients with lichen sclerosus–associated urethral strictures.
  8. Lichen sclerosus may be a premalignant lesion and often results in meatal stenosis.
  9. A spontaneous urethral fistula or unexplained periurethral abscess may be the harbinger of a urethral carcinoma.
  10. Circumcision provides protection for heterosexual men in areas of endemic HIV; it reduces the risk of acquiring herpes simplex type 2, papillomavirus, and genital ulcer disease.
  11. Cellulitis may be a problem in patients who have genital lymphedema.
  12. As a general rule in the urethra, flaps are best suited for distal reconstruction, grafts for proximal reconstruction.
  13. A urethral stricture involves the epithelium as well as the corpus spongiosum (spongiofibrosis).
  14. For urethral distraction injuries (posterior urethral disruptions), an aligning catheter, at the very worst, facilitates subsequent reconstruction and, at best, may leave the patient with an endoscopically manageable urethra.
  15. Because paraphimosis tends to recur, a dorsal slit or circumcision should be electively planned.
  16. For urethral reconstruction an onlay graft or flap has a higher success rate than tabularized grafts.
  17. Vesicourethrorectal fistulae are most successfully closed when normal tissue is interposed between the rectum and the bladder/urethra. The gracilis muscle interposition flap is an excellent tissue to interpose and, when used, has a high success rate.
  18. Curvature of the penis in patients with Peyronie disease who require repair are best managed with corporal plication techniques and not grafting.
  19. The corpora cavernosa are not separate structures but constitute a single space with free communication through an incompetent midline septum.
  20. Meatal stenosis in the male child appears to be a consequence of circumcision.
  21. It is imperative to completely evaluate the urethra proximal and distal to a stricture with endoscopy and bougienage during surgery, to ensure that all of the involved urethra is included in the reconstruction.
  22. The curative success rate of internal urethrotomy is 29% to 30% for all patients. The strictures that respond best to internal urethrotomy are strictures of the bulbous urethra that are less than 1.5 cm in length and are not associated with the dense or deep spongiofibrosis.
  23. The best results for primary reanastomosis are achieved when the following technical points are observed: (1) the area of the fibrosis is totally excised; (2) the urethral anastomosis is widely spatulated, creating a large ovoid anastomosis; (3) the anastomosis is tension free; and (4) epithelial apposition is achieved.
  24. In complete membranous urethra disruption, the most frequent point of distraction is at the departure of the bulbous urethra from the membranous urethra. The distraction can, however, involve all or any portion of the membranous urethra between the departure of the bulbous urethra and the apex of the prostate.
  25. Aggressive mobilization of the corpus spongiosum is performed with caution in patients with urethral disruptions because it is thought to have possible ill effects on retrograde blood supply to the urethra.