Atlas of Operative Andrology: Selected Operations on Male Genitalia and their Accessory Glands 9783110837780, 9783110081800

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Atlas of Operative Andrology

Al p a y K e l à m i

Atlas of Operative Andrology Selected Operations on Male Genitalia and their Accessory Glands

W DE Walter de Gruyter G Berlin • New York 1980

Alpay Kelämi, M.D. Professor of Urology Department of Urology Klinikum Steglitz Free University of Berlin Hindenburgdamm 30 D-1000 Berlin 45 With 389 illustrations by Wolfgang Nieblich.

CIP-Kurztitelaufnahme

der Deutschen

Bibliothek

Kelâmi, Alpay: Atlas of operative andrology: Selected operations on male genitalia and their accessory glands / Alpay Kelâmi. - Berlin, New York: de Gruyter, 1980. ISBN 3-11-008180-6 Library of Congress Cataloging in Publication Data Kelami, Alpay, 1936Atlas of operative andrology. Bibliography: p. Includes index. 1. Generative organ, Male--Surgery--Atlasses. I. Title. II. Title: Operative andrology. [DNLM: 1. Genitalia, Male—Surgery—Atlasses. WJ 17 K29a] RD586.K44 617'.463'00221 80-21025 ISBN 3-11-008180-6 Copyright © 1980 by Walter de Gruyter, Berlin • New York. All rights, including the right for reproduction and distribution as well as translation, are reserved. No part of this work may be reproduced in any manner (by photo-copying, microfilming or other methods) without written permission from the publisher, nor may it be adapted, reproduced or disseminated with the aid of electronic systems. Printed in Germany Cover Design: Wolfgang Nieblich, Berlin. Typesetting and printing: Passavia Druckerei GmbH, Passau. Binding: Liideritz & Bauer Buchgewerbe GmbH, Berlin.

To Serin

Preface

During the past few years operative andrology has emerged as a major component in genito-urinary surgery. Although a number of books already exist about the entire genitourinary system, including pediatric urology and reconstructive urology, a book on operative andrology was missing. The idea for this atlas originated from my "Urological Teaching Film Program - examination and operation technique" consisting of 44 films. After having filmed most of the routine procedures I had the feeling that an atlas would be appropriate as a supplement. My aim with this atlas of "Operative Andrology" was to cover selected operations on the male genitalia and their accessory glands in one book. In another volume selected operations on the kidney parenchyma, urinary transport and the collecting system, including the female urethra, will be handled in the same manner as "Operative Urology". The operations shown were selected on the basis of my own choice and experience. Some operations, being rare or outdated, have been omitted, as have some (notably incontinence prostheses) that are clinically still insufficiently tested; others have been included as new and promising. This atlas deals with operations on the urinary tract below the level of the bladder neck in males, as well as on all of the male genital organs. Starting at the scrotum and testis and ending at the meatus and the preputial opening, the andrological organs form an independent system. The andrological and urological systems are connected where the ejaculatory ducts join the verumontanum. The urethra serves as a conduit for both urine and ejaculate. Hypospadias causes not only urological but andrological problems as well. Disorders

of the prostate and subsequent operations can have andrological and urological consequences such as upper urinary tract dilation, infertility due to failure of prostatic secretion, retrograde ejaculation or postoperative incontinence. Testicular tumors have purely andrological consequences unless lymphnode metastases cause deviation of the ureters. Andrology is not only the science of fertility and sterility. Disorders that render coitus impossible such as congenital penile deviation, Peyronie disease, and erectile impotence have been added to it in recent years. As befits an atlas, the legends have been devised as explanatory supplements to the illustrations. The work is conceived as a step-by-step operative guide for genito-urinary surgeons after the diagnosis has been made and the type of operation chosen. It also gives the surgeon exact details on positions, skin incisions, suture material, instruments, drainage, dressing, and urinary diversion. In an extra paragraph suggestions are made for postoperative treatment during the next two to three weeks. This atlas would not have been written without the great support and help of my wife Serin in every sense. The illustrations were made by an excellent artist Wolfgang Nieblich, whom I would like to thank for his wonderful cooperation. Mrs. Angela Hinz, my secretary, likewise deserves many thanks for patiently doing all the typing. My appreciation and thanks also go to Mr. Bedürftig, Mrs. Dobler, Mr. Köhler, and to my publishing house de Gruyter.

Berlin, September 1980

Alpay Kelämi

Contents

Chapter 1 Positions in Operative Andrology

1

Chapter 9 Prostate

61

1.1 Supine Position 1.2 Pelvic Position 1.3 Lithotomy Position

3 4 5

9.1 9.2 9.3 9.4

Chapter 2 Skin Incisions in Operative Andrology . . .

7

Enucleation (Suprapubic - Transvesical) . . . . Transurethral Resection Perineal Prostato-Vesiculectomy Retropubic Prostato-Vesiculectomy 9.4.1 Ascending Technique 9.4.2 Descending Technique 9.5 Pelvic Lymph System Dissection

63 67 71 76 76 79 82

Chapter 10 Male Urinary Incontinence

87

10.1 Hauri Procedure 10.2 Tanagho-Smith Procedure

89 92

Chapter 11 Urethra

95

2.1 Scrotal Incision 2.2 Infrapubic Incision 2.3 Suprapubic Incision (Pfannenstiel) (Lower Abdominal Transverse Incision)

9 11 . . . .

14

Chapter 3 Scrotum

17

3.1 Reconstruction of the Scrotum

19

Chapter 4 Testis and Testicular Membranes

21

4.1 4.2 4.3 4.4 4.5

Funiculolysis and Orchidopexy Testicular Biopsy Exploration for Torsion of Testis Exploration of Testicular Appendages Orchidectomy 4.5.1 Simple Orchidectomy 4.5.2 Radical Orchidectomy 4.5.3 Testicular Prostheses 4.5.4 Retroperitoneal Lymph System Dissection . 4.6. Hydrocelectomy

23 26 27 28 29 29 30 31 32 34

Chapter 5 Epididymis

35

5.1 5.2 5.3 5.4

37 38 40 43

Spermatocelectomy Alloplastic Spermatocele Epididymovasostomy Epididymectomy

Chapter 6 Vas Deferens

45

6.1 Operation fur Sterilization (Vasodiatomy, S.S.Schmidt Procedure) 6.2 Vasovasostomy

47 49

Chapter 7 Testicular Vein

51

7.1 High Ligation of Testicular Vein 7.1.1 Muscle Splitting Flank Incision 7.1.2 Pararectal Incision

53 53 55

Chapter 8 Seminal Vesicles

57

8.1 Vesiculectomy (Suprapubic - Extravesical) . . .

59

11.1 Reconstruction of the Urethra 97 11.1.1 Denis Browne Procedure 97 11.1.2 Byars Procedure 101 11.1.3 Cecil Procedure 104 11.1.4 OmbrSdanne Procedure 107 11.1.5 Modified Allen-Spence Procedure . . . 109 11.1.6 King Procedure 114 11.1.7 Devine-Horton Procedure 117 11.1.8 Epispadias Repair 121 11.2 Operations for Stenoses of Meatus 124 11.2.1 Meatotomy 124 11.2.2 Meatoplasty 125 11.3 Repair of Urethral Fistulae 126 11.3.1 Pedicled Penile Skin Flap Technique . . 126 11.3.2 Two-Layer Repair 128 11.4 Diverticulectomy 130 11.4.1 Two-Layer Repair 130 11.4.2 Penile Denudation Technique 131 11.5 Urethrotomy 133 11.5.1 Non-Visual Urethrotomy 133 11.5.2 Visual Urethrotomy 134 11.6 Operations for Urethral Tumors 135 11.6.1 Transurethral Resection 135 11.6.2 Urethrectomy 136

Chapter 12 Penile Skin

139

12.1 Circumcision 12.1.1 Gomco Clamp Technique 12.1.2 Conventional Technique 12.2 Operation for Paraphimosis 12.3 Frenuloplasty 12.4 Reconstruction of the Penile Skin 12.5 Reconstruction of Congenital Penile Skin Deformities 12.5.1 Operation for Concealed Penis

141 141 145 146 147 148 150 150

X

Contents

12.5.2 Operation for Webbed Penis 12.5.3 Operation for Torsion of the Penis

151 . . 152

Chapter 13 Corpus Cavernosum Penis

153

13.1 Penile Amputation 13.2 Penectomy 13.3 Emasculation (Penectomy and Bilateral Orchidectomy) 13.4 Construction of the Vulva and Vagina . . . . 13.5 Construction of the Penis 13.6 Ileo-Inguinal Lymph System Dissection . . . 13.7 Operation for Priapism 13.8 Operation for Peyronie Disease 13.8.1 Excision of the Plaques and Duraplasty 13.8.2 Implantation of Penile Prostheses without Plaque Surgery 13.9 Operation for Penile Deviation 13.10 Operations for Microphallus 13.10.1 Johnston Procedure 13.10.2 Hinman Procedure 13.11 Chordectomy and Straightening of the Penis . 13.11.1 Meyer-Burgdorff Procedure 13.11.2 Johnston Procedure 13.12 Operation for Erectile Impotence

155 157

References Index

199 201

160 162 166 170 172 173 173 177 179 181 181 183 186 186 190 194

Chapter 1 Positions in Operative Andrology

1.1 Supine Position

Fig. 1 The patient lies on his back, straight, legs together or slightly apart. This position is suitable for most procedures on the scrotum, testis, testicular m e m b r a n e s , epididymis,

vas deferens, testicular vein, urethra, penile skin and corpus cavernosum penis,

1.2 Pelvic Position

Fig. 2 The patient lies on his back on a slightly cranially tilted table, legs apart and stretched downwards and on leg supports. Highest point of the body is the suprapubic re-

gion. This position is suitable for most procedures on the seminal vesicles, the prostate and for urinary incontinence,

1.3 Lithotomy Position

at the knees and on leg supports. This position is suitable for These three positions (Supine, Pelvic, Lithotomy) are the ones most commonly used. Others will be shown with each operation as required.

pus cavernosum penis, and for urinary incontinence.

Chapter 2 Skin Incisions in Operative Andrology

2.1 Scrotal Incision

Fig. 4 This is an approximately 2 cm long vertical incision on the cranial pole of the scrotum. The figure shows its relation to the infrapubic and suprapubic incisions. The scrotal incision should be used for sterilization and testicular biopsy only. For all other procedures on male genitalia the infrapubic incision should be preferred.

Fig. 5 To stabilize the right spermatic cord the t h u m b and index finger are placed above, the third and fourth fingers below the cord. The surgeon does this with his left hand, using his right hand for surgery.

10

2.1 Scrotal Incision

Fig. 6 The left spermatic cord is stabilized in the same m a n n e r as in Fig. 5, also using the left hand.

Fig. 7 Wound closure after scrotal incision: Subcutaneous fat tissue with single, 3/0, and the skin with continuous, 4 / 0 synthetic absorbable sutures.

2.2 Infrapubic Incision [24,25]

Fig. 8 The infrapubic incision (Kelâmi) is an approximately 4 cm long horizontal incision between the penile root and the symphysis. The figure shows its relation to the suprapubic and scrotal incisions. With the exception of operations for sterilization and testicular biopsy all other procedures - uni- or bilateral - on male genitalia can be performed through this incision or its variants.

Fig. 9 If necessary the infrapubic incision can be cranially extended on either side in a semicircular m a n n e r to gain better bilateral access to the inguinal region.

12

2.2 Infrapubic Incision

Fig. 10 For unilateral procedures the infrapubic incision begins in the middle of the penile root and extends either to the left or to the right.

Fig. 11 Again for unilateral procedures, if more space is needed, as for orchidopexy, the incision can be extended cranially.

2.2 Infrapubic Incision

Fig. 12 By using the Roux retractors better access is gained to different regions through the infrapubic incision. Top: Access to the right and left scrotal pouch. Bottom: Access to the right and left inguinal region. After the skin incision the subcutaneous fat tissue is dissected and the spermatic cord located. Further blunt dissection delivers the scrotal contents without disconnecting the lower pole from the scrotal pouch. The external inguinal ring is easy to reach. For operations on the penile root only the subcutaneous fat tissue needs to be dissected.

13

Fig. 13 Wound closure after the infrapubic incision: Subcutaneous fat tissue with single, 3/0, and the skin with continuous, subcuticular, 4/0 synthetic absorbable sutures.

2.3 Suprapubic Incision (Pfannenstiel) (Lower Abdominal Transverse Incision)

proximately 8 cm long horizontal incision, 2 - 3 cm above the symphysis. The figure shows its relation to the infrapubic and scrotal incisions. It gives very good access in operations on the bladder, seminal vesicles and prostate and in urinary incontinence procedures. If extended latero-cranially this procedure (one incision pararectal, extraperitoneal (OIPE) approach [30]) can be used for bilateral pelvic lymph system dessection without opening the midline and peritoneum (chapter 9.5). This approach is also suitable for all bilateral procedures on the lower 2/3 of the ureters.

tissue, rectus fascia and the rectus muscles are divided in the midline and held apart with Roux retractors. Then the anterior wall of the bladder and prostate as well as the retropubic region can be viewed.

2.3 Suprapubic Incision

Fig. 16 Wound closure after Pfannenstiel-incision: Rectus muscles (top) and rectus fascia (bottom) are approximated with single, synthetic absorbable sutures No. 1. These three incisions (Scrotal, Infrapubic, Suprapubic) are the ones most commonly used in operative andrology. The others will be shown with each operation as necessary.

15

Fig. 17 Subcutaneous fat tissue with single, 3/0 synthetic absorbable sutures and the skin with single, 2/0 Polyamid sutures (Donati technique).

Chapter 3 Scrotum

3.1 Reconstruction of the Scrotum [35]

Indication: Elephantiasis

Fig. 18 Through the infrapubic incision the scrotal contents are delivered, in order to prevent injuries while resecting the diseased part of the scrotum.

Postoperative Treatment: Bed rest is not necessary. The dressing is changed on the fourth postoperative day, then the wound left open and polyvidon and skin spray used only. A suspensory is placed for three weeks. Prophylactic antibiotics are not given.

Fig. 19 After eliminating the entire affected scrotal area, the testes are placed back into the remaining scrotal pouch and fixed onto its interior wall, each with two, single, 2/0 synthetic absorbable sutures, taking only thin bites of tunica albuginea. The scrotal skin is then closed with single, 4/0 synthetic absorbable sutures, and the infrapubic incision as described in chapter 2.2. No drainage is used; instead a pressure dressing is placed for three days.

Chapter 4 Testis and Testicular Membranes

4.1 Funiculolysis and Orchidopexy

Indication:

Maldescensus testis.

Fig. 20 Unilateral infrapubic incision, in this case with latero-cranial extension, is used. After skin incision, the subcutaneous fat tissue is dissected very carefully to avoid injuring the undescended testis. The testis is located and the spermatic cord followed up to the external inguinal ring. After inserting a grooved spatula u n d e r it the externus muscle fascia (aponeurosis) is incised - with the scalpel or scissors beyond the margin of the internus muscle.

Fig. 21 The spermatic cord is separated from all cremasteric tissue. The testicular vessels and the vas deferens are dissected from each other, the vessels followed cranially and the vas deferens medio-caudally. The utmost dissection of the vessels lengthens the spermatic cord.

24

4.1 Funiculolysis and Orchidopexy

Fig. 22 By undermining or dividing [18] the epigastric vessels an additional length of 1,5 cm can be achieved.

Fig. 23 In cases of open processus vaginalis or hernia the peritoneal sac is dissected free from the spermatic cord, resected, and the stump suture-ligated with a 2/0 synthetic absorbable suture. With this suture the secured peritoneal stump is pulled under the interior surface of the internus muscle and fixed. To enable further dissection of the spermatic cord - in cases of short vessels - the internus muscle can be incised. When the testis cannot be found at the level of the external and internal inguinal ring, the peritoneum should be opened and explored.

