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 cases. Two patients with micropenis who required revision responded to endocrine therapy. CONCLUSIONS: Excellent cosmetic results were obtained in all cases using this surgical technique.     

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%, erections were straight in 100%, and urinary streams were of good quality and without fistula in 100% 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.     

The anatomy of the tunica albuginea in the normal penis and Peyronie's disease

PURPOSE: We studied the fine architecture of the tunica albuginea of the penis. MATERIALS AND METHODS: The study included 6 human male cadavers and 10 surgical patients (5 with Peyronie's disease and 5 with normal penile anatomy). RESULTS: The tunica albuginea of the corpora cavernosa is a bi-layered structure with multiple sub layers. Inner layer bundles support and contain the cavernous tissue and are oriented circularly. Radiating from this layer are intracavernous pillars acting as struts, which augment the septum and provide essential support to the erectile tissue. Outer layer bundles are oriented longitudinally. These fibers extend from the glans penis to the proximal crura, where they insert into the inferior pubic ramus. There are no outer layer fibers between the 5 and 7 o'clock positions. Elastic fibers normally form an irregularly latticed network on which collagen fibers rest. In Peyronie's disease the well ordered appearance of the collagen layers is lost: excessive deposits of collagen, disordered elastic fibers and fibrin are found within the region of the plaque. CONCLUSIONS: The normal 3-dimensional structure of the tunica affords great flexibility, rigidity and tissue strength to the penis, which are lost consequent to structural changes in Peyronie's disease.     

A surgical algorithm for the treatment of Peyronie's disease

PURPOSE: When conservative treatment of Peyronie's disease fails, the optimal surgical approach is not well defined. Multiple factors, including penile rigidity, degree of curvature, shaft narrowing with hinge effect and erectile response to vasoactive penile injections, indicate that no single approach is likely to solve the problem in all patients. MATERIALS AND METHODS: A surgical algorithm was developed for the treatment of Peyronie's Disease based on our previous surgical experience, which was used prospectively in 103 consecutive men. Penile straightening without prosthesis was offered to patients with adequate rigidity for coitus. Specifically, for mild to moderate curvature less than 60 degrees without hourglass or hinge effect deformity the less complicated tunica albuginea plication procedure was performed. For those men with more severe, complex curvature greater than 60 degrees and/or significant hourglass or hinge effect deformity plaque incision or partial excision with dermal grafting was offered to limit shaft shortening and to reconstruct a shaft with normal caliber to provide optimal axial support during intromission. For men with poor sexually induced erections and/or inadequate response to intracavernosal pharmacotherapy penile prosthesis placement was recommended to provide adequate straightening and rigidity. RESULTS: Of 22 patients who underwent plication procedures 91% remained potent and the penis remained straight postoperatively. Of 52 patients who underwent an incision or partial excision and grafting procedure, 48 had dermal grafts with the penis remaining straight in 94% and 75% remaining potent postoperatively. A total of 29 patients received a prosthesis with the penis remaining straight in 93% who were sexually active postoperatively. During the follow up period (mean 22.3 months) there have been no mechanical device failures. CONCLUSIONS: Surgical outcome was optimized with this algorithm, which correlates surgical complexity to the underlying severity of the penile deformity and erectile capacity.     

Comparison of tunica albuginea substitutes for the treatment of Peyronie's disease

PURPOSE: Peyronie's disease is a connective tissue disorder resulting in fibrotic plaque formation on the tunica albuginea of the penis. One approach to repair consists of plaque excision and patching with one of many potential patch materials. Because the optimal patch material for covering the resultant defect has not been determined, this study compares histological and cavernosometric changes in the penis as a result of the placement of three different types of patch grafts used in surgery for Peyronie's disease. MATERIALS AND METHODS: Eleven mongrel dogs were divided into three groups, each receiving a different patch material (superficial dorsal penile vein, silicone fabric, and dermabraded preputial flap). Each dog had dynamic infusion cavernosometry (DIC) performed prior to placement of the patch over a 6 x 3 mm. defect surgically created in the tunica albuginea. Three months later, DIC was repeated prior to sacrifice. Histology of the penis was examined using Masson's trichrome, and hematoxylin and eosin stains. RESULTS: The only difference among the cavernosometric parameters (preop versus postop) was a higher initial pressure in the dermabraded preputial flap group postoperatively. The dogs undergoing vein patch had moderate fibrosis with apparent reformation of the tunica albuginea over the patch site. The normal venous architecture of the graft was no longer recognizable. Those dogs receiving a silicone patch had moderate fibrosis with a fibrous sheath of compressed histiocytes and fibroblasts enveloping the graft site. Finally, the dermabraded preputial flap patch group had mild-moderate fibrosis with focal loss of the cavernosal space underlying the flap. CONCLUSIONS: We feel that continued use of the vein patch for repair of Peyronie's disease is warranted.     

