Penis & Urethral Surgeries

Basic Anatomy

Anatomy of Penis

• The Length of the male urethra is 20 cm
• The Length of the female urethra is 4 cm

Parts of Urethra

• Posterior urethra
  • Prostatic urethra
  • Membranous urethra
• Anterior urethra
  • Bulbar urethra
  • Penile urethra
  • Urethra meatus

• Prostatic urethra - it is the widest & most dilatable part of the urethra
• Membranous urethra – it is the shortest, narrowest & least dilatable part of the urethra
• Penile urethra – it is the longest urethra

Meatus > Membranous Urethra - The narrowest part of the urethra

Congenital Abnormality Of Urethra

1. Hypospadias

• The most common congenital abnormality of the urethra
• Incidence
  • Hypospadias 1:250 live births.
  • Horseshoe kidney 1:400 live births.
  • Unilateral renal agenesis 1:1000 live births.
• Caused by failure of fusion of urethral folds - Meatus is present over the ventral aspect.
• The urethral fold usually closes in the posterior to anterior direction.

Types of Hypospadias

• Glandular Hypospadias
• Coronal Hypospadias
• Distal penile hypospadias
• Midshaft hypospadias
• Proximal penile hypospadias
• Penoscrotal hypospadias
• Scrotal hypospadias
• Perineal Hypospadias
• The most common are Anterior types (glandular, coronal, and distal penile)
• Galandular, Coronal hypospadias, and distal penile hypospadias contribute to 70% of cases of hypospadias.

Associations

• Hooded prepuce over dorsal aspect
• Ventral Chordee.
• Flattened Glans penis.
• Microphallus [ short length of penis]
• Ectopic Meatus
• Meatal Stenosis

• Anterior type of hypospadias- Circumcision is contraindicated because prepuce is used for urethral reconstruction

Clinical Features

Depends on Type of Hypospadias

• Anterior type, especially glandular hypospadias – Abnormal stream of urine
• Posterior Type (e.g., Midshaft / proximal penile) At the time of erection, there is downward curvature of the penis, causing chordee and painful erection.
• In proximal penile hypospadias, at the time of intercourse, semen is deposited outside the vagina, making than infertile.
• Abnormal Stream
• Painful erection.
• Infertility

Treatment

• The best age for repair is 6 – 12 Months
• Principle
  • 1st Principle – Meatal advancement
  • 2nd Principle – reconstruction of Glans Penis
  • Both Surgeries are performed together, known as MAGPI

Various Treatment Procedures

• MAGPI (Meatal advancement and glanuloplasty integrated)
• DENNIS-BROWN
• THIERSCH– DUPLAY
• BRACKA’S
• MATHIEW’S
• ASOPA & DUCKETT

Complications

• After reconstruction of the urethra, an infant feeding tube has to be inserted. If not inserted, the patient may experience complications like Urethral Fistula in 10% of cases (the most common complication of hypospadias repair)

1. Epispadias

Uncommon

• Characterized by the urethral opening over the dorsal aspect of the penis
• In females, it is a fissure or cleft in the anterior wall of the urethra that opens above the clitoris.
• Associated with
  • EctopiaVesicae
  • Dorsal chordee
  • VUR (40% of cases)

Clinical Features

• In Females
  • Maldevelopment of urinary sphincters leading to incontinence
  • Bifid clitoris
  • Widely separated labia with incontinence
• In Males 
  • Undescended testis 
  • Shallow scrotum

Treatment

• 1^st  – correction of incontinence
• 2^nd  – Removal of Chordee
• 3^rd  – Extension of urethral opening till glans penis

2. Posterior Urethral Valve 

• Symmetric folds of Urothelium that start from the prostatic urethra & extend to the external urinary sphincter 
• The male urethra is affected exclusively
• The most common type – Type 1
• Located just distal to verumontanum  /at verumontanum
• Posterior urethral value – secondary cause of VUR

Clinical Features

• Associated with Vesicoureteric reflex - 50% cases.
• Other associations of the posterior urethral valve are:
  • Oligohydramnios
  • Pulmonary hypoplasia (the most common cause of death in PUV) and also in CDH 
  • (congenital diaphragmatic hernia).
  • Renal parenchymal dysplasia
  • Bladder dysfunction.
• Most patients present with
  • Symptomatic after birth
  • Bilateral hydroureteronephrosis
  • Bilateral palpable abdominal mass
  • Distended bladder.
  • Ascites (urinary ascites)
  • Infants increased UTI/ Sepsis

Investigation for Posterior Urethral Valve

• IOC – MCU (Micturating PUV   

Cysto urethrogram)  Posterior Urethral Stricture

Vesicourethral Reflex

• Prenatal Ultrasound done  At 28 weeks shows a keyhole sign.

Management of Posterior Urethral Valve

• 1^st  step – Infant feeding tube insertion
• 2^nd  step -After tube insertion

If Creatinine is normal,                       If Creatinine is raised

↓ (means there is no effective drainage 

Endoscopic Fulguration ↓

Of valve       Suprapubic cystostomy by Blockson Technique.