4.1 Funiculolysis and Orchidopexy

Fig. 24 The externus muscle fascia - and, if divided, the interims muscle - is approximated with single, synthetic absorbable sutures No. 1. The lowest point of the scrotum is fixed externally with an Allis clamp and pushed upwards, inside out. Two points at the lower pole of the tunica albugínea of the testis are sutured with 2/0 synthetic absorbable sutures onto the inner surface of the lowest point of the scrotum without breaking through the entire skin thickness.

Postoperative Treatment: Bed rest for three days. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given.

25

Fig. 25 After the sutures are secured the Allis clamp is pulled down and released. It is important to make sure that the testis is fixed in a non-torsion manner and that the vas deferens lies medially. To help keep the testis in the scrotal pouch the fat tissue on the upper pole of the scrotal pouch is closed with single, 2/0 synthetic absorbable sutures. Care must be taken not to obstruct the spermatic cord when placing the sutures on the externus fascia and scrotal pouch. Wound closure as described under chapter 2.2. No drainage is used.

4.2 Testicular Biopsy

Indication: Infertility (oligozoospermia, azoospermia).

The procedure can also be performed under local anesthesia and on an out-patient basis.

Fig. 26 The assistant fixes the testis firmly with one hand and never changes the position of the fingers during the operation. Through a scrotal incision at the level of the upper testicular pole the skin and the subcutaneous fat tissue are separated. Through this approximately 2 cm long incision the tunica albugínea of the testis is identified.

Fig. 27 To avoid injury to the vascular supply of the testis, the incision of the tunica albugínea should be performed on the upper pole only. After a stab incision with a pointed scalpel the tubules extrude. These are excised with a pair of scissors and put into Bouin's solution. The tunica albugínea is closed with single, 4/0 synthetic absorbable sutures. Wound closure, as described under chapter 2.1. No drainage is used.

Postoperative Treatment: Patients walk back home. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. A suspensory is placed for three weeks. Prophylactic antibiotics are not given. Showers are allowed from the first postoperative day on, and full bath after complete wound healing.

4.3 Exploration for Torsion of Testis

Indication:

Torsion of the Testis.

Fig. 28 On the right side, the figure shows an "extravaginal" and on the left an "intravaginal" torsion of the testis. Torsion is the most c o m m o n acute event in childhood and has to be explored immediately in order to save the testes [33, 34].

Postoperative Treatment: Bed rest is not necessary. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. A suspensory is placed for three weeks. Prophylactic antibiotics are not given.

Fig. 29 The "infrapubic" approach facilitates exploration on both sides. The affected (right) side is delivered, the twisted spermatic cord and testis u n d o n e and returned to its normal anatomical position. Again an Allis clamp is used to turn the lowest point of the scrotum inside out and the testis fixed onto it with two, single, 2/0 synthetic absorbable sutures (as in orchidopexy). As a prophylaxis the non-affected (left) side should also be fixed in the same manner. Wound closure as described u n d e r chapter 2.2 No drainage is used.

4.4 Exploration for Testicular Appendages

Indication: Torsion of the testicular appendages.

Fig. 30 The torsion of the testicular appendages have the same acute symptoms as torsion of the testis. Only the exploration of the scrotal contents can give the right diagnosis. The treatment consists of either fulgurating or ligating (with 4/0 synthetic absorbable sutures) the base of the appendage and removing it. Wound closure as described under chapter 2.2.

Postoperative treatment: As described under chapter 4.3.

4.5 Orchidectomy

4.5.1 Simple Orchidectomy Indication: Hormonal treatment of prostatic cancer, inflammatory disease, testicular hemorrhage, testicular atrophy, unilateral retention after puberty.

i i / t" 1

The procedure can also be performed under local anesthesia and on an out-patient basis.

\i

Fig. 31 Through an infrapubic incision the spermatic cord is identified and dissected. Then the scrotal contents are delivered and separated from the scrotal wall. The spermatic cord is divided into vas deferens and testicular vessels. The vessels are ligated and suture-ligated, the vas deferens only ligated, with 2/0 synthetic absorbable sutures and severed at the level of the external inguinal ring and the testis removed. It is important to coagulate all the bleeding sites to ensure hemostasis. A suction drain is placed only after an inflammatory disease and diverted through a separate incision. A pressure dressing is also placed.

Postoperative Treatment: Bed rest is not necessary. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Pressure dressing is removed on the fourth postoperative day. Prophylactic antibiotics are not given.

30

4.5 Orchidectomy

4.5.2 Radical Orchidectomy Indication: Testicular Tumors.

The procedure can also be performed under local anesthesia and on an out-patient basis.

R

Fig. 32 The approach is similar to the simple orchidectomy performed through the infrapubic incision. As soon as the spermatic cord is dissected from its surrounding tissue, a rubber-shod clamp is placed on it at the level of the external inguinal ring to prevent the spreading of t u m o r cells. Then the scrotal contents are delivered and separated from the scrotal wall. After incising the externus muscle fascia, as for orchidopexy (chapter 4.1), the spermatic cord is followed up to the peritoneal sack where the vas deferens and testicular vessels turn to different directions (vas deferens medio-caudal, vessels cranial). The division of the spermatic cord is done in the same m a n n e r as in simple orchidectomy (above the rubber-shod clamp) and the testis removed. Wound closure as described under chapter 2.2.

Postoperative

Treatment: As described under chapter 4.5.1.

4.5 Orchidectomy

31

4.5.3 Testicular Prostheses Indication:

After orchidectomy, testicular agenesis.

The procedure can also be performed under local anesthesia and on an out-patient basis.

r\

1 1"

Fig. 33 The option of having a testicular prosthesis implanted should be offered to all patients before surgery. It is a fact that absent testis causes psychological disorders [53], The implantation of testicular prostheses can be performed either at the time of orchidectomy or later. At both times an infrapubic approach is used. After cutting the subcutaneous fat tissue, the scrotal pouch is dissected bluntly with two fingers and space opened for the prosthesis. I prefer the silicon prosthesis without gel and fixation. After placing the prosthesis, the scrotal pouch is closed with single, 2 / 0 synthetic absorbable sutures. This keeps the prosthesis in place, that is, motile in the scrotal pouch, but without the danger of extrusion into the inguinal area. Wound closure as described under chapter 2.2.

Postoperative Treatment: No drainage, pressure dressing, or bed rest is necessary. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. A suspensory is placed for three weeks. Broad spectrum antibiotics are given for a week, starting 8 hours before surgery.

32

4.5 Orchidectomy

4.5.4 Retroperitoneal Lymph System Dissection Indication: Testicular tumors.

Fig. 34 Among many other approaches, the transperitoneal one is the most commonly used. The patient is in supine position and the skin incision extends from the xiphoid to the symphysis.

Fig. 35 After the exposure of the peritoneal cavity, self-retaining retractors are used and the intestine delivered into a plastic bag or moist towels. The retroperitoneum is incised from the ligament of Treitz till the bifurcation of the aorta. Then from this level the dissection of the lymphsystem (lymph nodes and lymph vessels) of the aorta and vena cava starts in the caudo-cranial direction.

4.5 Orchidectomy

Fig. 36 There are various techniques of dissecting the lymphsystem where it is important to avoid possible lymphleakage. I prefer using clips. After dissecting with scissors, the tissue is divided between the clips. The clips also help identify the operative site on future X-ray examinations.

Postoperative Treatment: Bed rest is not necessary. The dressing is changed on the first postoperative day, then the wound left open and Polyvidon and skin spray used only. Prophylactic antibiotics are not given. Care must be taken for intestinal integrity.

33

Fig. 37 At the end of the dissection the following area is entirely freed from the lymphatic tissue: Cranial: 1 - 2 cm above the left renal vein. Left lateral: The left ureter. Right lateral: The right ureter. Caudal: Bifurcation of the internal and external iliac vessels. The inferior mesenteric artery can be divided without damage. Aorta and vena cava are freed from all the lymphatic tissue and from the vertebrae. Especially the region between the aorta and cava must be cleaned, and the testicular vessels of the affected side removed. Retroperitoneal space is closed with continuous, 2/0 synthetic absorbable sutures without drainage. The anterior peritoneum is also closed in the same manner. No retention sutures are used. The rectus muscle fascia is approximated with single, synthetic absorbable sutures No. 1, the subcutaneous tissue with single, 3/0 synthetic absorbable sutures, and the skin with single, 2/0 polyamid sutures.

4.6 Hydrocelectomy

Indication:

Hydrocele

The procedure can also be performed under local anesthesia and on an out-patient basis.

1

Fig. 38 Through an infrapubic incision the scrotal contents are delivered. The tunica vaginalis is incised, the fluid aspirated and the testis and epididymis explored. In cases of large hydroceles the fluid can be aspirated beforehand to ease the delivery from t h e scrotum. T h e n , t h e tunica vaginalis is excised, leaving a 0.5 cm margin. A continuous, locked, 2 / 0 synthetic a b s o r b a b l e suture ensures the hemostasis. After placing the scrotal contents back into t h e scrotal pouch, w o u n d closure is done as described u n d e r chapter 2.2.

Postoperative Treatment: Drainage and b e d rest are not necessary. Pressure dressing is placed for t h r e e days and a suspensory for t h r e e weeks. Prophylactic antibiotics are not given. Suction drainage is used only after an inflammatory disease and diverted t h r o u g h a separate incision.

Fig. 39 Pressure dressing after hydrocelectomy. T h e scrotal area is padded and an elastic 10 cm wide b a n d a g e placed crosswise onto t h e scrotum. T h e pressure dressing helps avoid postoperative h e m o r r h a g e and e d e m a .

Chapter 5 Epididymis

5.1 Spermatocelectomy

Fig. 40 Through an infrapubic incision the scrotal contents are delivered. The tunica vaginalis is then incised and the spermatocele identified and enucleated with scissors from the epididymis. The tunica of the epididymis is closed with single, 4/0 synthetic absorbable sutures to avoid sperm granuloma. The tunica vaginalis is closed with continuous, 2/0 synthetic absorbable sutures and the scrotal contents placed back into the scrotal pouch. Wound closure as described under chapter 2.2.

Postoperative Treatment: Drainage and bed rest are not necessary. A suspensory is placed for three weeks. The dressing in changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given.

5.2 Alloplastic Spermatocele [26]

Indication: Vas deferens aplasia, long distance stenosis of the vas deferens, unsuccessful reanastomosis of the vas deferens, spinal cord injury, obstruction of the ejaculatory ducts.

Fig. 41 The alloplastic spermatocele (Kelami-Affeld prosthesis, [26]) is made out of one piece of silicone consisting of three parts: 1. a semen reservoir with a volume of 1.5 ml, 2. a non-kinking connecting tube, and 3. a puncture port. To achieve a good tissue fixation, the inner surface of the margin of the reservoir and the puncture port is lined with Dacron-velour. The Wagenknecht-Schirren prosthesis [52] consists of a reservoir only, which has to be transscrotally punctured. This can be painful in the first postoperative days and can damage the reservoir as well. The very proximal epididymal tubule, which is the only extrusion point of the sperms can also be injured. The Kelami-Affeld pros-

thesis avoids these dangers by puncturing the "puncture port" in the subcutaneous inguinal area without any local anaesthetics.

5.2 Alloplastic Spermatocele

39

Fig. 42 Through the infrapubic incision the scrotal contents are easily explored. The epididymis is incised first on the cauda region and checked for sperms. If there are none, this procedure is repeated on the corpus and caput areas until sperms are found. Only one (proximal) tubule needs to be cut opened. As a motility increasing agent, the operative area is steadily irregated with Baker's solution.* The Kelámi-Affeld prosthesis is then sutured (with continuous, 2/0 monofilament sutures) onto the tunica of the epididymis and partly onto the tunica albugínea of testis without handling the tubuli, especially the proximal one.

Fig. 43 After the termination of the anastomosis the tunica vaginalis is closed (continuous,2/0 syntheticabsorbable sutures) and the scrotal contents placed back. Then using Roux retractors the inguinal region is explored and a subcutaneous tunnel made for the puncture port, which is placed without fixing. Wound closure as described under chapter

Postoperative Treatment: Drainage and bed rest are not necessary. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. A suspensory is placed for three weeks and broad spectrum antibiotics given for one week, starting 8 hours before surgery. The implantation is performed three to five days before the ovulation of the partner. The aspiration is done on the day of ovulation under sterile conditions. After puncturing and aspirating the reservoir is irrigated with Baker's solution. The first undiluted aspirate and the second aspirate diluted with Baker's solution are examined spermatologically. The ejaculate of the patient and, if needed, motility increasing

agents (Callicrein, Carnitin, Caffein) are added to the aspirated fluid and the mixture high-cervically inseminated by the gynecologist.

* Baker's solution: Glucose 6% 50 ml, to be added to N a 2 H P 0 4 . 2 H 2 0 1 %, K H 2 P 0 4 0,22 %, NaCl 0,4 %, in dest. H 2 0 50 ml

2.2.

The prosthesis is punctured and irrigated with an 18 gauge needle and a 2 ml syringe using Baker's solution. This procedure should also be continuously performed during the operation to avoid blockage of the system due to oozing. At the end of the operation 1.5 ml of Baker's solution is left in the reservoir.

5.3 Epididymovasostomy

/«i/icai/on:Transportazoospermia (stenosis of the vas deferens at the testicular end, obstruction of the cauda and corpus epididymidis).

The procedure can also be performed under local anesthesia and on an out-patient basis.

Fig. 44 The patients with transportazoospermia (diagnosis can be made through hormonal tests and spermatology) can be explored in one session through the infrapubic incision. After delivering the scrotal contents the tunica vaginalis is opened and the testis and epididymis inspected. Then a testicular biopsy is done on the upper pole as described in chapter 4.2. The next step is to explore the vas deferens. During the dissection of the vas deferens, its adventitial tissue with blood and nerve supply should be preserved to enable viability and handling during the operation. This is then divided close to the cauda epididymidis and cannulated with a 12 gauge blunt needle to prove the patency. If 20 ml of saline solution flow easily through it, it can be assumed that the fluid is in the urethra; if not, there is an obstruction. In this case the vas is followed up to that point and

the same irrigation procedure repeated. A vasography is not performed. In a long distance stenosis, a point can be reached where an anastomosis is impossible. In these cases the epididymis remains u n t o u c h e d to allow the implantation of an alloplastic spermatocele at a later date. If the vas deferens is intact for epididymovasostomy, then the dissection of epididymis starts with sperm examinations in the caudo-cranial direction. The anastomosis is done where sperms are detected. After the tunic is incised, the tubules extrude. Only one tubule is divided or its wall excised with very fine (ophthalmological) instruments.

5.3 Epididymovasostomy

Fig. 45 The anastomosis is also done with very fine (ophthalmological) instruments. I do not use magnification. The vas deferens is incised 1 - 1.5 cm using the grooved spatula [27]. This instrument prevents injuries to the posterior wall and guides the other instruments (scalpel, scissors, needle). After the incision of the vas deferens, the spatula remains in situ until the first stitch at the corner is performed. For easier understanding the figure shows single stitches at the most important corners of the anastomosis site, although in reality it is one single continuous locked 7/0 synthetic absorbable suture [29]. The vas deferens is taken in its entire thickness (mucosa and muscularis), but the tunic should be taken on the epididymal side only. Accidental suturing of the "proximal" epididymal tubule would lead to an unsuccessful anastomosis.

41

Fig. 46 The epididymovasostomy is terminated. It is a termino-lateral anastomosis at the caput region. Care must be taken to avoid tension of the anastomosis. To secure the anastomosis further, single 7/0 synthetic absorbable sutures between the adventitia of the vas deferens and the tunic of epididymis are placed. No splints are used. Wound closure as described under chapter 2.2.

42

5.3 Epididymovasostomy

in male fertility. At the end of each examination and operation the findings are marked on it and it is added to the patient's chart. It is also useful in informing the patients of their fertility condition. Postoperative Treatment: Drainage and bed rest are not necessary. A suspensory is placed for three weeks. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not used. Sexual activities should be resumed as soon as tolerable.