Electrosurgery for routine pediatric penile procedures

PURPOSE: Traditional teaching in urology has been to avoid electrosurgical devices in penile surgical procedures. In the last several years cutting current has been routinely used on the penis for making skin incisions, degloving, creating Byars flaps and destroying skin bridges. The purpose of this study was to determine the complications and final outcomes of electro-surgery. MATERIALS AND METHODS: A 5-year retrospective chart review was done to determine the complications and final outcomes of exclusively using electrical current to perform pediatric penile procedures. RESULTS: Electrosurgery was used to perform the entire surgical dissection in 346 patients, including circumcision in 124, repeat circumcision in 68, penoscrotal fusion/chordee repair in 127 and skin bridge procedures in 27. All patients had a satisfactory cosmetic result. After correction of penoscrotal fusion, separation at the scrotal suture line in 2 patients healed secondarily without sequelae. There was no hematoma, tissue necrosis or skin sloughing and all surgery was performed on an outpatient basis. CONCLUSIONS: Electrosurgery can be used safely and effectively for routine penile procedures, providing a bloodless operative field and excellent cosmetic results.     

Use of Doppler ultrasonography and positive-contrast corpus cavernosography to evaluate a persistent penile hematoma in a bull

A 32-month-old Angus bull was evaluated because of a 2-month history of a slowly progressive swelling located cranial to the base of the scrotum. The mass was 8 x 8 x 6 cm, and was causing phimosis. The mass was determined to be a penile hematoma on the basis of results of ultrasonography and exploratory surgery. Surgical evacuation was not performed initially because the deep fascia of the penis was intact and the hematoma was small; however, the hematoma enlarged slowly during the ensuring 2 months, despite sexual rest and isolation from other livestock. Doppler ultrasonography and positive-contrast corpus cavernosography were performed, and the hematoma was seen as a space-occupying mass within the corpus cavernosum penis; vascular anomalies were not found. The penile hematoma was surgically excised, and the bull was isolated for 60 days. At follow-up, the owner indicated that the bull had returned to pasture-breeding soundness and was still being used 2 years after surgery. The small penile hematoma in this bull was unusual in that it did not respond to medical treatment. Surgical treatment was apparently curative, even though surgery was not performed until 4 months after the hematoma was first detected.     

Fracture of the penis: two new cases. Review of the literature. Usefulness of echography

OBJECTIVE: To analyze the diagnostic and therapeutic difficulties in rupture of the albuginea penis and review the literature. METHODS/RESULTS: Two additional cases of penile rupture are described. Penile ultrasound evaluation disclosed a hematoma in the corpus cavernosum in one case and hematoma and a probable rupture of the albuginea penis in the other case. Treatment was by immediate surgery which achieved good cosmetic and functional results. CONCLUSIONS: Penile fracture is an uncommon condition which occurs when the penis is in erection. Ultrasound is useful in its diagnosis, but MRI is more precise. Treatment is by immediate surgery to avoid sequelae, which are common in cases treated conservatively.     

Urethral duplication in children: surgical treatment and results

PURPOSE: Urethral duplication is a rare congenital anomaly. We report the clinical presentation, imaging findings and surgical treatment in 7 boys with incomplete sagittal duplication of the urethra. MATERIALS AND METHODS: Duplication involved hypospadias in 5 cases (group 1) and a bifid urethra with an accessory preanal tract (Y duplication) in 2 (group 2). Group 1 was treated with 1-stage urethroplasty, including marsupialization of the dorsal orthotopic urethra, ventral-to-dorsal urethrourethrostomy and penile island flap onlay repair to cover the open dorsal urethra. In contrast, group 2 was treated with 2-stage urethral reconstruction with detachment and mobilization of the accessory preanal branch in association with a scrotal tubed neourethra followed by urethroplasty, as in group 1. In all cases the dorsal penile urethra was located between the corpora cavernosa and surrounded by the tunica albuginea. RESULTS: A urethrocutaneous fistula developed in 1 of the 5 group 1 patients. In group 2, 1 patient had recurrent penoscrotal meatal stenosis after the 1-stage procedure and 1 had a urethral diverticulum with calculi at the scrotal tubed neourethra 7 years after urethral reconstruction. Six of the 7 patients now void spontaneously through a meatus located normally at the tip of the glans. The remaining patient with a neurogenic bladder is on intermittent catheterization via appendicovesicostomy due to difficult catheterization of the irregular and sensitive neourethra. CONCLUSIONS: While the ideal surgical management of urethral duplication anomalies remains uncertain, we used a combination of surgical techniques to correct this severe malformation.     

