Benign Penile/Urethral Surgeries

Strictures

Preop planning

Excision and Primary Anastomosis

  1. Place patient in dorsal lithotomy, prep/drape, give antibiotics (cefazolin +/- gentamicin)
  2. Make midline perineal incision, divide underlying layers, place lone star retractor
  3. Divide bulbospongiosus with metzenbaum scissors, identify urethra
  4. Circumferentially free urethra proximally and distally to allow for adequate mobilization
  5. Place cystoscope to identify stricture and mark site with cautery on outside of urethra
  6. Place 3 clamps - two at distal stricture site, then 3rd clamp very proximal to control sponge bleeding
  7. Cut urethra with heavy scissors
  8. Continue to remove strictured urethra until it accommodates 22-26Fr bougie, send urethra for pathology
  9. Spatulate urethra - distal dorsally, proximal perineally
  10. Start placing 4-0 monocryl anastomotic stitches, starting at 12 on proximal urethra and moving counterclockwise, with tails out outside
  11. Tip: place catheter after 6 o'clock stitch, ensuring it does not tangle the already-placed sutures and that the new sutures don't tag the catheter
  12. Tip: place dorsal stitches full thickness (9 to 3), place ventral stitches only through mucosa and not the spongiosum (8 to 4)
  13. After all stitches placed, tie down starting with 12 o'clock and moving counterclockwise, tying in order, confirm catheter is still mobile
  14. Close ventral spongiosum with 5-0 PDS running stitch
  15. Close bulbospongiosus and colles with 2-0 monocryl running, then close skin with 4-0 monocryl horizontal mattress interrupted, then place bacitracin, telfa, and dressing

Dorsal onlay buccal mucosa graft

  1. Position patient in high lithotomy position, shave perineum
  2. Give 1st/2nd gen cephalosporin, alternatively gentamicin + clindamycin
  3. Place buttock drape, staple towel across anus (to protect field), then drape legs and perineum (cut drape to access suprapubic region if needed
  4. Perform flexible cystoscopy, place wire through stricture (if able) into bladder to palpate in urethra
  5. Made midline incision along perineum with #15 blade, can extend anteriorly to scrotum
  6. Place Lone Star retractor (larger circle on perineum) and place hooks to retract skin, larger rakes for scrotal retraction
  7. Divide further layers down to bulbospongiosus, continue to reposition hooks, then divide bulbospongiosus
  8. Choose one side of urethra and divide urethra from surrounding tissue until dorsal portion is accessible
  9. Place 22Fr Bougie through meatus to level of distal stricture, mark urethra and start dorsal incision 1cm distal
  10. Incise further proximal until able to pass 22-28Fr Bougie, then perform cystoscopy to confirm no bladder abnormalities, can retract urethra with 4-0 vicryl retracting stitches through urethral edge
  11. Take fenestrated graft and suture (with 4-0 vicryl) at 5, 6, and 7 o'clock at proximal portion of graft, suture graft directly to urethra, then suture distal apex to hold in place
  12. Place 4-0 vicryl interrupted sutures on both edges - on side with native urethra, suture urethral edge + corpus underneath + graft edge
  13. Place 6-0 monocryl on TF needle in running fashion to quilt graft and hold it onto corpus, be careful not to wrinkle or tug on graft
  14. Place running 5-0 PDS on urethral edge, include corpus underneath
  15. Place catheter and run 5-0 PDS x2 from top and bottom to close urethra completely
  16. Close bulbospongiosus with 4-0 vicryl, then close overlying layers in two layers
  17. Close skin with interrupted horizontal mattress 3-0 monocryl suture, then place bacitracin
  18. Can discharge home with catheter same day
  19. Perform RUG in 3 weeks at time of catheter removal to assess for extravasation