5.4 Epididymectomy

Indication:

Epididymal tumors, chronic epididymitis.

Fig. 48 Scrotal contents are delivered through an infrapubic incision. After opening the tunica vaginalis the testis and epididymis are inspected. Starting on the cauda region, the dissection is followed cranially. The vas deferens is ligated (3/0 synthetic absorbable suture) and divided. The epididymal artery is also ligated (3/0 synthetic absorbable suture), divided, and the epididymis removed. On the upper pole care must be taken not to injure the testicular artery. The tunica vaginalis is then closed with continuous, 2/0 synthetic absorbable sutures and the scrotal contents placed back. Wound closure as described u n d e r chapter 2.2. A suction drain is placed only after an inflammatory disease and diverted through a separate incision. A pressure dressing is also placed.

The procedure can also be performed under local anesthesia and on an out-patient basis.

Postoperative Treatment: The pressure dressing is removed on the fourth postoperative day, then a suspensory placed for three weeks. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given.

Chapter 6 Vas Deferens

6.1 Operation for Sterilisation (Vasodiatomy, S.S.Schmidt Procedure) [45,46]

Indication: Male contraception, preventive procedure for epididymitis.

The procedure can also be performed under local anesthesia and on an out-patient basis.

Fig. 49 The spermatic cord is stabilized in the same manner as shown in Fig. 5 and 6. A 1.5 cm long vertical skin incision is m a d e and the subcutaneous fat tissue dissected with scissors. The vas deferens is held with a Backhaus clamp and dissected only 1 cm from its fascia (adventitial tissue). The fascia is fixed with mosquito clamps and the vas deferens divided with a scalpel. A blunt 12 gauge needle is inserted about 0.5 cm into the urethral end and the vas deferens irrigated with 10 ml of 0.9 % Nitrofurantoin solution. This is a spermicide agent which enables earlier azoospermia after sterilisation [1,9]. As soon as the Nitrofurantoin reaches the urethra the patient reacts with a burning sensation. The needle remains in the vas deferens and is used for f i g u r a tion of the lumen. Bipolar electrocautery should be preferred (to monopolar) as this only destroys the mucosa [45,

46], The testicular end is fulgurated only. Resection of 1 to 3 cm of the vas as proof is unnecessary since postoperative azoospermia will be proof enough.

48

6.1 Operation for Sterilisation

Fig. 50 The bipolar fulguration destroys only the mucosa (top). As resection of the vas deferens is avoided, a possible reanastomosis can be easier to perform. The fascia (adventitial tissue) is used to cover both ends with single, 4/0 synthetic absorbable sutures. Wound closure as described under chapter 2.1. All procedures for sterilisation are unfortunately called "vasectomy" but in none of the cases is the vas deferens removed totally. "Vasectomy" would certainly be wrong for the above mentioned procedure, since the vas deferens is only divided and not even resected. Postoperative Treatment: Drainage or bed rest are not necessary. A suspensory is placed for three weeks. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given. Showers are allowed from the first postoperative day on and full baths after complete wound healing. Sexual activities without protection are allowed only after proof of azoospermia in three consecutive tests.

6.2 Vasovasostomy

Fig. 51 Through an infrapubic incision the spermatic cord is identified and the scrotal contents delivered without disconnecting them from the scrotal wall. The vas deferens is dissected about 2 cm in length at the site of the lesion, leaving the blood and nerve supply of the adventitial tissue intact. The obstructed area is resected, the urethral end of the vas deferens cannulated with a 12 gauge needle, and the patency tested by injecting 20 ml of saline solution. From the testicular end a smear is made and checked for spermatozoa. If spermatozoa are present, a vasovasostomy can be performed; if not, an epididymovasostomy has to be tried, as described in chapter 5.3. Using two mosquito clamps or special holding devices at each end of the adventitia of the vas deferens, both ends are approximated. To ease the guidance of the needle and prevent injuries to the posterior wall of the vas deferens, a

grooved spatula [27] is inserted 1 cm into the lumen, and 3 single, 7/0 synthetic absorbable sutures taken through the entire thickness (mucosa and muscularis) (top). The same needles are also used for the corresponding three sutures at the other end of the vas deferens, also using the grooved spatula. Care must be taken to have the mucosa exactly approximated. Before tying the three sutures (figure shows only two), a 3 cm long 3/0 plain catgut suture is inserted into the lumen as an absorbable splint [38]. This straightens the site of the anastomosis and prevents sperm leakage (middle). After tying the three sutures a second suture layer (7/0 synthetic absorbable) of only adventitial tissue is taken to cover the anastomosis (bottom). I do not use any magnification. After replacing the scrotal contents, the wound closure is done as described under chapter 2.2.

50

6.2 Vasovasostomy

Postoperative Treatment: Drainage or bed rest are not necessary. A suspensory is placed for three weeks. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given. Showers are allowed from the first postoperative day on and full baths after complete wound healing. Sexual activities are recommended two weeks after surgery.

Chapter 7 Testicular Vein

7.1 High Ligation of the Testicular Vein

7.1.1 Muscle Splitting Flank Incision Indication:

Varicocele.

Fig. 52 For high ligation of the left testicular vein the patient lies on his right flank, leaving the left flank free for the muscle splitting incision. The body is flexed at the operative

area. The skin incision starts at the tip of the twelfth rib and extends approximately 10 cm ventro-caudally.

54

7.1 High Ligation of the Testicular Vein

Fig. 53 After the skin, the subcutaneous fat tissue and the fascia of the external oblique abdominal muscle are incised. The muscle fibers of the external oblique muscle are split by blunt dissection, without cutting (top). Using Roux retractors again, the fibers of the internal oblique muscle are separated (middle). The transversus abdominal muscle, as the last layer, is also separated, opening the retroperitoneal space (bottom). The peritoneal envelope and fat tissue are pushed medially to identify the ureter (lateral) and the testicular vein (medial).

Postoperative Treatment: Drainage and bed rest are not necessary. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given.

Fig. 54 The ureter always lies laterally to the vein and has a different structure and appearance. After exact identification, the testicular vein is ligated with two clips, but not divided. Then, wound closure in three muscle layers using single synthetic absorbable sutures No. 1 follows. The subcutaneous fat tissue is closed with single, 3/0 and the skin with subcuticular continuous, 4 / 0 synthetic absorbable sutures.

7.1 High Ligation of the Testicular Vein

55

7.1.2 Pararectal Incision Indication:

Varicocele.

Fig. J J The left pararectal incision is an alternative approach to the flank incision. The patient is in the supine position. The skin incision is an approximately 10 cm long pararectal vertical incision. The middle of the incision is approximately at the same level as the umbilicus.

Fig. 56 After t h e skin, s u b c u t a n e o u s fat tissue and t h e anterior sheath of t h e rectus fascia are incised, t h e posterior sheath is cut.

56

7.1 High Ligation of the Testicular Vein

Fig. 57 The peritoneal envelope is pushed medially with sponge sticks (top) until the ureter and the testicular vein are identified. The ureter always lies laterally to the vein and has a different structure. The testicular vein is then dissected and clamped with two clips, but not divided (bottom). The ureter is never touched, only visualized. Postoperative Treatment: As under chapter 7.1.1

Fig. 58 Wound closure: The rectus fascia is closed with single synthetic absorbable sutures No. 1 (top), the subcutaneous fat tissue with single, 3/0 (middle) and the skin with subcuticular, continuous, 4/0 synthetic absorbable sutures.

Chapter 8 Seminal Vesicles

8.1 Vesiculectomy (Suprapubic - Extravesical)

Indication: Tumors of seminal vesicles, chronic inflammation.

Fig. 59 The patient lies in the pelvic position. A sterile transurethral catheter (16 Ch) is inserted before surgery. The bladder is visualized through a Pfannenstiel incision. It is important to dissect the bladder entirely from its surrounding tissue, including the peritoneal envelope. At the end of the dissection, the bladder hangs on the trigonal region and the seminal vesicles are then visible. Most of the dissection can be made bluntly. Care should be taken not to injure the ureters. After identifying the vas deferens on both sides, they are clipped and divided. The seminal vesicles are also clipped before they j oin the ampulla of the vas deferens, divided and removed. A suction drain is placed into the retrovesical space and diverted through a seperate incision. Wound closure as described under chapter 2.3.

Postoperative Treatment: Bed rest is not necessary. The transurethral catheter is removed after surgery and the drain when the secretion is less than 30 ml. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given.

Chapter 9 Prostate

9.1 Enucleation (Suprapubic - Transvesical)

Indication: Adenoma of the Prostate k

Fig. 60 Through a Pfannenstiel incision the anterior wall of the bladder is approached. The dissection of the bladder wall as well as the protection of the peritoneal cavity can be simplified by filling up the bladder with air or saline solution before surgery. Between two stay sutures the anterior bladder wall is transversally opened, leaving a 2 to 3 cm wide margin between the incision and prostate.

(

Fig. 61 After opening the bladder, retractors are used and the prostatic region and the trigone visualized. At this point, 20 mg of Furosemid is injected by the anesthesiologist to identify the ureteral orifices. This forced diuresis also helps to prevent injuries through sutures at the end of the operation. The bladder mucosa is circumferentially incised at the prostato-vesical region using an electrical needle.

64

9.1 Enucleation

Fig. 62 The right index finger of the surgeon enters the prostatic urethra, breakes the boundary between the adenoma and prostate by pressure, and proceeds with the enucleation. By entering the rectum with his left index finger the surgeon can elevate the prostate to ease the enucleation.

Fig. 63 The layer between the adenoma and the prostate can be entered medio-laterally from the prostatic urethra or, as seen above, directly laterally. The remaining urethral tissue can be cut with scissors. As the entire procedure is done digitally and the adenoma not cut out with instruments the procedure is called "enucleation". "Adenomectomy" would not be correct, "prostatectomy" wrong, since the prostate remains in situ and only adenomatous peri-urethral tissue is removed.

9.1 Enucleation

Fig. 64 After the enucleation the margins of the prostatic fossa is held with two Allis clamps and a 16 Ch Nelaton 15 ml balloon catheter inserted transurethrally into the bladder.

65

Fig. 65 One of the following methods is used to ensure hemostasis. The prostatic fossa is closed with continuous, locked, 2/0 plain catgut sutures over the catheter, starting at the lower corner (top). The plain catgut ensures hemostasis and dissolves after 5 to 6 days, opening the fossa again. Or the prostatic fossa remains open but the bleeders are either fulgurated or suture-ligated (2/0, synthetic absorbable sutures) (bottom).

66

9.1 Enucleation

Fig. 66 The balloon of the transurethral catheter is inflated with 15 ml of aqua dest. and withdrawn to the bladder neck. Another 16 Ch Nelaton, 5 ml balloon catheter is laterally inserted into the bladder through a stab incision. To prevent injury during suturing, the balloon is inflated at the end of the operation. Saline solution is continuously irrigated through this closed sterile catheter system in the first and second postoperative days. Usually a manual irrigation disconnecting the catheter system is avoided. Closure of the bladder is done in one layer with 2/0 synthetic absorbable, extramucosal, mattres sutures [47]. A perivesical suction drain is used and diverted through a separate incision. Wound closure as described under chapter 2.3. Postoperative Treatment: Bed rest is not necessary. The transvesical catheter is removed as soon as the urine is clear and the drain after secretion ceases (below 30 ml). The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given. On the 8th postoperative day the sutures and the transurethral catheter are removed. If the fulguration or suture-ligation technique is used, the transurethral catheter can be removed when urine is clear and the transvesical catheter on the 8th postoperative day.

9.2 Transurethral Resection

Indication:

A d e n o m a or carcinoma of the prostate, obstruc-

tion of the bladder neck.

I\ II..

Fig. 67

Patient lies in a lithotomy position. A 24 Ch resec-

toscope is inserted transurethrally and the bladder filled up

Fig. 68

The resectoscope with the working element (loop)

makes the resection of the prostatic tissue as well as the

with isotonic solution. Then a suprapubic troicar catheter

coagulation of the bleeders possible. For each action a

(synthetic) is placed transvesically and sutured onto the skin

different electric current (cutting or coagulating) should be

for security. T o facilitate continuous irrigation and drainage

used. Resection starts at the 6 o'clock position. First, the

during the entire resection, the catheter is connected to a

median bar or the middle lobe up to the verumontanum is

drainage basin.

resected.

68

9.2 Transurethral Resection

Fig. 69 After the verumontanum is reached, resection of the right lobe starts, beginning at the 6 to 7 o'clock position and moving towards the 12 o'clock position. In large adenomas the full length and depth of the loop should be used. The length can even be extended if the entire instrument is also moved during the resection.

Fig. 70 The right lobe has been resected. Resection of the left lobe also starts, in the caudo-cranial direction. With this technique, as soon as the caudal parts are eliminated, the cranial parts, losing support from below, hang down, making the resection easier. To minimize blood loss it is recommended to ensure immediate hemostasis, especially of the arterial bleeders.

9.2 Transurethral Resection

Fig. 71 At the end of the resection the index finger is inserted into the rectum through a rectal sheath to elevate the prostate. This eases the resection of the apical region and the removal of the rest tissue.

69

Fig. 72 A last inspection shows possible rest tissue at the 12 o'clock position. The entire adenomatous tissue from the "true" prostate can be removed. Care should be taken not to u n d e r m i n e the bladder at the 5 to 7 o'clock position. The passage into the bladder should be smooth. Perforating the capsule (prostate) can cause intrusion of irrigation fluid into the periprostatic space. If a venous sinus is opened, the irrigation fluid can flow into the circulatory system, causing the T U R syndrome. Venous sinuses are closed by coagulating the surrounding tissue (bottom left). The arterial bleeders are attacked directly with the loop (bottom right). At the end of the resection no more adenomatous tissue should be seen at the level of the v e r u m o n t a n u m .

70

9.2 Transurethral Resection

Fig. 73 After the operation is terminated a 22 Ch h e m a t u ria catheter (a metal spiral in its wall prevents its collapsing) is inserted and the balloon inflated up to 50 ml with aqua dest. The bladder is filled and traction applied onto the transurethral catheter for five minutes. This maneuver enables complete hemostasis if no arterial bleeders exist. In case of further bleeding the resectoscope should be reinserted and hemostasis ensured.

Postoperative Treatment: After surgery the flow direction of the irrigation fluid is reversed. The transvesical catheter remains in situ and the irrigation fluid now flows through it into the bladder. The bladder is drained with the transurethral catheter, creating a closed sterile system for postoperative irrigation. After the urine clears up (first to second postoperative day) the transurethral catheter is removed first. The transvesical catheter is clamped and the patient allowed to urinate. By filling the bladder with a certain a m o u n t of fluid through the transvesical catheter and letting the patient void, residual urine should be tested. Uroflowmetry is also performed before removing the transvesical catheter (third to fourth postoperative day). Prophylactic antibiotics are not given. Bed rest is not necessary.

9.3 Perineal Prostato-Vesiculectomy

Indication: Carcinoma of the Prostate.

Fig. 74 The patient is in an exaggerated lithotomy position with his legs slightly apart and bent at the knees and pelvis level. It is important to have the perineum parallel to the floor. The sacral region is also elevated.

Fig. 75 The figure shows the positioning from the standpoint of the surgeon. After covering the entire operative area with a plastic drape the skin is horizontally incised 1 to 2 cm proximal to the anus and extended down on both sides.

72

9.3 Perineal Prostato-Vesiculectomy

Fig. 76 The scrotum is usually held away from the operating site with a plastic drape, otherwise it should be sutured onto the skin of the thighs. After the ischio-rectal fossa is incised on both sides, the central tendon is undermined with the index finger and cut with the scalpel.

Fig. 77 The index finger is inserted into t h e rectum through a rectal sheath and elevated to make the layer between the recto-urethral muscle and rectum visible and the incision easier. After the incision of the recto-urethral muscle the rectum drops back, leaving the operating space free for the prostate.