Age-related increase in an advanced glycation end product in penile tissue

Nonenzymatic glycosylation (glycation) of proteins, often referred to as the Maillard reaction, has been proposed to play a role in age and diabetes-related processes by forming protein and DNA adducts and cross-links. These cross-links may contribute to erectile dysfunction by scavenging nitric oxide, which is needed for erection. As the basis for a possible role of the advanced Maillard reaction in age-related erectile dysfunction, we investigated the presence of the specific advanced glycation endproduct (AGE) pentosidine in penile corpus cavernosum tissue and penile tunica albuginea tissue as a function of age. A total of 23 penile tissue specimens were obtained at autopsy, from which 19 samples of tunica albuginea and 21 samples of corpus cavernosum were derived. In addition, 13 penile corporal and tunical specimens were procured at the time of insertion of a penile prosthesis, from which 12 tunica albugineal specimens and 10 samples of corpus cavernosum were derived. Collagen was extracted with acetic acid and pepsin digestion, and the final insoluble collagen product was acid-hydrolyzed with 6 N HCL for 24 h at 110 degrees C. Pentosidine was quantified by high-performance liquid chromatography using a reverse-phase column. The level of pentosidine (expressed in picomoles per milligram of insoluble collagen) was found to increase with age in cadaver as well as living penile corporal and tunical albugineal tissues. Best-fit analysis revealed an exponential increase in both types of cadaver penile tissue, with regression equations of y = 15.29 x 10(9.9e-3x), R2 = 0.79, being obtained in the tunica and y = 13.2 x 10(7.63e-3x), R2 = 0.56, in the corpora. These correspond to 6- and 4-fold increases in pentosidine levels from puberty to the age of 100 years (P < 0.05), respectively. Mean pentosidine levels were higher in the tunica than in the corpora. Comparison of pentosidine levels in the tunica versus the corpora revealed a weakly linear correlation (y = 24.88 + 1.08x, R2 = 0.32). Levels in the tunical and corporal specimens from the living human specimens fell with the predicted confidence intervals of the cadaveric tissue. Tunical specimens from patients who underwent repair or revision of a previously inserted penile prosthesis had very low levels of pentosidine. The exponential age-related increase in pentosidine observed in both types of penile tissue suggests an impairment of collagen turnover, which could be related to the advanced glycation reaction in aging. It is not known whether pentosidine itself is directly associated with erectile dysfunction, but its formation is usually accompanied by extensive tissue modification. Formation of advanced Maillard reaction products, which is greatly accelerated in aging, diabetes, and uremia, could contribute to erectile dysfunction in these syndromes.     

The use of human dura in urology, except as a substitute of urinary bladder (author''s transl)]

The human dura cannot only be used to replace the urinary bladder wall, but also to replace the capsula fibrosa of the kidney for transposition of aberrant vessels in hydronephrosis, for interposition in vesicovaginal fistula, for suspension of the urethra in stress incontinence and to replace the tunica albuginea of the corpus cavernosum penis after resection of plaque in Peyronie's disease.     

International Conference on Peyronie's disease advances in basic and clinical research. March 17-19, 1993. Introduction

The articles in this section of the Journal support the theory that the lesion of Peyronie's disease is a scar that has developed following trauma to the erect penis in a susceptible individual. The scar involves only the tunica albuginea and does not extend into the erectile tissue. Factors related to the formulation of this scar, discussed on a biochemical and cellular level, are elucidated in the following papers.     

Splenic lymphoma with villous lymphocytes and Waldenstrom disease: diagnostic difficulties by way of a case report

A 67-year-old man visited our hospital with complaints of scrotal swelling associated with occasional febrile episodes. Physical examination disclosed a huge scrotal mass, approximately the size of a child's head, with numerous papillomatous lesions on its surface. His past medical history was significant in that he was diagnosed with penile carcinoma at the age of 35 years old and was treated with partial penectomy followed by radiation and chemotherapy at other hospital. During this admission tumor marker squamous cell carcinoma (SCC) and microbiological tests for mcroflariae were both negative. Ultrasound (US), computed tomographic (CT) scan and magnetic resonance imaging (MRI) revealed markedly thickened scrotal skin and small hydrocele with no evidence of local recurrence of the previous penile carcinoma. A percutaneous cystostomy was created because of chronic urinary retention and possible urine extravasation into the scrotum. Histopathological examination of the biopsy specimen from the scrotal mass demonstrated lymphangiectasia consistent with elephantiasis of the scrotum. Surgical excision of this huge scrotal mass was performed in August 1997. The resected tissue weighed 1,400 g. Convalescene was uneventful. He subsequently underwent perineal urethrostomy in place of the suprapubic cystostomy.     