Inflatable Penile Prosthesis

Penoscrotal approach

  1. Position in supine position, shave with razor if available (preferred over clippers)
  2. Prep and drape, use iodine sticky drape to decrease infectious risk - large half over superior portion of drape, smaller half as X shape to close hole between legs posterior to scrotum
  3. Give vancomycin + gentamicin (5mg/kg ideal body weight)
  4. Place 14Fr catheter into urethra, minimize lubrication
  5. Place Lone Star retractor with small loop inferiorly and white connector across behind infrapubic region, place hook into urethra to retract superiorly
  6. Perform ~2-3cm penoscrotal transverse incision, dissect through dartos, place 6 hooks for retraction
  7. Identify urethra and bluntly dissect laterally to identify corpora
  8. Protecting urethra, place 2-0 PDS stitch ~5mm lateral to urethra in corpora in proximal-to-distal fashion, snap/cut, then repeat ~1cm further lateral (repeat more proximally to create 4 stitches total)
  9. With #15 scalpel on finger, incise between stitches longitudinally, going 5mm proximal to stitch all the way to distal point of stitch
  10. Use #11 dilator distally and #13 proximally, aim laterally to avoid urethral injury, measure corpora and perform goal-post test (dilators in proximal corpora should not cross), irrigate to confirm no urethral injury
  11. Prepare appropriate size device
  12. Thread Keith needle and load urethrotome, pass distally and pass needle through glans (grab w/ hemostat), feed distal portion of prosthesis into corpus and secure stitch to retractor
  13. Place proximal end into corpus and use placement tool to secure and seat device
  14. Once device seated, tie proximal ends of stitch over a finger x8, then tie distal ends securely under tension to avoid prosthesis herniation or incisional bleeding
  15. Once prosthesis secured bilaterally, test inflate to ensure adequate placement and length
  16. Identify external inguinal ring, place plastic retractor, pop through with finger to enter retropubic space of Retzius, place retractor further interior, then place reservoir and inflate (waist should fill inguinal ring without herniating
  17. Grasping lateral and inferior incisional edges, create subdartos pouch and dilate with nasal speculum, then place pump into pouch
  18. Cut excess tubing length, fill ends with water, and secure connector
  19. Close inferior dartos hole vertically then close incisional dartos hole horizontally (both with 3-0 vicryl)
  20. Close skin with 4-0 monocryl interrupted fashion
  21. Place bacitracin ointment then provide mummy wrap

5-step high submuscular technique for reservoir placement

  1. Place patient in trendelenberg position
  2. Palpate external inguinal ring and place pediatric Deaver retractor
  3. Create submuscular tunnel above transversalis using finger blunt dissection, avoid widening neck (will prevent balloon prolapse)
  4. Place sponge stick, aim medial (towards ipsilateral nipple, keeps pocket deep to rectus)
  5. Ensure pocket is ≥ 10cm
  6. Insert reservoir via clamp, overfill to 120mL, then compress
  7. Palpate to ensure device is not too deep or too lateral

Peyronie's disease

Penile plication

  1. Once patient intubated, position supine and inject 20ug alprostadil in 1mL sterile water (do not use saline), inject into lateral corpus
  2. Prep, drape, give cefazolin, and place catheter (capped)
  3. Assess penile curvature, making longitudinal incision opposite maximal curvature (ventral midline if dorsal curvature only)
  4. Incise layers down to tunica albuginea over corpora, taking care to avoid urethra
  5. Use small retractors to assess corpora, choose proximal and distal areas at point of maximal bulge
  6. Place non-absorbable braided stitch in a 2-1-4-3 fashion, tie down to bury the knot
  7. After placing 3-4 stitches, assess erection for residual curvature
  8. Close deep layers x2 with monocryl or vicryl then close skin with subcuticular 4-0 monocryl, apply dermabond, telfa, and compressive dressing

Circumcision

Potential benefits

Contraindications

Complications

Postoperative care

  1. Depending on patient age and habitus, may benefit from gently retracting shaft skin to prevent adhesions
  2. Usually dressing can be removed after 24hr, may benefit from applying bacitracin or vaseline to incision
  3. Usually avoid physical activity for 2-3 weeks, avoid sexual activity for 6 weeks