9.3 Perineal Prostato-Vesiculectomy

Fig. 78 At this stage to prevent injuries the rectum is padded heavily and retracted downwards. A Lowsley tractor is inserted transurethrally into the bladder and the prostate elevated to a rather superficial position [4]. The Denonvilliers' fascia is then incised 1 cm below the apex region.

73

Fig. 79 The apex region of the prostate is dissected and the urethra divided from the prostate. If the t u m o r site is not at the apex, a cuff at the urethral stump can be left to avoid possible urinary incontinence [42].

74

9.3 Perineal Prostato-Vesiculectomy

Fig. 80 The Lowsley tractor is removed and the prostate turned down using a catheter in the prostatic urethra. Then the dissection proceeds at the level of the bladder neck. Most of the dissection can be done bluntly. After the prostate is separated from the bladder neck the seminal vesicles can be approached.

Fig. 81 The seminal vesicles and vas deferens are identified and dissected free. The vessels of the prostate as well as the vas deferens are ligated with 2/0 synthetic absorbable sutures and cut. Then the entire specimen is removed.

9.3 Perineal Prostato-Vesiculectomy

Fig. 82 A 16 Ch Nelaton 5 ml balloon catheter is inserted into the urethra and the bladder. The bladder neck is reduced to the size of the urethra with single, 2/0 synthetic absorbable sutures.

Postoperative Treatment: Bed rest is not necessary. Pressure dressing is removed on the fourth postoperative day and the drain when the secretion is less then 30 ml. Prophylactic antibiotics are not given. The transurethral catheter is removed after 10 to 14 days.

75

Fig. 83 Then the urethra and the bladder neck are approximated over the catheter with 4 to 6 single, 2/0 synthetic absorbable sutures. A suction drain is placed and diverted separately. Subcutaneous fat tissue is closed with single, 3/0 and the skin with subcuticular, continuous, 4 / 0 synthetic absorbable sutures. A pressure dressing is applied for 3 days, as described in chapter 4.6.

9.4 Retropubic Prostato-Vesiculectomy

9.4.1 Ascending Technique Indication:

Carcinoma of the prostate.

-

Jr Fig. 84 The patient is in the pelvic position. By supporting the sacral region the pelvis is elevated. To facilitate dissection, a sterile 16 Ch transurethral catheter is inserted into the bladder. Through a Pfannenstiel incision the anterior wall of the bladder and the prostate are visualized. There is no need to divide the rectus muscles. After penetrating the endopelvic fascia, the pubo-prostatic ligament is divided.

Fig. 85 Then the apex region is dissected and the urethra divided at the apex of the prostate. To ease anastomosis and prevent urinary incontinence, here again a cuff on the apex can be left if the site of the malignancy is not close [42],

9.4 Retropubic Prostato-Vesiculectomy

Fig. 86 Once the division has been completed, the prostate can be reflected to visualize the posterior surface with the seminal vesicles.

77

Fig. 87 After applying traction onto the prostate with a catheter it is divided from the bladder neck.

78

9.4 Retropubic Prostato-Vesiculectomy

Fig. 88 The vascular pedicle and vas deferens are divided between two, 2/0 synthetic absorbable ligatures. After the prostate - including the attached seminal vesicles and parts of the vas deferens on both sides - are removed, the urethra and the bladder remain to be anastomosed.

Postoperative Treatment: Bed rest is not necessary. The dressing in changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given. The drain is removed when the secretion is less than 30 ml and the transurethral catheter 10 to 14 days after surgery.

Fig. 89 If the bladder neck is too wide, it is reduced to the size of the urethra as in Fig. 82, and the anastomosis accomplished over a 16 Ch Nelaton catheter with 4 to 6 single, 2/0 synthetic absorbable sutures. A suction drain is placed into the retropubic area and diverted separately. W o u n d closure as described u n d e r chapter 2.3.

9.4 Retropubic Prostato-Vesiculectomy

79

9.4.2 Descending Technique Indication:

Carcinoma of the prostate.

Fig. 90 The patient lies in the pelvic position. By supporting the sacral region the pelvis is elevated. Through a Pfannenstiel incision this time the dissection starts in the craniocaudal direction [37]. After the anterior bladder wall and the prostate are dissected, the bladder is circularly incised approximately 1 cm above the vesico-prostaticjunction to separate the prostate. A 16 Ch Nélaton catheter inserted before surgery eases the dissection.

Fig. 91 Using Duval clamps the prostate is lifted to facilitate the separation from the posterior wall. Thereafter the catheter is removed.

80

9.4 Retropubic Prostato-Vesiculectomy

Fig. 92 The next step is to dissect the seminal vesicles and the vas deferens on both sides. Then the vascular pedicle as well as the vas deferens are divided between 2/0 synthetic absorbable ligatures.

Fig. 93 The urethra is divided with or without a cuff at the apex level and the specimen removed. Using the Scott technique [47] the bladder is closed to fit the size of the urethra, as in Fig. 66.

9.4 Retropubic Prostato-Vesiculectomy

Fig. 94 The anastomosis between the urethra and the bladder neck is accomplished over a 16 Ch Nelaton catheter with 4 to 6 single, 2/0 synthetic absorbable sutures. The Tanagho-Smith technique [50, 51] can also be applied (chapter 10.2). A suction drain is placed into the retropubic area and diverted separately. Wound closure as described under chapter 2.3.

Postoperative

Treatment: As u n d e r chapter 9.4.1.

81

9.5 Pelvic Lymph System Dissection

Indication: Staging procedure in carcinoma of the prostate and bladder. k

Fig. 95 An extended Pfannenstiel incision which can be prolonged up to the anterior iliac spines is performed. The figure shows its relation to the operative field. Through this "one incision, pararectal, extraperitoneal" (OIPE) approach both iliac regions can be explored without cutting any muscles or entering the abdominal cavity [30].

(

Fig. 96 After the skin, the subcutaneous fat tissue, rectus and externus muscle fascia are incised.

9.5 Pelvic Lymph System Dissection

Fig. 97 The rectus muscles are retracted medially and the oblique abdominal muscles laterally, visualizing the peritoneal envelope.

83

Fig. 98 Then the peritoneal envelope is retracted mediocranially, making the ureters and the iliac vessels visible.

84

9.5 Pelvic Lymph System Dissection

Fig. 99 The vascular system, the nerves and the ureter in the right lateral pelvic region with the lymph system and fat tissue. The dissection will cover the entire area shown, from the c o m m o n iliacs down to the obturator fossa.

Fig. 100 The dissection starts at the level of the common iliacs and proceeds caudally. Here the cranial region has already been cleared from the lymph tissue (nodes and vessels).

Fig. 101 The lymphatic tissue is u n d e r m i n e d with scissors, clipped and divided between the clips.

9.5 Pelvic Lymph System Dissection

Fig. 102 Dissection is easier if the tip of the scissors is opened just a little and the fat tissue raked without cutting. This action leaves the lymph vessels free for clipping and dividing. It is essential to clip all lymphatic vessels, especially in the obturator area, to avoid lymphoceles.

Postoperative

Treatment: As under chapter 9.4.1.

85

Fig. 103 At the end of the dissection the entire lymphatic tissue is removed, leaving the vital structures clean. The boundaries of the dissection area are: lateral: the genito-femoral nerve cranial: common iliac vessels caudal: the obturator and femoral fossa. A suction drain is placed and diverted separately. Wound closure as described under chapter 2.3.

86

9.5 Pelvic Lymph System Dissection

Fig. 104 The same approach (one incision, pararectal, extraperitoneal - OIPE) can also be used for any kind of bilateral surgery on the lower 2/3 rds of the ureter. For urinary diversion one ureter is pulled through with two fingers under the peritoneal envelope without opening the latter.

Fig. 105 Then any kind of uretero-cutaneostomy can be performed. The figure shows a transuretero-ureterocutaneostomy. •

Chapter 10 Male Urinary Incontinence

10.1 Hauri Procedure [19]

Indication:

Urinary incontinence.

Fig. 106 The patient lies in an exaggerated lithotomy position. Urinary diversion is accomplished with troicar cystostomy. After covering the operative area with a plastic drape the skin incision is done in a semicircular m a n n e r in the mid-scrotal region.

Fig. 107 The bulbo-cavernosus muscle is incised to visualize the urethra.

90

10.1 Hauri Procedure

Fig. 108 The urethra is dissected approximately 10 cm in length. Then, to isolate the corpora cavernosa penis, they are divided along their septum up to a length (10 to 12 cm) that is needed to cover and compress the urethra.

Fig. 109 The compression of the urethra is achieved by approximating both of the corpora cavernosa penis over the urethra with single, 2/0 synthetic absorbable sutures. At the end, the bulbo-cavernosus muscle is also approximated with the same suture material.

10.1 Hauri Procedure

Fig. 110 Subcutaneous fat tissue is sutured with single, 3/0, and the skin with subcuticular, continuous, 4/0, synthetic absorbable sutures. No drainage is used; instead a pressure dressing is applied. Postoperative Treatment .Bed rest is not necessary. The pressure dressing is removed after three days, then the wound left open and polyvidon and skin spray used only. Cystostomy catheter is removed after satisfactory micturition. Prophylactic antibiotics are not given.

91

10.2 Tanagho-Smith Procedure [50,51]

Indication: Urinary incontinence.

Fig. Ill The anterior bladder wall is cut vertically in the required length and width to form a flap. The bladder opening is closed using the Scott technique [47] as described in Fig. 66.

Fig. 112 From the bladder flap a tube is formed with 2/0 synthetic absorbable sutures also using the Scott technique. Its diameter should correspond to the size of the urethra.

10.2 Tanagho-Smith Procedure

Fig. 113 The anastomosis between the urethra and the newly formed bladder tube is accomplished over a 16 Ch Nelaton catheter with 4 to 6 single, 2/0 synthetic absorbable sutures. A suction drain is placed into the retropubic area and diverted separately. Wound closure as described under chapter 2.3. Postoperative Treatment: Bed rest is not necessary. The dressing is changed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Prophylactic antibiotics are not given. The drain is removed when secretion is less than 30 ml, and the catheter after 10 to 14 days.

93

Chapter 11 Urethra

11.1 Reconstruction of the Urethra

11.1.1 Denis Browne Procedure [6,7] Indication: Hypospadias without chordee, second stage operation after chordectomy.

Fig. 114 Before starting the surgery a traction suture (2/0 Polyamid) is placed onto the glans penis. The meatus is in the peno-scrotal junction. A U-shaped incision is made around the meatus and extended laterally from the corona on both sides, forming two flaps. In all cases of urethral reconstructions a suprapubic transvesical urinary diversion is applied.

Fig. 115 To facilitate the covering of the skin strip a catheter, corresponding to the size of the urethra, is inserted for the duration of the operation only. The lateral skin flaps are dissected from the tunica albugínea of corpus cavernosum penis with scissors, proceeding as far laterally as needed to gain skin flaps without tension. These flaps are then used to cover the skin strip in two layers.

98

11.1 Reconstruction of the Urethra

Fig. 116 Forming the new urethra, the closure of the skin strips starts at the peno-scrotal area, where material is ample. The continuous, subcutaneous suture (5/0 synthetic absorbable) runs approximately 0.5 cm below the skin margin. According to the size of the new urethra, it should be interrupted once or twice, ending 1 cm below the coronal area. To extend the urethra distally the epithelium of the glans penis is excised on both sides.

Fig. 117 To cover the skin strip the skin flap is brought to the excised area of the glans penis, as shown in the figure with single sutures. Care should be taken to leave a 0.3 to 0.5 cm margin for the second layer.

11.1 Reconstruction of the Urethra

Fig. 118 The first layer has b e e n closed and the new meatus and urethra formed. The skin strip lies u n d e r this subcutaneous layer. The principle of this procedure is that an epithelial tube (as new urethra) will be formed from the skin strip in 2 to 3 weeks time.

99

Fig. 119 The second layer or the skin closure is accomplished with a continuous, subcuticular, 5/0 synthetic absorbable suture, if necessary with one or two interruptions.

100

11.1 Reconstruction of the Urethra

Fig. 120 At the end of the operation the transurethral catheter is removed. Urinary diversion is accomplished with the cystostomy catheter inserted prior to surgery.

Postoperative Treatment/Bed rest is not necessary. The pressure dressing and the traction suture are removed after one week. The penis is left open without any medication or dressing. Prophylactic antibiotics are not given. Depending upon the length of the new urethra and wound healing, the urinary diversion is left in place for three or more weeks and the catheter removed after micturition proves satisfactory.

Fig. 121 No dorsal skin incision is done as a tension relief for the suture line. Drainage is not used either. Instead a circular elastic bandage is used for one week. The traction suture is taped onto the abdominal wall to elevate the penis.

11.1 Reconstruction of the Urethra

101

11.1.2 Byars Procedure [8] Indication: Hypospadias without chordee, second stage operation after chordectomy.

1

1 1

1

Fig. 122 A troicar cystostomy for urinary diversion is performed prior to surgery and a traction suture (2/0 Polyamid) placed onto the glans penis. To form the new urethra a Ushaped incision is performed around the meatus extending laterally on both sides of the corona. The difference to the Denis Browne procedure is that, the skin strip is wider to facilitate a primary closure of the new urethra.

Fig. 123 The lateral skin flaps are dissected from the tunica albugínea of the corpus cavernosum penis and the epithelium of the glans penis excised to extend the new urethra. According to the size of the urethra a temporary transurethral catheter is placed, over which the new urethra is constructed. The skin strip is also mobilized to enable a tensionfree formation. This is done with a continuous, 5/0 synthetic absorbable suture, with 1 or 2 interruptions depending upon the length of the new urethra.

102

11.1 Reconstruction of the Urethra

Fig. 124 To cover the primarily constructed skin tube (new urethra), the Denis Browne procedure is applied (Fig. 116 119), also using the same suture material.

Fig. 125 The first and second layers have already been closed up to the midshaft and the glans area covered as described in Fig. 117.

11.1 Reconstruction of the Urethra

Fig. 126 At the end of the operation the transurethral catheter is removed. The urine is diverted with the cystostomy catheter inserted prior to surgery. A dorsal incision is not necessary, relief of tension on the suture line is accomplished with a circular elastic bandage for one week. No drainage is used. The penis is elevated by taping the traction suture onto the abdominal wall. Postoperative Treatment: As under chapter 11.1.1.

104

11.1 Reconstruction of the Urethra

11.1.3 Cecil Procedure [10] Indication: Hypospadias without chordee, second stage operation after chordectomy.

v ip^Y px 1 1i 1

Fig. 127 The procedure up to this stage where the urethra has already been formed is the same as Byars procedure (chapter 11.1.2). Then, if there is a skin shortage to cover the new urethra, the skin incision is extended into the scrotum in the midline. The penis is then brought down and the ventrum penis sutured onto the scrotum to be released three four months later.

Fig. 128 The lateral skin flap as well as the scrotal subcutaneous tissue is dissected to the required length. To extend the new urethra distally the epithelium of the glans penis is excised as well.

11.1 Reconstruction of the Urethra

Fig. 129 The penis is turned down to its normal position and the lateral penile skin flaps anastomosed to the scrotal skin up to the new meatus, in two layers: first, the subcutaneous fat tissue with continuous, then the skin with subcuticular, continuous, 5/0 synthetic absorbable sutures. A pressure dressing is applied. No drainage is used. Postoperative Treatment /Bed rest is not necessary. The pressure dressing is removed after one week. Micturition is allowed three weeks after surgery, then the cystostomy catheter removed. Three to four months later the second stage of the operation is done to release the penis from the scrotum.

105

Fig. 130 Three to four months later a scrotal skin incision is made in a semicircular manner and the penis freed from the scrotum. To cover the ventrum penis without tension the distance of the incision line from the penis should be according to the size of the penis.

106

11.1 Reconstruction of the Urethra

Fig. 131 The scrotum is closed in one layer with a continuous, subcuticular, 5/0 synthetic absorbable suture. The new urethra is covered with the scrotal skin in two layers beginning with the subcutaneous fat tissue using continuous, 5/0 synthetic absorbable sutures.