1. Phimosis

• Contracted foreskin or prepuce cannot be retracted over the glans penis.
• Most common cause of phimosis chronic infection is because of poor hygiene
• Other causes:
  • Congenital
  • Acquired
    • Trauma
    • Carcinoma Penis
    • BXO

(Balanitis Xerotica Obliterans)

Clinical Features

• The most common symptom is difficulty in micturition
• In children – Ballooning of Prepuce
• In adults – Difficulty in intercourse

Complications

• Infection of glans/ prepuce - Increased risk of Balanoposthitis
• Secretion becomes solidified - Preputial calculi
• Chronic inflammation – Carcinoma penis

Treatment

• In Children – Conservative management (Steroidal cream application for 4-6 Weeks)
• Circumcision
  • It is not preferred for young patients because they are not cooperative with local anesthesia.
  • Performed for younger age only when there is an indication for circumcision

Indications of Circumcision

• No improvement after steroidal cream application
• Recurrent infection
• Age 16 – 18 years

Acquired Abnormality Of Urethra

Paraphimosis

• This is caused by the formation of a ring of Prepuce around the glans because once prepuce is retracted, it cannot be brought to its Normal position.

Formation of ring around Glans penis

↓

Impaired Lymphatic Drainage

↓

Edema of Glans

↓

Impaired venous Drainage

↓

Further edema

↓

Impaired Arterial Supply

↓

Gangrene formation [ in severe cases]

• Urine flow not obstructed.

Treatment

• Ice bag application(cause vasoconstriction)
• Manual compression
• Hyaluronidase injection
• For non-responding patients – Circumcision

Priapism

• Persistent painful erection in the absence of sexual excitement/desire, or it persists after sexual excitement/desire.
• Min duration of painful erection – 24 hours
• It is an emergency & delay in treatment leads to Cavernosal fibrosis & impotence.
• It should be treated within 6 hours to prevent other complications
• In the case of testicular torsion, it should be treated in 4 hrs)
• Priapism is of 2 types

Clinical Presentation

• In children (4– 10 years) with sickle cell disease - Painful erection during nights
• In Adults – iatrogenic

Diagnosis

• Mainly clinical
• Doppler is helpful in the diagnosis

Treatment

• If the patient comes within 4-6 hrs.

ketamine injection is given (> 50% cases improve)

↓ No improvement 

Aspiration & saline irrigation

↓ No improvement 

Hyaluronidase injection

• For High flow priapism – Selective internal Pudendal Angiography f/b embolization of feeding vessel.
• Another surgical option is shunts, where the Blood is shunted from corpora cavernosa
  • Corporo-glandular shunt – 
  • Corporo-spongiosal Shunt – QUACKEL or SACHER shunt
  • Corporo–saphenous shunt – GRAYHACK shunt
  • Corporo-dorsal vein shunt – BARRY shunt

Urethral Injuries

Posterior Urethral Injuries

• Most common type
• Caused by road traffic accident
• Leading to pelvic fracture, which further leads to
  • Extraperitoneal bladder rupture
  • Posterior Urethral injuries (20%)
• The most common site of injury the membranous Urethra (Bulbomembranous junction >Prostatomembranous junction)

Clinical features

• Urinary retention + Blood at meatus + pelvic hematoma
• If injury at Prostatomembranous junction - High-lying prostate

↓

On IVP - Pie in the sky appearance

Instrumentation

• Catheterization Shouldn’t be done [ if blood is found at meatus] - A partial tear may get converted to a complete tear(but in case of a small partial tear, a single gentle attempt of catheterization with the smallest catheter can be done)
• Retrograde urethrogram (RGU) can only be performed to rule out Urethral injuries.

Management

• Gold standard Treatment - SPC (Suprapubic cystostomy)
• Emergency repair should not be attempted - Can lead to an increased risk of
  • Impotence
  • Incontinence
  • Stricture formation
• Delayed repair within 3 months is performed

Anterior Urethral Injuries

• The most common injured anterior urethral part - the bulbar part of the urethra

Causes of Anterior Urethral Injuries

• External blow / kick
• Straddle / manhole injury

Clinical Features of Anterior Urethral Injuries

• Urinary retention
• Blood at meatus
• Perineal Hematoma - involves shaft & Bilateral scrotum (butterfly-shaped)

Treatment of Anterior Urethral Injuries

• Suprapubic cystotomy is performed, followed by delayed repair
• Usually Asymptomatic even after the development of strictures
• Antibiotics

Urinary Stricture 

The most common cause of urinary stricture is trauma.