Adult OR technique

  1. Place patient supine, prep/drape (clean under foreskin), give cefazolin for skin flora
  2. Give dorsal penile and ring block
  3. Place glans traction stitch with 2-0 silk (place deep to avoid tearing)
  4. Mark distal and proximal incisions, ensure adequate length by tensioning skin at base
  5. Gently incise skin with #15 scalpel, make sure skin separates but do not go through underlying layers
  6. Place mosquito snaps x4 on dorsal skin, then create tunnel with metzenbaum scissors and incise skin to create flaps
  7. Completely excise skin off penis with electrocautery, taking care not to cauterize remaining penile skin or shaft, send skin for specimen if needed
  8. Obtain hemostasis with point cautery
  9. Reapproximate frenulum with U-stitch (can use chromic or monocryl)
  10. Place stitches at 6, then 3 and 9 o'clock
  11. Close remaining skin edges with either simple or horizontal mattress interrupted
  12. Apply bacitracin, telfa, and coban dressing

Gomco technique

  1. Place on circumcision board
  2. Inject ~5mL 1% lidocaine as dorsal penile block, sit for 5 minutes
  3. Dilate phimotic ring with hemostat
  4. Crush foreskin at 12 o'clock position then cut to expose glans
  5. Remove all smegma and adhesions to fully expose glans
  6. Place hemostat x2 on the corners of the cut foreskin and place bell within foreskin on top of glans
  7. Place outer device over foreskin, grasp corners with new hemostat to bring the foreskin up and through device
  8. Confirm adequate and even position of Gomco device prior to tightening
  9. Leave for 5 minutes after tightening, can cut off foreskin at any time
  10. After 5 minutes, remove device and gently push edges off bell to expose penis
  11. Apply bacitracin and dressing

Pediatric OR technique #1

  1. Supine positioning
  2. Take down adhesions with a snap and sponge, sterilize with betadyne
  3. Demarcate proximal border, make incision w/ #15 scalpel
  4. Demarcate distal border, make incision w/ #15 scalpel
  5. Use 4 snaps to grap foreskin at dorsal aspect
  6. Spread with tenotomy scissors, cut at dorsal aspect
  7. Remove foreskin with cautery, discard unless abnormal appearing
  8. Obtain hemostasis of any active or potential bleeding
  9. Place two 5-0 stitches at ventral portion
  10. Reapproximate frenulum if necessary with simple interrupted
  11. Suture subcutaneous at 12 o’clock with 6-0, then perform running subcuticular dorsal to ventral, perform on either side
  12. At ventral portion, put stitch through skin, then go back through skin again and tie to loop
  13. Place mastisol, telfa strip, and tegaderm with cut on ventral then dorsal portion
  14. Cover with bacitracin
  15. Send home with tylenol, ibuprofen, and bacitracin

Pediatric OR technique #2

  1. Supine positioning
  2. Take down adhesions, sterilize with betadyne
  3. Demarcate proximal border, make incision w/ #15 scalpel
  4. Demarcate distal border, make incision w/ #15 scalpel
  5. Use 4 snaps to grap foreskin at dorsal aspect
  6. Spread with tenotomy scissors, cut at dorsal aspect
  7. Remove foreskin with cautery, discard unless abnormal appearing
  8. Obtain hemostasis of any active or potential bleeding
  9. Place 12 6-0 chromic stitches simple interrupted
  10. Place mastisol, telfa strip, and tegaderm with cut on ventral then dorsal portion
  11. Send home with tylenol and ibuprofen