Postoperative Treatment: Drainage or bed rest are not necessary. After one week the dressing, bandage and traction suture as well as the catheter are removed. Prophylactic antibiotics are not given.

Fig. 132 The second layer is closed in the same manner as in the Denis Browne procedure with 5/0 synthetic absorbable subcuticular sutures. Urinary diversion is accomplished with a troicar cystostomy. A circular elastic bandage is placed on the penis and a pressure dressing onto the scrotum. The traction suture is taped onto the abdominal wall.

11.1 Reconstruction of the Urethra

107

11.1.4 Ombrédanne Procedure [40] Indication:

Hypospadias without chordee.

Fig. 133 A traction suture (2/0 Polyamid) is placed onto the glans penis. The meatus is in the coronal area. A Ushaped skin flap is incised, leaving the meatus in the middle of the flap. To extend the new urethra, the incision line runs into the glans penis.

Fig. 134 A transurethral catheter according to the size of the urethra is inserted temporarily. The skin flap is dissected with scissors from the distal urethra.

108

11.1 Reconstruction of the Urethra

Fig. 135 Dissection of the lateral penile skin is necessary to facilitate coverage of the distal new urethra. The epithelium of the glans penis is also excised. The skin flap is then folded up to cover the distal skin strip and both are sutured together with single, 5/0 synthetic absorbable sutures. The dissected penile skin is pulled up to the level of the new meatus and sutured onto the glans penis.

Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed after one week. Micturition is allowed two - three weeks after surgery, then the cystostomy catheter removed. Prophylactic antibiotics are not given.

Fig. 136 The penile skin is sutured onto the glans penis with single, and in the midline with continuous subcuticular, 5/0 synthetic absorbable sutures. Urinary diversion is accomplished with the troicar cystostomy performed prior to surgery. A circular elastic bandage is placed onto the penis and the traction suture taped onto the abdominal wall.

11.1 Reconstruction of the Urethra

109

11.1.5 Modified Allen-Spence Procedure [2] Indication: dias).

Hypospadias w i t h o u t chordee (coronal hypospa-

Fig. 137 A traction suture (2/0 Polyamid) is placed o n t o the glans penis a n d a troicar cystostomy p e r f o r m e d for urinary diversion. A transurethral catheter, according to the size of the urethra, is inserted temporarily. T h e m e a t u s is in the coronal area. A U - s h a p e d skin flap is incised, leaving t h e m e a t u s in the m i d d l e and e x t e n d i n g into t h e glans penis. T h e n a circumferential incision, starting bilaterally f r o m the skin flap is p e r f o r m e d .

Fig. 138 T h e circumcising incision is c o n t i n u e d on t h e d o r s u m penis.

110

11.1 Reconstruction of the Urethra

Fig. 139 This procedure utilizes the prepuce to cover the new urethra. At the coronal level of the preputial skin a buttonhole in the size of the glans penis is made with scissors. It is important to make the buttonhole before unfolding the prepuce.

Fig. 140 The prepuce is held with traction sutures and bilateral incisions m a d e between the two sheaths.

11.1 Reconstruction of the Urethra

Fig. 141 T h e interior s h e a t h is t h e n u n f o l d e d . The catheter (and consequently t h e glans penis) is pulled t h r o u g h t h e b u t t o n h o l e . T h e U - s h a p e d skin flap is dissected f r o m the distal urethra.

111

Fig. 142 T h e e p i t h e l i u m of the glans penis is excised bilaterally and t h e lateral penile skin dissected f r o m t h e tunica albugínea. T h e skin flap is folded u p to cover t h e distal skin strip a n d s u t u r e d t o g e t h e r with single, 5 / 0 synthetic absorbable sutures.

112

11.1 Reconstruction of the Urethra

Fig. 143 The glans penis is n o w pulled t h r o u g h the b u t t e n hole. T h e area which is to cover the new u r e t h r a is vertically incised 0.5 cm in length on b o t h sides to fit t h e width of t h e new u r e t h r a a n d facilitate coverage w i t h o u t tension (Kelàmi et al. [23]).

Fig. 144 T h e preputial skin flap is sutured o n t o t h e glans penis with single, 5 / 0 synthetic a b s o r b a b l e s u t u r e s covering the new urethra. T h e u n f o l d e d interior sheath as well as part of the exterior s h e a t h of the prepuce are excised to leave only as m u c h skin as n e e d e d to cover the penile skin defect.

11.1 Reconstruction of the Urethra

Fig. 145 The new urethra and the penile skin defect have been covered and the transurethral catheter removed. No drainage is used. A circular elastic bandage is placed onto the penis and the traction suture taped onto the abdominal wall to elevate the penis. Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed after one week. Micturition is allowed three weeks after surgery, then the cystostomy catheter removed. Prophylactic antibiotics are not given.

114

11.1 Reconstruction of the Urethra

11.1.6 King Procedure [32] Indication: Hypospadias without chordee (coronal hypospadias).

Fig. 146 Traction sutures (2/0 Polyamid) are placed onto the glans penis and prepuce. A troicar cystostomy is performed for urinary diversion. The meatus is on the coronal area. A U-shaped incision extending into the glans penis is made arround the meatus leaving this in the middle.

Fig. 147 A transurethral catheter, according to the size of the urethra, is placed temporarily. The skin flap is dissected from the urethra and a circumcising incision made at the coronal level.

11.1 Reconstruction of the Urethra

Fig. 148 The e p i t h e l i u m of t h e glans penis is bilaterally excised. After t h e skin strip is mobilized on b o t h sides, t h e lateral margins are a p p r o x i m a t e d in the m i d l i n e to form a t u b e a r o u n d t h e catheter with c o n t i n u o u s , 5 / 0 synthetic a b s o r b able sutures. T h e penile a n d preputial skin are t h e n dissected a n d the interior s h e a t h of t h e p r e p u c e cut a n d u n f o l d e d .

115

Fig. 149 T h e u n f o l d e d p r e p u c e is divided in t h e midline, gaining two large skin flaps to cover the n e w u r e t h r a a n d t h e penile skin defect.

116

11.1 Reconstruction of the Urethra

Fig. 150 T h e entire operative area is covered with t h e two preputial skin flaps using single, 5 / 0 synthetic a b s o r b a b l e sutures a n d the t r a n s u r e t h r a l catheter r e m o v e d . A circular elastic b a n d a g e is placed a r o u n d t h e penis and the traction suture taped o n t o the a b d o m i n a l wall. N o drainage is used. Postoperative Treatment: Bed rest is not necessary. The dressing a n d traction suture are r e m o v e d after one week. Micturition is allowed t h r e e weeks after surgery, t h e n the cystostomy catheter r e m o v e d . Prophylactic antibiotics are not given.

11.1 Reconstruction of the Urethra

117

11.1.7 Devine-Horton Procedure [11] Indication: Hypospadias with chordee (one-stage construction of the urethra).

Fig. 151 Traction sutures (2/0 Polyamid) are placed onto the glans penis and the prepuce. A troicar cystostomy is performed to accomplish urinary diversion. The m e a t u s is in the midshaft region. A circumcising skin incision leaving a 3 m m cuff around the meatus is extended in the midline to and around the corona.

Fig. 152 The penile and preputial skin are dissected and the interior sheath of the prepuce cut. The entire chordee between the meatus and corona is excised from the tunica albuginea with scissors. This step straightens the penis.

118

11.1 Reconstruction of the Urethra

Fig. 153 T h e e p i t h e l i u m of t h e glans penis is bilaterally excised. T h e p r e p u c e is u n f o l d e d and a preputial skin flap - according to t h e size of t h e u r e t h r a - excised to form a t u b e as a n e w urethra.

Fig. 154 After the s u b c u t a n e o u s tissue is r e m o v e d , the flap, cutis side in, is f o r m e d into a t u b e over a catheter with c o n t i n u o u s , 5 / 0 synthetic a b s o r b a b l e sutures, leaving an approximately 0.5 cm part u n s u t u r e d at each e n d for easier anastomosis.

11.1 Reconstruction of the Urethra

Fig. 155 A t r a n s u r e t h r a l catheter is inserted temporarily. T h e new urethra is a n a s t o m o s e d first with the original m e a tus, t h e n the other e n d s u t u r e d o n t o t h e glans penis to form the new m e a t u s , using single, 5 / 0 synthetic a b s o r b a b l e sutures.

119

Fig. 156 T h e rest of the p r e p u c e is divided into two. T h e s e skin flaps will be wrapped a r o u n d the shaft to cover t h e n e w u r e t h r a and the penile skin defect.

120

11.1 Reconstruction of the Urethra

Fig. 157 The left flap covers the operative area from the left to the right, the right flap, from the right to the left. The preputial skin is anastomosed with the glans penis and penile skin using single, 5/0 synthetic absorbable sutures. The transurethral catheter is removed. Urinary diversion is accomplished with the troicar cystostomy. A circular elastic bandage is placed around the penis and the traction suture taped onto the abdominal wall. Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed after one week. Micturition is allowed three weeks after surgery, then the cystostomy catheter removed. Prophylactic antibiotics are not given.

11.1 Reconstruction of the Urethra

121

11.1.8 Epispadias Repair Indication: Epispadias.

Fig. 158 A traction suture (2/0 Polyamid) is placed onto the glans penis. The meatus is at the base of the penis.

Fig. 159 An appropriate transurethral catheter is inserted temporarily. A U-shaped incision around the meatus is extended to the glans penis on both sides. Epithelium of the glans penis is excised bilaterally.

122

11.1 Reconstruction of the Urethra

Fig. 160 The penile skin is dissected from the tunica albuginea of the corpus cavernosum penis with scissors. The skin strip too is mobilized and formed into a tube around the catheter with continuous, 5/0 synthetic absorbable sutures. To extend the new urethra the epithelium of the glans penis is also approximated around the catheter with single sutures. The new urethra is then covered with subcutaneous fat tissue of the penile skin (continuous, 5/0 synthetic absorbable sutures) leaving a 0.5 cm margin for the second layer.

Fig. 161 The first layer has been completed. The second layer is sutured with continuous, subcutaneous, and the glans covered in the same manner as in Fig. 124 with single, 5/0 synthetic absorbable sutures.

11.1 Reconstruction of the Urethra

Fig. 162 At the e n d of the operation the transurethral catheter is removed. A circular elastic b a n d a g e is placed a r o u n d the penis. N o drainage is used. The urinary diversion is accomplished with a troicar cystostomy catheter placed prior to surgery.

Postoperative Treatment: Bed rest is not necessary. T h e dressing is r e m o v e d after o n e week. Micturition is allowed three weeks after surgery, t h e n t h e cystostomy catheter r e m o v e d . Prophylactic antibiotics are not given.

11.2 Operations for Stenoses of Meatus

11.2.1 Meatotomy Indication: Stenoses of meatus.

Fig. 163 A traction suture (2/0 Polyamid) is placed onto the glans penis. The meatus is cut open vertically towards the corona with scissors until a non-scarry area is reached (top). The meatal mucosa is then approximated with the epithelium of the glans penis using single, 5/0 synthetic absorbable sutures (bottom). The traction suture is removed at the end of the operation. No transurethral catheter is used and micturition is allowed immediately.

The procedure can also be performed under local anesthesia and on an out-patient basis.

11.2 Operations for Stenoses of Meatus

125

11.2.2 Meatoplasty [5] Indication: Stenoses of meatus.

The procedure can also be performed under local anesthesia and on an out-patient basis.

1-

Fig. 164 A traction suture (2/0 Polyamid) is placed onto the glans penis. A wide reversed V incision is made on the penile skin at the coronal level and the meatus incised vertically down to the corona until the non-scarry area is reached (top). The resulting skin flap and the lower part of the widened meatus are sutured together. Then the urethral mucosa is approximated with the epithelium of the glans penis with single, 5/0 synthetic absorbable sutures (bottom). The traction suture is removed. No transurethral catheter is used and micturition allowed immediately.

11.3 Repair of Urethral Fistulae

11.3.1 Pedicled Penile Skin Flap Technique Indication:

Urethral fistulae.

Fig. 165 A traction suture (2/0 Polyamid) is placed onto the glans penis. A circumferential incision, leaving a margin of 3 m m around the fistula and extending proximally in a curved manner, is made.

Fig. 166 The 3 m m margin around the fistula is excised and the penile skin mobilized.

11.3 Repair of Urethral Fistulae

Fig. 167 The mobilized penile skin is sutured together, covering the fistula with single, 5/0 synthetic absorbable sutures. Care should be taken that no suture overlies the fistula.

Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed after one week. Micturition is allowed three weeks after surgery, then the cystostomy catheter removed. Prophylactic antibiotics are not given.

127

Fig. 168 The fistula has b e e n overlapped with intact penile skin. A circular elastic bandage is placed around the penis and the traction suture taped on the abdominal wall. No drainage is used. Urinary diversion is accomplished with a troicar cystostomy performed prior to surgery.

128

11.3 Repair of Urethral Fistulae

11.3.2 Two-Layer Repair Indication: Urethral Fistulae

Fig. 169 A traction suture (2/0 Polyamid) is placed onto the glans penis. A circumferential incision, leaving a 3 mm margin around the fistula and extending both distally and proximally, is performed.

Fig. 170 The margin around the fistula is excised with a scalpel and the penile skin mobilized with scissors,

11.3 Repair of Urethral Fistulae

Fig. 171 The fistula opening is covered in two layers: first the subcutaneous fat tissue with continuous, then, the skin with subcuticular continuous, 5/0 synthetic absorbable sutures. A circular elastic bandage is placed around the penis and the traction suture taped onto the abdominal wall. Urinary diversion is accomplished with a troicar cystostomy performed prior to surgery. Postoperative Treatment: As under chapter 11.3.1.

129

11.4 Divertici!lectomy

11.4.1 Two-Layer Repair Indication:

Urethral diverticulae.

Fig. 172 A traction suture (2/0 Polyamid) is placed onto the glans penis and the penile skin incised over the diverticulum.

Postoperative

Treatment: As u n d e r chapter 11.3.1.

Fig. 173 The diverticulum is dissected and cut off the urethra, and the penile skin mobilized. The remaining opening is repaired in the same m a n n e r as in an urethral fistula in two layers (chapter 11.3.2, Fig. 171).

11.4 Diverticulectomy

131

11.4.2 Penile Denudation Technique Indication: Urethral diverticulae.

Fig. 174 A traction suture (2/0 Polyamid) is placed onto the glans penis. A circumferential incision is made and the penile skin mobilized and stripped down to identify the diverticulum.

Fig. 175 The diverticulum is excised from the urethra (top). To avoid strictures, no attempt is made to close the urethral opening (bottom).

132

11.4 Diverticulectomy

Fig. 176 The penile skin is then pulled back to its original position and sutured as in a circumcision, with single, 5/0 synthetic absorbable sutures. A circular elastic bandage is placed around the penis and the traction suture taped on the abdominal wall. No drainage is used. Urinary diversion is accomplished with the troicar cystostomy performed prior to surgery. Postoperative Treatment: As under chapter 11.3.1.

11.5 Urethrotomy

11.5.1 Non-Visual Urethrotomy Indication: Urethral strictures.

Fig. 177 The Otis urethrotome [41] consists of a dilator and a cold incision knife. To make the insertion of this instrument possible, the urethral stricture has to be dilated up to 15 Ch. After passing the strictured area, the dilator is expanded up to 35 Ch and the blade pulled back, incising the stricture. It is best to leave the incised urethra without any catheter. If, due to extensive bleeding, insertion of a catheter becomes necessary, only a thin one (16 Ch), for a very short period of time (24 hours), should be used. If urinary diversion is necessary a troicar cystostomy can always be performed. Postoperative controls with uroflowmetry and urethrograms are essential.

The procedure can also be performed under local anesthesia and on an out-patient basis.

134

11.5 Urethrotomy

11.5.2 Visual Urethrotomy Indication: Urethral strictures, urethral valves.

The procedure canalsobeperformedunderlocalanesthesia and on an out-patient basis.