Parents'' developmental expectations and child characteristics: longitudinal study of children with developmental delays and their families

Infection of isolated organs of the reproductive system by Trypanosoma cruzi has been described since Chagas' disease was first studied. A detailed histopathological analysis of mice acutely infected with T. cruzi CL strain showed colonization of male (preputial glands and skin, penis, testicular albuginea, epididymis, vas deferens, seminal vesicles, prostate, coagulative, bulbo urethral and urethral glands) and female (vagina, uterus, oviduct, ovary, mesovary, clitoris and mammary glands) structures of the reproductive system. The results presented herein demonstrated invasion of epithelial cells, pronounced colonization of the epididymis and male genital adnexa, but absence of parasitism in penile corpora cavernosa.     

Hypospadias repair in the 1990s

Hypospadias is a congenital anomaly in which the urethral meatus is abnormally located anywhere from the glans to the perineum. Refinements in pediatric anesthesia, surgical technique and instrumentation, and a greater understanding of the psychologic and emotional issues related to hypospadias repair have led to this procedure being performed at an earlier age. The goal of reconstruction is to bring the urethral meatus to the tip of the penis, to correct associated penile curvature if present, to create a conical-shaped glans, and to achieve cosmetically acceptable penile shaft skin coverage. The surgical technique employed varies with the penile anatomy and surgeon's preference. Complications may occur both immediately and long after the surgical procedure, and thus follow-up is necessary.     

Induratio penis plastica

The symptoms of Peyronie's disease consist of fibrotic plaque formation, penile deviation and painful erection. The etiology is still unknown. During its progress the disease can cause erectile failure. The plaques mainly involve the dorsal tunica of the penis. The diagnosis is made by palpation of the penis. The ultrasound examination evaluates the plaque localization and possible calcifications. Autophotography of penile deviation and duplex sonography of the cavernous arteries used to measure arterial blood flow complete the diagnostic efforts. Spontaneous remissions occur as well as chronic courses. Oral medication is the first step in therapy. In cases with severe penile deviation leading to disability to perform intercourse, persisting pain or erectile failure operative management is indicated. Plaque surgery, modified corporal plication or implantation of a penile prosthesis must be evaluated individually.     

Respiratory pauses in the newborn up to 2 months of age

A patient with an unusual form of priapism is described. Only the corpora cavernosa proximal to the suspensory ligament were erect. A well defined membrane was found in each corpus cavernosum at the penoscrotal junction, separating turgid and flaccid erectile tissue. When these membranes were removed the erect proximal corpora drained into the flaccid distal corpora and the entire penis remained flaccid 6 weeks later.     

A histopathological study of deep dorsal penile vein in venogenic impotence

We have studied the histopathology of 87 dorsal penile veins, obtained from patients who underwent a resection of the deep dorsal penile vein because of proven venous leakage. The amount of muscle tissue and of collagenous connective tissue has been numerically quantified. Special attention has been focused on the muscular/collagenization ratio. We show that this ratio is not correlated to age neither with the outcome of the operation and that no differences exist between veins in venous leakage patients and in potent patients. This study confirms that the reduction of venous outflow-the so called corporeal veno-occlusive mechanism-is probably a secondary passive phenomenon, due to smooth muscular relaxation, and mainly located within the corpora cavernosa, between the expanding sinusoidal wall and the noncompliant tunica albuginea. Our findings also strongly refute the hypothesis that polsters or other venous wall characteristics contribute to the normal physiology of the deep dorsal penile vein.     

One-stage hypospadias repair with stent or suprapubic diversion: which is better?

PURPOSE: The authors report on 105 consecutive patients who underwent one-stage hypospadias repair based on use of suprapubic diversion or transurethral drainage with stenting. METHODS: The surgical procedures included 52 metal-based flap urethroplasty (Mathieu) for coronal, subcoronal, and distal shaft hypospadias; 32 transverse island pedicle graft (Duckett) for mid and proximal shaft hypospadias; 21 transverse island pedicle (Duckett) plus rolled midline tube (Thierchs) for penoscrotal and scrotal hypospadias. To accomplish urinary drainage, suprapubic diversion (cystofix) was used in 28 of 52 Mathieu operations, in 17 of 32 Duckett operations, and in 11 of 21 transverse island pedicle graft plus rolled midline tube operations. In the rest of the cases, transurethral drainage with stenting was used. RESULTS: All children had excellent cosmetic and functional outcomes. But the rates of complications such as fistula and meatal stenosis were significantly different between the groups in which suprapubic tube or urethral stent was used. In 56 of the 105 patients in whom suprapubic diversion was used, four (7.14%) had fistulas and three (5.35%) had meatal stenosis, in contrast to a fistula rate of 14.28% and meatal stenosis rate of 12.24% in patients that urethral stent is used for urinary drainage. CONCLUSION: The authors believe that the use of suprapubic diversion is advantageous for the outcome of one-stage hypospadias repair in relation to fistula occurrence and meatal stenosis.