Pediatric OR technique #3

  1. Supine positioning
  2. Take down adhesions, no betadyne
  3. Place 5-0 prolene stitch in glans for positioning
  4. Demarcate borders, incise with electrocautery on cut (or coag)
  5. Use 4 snaps to grap foreskin at dorsal aspect, spread with tenotomy scissors, cut at dorsal aspect
  6. Can also just cut through foreskin and take down in parts
  7. Remove foreskin with cautery, discard unless abnormal appearing
  8. Obtain hemostasis of any active or potential bleeding
  9. Place 12 o’clock stitch and 6 o’clock stitch and hold on with snaps (5-0 fast gut)
  10. Place 8 stitches total with 5-0 fast gut
  11. Place dermabond
  12. Send home with tylenol and ibuprofen

Dorsal Slit at bedside

  1. Perform dorsal penile and ring block, prep/drape
  2. Crush preputial skin at 12 o'clock with straight hemostat then incise - take care not to insert hemostat into meatus!
  3. If necessary, retract skin and continue to crush/cut until glans of penis completely exposed
  4. Suture edges with 3-0 or 4-0 chromic as running or interrupted stitch to provide hemostasis

Phalloplasty (for buried penis)

  1. Prep/drape, perform dorsal penile and ring blocks
  2. Take down all adhesions and clean smegma to visualize entire penis, then place 4-0 ethibond traction stitch
  3. Demarcate the inner preputial incision by drawing a circumferential line, then incise with #15 scalpel
  4. Deglove the penis down to the base, exposing edges and using cautery or tenotomy to cut attachments
  5. Assess where skin will comfortably lie on the shaft, then cut the dorsal skin at 12 o'clock with tenotomy until a point where it will come together with the glans edge
  6. Place fixation sutures at 12, 5, and 7 o'clock to fix shaft skin to penile base, bury the knots, use 5-0 PDS (or similar suture)
  7. Wrap dorsal skin flaps around ventrally for coverage and excise the excess tissue
  8. Realign ventrally, recreate frenulum and raphe as needed to bring skin together without tension
  9. Bring circumcising incision together through desired technique (running/interrupted)
  10. Apply dermabond and dressing, remove traction stitch

Hypospadias

Preoperative considerations

Repair tips/techniques

Postoperative management

Hypospadias complications

Penile curvature (chordee)

Penile torsion

Tubularized incision of plate (TIP) technique

  1. Can perform penile block or caudal block (some concern that caudal block increases risk for fistula formation)
  2. Position supine, prep/drape, can give cefazolin or other antibiotic due to urethral manipulation
  3. Take down preputial adhesions to assess foreskin length and location, assess degree and direction of curvature
  4. Place ethibond traction stitch into glans, place 8Fr feeding tue
  5. Perform dorsal circumcision incision, extend laterally to create Firlit wings (inner preputial wings), then extend ventraly taking care over urethra
  6. Deglove the penis, create an artificial erection to assess curvature
  7. Can perform plication stitches dorsally if necessary due to curvature (will worsen during puberty)
  8. Apply tourniquet with umbilical tape when performing glansplasty to minimize bleeding
  9. Incise urethral place at midline from glans down to meatus, use wescott scissors or small scalpel
  10. Create glans wing incisions on either side of urethra, then close with running 7-0 PDS in two layers
  11. Using excess dorsal dartos, create dartos flap (remove overlying skin), create buttonhole and place over penis so that flap lies ventrally, then secure over urethroplasty with 7-0 interrupted PDS
  12. Complete glansplasty with 5-0 PDS horizontal mattress sutures and epithelial 7-0 vicryl
  13. Exchange 8Fr feeding tube for 7Fr stent, stitch to glans to ensure it stays in place
  14. Assess and adjust skin for coverage, and place fixation stitches at penopubic and penoscrotal junctions at 12, 5, and 7 o'clock
  15. Complete circumcision, bring flaps around for adequate coverage, close with interrupted 5-0 plain gut (can perform simple or subcuticular interrupted)
  16. Apply circumferential telfa dressing, then tegaderms to hold in place
  17. Remove dressing POD#4, remove catheter POD#7, prophylactic antibiotics until POD#9

References