Investigation of Urinary Stricture 

• Investigation of choice for diagnosis of post-urethral Stricture - MCU
• Investigation of choice for diagnosis of ant Urethral Stricture - RGU
• Perform both RGU + MCU in an emergency patient for adequate evaluation of stricture

Management of Patients of Stricture

1. Dilatation
2. Optical internal urethrotomy at 12”0 clock Position - only performed for short bulbar stricture
3. If the length of stricture is up to 2cm - Excisions with end to end Anastomoses
4. If the length of stricture > 2cm – Excision with tissue transfer 
   • for reconstruction
   • ↓
   • Tissues used are derived from
     • Buccal mucosa (Most commonly used)
     • Bladder mucosa
     • Penile skin

Peyronie’s Disease

• As we are discussing the penile and urethral surgeries, we have to talk about Peyronie’s disease. 
• It is also known as  Penile fibromatosis
• Chronic vasculitis involving tunica albuginea
• Characterized by 

fibrous plaque over the dorsolateral aspect of the penis

↓

Contraction causes Characteristic curvature of the penis

• Associated with GALEZIA’S triad

• DUPUYTREN’S contracture (+)
• PEYRONIE’S disease (+)
• RPF- Retroperitoneal fibrosis

Clinical Features of Peyronie’s Disease

• Painful erection
• Poor erection (Distal to plaque)
• Upward curvature on erection
• Impotence & infertility
• Dorsolateral plaque over the penis

Treatment of Peyronie’s Disease

• >50% cases spontaneous resolution - observation + emotional support
• If it doesn’t reduce, we go for - NESBIT Operation by placement of Non–absorbable suture opposite to the plaque

Carcinoma Penis

• In certain forms of penile carcinoma, we have to perform surgery.
• The most common histological type of penile carcinoma is squamous cell carcinoma
• This is commonly seen in people who have a Low socioeconomic status
  • Poor hygiene
  • 6th decade
• 40 % of patients < 40 years of age
• > 50 % of cases associated with phimosis only
• Neonatal circumcision is protective for CA Penis, HIV/ STDs
• Viral infections like HPV infection(16,18,31,33) can be another cause of CA penis.

Also Read: Robotic, Laparoscopy & Bariatric Surgery

Important Points about CA Penis

• In Carcinoma of the penis - Skin and Colle’s fascia are involved
• Most common route of spread in CA penis - Hematogenous
• Most common cause of death in CA penis - Bleeding caused by enlarged inguinal lymph nodes leading to erosion of Femoral blood vessels
• In Ca Penis - Incidence of Pulmonary metastasis is rare 

↓ (even in advanced cases)

Tunica Albuginea & Buck’s fascia (Strong barriers)

↓

Prevents invasion vessels

Premalignant Lesion in CA Penis 

• BUSHKEE LOWENSTEIN TUMOR – locally malignant, also known as verrucous carcinoma.
• BXO (balanitis xerotica obliterans)
• Cutaneous Horns
• Genital Warts
• Leukoplakia

BUSHKEELOWESTEINTUMOR

Carcinoma In SITU Forms In CA Penis

• If it involves the penis known as Bowen’s disease
• Erythroplasia of Queyret - Glans Penis Malignancy, in this case, I.e., most common site: Glans > Prepuce > Sulcus

Clinical features of Carcinoma In SITU Forms In CA Penis

• The most common Presentation is the lesion associated with foul-smelling discharge & is associated with minimal or no pain.
• More than 50% of cases have enlarged inguinal lymph nodes, out of which half are because of

Metastasis Sepsis

• In all cases, prophylactic antibiotics are again used for 4 -6 weeks.
• So, the most common cause of death is bleeding caused by erosion of femoral vessels.
• 2nd most common cause of death is sepsis
• Earliest & most common symptom of metastasis or CA Penis – priapism
• The most common route of spread is hematogenous

Diagnosis

• Investigation of choice – Biopsy
• Investigation of choice for staging - MRI
• SLN Biopsy
  • CA Breast
  • Malignant melanoma
  • CA Penis
  • H& N malignancy
  • Vulval CA 
  • 1st SLN Biopsy was performed by CABANA & Procedure was known as CABANA Procedure.

8th AJCC. TNM Classification for CA Penis

To make a proper diagnosis and line of treatment, it is important to grade the CA Penis. For the new doctors, T stands for tumor spread, N stands for lymph node status, and M stands for the metastasis of the disease, which tells us how far the disease has traveled. These TNM classifications are important not only for penile carcinoma but also for other carcinomas. These can be asked in the NEET-PG / FMGE examinations as clinical-based questions.

Treatment

• Circumcision for CA Penis involving prepuce
• CA involving distal part
• Partial penectomy with 2cm margin
• CA Penis involving proximal Part
• Total penectomy + perineal urethrostomy

Chemotherapy Agents

• Bleomycin + cisplatin

CA MALE URETHRA

Cancer of the male urethra can be due to

• Chronic irritation
• Infection (HPV – 16%)
• Stricture (24 – 76 %)

Clinical Features

• Palpable mass
• obstructive symptoms like difficulty passing urine.
• Most common site of CA male Urethra - Bulbomembranous> Penile urethra > Prostatic urethra
• The most common histological type is squamous cell carcinoma > Transitional cell carcinoma > Adenocarcinoma.
• Penile Urethra - SCC > TCC
• Prostatic – TCC > SCC

Investigations

• Investigation of choice for diagnosis: MRI + Gadolinium contrast

Treatment

• Surgery ± radiotherapy
• If lymph node involvement, then ilioinguinal lymph node dissection

Also Read: Tubes, Catheters And Drains

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