Fig. 178 Visual urethrotomy was popularized by Sachse [44]. The instrument has a diameter of 20 Ch. It is constructed like a resectoscope. Instead of an electrical working loop, its working element is a cold blade (without electrical current). A preoperative dilation of the urethral stricture is not necessary. Cutting is performed under visual control with the cold blade "1". A new improved urethrotome [28] has an additional electrical coagulation wire "2" that also facilitates the immediate pointy coagulation of the arterial bleeders without having to change the instrument. The area between the electrical and non-electrical parts is isolated "3". Through this procedure no transurethral catheter is necessary. An alternative method of treatment of urethral strictures is the insertion of a urethral catheter (5 Ch) into the bladder, followed by the urethrotome cutting the strictured area. But this catheter can also be a hindrance for the urethrotomy. If urinary diversion is necessary a troicar cystostomy can be performed. Postoperative control with uroflowmetry and urethrograms are essential.

Fig. 179 Urethral valves of any type can also be divided with the urethrotome under optical control. A transurethral catheter should not be inserted unless the bleeding is uncontrollable.

11.6 Operations for Urethral Tumors

11.6.1 Transurethral Resection Indication: Urethral tumors.

Fig. 180 The resection is done with a resectoscope as in bladder tumors, with a loop and cutting current. The base of the tumor and the bleeders should be coagulated, but to avoid excessive scarring care should be taken not to coagulate unnecessarily. A transurethral catheter should not be inserted unless bleeding cannot be controlled.

The procedure can also be performed under local anesthesia and on an out-patient basis.

136

11.6 Operations for Urethral Tumors

11.6.2 Urethrectomy Indication: Urethral tumors, bladder tumors localized at the bladder neck and trigone.

In cases of primary urethral tumors, the urethra is dissected up to the prostate, divided at the apex and a urethrectomy performed, followed by a cysto-prostatectomy. An alternative procedure would be to performd a urethro-porstatectomy, close the bladder neck and divert the urine through a cystostomy. In cases of primary bladder tumors, a cysto-prostatectomy is performed first, then the urethra divided at the apex of the prostate and the stump closed. Then urethrectomy follows.

Fig. 181 To perform a urethrectomy, traction sutures (2/0 Polyamid) are placed onto the glans penis and scrotum. The skin is incised vertically between the scrotum and anus.

Fig. 182 The bulbo cavernosus muscle is divided and the urethra dissected from the corpora cavernosa penis.

11.6 Operations for Urethral Tumors

Fig. 183 The penis is everted by pulling at the urethra and the urethra dissected up to the glans.

137

Fig. 184 Using the traction suture the glans is pulled back to its normal position and the meatus circumcised. Then the urethra is entirely dissected from the glans penis and pulled out to be removed.

138

11.6 Operations for Urethral Tumors

Fig. 185 The meatus is closed with single, 4/0 synthetic absorbable sutures. A suction drain is placed into the perineum and diverted through a separate incision. The perineal wound is closed in two layers, subcutaneously with single, 3/0, and subcuticular with continuous, 4/0 synthetic absorbable sutures. A pressure dressing is placed onto the perineum and an elastic bandage around the penis. Postoperative Treatment: Bed rest is not necessary. The bandage and pressure dressing are removed after three days, then the wound left open and polyvidon and skin spray used only. The drain is removed when the secretion is less than 30 ml. Prophylactic antibiotics are not given.

Chapter 12 Penile Skin

12.1 Circumcision

12.1.1 Gomco Clamp Technique Indication: Circumcision for ritual or hygienic purposes.

The procedure can also be performed under local anesthesia (in newborns without any anesthesia) and on an out-patient basis.

Fig. 186 The Gomco clamp exists is many different sizes (8 to 32 mm diameter) and consists of four parts including a bell to cover and protect the glans penis during the operation. The four parts should be left in loose contact to ease the closing maneuver [22].

Fig. 187 The prepuce is held with mosquito clamps and incised at the 12 o'clock position, leaving only 4 mm of interior sheath. The adhesions between the glans penis and the interior sheath of the prepuce should be eliminated before placing the clamp.

142

12.1 Circumcision

Fig. 188 The bell of the Gomco clamp, which is chosen according to the size of the glans penis, is placed on it.

Fig. 189 The bell covers the glans penis completely. The prepuce is then pushed through the hole of the base plate.

12.1 Circumcision

Fig. 190 After the prepuce is entirely pulled through, the base plate is pushed down onto the margin of the bell.

143

Fig. 191 Then the bell is secured onto the base plate. This compression for five minutes adheres the interior and exterior sheaths of the prepuce and stops the bleeders. In the meantime the prepuce is excised with a scalpel.

144

12.1 Circumcision

Fig. 192 After the excision of the prepuce the Gomco clamp is removed.

Postoperative Treatment: The dressing is changed daily, in newborns after every diaper-change, and bathing is allowed after one week.

Fig. 193 At the end of the operation, if performed on newborns, suturing is not necessary as both sheaths have adhered together and no bleeding is to be expected. In all other age groups the bleeders should be fulgurated and both sheaths sutured together using single, 5/0 synthetic absorbable sutures. A light pressure dressing is placed only upon the operative area. Circumcision with the Gomco clamp gives a very smooth wound margin.

12.1 Circumcision

145

12.1.2 Conventional Technique Indication: Phimosis, circumcision for ritual or hygienic purposes.

1v

(

The procedure can also be performed under local anesthesia (in newborns without any anesthesia) and on an out-patient basis.

rV

Fig. 194 The preputial opening is held with mosquito clamps and an incision made at the 12 o'clock position, leaving only 4 mm of interior sheath (top). Then both sheaths are circumferentially excised together. Bleeders are coagulated and the interior and exterior sheaths of the rest of the prepuce approximated with single, 5/0 synthetic absorbable sutures (bottom). A light pressure dressing is placed only upon the operative area.

Postoperative Treatment: As under chapter 12.1.1.

12.2 Operation for Paraphimosis

Indication: Paraphimosis.

The procedure can also be performed under local anesthesia and on an out-patient basis.

I-

f\

Fig. 195 The swollen prepuce proximal to, or as shown here, around the corona, is incised vertically with a scalpel.

Postoperative Treatment: The dressing is changed daily and the wound left open after 2 to 3 days. Bathing is allowed after one week.

Fig. 196 Using two mosquito clamps the incised area is expanded transversally and sutured with single, 5/0 synthetic absorbable sutures. Due to this operation the prepuce becomes wide enough to cover the glans penis when pulled down. A light pressure dressing is placed onto the operative area. A circumcision is done at a later date.

12.3 Frenuloplasty

Indication:

Short frenulum.

The procedure can also be performed under local anesthesia and on an out-patient basis.

K -

Fig. 197 A short f r e n u l u m causes a b e n t penis and pain, especially w h e n erect. The f r e n u l u m is incised transversally at the coronal level.

Postoperative Treatment: The dressing is removed the next day. Bathing is allowed after one week. Prophylactic antibiotics are not given.

Fig. 198 Using two mosquito clamps the incised area is expanded vertically and sutured together with single, 5/0 synthetic absorbable sutures. After the operation the penis is straight. A light pressure dressing is placed on the operative area.

12.4 Reconstruction of the Penile Skin

Indication:

Laceration of the penile skin.

Fig. 199 A traction suture (2/0 Polyamid) is placed onto the glans penis. The margins of the non-lacerated penile skin are excised and an appropriate tunnel m a d e in the scrotal skin.

Postoperative Treatment: The dressing is changed daily and the wound left open after 2 to 3 days. Full baths are allowed after one week. Prophylactic antibiotics are not given.

the penile and scrotal skin approximated in this position with single, 5/0 synthetic absorbable sutures. The penis remains in this position for three months.

12.4 Reconstruction of the Penile Skin

Fig. 201 Three m o n t h s later, after placing a traction suture onto the glans penis, the scrotal skin is incised as shown in the figure with lateral flaps and the ventrum penis dissected from the scrotum. The flaps should be wide enough to cover the ventrum penis.

Postoperative Treatment: Bed rest ist not necessary. The pressure dressing, the traction suture and cystostomy catheter are removed after one week. Prophylactic antibiotics are not given.

149

Fig. 202 The denuded part of the penis is now covered with the scrotal skin using single, 5/0 synthetic absorbable sutures. The scrotal wound is also closed in the same m a n n e r . A pressure dressing is placed onto the penis and scrotum and the traction suture taped onto the abdominal wall. No drainage is used, the urine is diverted with a troicar cystostomy performed prior to surgery.

12.5 Reconstruction of Congenital Penile Skin Deformities

12.5.1 Operation for Concealed Penis Indication:

Concealed penis.

Fig. 203 A traction suture (2/0 Polyamid) is placed onto the glans penis. A circumferential skin incision is performed at the penile root and, to gain length, the penis dissected free.

Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the third postoperative day and bathing allowed after one week. Prophylactic antibiotics are not given.

Fig. 204 The reconstruction is terminated by suturing the penile skin together, but additionally by taking deep bites from the prepubic fascia and tunica albugínea of corpora cavernosa penis and corpus cavernosum urethrae (single, 3/0 synthetic absorbable sutures). A pressure dressing is placed onto the penis and no drainage used.

12.5 Reconstruction of Congenital Penile Skin Deformities

151

12.5.2 Operation for W e b b e d Penis Indication: Webbed penis.

Fig. 205 A traction suture (2/0 Polyamid) is placed onto the glans penis. Excessive scrotal skin on the ventrum penis is incised, freeing and straightening the penis.

Postoperative Treatment: Bed rest is not necessary. The pressure dressing and traction suture are removed after three days and bathing allowed after one week. Prophylactic antibiotics are not given.

Fig. 206 The scrotal skin is then approximated vertically with continuous, subcuticular, 5/0 synthetic absorbable sutures. A pressure dressing is placed onto the penis and the traction suture taped onto the abdominal wall. No drainage is used.

152

12.5 Reconstruction of Congenital Penile Skin Deformities

12.5.3 Operation for Torsion of the Penis Indication:

Torsion of the penis.

t"

Fig. 207 A traction suture (2/0 Polyamid) is placed onto the glans penis. The penis has b e e n rotated approximately 90° to the right (notice the position of the meatus). A circumferential incision as deep as the tunica albugínea is performed at the base of the penis. Postoperative Treatment: Bed rest is not necessary. The dressing is removed after three days and the wound left open. Bathing is allowed after one week. Prophylactic antibiotics are not given.

Fig. 208 After dividing all penile skin attachments the penis is returned to its normal position and the skin approximated using single, 5/0 synthetic absorbable sutures. A light pressure dressing is placed onto the penis. N o drainage is used.

Chapter 13 Corpus Cavernosum Penis

13.1 Penile Amputation

Indication:

Penile tumors at glans or coronal level.

Fig. 209 The tumor-carrying part of the penis is covered with a condom. A tourniquet is placed at the base of the penis to achieve a clear operative field. A circumferential skin incision is performed approximately 3 cm below the tumorous area, leaving an inverted V-shaped flap at the 6 o'clock position for the urethro-cutaneous anastomosis.

Fig. 210 To achieve agood urethro-cutaneous anastomosis and good skin coverage for the rest of the corpora cavernosa penis the urethra and the penile skin are divided approximately 1 cm higher than the corpora cavernosa penis.

156

13.1 Penile A m p u t a t i o n

Fig. 211 After the removal of the tumor-carrying part of the penis, the corpora cavernosa penis are approximated with single, 2/0 synthetic absorbable sutures. Then the urethral stump is incised at the 6 o'clock position. The penile skin flap will be used to enlarge t h e incised urethral wall to avoid strictures (bottom). Postoperative Treatment: Bed rest is not necessary. The dressing is removed on the third postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

Fig. 212 The anastomosis of the new meatus as well as skin closure are done with single, 5/0 synthetic absorbable sutures (top). Surplus skin at the penile stump will be used to direct urinary stream. No urethral catheter is used; instead a suprapubic troicar cystostomy catheter is placed. A pressure dressing is also used.

13.2 Penectomy

Indication:

Penile tumors at midshaft or proximal level.

Fig. 213 The tumor-carrying part of the penis is covered with a condom. A circumferential skin incision is m a d e at the base of the penis. This can be extended vertically to the scrotum if necessary.

fied and divided, then the urethra and the crura of corpus cavernosum penis are visualized.

158

13.2 Penectomy

Fig. 215 T h e crura are divided at their skeletal insertion point a n d their s t u m p suture-ligated with 2 / 0 synthetic absorbable sutures. The u r e t h r a is also divided, leaving e n o u g h u r e t h r a for a tension-free u r e t h r o - c u t a n e o u s anastomosis.

Fig. 216 T h e tumor-carrying part of the penis is t h e n rem o v e d . B e t w e e n the scrotal b a s e and the a n u s an inverted V-shaped stab incision is m a d e f o r m i n g a skin flap for the u r e t h r o - c u t a n e o u s anastomosis. T h e u r e t h r a is pulled t h r o u g h a n d incised at the 6 o'clock position. The skin flap will be used to enlarge the incised urethral m e a t u s to avoid strictures. T h e w o u n d closure is d o n e in two layers, the subc u t a n e o u s fat tissue with single, 3 / 0 a n d the skin with continuous, subcuticular 4 / 0 synthetic a b s o r b a b l e sutures.

13.2 Penectomy

Fig. 217 Inverted V skin incision (top). The urethro-cutan e o u s a n a s t o m o s i s is done with single, 5 / 0 synthetic sutures (bottom).

Postoperative Treatment: Bed rest is not necessary. The dressing is r e m o v e d on the third postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

159

Fig. 218 At t h e e n d of t h e operation n o t r a n s u r e t h r a l catheter is inserted; instead a s u p r a p u b i c troicar cystostomy is p e r f o r m e d . A pressure dressing w i t h o u t drainage is used.

13.3 Emasculation (Penectomy and Bilateral Orchidectomy)

Indication:

Penile tumors involving the scrotum.

Fig. 219 A circular incision around the base of the scrotum and penis is made.

Fig. 220 After the subcutaneous fat tissue has b e e n dissected the spermatic cords on both sides are divided (ligated and suture-ligated with 2/0 synthetic absorbable sutures) at the level of the external inguinal ring as described in chapter 4.5 and the testes removed. The corpora cavernosa penis and the urethra are dissected and divided in the same manner as for penectomy (chapter 13.2).

±

Fig. 221 The closure of the scrotal perineal skin wound can be either horizontal or vertical. The subcutaneous fat tissue is closed with single, 3/0, and the skin with subcuticular, continuous, 4/0 synthetic absorbable sutures. The urethro-cutaneous anastomosis is done in the same manner as described in chapter 13.2. No transurethral catheter is used; urinary diversion is accomplished with a suprapubic troicar cystostomy performed prior to surgery. A pressure dressing without drainage is applied. Postoperative Treatment: Bed rest is not necessary. The dressing is removed on the third postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

13.4 Construction of the Vulva and Vagina [17]

Indication:

Male to female transsexualism.

Fig. 222 A vertical skin incision between the scrotum and anus is made, and traction sutures placed onto the scrotal skin.

Fig. 223 The urethra and the crura of the corpus cavernosum penis are identified. The crura are divided at their skeletal insertion point and their stumps ligated with 2/0 synthetic absorbable sutures.

13.4 Construction of the Vulva and Vagina

Fig. 224 The spermatic cords are divided at the level of the external inguinal ring - ligated and suture-ligated with 2/0 synthetic absorbable sutures - performing a bilateral orchidectomy. Then the urethra is dissected from the corpora cavernosa penis.

163

Fig. 225 Allowing for a tension-free urethro-cutaneous anastomosis the urethra is divided. The penis is then inverted and the penile skin dissected. It is important to leave the penile skin free from all fat tissue. The corpora cavernosa penis and the urethra are excised at the corona, leaving only the penile skin and the glans penis. These will serve as "vagina" and "cervix".

164

13.4 Construction of the Vulva and Vagina

Fig. 226 The urethral stump is followed to the prostate and the prostate dissected off the rectum to make space for the new vagina.

Fig. 227 The subcutaneous fat tissue above and around the symphysis is also dissected to make more room and ease the invagination.

13.4 Construction of the Vulva and Vagina

165

® Fig. 228 Using a plastic mold the penile skin with the glans penis (new vagina and cervix) is invaginated into the space provided between the prostate and rectum. The urethra is pulled through an inverted V stab incision m a d e above the "vaginal introitus". The scrotum is tailored and the surplus skin resected to form the vulva. The skin is closed with single, 4/0 synthetic absorbable sutures.

Postoperative Treatment: Bed rest is not necessary. The dressing and the vaginal pack or the "adjustable vaginal stent" are removed after one week and the cystostomy catheter after satisfactory micturition. The drain is removed when the secretion is below 30 ml. The vagina is kept in place in its new form with the stent during the night for 6 weeks, thereafter as needed. The urethra and vagina should be calibrated and if necessary dilated at intervals. Steady controls are essential.

single, 5/0 synthetic absorbable sutures, as in Fig. 217. The scrotal skin is approximated, forming the new vulva. A suction drain is placed. No transurethral catheter is used, instead urine is diverted with a suprapub ic troicar cystostomy. The "vagina" is packed firmly and a pressure dressing placed. Instead of the vaginal pack an "adjustable vaginal stent" with a drainage canal can also be used.

13.5 Construction of the Penis

Indication: Penectomy, emasculation, female to male transsexualism.

1

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1 1"

1

Fig. 230 Construction of the penis is performed in three sessions. First session: Two oblique parallel skin incisions are made on the middle abdominal wall forming a skin strip (approximately 20 cm long and 10 cm wide), which is then undermined. To ease the anastomosis, the lateral abdominal wall is dissected from the abdominal fascia on both sides.

Fig. 231 The skin strip - cutis side out - is formed into a penile rod with single, 2/0 Polyamid sutures. The well-dissected lateral abdominal skin is approximated below the newly formed penile rod in the same manner. Subcutaneous suction drains are placed. The next session follows three months later.

13.5 Construction of the Penis

Fig. 232 Second session: T h r e e m o n t h s after the first session the penile rod is divided at the cranial insertion point a n d b r o u g h t down to t h e symphyseal area w h e r e the b a s e of the penis would normally be. At this site an appropriate piece of skin with s u b c u t a n e o u s tissue is excised to e n a b l e the a n a s t o m o s i s with the pedicled penile rod. For t h e subc u t a n e o u s layer single, 3 / 0 synthetic a b s o r b a b l e , and for the skin single, 2 / 0 Polyamid sutures are used. The cranial w o u n d is also closed with single, 2 / 0 Polyamid sutures.

167

Fig. 233 Third session: A n o t h e r t h r e e m o n t h s later the pedicled a n d well-nourished penile rod is divided at its cranial insertion p o i n t a n d b r o u g h t down to h a n g like a penis. T h e skin at the a b d o m i n a l wall is closed with single, 2 / 0 Polyamid sutures.

168

13.5 Construction of the Penis

Fig. 234 Through the distal end of the new penis the subcutaneous fat tissue is dilated to make space for the penile prosthesis.

Fig. 235 After the dilation, an appropriate penile prosthesis is selected. The Small-Carrion prosthesis is cut at the curved end, suited in length and rounded up. Only one penile rod is inserted. The subcutaneous fat tissue at the open end of the new penis is closed with single, 3/0 and the skin with subcuticular 4/0 synthetic absorbable sutures.

13.5 Construction of the Penis

Fig. 236 At t h e e n d of the operation the new penis with the prosthesis hangs down. T h e figure also shows t h e original site of the pedicled skin rod. T h e m e a t u s u r e t h r a e r e m a i n s at its original site. N o a t t e m p t is m a d e to m a k e a new u r e t h r a t h r o u g h the new penis as this fails frequently. In cases of f e m a l e to m a l e t r a n s s e x u a l i s m the labia can b e u s e d as a scrotal p o u c h to incorporate testicular prosthesis (implantation t e c h n i q u e of testicular prosthesis u n d e r chapter 4.5.3). Broad s p e c t r u m antibiotics are given for one week, starting 8 h o u r s before surgery. Sexual activities are p e r m i t t e d after c o m p l e t e w o u n d healing, mostly 6 to 8 weeks postoperatively.

13.6 Ileo-Inguinal Lymph System Dissection [14]

Indication: Penile tumors.

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Fig. 237 Two parallel skin incisions - 15 cm apart, slightly curved and 20 cm long - are performed. The cranial incision is 5 cm above the inguinal ligament.

Fig. line and one

238 One cm of the upper margin of the lower incision is excised. This technique enables a viable skin bridge better wound healing than other procedures with only skin incision (Fraley and Hutchens [14]).

13.6 Ileo-Inguinal Lymph System Dissection

tive area freed f r o m all l y m p h a t i c tissue. T h e dissection t e c h n i q u e is the same as in chapters4.5.4 a n d 9.5. The u p p e r b o r d e r of the dissected region is the bifurcation of the external a n d internal iliac vessels. Medially it is t h e ureter, laterally t h e genito-femoral nerves a n d caudally t h e s a p h e n o u s vessels. To avoid l y m p h a t i c drainage it is i m p o r t a n t to clip the l y m p h a t i c vessels caudally. Two suction drains are placed at the proximal and distal e n d of the operative area. S u b c u t a n e o u s fat tissue is a p p r o x i m a t e d with single, 3 / 0 synthetic a b s o r b a b l e a n d the skin with single, 2 / 0 Polyamid sutures.

Postoperative Treatment: Bed rest is n o t necessary. The dressing is changed on the first postoperative day, t h e n the w o u n d left o p e n and polyvidon and skin spray used only. T h e suction drains are r e m o v e d w h e n secretion is below 30 ml. Prophylactic antibiotics are not given. Skin sutures are taken o n t h e 14th postoperative day.

171

13.7 Operation for Priapism [12,54]

Indication: Priapism.

Fig. 240 In cases of priapism all procedures intend to evacuate the blood from the corpus cavernosum penis, mostly by creating a fistula. A simple operation for this was described by Ebbehej [12] and later by Winter [54]. A fistula between the corpus cavernosum urethrae and corpus cavernosum penis is created by using the trucut needle otherwise used for prostatic biopsy. The needle is inserted through the glans penis into the corpus cavernosum penis and the septum between them removed opening a fistula between the two corpora. To evacuate the entire venous blood the penis is manually squeezed until arterial blood appears. The opening on the glans is closed with single, 4/0 synthetic absorbable sutures. It is advisable to create the fistula bilaterally. At the end of the operation an elastic circular bandage is placed onto the penis. A pediatric blood-pressure cuff can also be used but should be pumped at regular intervals. Urinary diversion during this period can be accomplished

through a troicar cystostomy. To avoid fibrosis and subsequent erectile impotence it is very important to perform the shunt operation as soon as priapism is diagnosed.

Postoperative Treatment: Bed rest is not necessary. The elastic bandage is left on for three days and renewed every day during this period. The penis should also be squeezed manually in regular intervals. Prophylactic antibiotics are not given. The troicar cystostomy catheter is removed after satisfactory micturition.

13.8 Operation for Peyronie Disease

13.8.1 Excision of the Plaques and Duraplasty [31] Indication: Peyronie disease in patients under 50 years of age. (Only patients with massive curvature, painful and unsteady erection and calcification of the plaques are operated on, after an observation period of one year).

Fig. 241 A traction suture (2/0 Polyamid) is placed onto the glans penis and the urin diverted through a troicar cystostomy catheter. A circumferential incision is made at the coronal level and the penile skin stripped down.

Fig. 242 An artificial erection, induced temporarily by putting a tourniquet around the penile root and injecting saline solution into the corpus cavernosum penis, shows the deviation caused by the plaque.

174

13.8 Operation for Peyronie Disease

Fig. 243 The plaque is located one cm proximal to the corona. In patients under 50 years of age, the plaques are excised and duraplasty performed. The vascular and nerval bundle is retracted to avoid injuries.

Fig. 244 If this is impossible, the bundle can be divided without any consequences [16]. Then the plaque is palpated and entirely excised with a scalpel. A tourniquet can be used to prevent blood loss, although this is extremely low.

13.8 Operation for Peyronie Disease

Fig. 245 The defect is covered with lyophilized human dura, which is put into lukewarm saline solution for rehydration for two to three minutes. The dura is cut larger than the defect, allowing for a 0.5 cm overlapping margin when sutured. The anastomosis is done in two layers: first, the dura and the tunica albugínea of corpus cavernosum penis are sutured together using 2/0 synthetic absorbable single U-sutures, leaving a 0.5 cm dura margin. This margin is then sutured onto the tunica albuginea using continuous sutures of the same material.

175

Fig. 246 To detect any leaking points and prove the straightening of the penis, the artificial erection is repeated. If necessary additional single sutures are performed to stop leakage. If the penis is not straight further excisions of the tunica albuginea should be done.

176

13.8 Operation for Peyronie Disease

Fig. 247 The penile skin is then pulled back and sutured with single, 5/0 synthetic absorbable sutures. A circular elastic bandage is placed onto the penis and the traction suture taped onto the abdominal wall. Urinary diversion is accomplished through a troicar cystostomy. Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the eighth postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given. The patients gain their erectile ability during the next few days after removing the pressure dressing.

13.8 Operation for Peyronie Disease

177

13.8.2 Implantation of Penile Prosthesis without Plaque Surgery [31] Indication: Peyronie disease in patients over 50 years of age. (Only patients with massive curvature, painful and unsteady erection and calcification of the plaques are operated on after an observation period of one year).

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Fig. 248 Through the infrapubic approach the penile root is exposed. An artificial erection induced as described in chapter 13.8.1 shows the deviation.

Fig. 249 In patients over 50 years of age the penile prostheses (Small-Carrion) are implanted without incising or excising the plaques. After the penile prostheses are inserted into the corpora cavernosa, depending upon the degree of the deviation, the penis shows some straightening. (More details on implantation of penile prostheses are given under chapter 13.12).

178

13.8 Operation for Peyronie Disease

Fig. 250 The tunica albugínea is closed with single synthetic absorbable sutures No. 1 and the skin as described in chapter 2.2. On the operating table a straightening of the penis (that would enable sexual relations) can already be noticed. During the following postoperative weeks (12 to 16), in spite of the presence of the plaques, the penis straightens entirely. Through this technique less surgery is performed than with other methods {Furlow [15], Subrini [49], Raz and Kaufman, [43]) but the same results achieved. Postoperative Treatment: Bed rest ist not necessary. The dressing is removed on the first postoperative day, then the wound left open and polyvidon and skin spray used only. Broad spectrum antibiotics are given for eight days, starting 8 hours before surgery. Sexual relations are allowed 6 weeks postoperatively.

[39]

Indication: Congenital penile deviation.

1

*

1

Fig. 251 A traction suture (2/0 Polyamid) is placed onto the glans penis. The penile skin is incised circumferentially at the coronal level and stripped down. An artificial erection, induced as described in chapter 13.8.1, shows that the short corpus cavernosum penis causing the deviation is on the right side of the penis.

Fig. 252 From the long side of the corpus cavernosum penis, using Allis clamps, as many bites as necessary are taken until the penis straightens. These "bites" of the tunica albugínea are then excised in a diamond shape.

180

13.9 Operation für Penile Deviation

Fig. 253 The diamond-shaped defects are then closed horizontally using single, 2/0 synthetic absorbable sutures, thus shortening the long side of the corpus cavernosum penis and straightening the penis. Another artificial erection should show a straight penis; if not, more "diamonds" should be excised. Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the 8th postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

Fig. 254 At the end, the penile skin is pulled back and approximated with single, 5/0 synthetic absorbable sutures. A circular elastic bandage is applied onto the penis and the traction suture taped onto the abdominal wall. No drainage is used. The urinary diversion is accomplished with a suprapubic troicar cystostomy.

13.10 Operations for Microphallus

13.10.1 Johnston Procedure [21a] Indication: Microphallus.

Fig. 255 A traction suture (2/0 Polyamid) is placed onto the glans penis and a V-shaped incision made at the base of the penis.

Fig. 256 The corpora cavernosa penis are sharply dissected from their surrounding, gaining in length.

182

13.10 Operation for Microphallus

penis are approximated with each other using single, synthetic absorbable No. 1 sutures.

Postoperative Treatment: Bed rest ist not necessary. The dressing is removed on the 8th postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

Fig. 258 Then to lengthen the penile skin as well the incision is closed in a Y-shape (subcuticular, continuous 4/0 synthetic absorbable sutures). A circular elastic bandage is placed onto the penis. The urine is diverted through a suprapubic troicar cystostomy catheter.

13.10 Operation for Microphallus

183

13.10.2 Hinman Procedure [20] Indication: Microphallus.

M

Fig. 259 First session: A traction suture (2/0 Polyamid) is placed onto the glans penis. A circular incision around the base of the penis (glans penis) and a horizontal incision 1 cm above the lower pole of the scrotum are performed.

Fig. 260 A tunnel is made between these two incisions. With the help of the traction suture the penis is delivered by dissecting it from its surrounding tissue.

184

13.10 Operation for Microphallus

Fig. 261 After the penis is delivered, it is pulled through the newly formed scrotal tunnel.

Postoperative Treatment: Bed rest ist not necessary. The pressure dressing is removed on the fourth postoperative day, then the wound left open and polyvidon and skin spray used only. The cystostomy catheter is removed after satisfactory micturition. Prophylactic antibiotics are not given.

Fig. 262 The penis, with the exception of the glans, is buried into the scrotal tunnel. The prepuce is then sutured with the scrotal skin using single, 5/0 synthetic absorbable sutures. The cranial opening is closed subcutaneously with single, 3/0 and subcuticularly with continuous 4/0 synthetic absorbable sutures. A pressure dressing is applied and the urine diverted through a troicar cystostomy catheter. Three months later the second session follows.

13.10 Operation for Microphallus

Fig. 263 Second session: Outlining the penis, a U-shaped incision is made on the scrotum. This scrotal skin flap should be wide enough to cover the ventrum penis.

Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the eighth postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

185

Fig. 264 The penis is unfolded (with a traction suture) and the wound closed in two layers: first the subcutaneous fat tissue with continuous, 5/0 and then the skin with continuous, subcuticular, 5/0 synthetic absorbable sutures. A circular elastic bandage is placed onto the penis and the traction suture taped onto the abdominal wall. The urine is diverted through a suprapubic troicar cystostomy catheter.

13.11 Chordectomy and Straightening of the Penis

13.11.1 Meyer-Burgdorff Procedure [36] Indication: Chordee with hypospadias.

IS).

Fig. 265 A traction suture (2/0 Polyamid) is placed onto the glans penis. The meatus urethrae is at the peno-scrotal junction. A circumferential skin incision, leaving a 0.4 cm margin around the meatus and extending up and on both sides of the corona, is performed.

®

Fig. 266 Two parallel traction sutures are placed onto the prepuce. To straighten the penis the chordee is identified and entirely excised from the tunica albugínea.

13.11 Chordectomy and Straightening of the Penis

Fig. 267 The penile skin and the prepuce are completely dissected and the latter cut and unfolded.

187

Fig. 268 A hole is made into the prepuce and the glans penis pulled through. (At this point a one-stage hyposadias repair can be performed using the Devine-Horton technique as described in chapter 11.1.7).

188

13.11 Chordectomy and Straightening of the Penis

Fig. 269 The skin defect is closed with the preputial skin using single, 5/0 synthetic absorbable sutures and the urethra constructed in a second session. The urine is diverted through a suprapubic troicar cystostomy catheter. A circular elastic bandage is placed onto the penis and the traction suture taped on the abdominal wall.

Fig. 270 An alternative skin closure technique where the prepuce is divided into two flaps is described by Edmunds [13].

13.11 Chordectomy and Straightening of the Penis

Fig. 271 The preputial and penile skin are then wrapped around the penis, covering the skin defect using single, 5/0 synthetic absorbable sutures. A circular elastic bandage is placed onto the penis and the traction suture taped onto the abdominal wall. Urinary diversion is accomplished through a troicar cystostomy. Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the 8th postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

190

13.11 Chordectomy and Straightening of the Penis

13.11.2 Johnston Procedure [21 b] Indication: Chordee without hypospadias.

Fig. 272 A traction suture (2/0 Polyamid) is placed onto the glans penis and a circumferential skin incision performed at the coronal level.

Fig. 273 All adhesions between the penile skin and the urethra and the corpora cavernosa penis are eliminated with scissors. The penile skin including the prepuce are then stripped down to the penile root.

13.11 Chordectomy and Straightening of the Penis

Fig. 274 Using traction sutures on the prepuce the penile skin is pulled up. Then the prepuce is cut, unfolded, and a buttonhole m a d e into it and the penis pulled through.

Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the ninth postoperative day, and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

191

Fig. 275 The penile skin defect on the straightened penis is now covered with the preputial skin (single 5/0 synthetic absorbable sutures). A circular elastic bandage is placed onto the penis and the traction suture taped onto the abdominal wall.The urine is diverted through a suprapubic troicar cystostomy catheter.

192

13.11 Chordectomy and Straightening of the Penis

Fig. 276 When the deviation of the penis is additionally due to a short urethra, a semicircumferential skin incision is made on the ventrum penis at the coronal level. To straighten the penis the urethra is dissected from the adhesions and divided.

Postoperative Treatment: Bed rest is not necessary. The dressing and traction suture are removed on the 8th postoperative day and the cystostomy catheter after satisfactory micturition. Prophylactic antibiotics are not given.

Fig. 277 After bilateral penile skin dissection the urethral openings are anastomosed with the skin and the penile skin defect covered using single, 5/0 synthetic absorbable sutures. In a second session three months later, a new urethra is constructed. No catheter is used; instead a troicar cystostomy catheter is placed. An elastic bandage is placed onto the penis, and the traction suture taped onto the abdominal wall.

13.11 Chordectomy and Straightening of the Penis

Fig. 278 When enough preputial skin is available the new urethra can be constructed at the same session.

193

Fig. 219 The Devine-Horton technique enables chordectomy and urethroplasty (chapter 11.1.7) in one stage.

13.12 Operation for Erectile Impotence

Indication: Erectile impotence.

Fig. 280 Through an infrapubic approach the corpora cavernosa penis are identified.

Oi

Fig. 281 Using a scalpel, a two cm long incision is m a d e on the tunica albuginea and the corpus cavernosum penis dilated bluntly with a pair of long scissors.

13.12 Operation für Erectile Impotence

Fig. 282 After the tip of the scissors reaches the glans area it is withdrawn in an opened condition. Blunt dissection of the corpus cavernosum penis using the scissors is sufficient except in cases after priapism where sharp dissection and dilation with Hegar dilators are necessary.

195

Fig. 283 The proximal side of the corpus cavernosum penis is dilated in the same manner. As the corpus cavernosum penis incision is approximately in the middle, it is almost equidistant from the proximal and distal ends.

196

13.12 Operation für Erectile Impotence

Fig. 284 With the help of a "sizer" the prosthesis (SmallCarrion) is selected in the required length and width and the distal end inserted first.

Fig. 285 After inserting the first penile rod the tunica albuginea is closed with single, synthetic absorbable sutures No. 1 and the second rod inserted in the same manner.

13.12 Operation für Erectile Impotence

Fig. 286 Both sides have been implanted, the tunica albuginea approximated and wound closure done without drainage as described in chapter 2.2. No catheter is necessary either during or after surgery. Postoperative Treatment: Bed rest is not necessary. The dressing is removed on the first postoperative day, then the wound is left open and polyvidon and skin spray used only. Broad spectrum antibiotics are given for eight days, starting 8 hours before surgery. Sexual relations are allowed 6 weeks after surgery.

197

Fig. 287 After healing, the penis hangs down, elongated and firm but not in an erect position that might cause social embarrassment.

References

[1]

Albert, P.S., Salerno, R.G., Kappor, S.N., Davis, J.E.:The Nitrofurans as sperm-immobilizing agents, their tissue toxicity and their clinical application in vasectomy. Fert. & Ster. 26: 285 (1975) Allen, T.D., Spence, H.M: The surgical treatment of coronal hypospadias and related problems. J. Urol. 100: 504 (1968) American Medical System: A survey of clinical experience to date with A M S inflatable penile prosthesis. Report published at the A U A Meeting in New York, May 1979. Americ. Med. Syst., Minneapolis, Minnesota. Belt, E., Ebert, C.E., Surber, A.C.: A new anatomic approach in perineal prostatectomy. J. Urol. 41: 1 (1939) Blandy, J.P., Tressider, G.C.: Meatoplasty. Brit. J.Urol. 39: 633 (1967) Browne, D.: An operation of hypospadias. Lancet, 1: 141 (1936) Browne, D.: An operation for hypospadias. Proc.Roy.Soc. Med. 42: 466 (1949) Byars, L.T.: A technique for consistently satisfactory repair of hypospadias. Surg.Gyn.Obst. 100: 184 (1955) Carl, P., Schill, W.B.: Forensische u n d operationstechnische Richtlinien bei der Sterilisation des M a n n e s . Urologe A, 16: 298 (1977)

Cecil, A.B.: The penis and urethra. In: Cabot's M o d e r n Urology (Vol. 1). Lea & Fobinger, Philadelphia, 1936, p. 120 Devine, Jr. C.J., Horton, C.E.: One-stage hypospadias repair. J.Urol. 85: 166 (1961) Ebbehoj, J.: A new operation for priapism. Scand.J.Plast.Reconst.Surg. 8: 241 (1975) Edmunds, A.: A n operation for hypospadias. Lancet 7 : 4 4 7 (1913) Fraley, E.T., Hutchens, H.C.: Radical ilio-inguinal node dissection: The skin-bridge technique. A new procedure. J.Urol. 108: 279 (1972) Furlow, W.L.: Paper presented at the annual meeting of the American Urological Association, New York, May 1979. Furlow, W.L.: Personal communication. Granato, C.R.: Surgical approach to male transsexualism. Urol. 3: 792 (1974) Gross, R.E.: Atlas der Kinderchirurgie. Schattauer, Stuttgart, 1971, p. 72 Hauri, D.: Eine n e u e Operation gegen die Postprostatektomie-Inkontinenz. Urologe A, 16: 320 (1977) Hinman, Jr. F.: Surgical m a n a g e m e n t of microphallus. J.Urol. 105: 901 (1971) [21a] Johnston, J.H.: Lengthening of the congenital or acquired short penis. Brit.J.Urol. 46: 685 (1974) [21b] Johnston, J.H.: In Eckstein, Hohenfellner, Williams: Surgical Pediatric Urology. Thieme, Stuttgart, 1977, p. 407 - 408 [22] Kelämi, A.: Die sogenannte G o m c o t o m i e als M e t h o d e der Wahl für Circumcision. D e r Chirurg, 37: 512 (1966) [23] Kelämi, A., Fiedler, U., Richter-Reichhelm, M.: One-stage correction of distal hypospadias. Modification of Allen-SpenceHoffmann-Hall Procedure. Urol. 8: 496 (1976) [24] Kelämi, A.: Infrapubic approach for Small-Carrion prosthesis in erectile impotence. Urol. 2: 164 (1976) [25] Kelämi, A.: Operative procedures on male genitalia using a new "Infrapubic" approach. Eur.Urol. 4: 468 (1978) [26] Kelämi, A.: Alloplastische Spermatozele. E i n e kritische Betrachtung u. Verbesserungsvorschläge. Ext. Urol.7:245 (1978)

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Kelämi, A.: Grooved spatula for macroscopic operations on vas deferens. U r o l . « : 376 (1979) Kelämi, A.: Kaltschneiden - Sofortkoagulieren: N e u e Messerelektrode zur Behandlung von Urethrastrikturen. Proceedings of Dtsch.Ges.f.Urol., 31. Congress in M ü n c h e n , 1979, Springer-Verlag, Berlin, 1980 Kelämi, A. : A new concept for macroscopical anastomoses of vas deferens. Andrologia 12: 245-249 (1980) Kelämi, A.: One-Incision-Pararectal-Extraperitoneal (OIPE) Approach for bilateral procedures on the lower two thirds of the ureters. Urol. 15: 296 (1980) Kelämi, A.:Peyronie disease and surgical treatment. - A new concept. Urol. 14: J u n e 1980 King, L.R.: Hypospadias - a one-stage repair without skin graft based on a new principle. J.Urol. 103: 660 (1970) Ludwig, G., Haselberger, J., Miinzenmaier, /?.: Frühveränderungen des H o d e n g e w e b e s bei experimenteller Samenstrangstorsion. Urologe A, 18: 294 (1979) Ludwig, G., Haselberger, J., Miinzenmaier, R.: Spätveränderungen des H o d e n g e w e b e s bei experimenteller Samenstrangstorsion. Urologe A, 18: 350 (1979) Meilin, P.: Kinderurologische Operationen. Thieme, Stuttgart, 1966, p. 250 - 252 Meyer-Burgdorff, H.: Eine einfache Hautplastik für die Beh a n d l u n g der Hypospadie. Langenbeck's Archiv f.Klin.Chir. 155: 588 (1929) Mittermeyer, B.T., Cox, H.D.: Modified Radical Retropubic Prostatectomy. Urology 72:313 (1978) Montie, E.T., Stewart, B.H., Lewin, U.S.: Intravasal stints for vasovasostomy in canine subjects. Fert. & Ster. 24: 877 (1973) Nesbit, R.M. : Congenital curvature of the phallus : Report of three cases with description of corrective operation. J.Urol. 93: 230 (1965) Ombrédanne, L. : Précis clinique et opératoire de chirurgie infantile. Masson, Paris, 1932, p. 684 Otis, F.N.: Remarks on strictures of the urethra of e x t r e m e calibre with cases, and a description of new instruments for their treatment. New York Med.J. 15: 152 (1872) Parry, W.E.: Prostate Malignancies. In Glenn, J.F.: Urologie Surgery 2. Edition, Harper & Row, New York, 1975, p 561 Rai, S., Kaufman, J.: Surgical t r e a t m e n t of Peyronie disease: A new approach. J.Urol. 117: 598 (1977) Sachse, H.: Die Sichturethrotomie mit scharfem Schnitt. Indikation - Technik - Ergebnisse. Urologe A, 17:177 (1978) Schmidt, S.S. : Prevention of failure in vasectomy. J.Urol. 109: 296 (1973) Schmidt, S.S. : Vasectomy should not fail. Contemporary Surgery 4: 13 (1974) Scott, F.B.: Extramucosal mattress sutures. Film shown at the A n n u a l Meeting of Am.Urol. Ass. in St. Louis, May 1974 Small, M., Carrion, H., Gordon, J.A.: Small-Carrion penile Prosthesis. New implant for m a n a g e m e n t of impotence. Urol. 4: 479 (1975) Subrini, L.M.P.: Paper read at the 18th Congress of International Society of Urology, Paris, J u n e 1979 Tanagho, E.A., Smith, D.R., Meyers, F.H., Fisher, R.: Mechanism of urinary incontinence. Technique for surgical correction of incontinence. J.Urol. 101: 305 (1969) Tanagho, E.A., Smith, D.R.: Clinical evaluation of a surgical

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Index

Allen-Spence Procedure, Modified 109 Alloplastic Spermatocele 38 Azoospermia, Transport 26, 40 Byars Procedure 101 Cecil Procedure 104 Chordectomy and Straightening of the Penis 186 - Meyer-BurgdorfF Procedure 186 - Johnston Procedure 190 Circumcision 141 - Conventional Technique 145 - Gomco Clamp Technique 141 Concealed Penis 153 Corpus Cavernosum Penis 153 Denis Browne Procedure 97 Devine-Horton Procedure 117 Elephantiasis 19 Emasculation 160 Enucleation (suprapubic - transvesical), adenoma of the prostate 63 Epididymis 35 Epididymitis, chronic 43 Edididymectomy 43 - Epididymal Tumors 43 Epididymovasostomy 40 Epispadias 121 Epispadias Repair 121 Exploration fur Torsion of Testicular Appendages 28 Exploration for Torsion of Testis 27 Frenuloplasty 147 - Frenulum, short 147 Funiculolysis 23 Gomco Clamp 141 Hauri Procedure 89 Hydrocele 34 Hydrocelectomy 34 Hypospadias 97 - 120 Ileo-Inguinal Lymph System Dissection 170 Impotence, Erectile 194 Incontinence, Male Urinary 87, 89, 92 Infertility 26 Infrapubic Incision 11 King Procedure 114

Meatus, Stenoses of 124 - Meatotomy 124 - Meatoplasty 125 Microphallus 181, 183 - Hinman Procedure 183 - Johnston Procedure 181 Muscle Splitting Flank Incision 53 Nesbit Procedure 179 Oligozoospermia 26 Ombr6danne Procedure 107 One - Incision - Pararectal - Extraperitoneal (OIPE) Approach 82 Orchidectomy 29, 160 - Simple Orchidectomy 29 - Radical Orchidectomy 30 Orchidopexy 23 Paraphimosis 146 Pararectal Incision 55 Pelvic Position 4 Pelvic Lymph System Dissection 82 Penectomy 157, 160 Penile Amputation 155 Penile Deviation 179 Penile Prostheses 177, 194 Penile Skin 139 - Congenital Penile Skin Deformities 150 - Operation for Concealed Penis 150 - Operation for Torsion of the Penis 152 - Operation for Webbed Penis 151 - Reconstruction of the Penile Skin 148 Penile Tumors 155, 157, 160, 170 Peyronie Disease 173 - Excision of the Plaques and Duraplasty 173 - Implantation of Penile Prostheses 177 Pfannenstiel Incision 14 Phimosis 145 Positions in Operative Andrology 1 Priapism 172 Prostate 61 - Adenoma 63, 67 - Carcinoma 67, 71. 76, 79, 82 Prostato-Vesiculectomy 71 - Perineal 71 - Retropubic 76 - Ascending Technique 76 - Descending Technique 79 Refertilisation 49 Retroperitoneal Lymph System Dissection 32

Lithotomy Position 5 Maldescensus testis 23

Scrotal Incision 9 Scrotum 17

202

Index

- Reconstruction of the Scrotum 19 Seminal Vesicles 57 Skin Incisions in Operative Andrology 7 Small-Carrion Penile Prostheses 177, 194 Spermatocele 37 Spermatocelectomy 37 Sterilization 47 Supine Position 3 Suprapubic Incision 14 Tanagho-Smith Procedure 92 Testis 21 Testicular Appendages 28 Testicular Biopsy 26 Testicular Membranes 21 Testicular Prostheses 31 Testicular Tumors 30 Testicular Vein 51 - High Ligation of the Testicular Vein 53 - Muscle Splitting Flank Incision 53 - Pararectal Incision 55 Torsion, of - Penis 27 - Testicular Appendages 28 - Testis 27 Transsexualism 162 - Construction of the Penis 166 - Construction of the Vulva and Vagina 162 Transurethral Resection 67 Urethra 95 - Reconstruction of the Urethra 97 - Urethro-cutaneoustomy 155, 157, 160, 162 Urethral Diverticulum 130 - Diverticulectomy 130 - Penile Denudation Technique 131 - Two-Layer Repair 130 Urethral Fistulae 126 - Pedicled Penile Skin Flap Technique 126 - Two-Layer Repair 128 Urethral Strictures 133, 134 Urethral Tumors 135, 136 - Transurethral Resection 135 - Urethrectomy 136 Urethral Valves 134 Urethrotomy 133 - Non-Visual Urethrotomy 133 - Visual Urethrotomy 134 Varicocele 53, 55 Vas Deferens 45 - Aplasia 38 - Stenosis 38, 40, 49 Vasodiatomy (S.S.Schmidt Procedure) 47 Vasovasostomy 49 Vesiculectomy (suprapubic - extravesical) 59 Webbed Penis 151