Penis and Urethra Surgery

Reconstructive Principles

The foundation of penile and urethral reconstruction is the distinction between a graft (transferred to a new bed, where it develops a new blood supply) and a flap (transferred with its blood supply). This tab covers graft biology, graft types and their urologic uses, and general reconstructive technique.

Graft vs Flap

• A flap is excised and transferred with its blood supply preserved or surgically re-established at the recipient site (key considerations: the nature of the flap tissue, its vasculature, and the mechanics of transfer).
• A graft is transferred to a host bed where a new blood supply develops by a process called take, which requires ≈96 hours in two phases:
  • Imbibition (≈48 h) — the graft "drinks" nutrients from the host bed; its temperature stays below core body temperature.
  • Inosculation (≈48 h) — true microcirculation is re-established and the graft warms to core temperature.

Tissue Grafts

The skin layers, superficial to deep, are the epidermis (barrier), the superficial (papillary) dermis (bearing the superficial/intradermal plexus and some lymphatics), and the deep (reticular) dermis (bearing the deep/subdermal plexus, most of the lymphatics, and the greater collagen content that gives tissue its physical characteristics).

• Split-thickness graft — epidermis plus a variable amount of superficial dermis (no reticular dermis), exposing the superficial (intradermal) plexus. Advantage: favourable vascularity. Disadvantage: contracts and becomes brittle when mature. A mesh graft is a slit split-thickness graft (slits allow expansion or drainage of subgraft collections).
• Full-thickness graft — epidermis plus all the dermis, exposing the subdermal plexus and carrying most lymphatics and the tissue's physical characteristics. Advantage: contracts less, more durable. Disadvantage: more fastidious vascularity.

Grafts in Urology

• Primary urethral reconstruction uses (in order of usefulness): the oral mucosal graft (buccal, labial, or lingual — buccal mucosa has a panlaminar plexus), the bladder epithelial graft (limited distally by desiccation/hypertrophy), the rectal mucosa graft, skin grafts (FTSG/STSG — extragenital FTSGs take poorly except the posterior auricular/Wolfe graft), and dartos-based skin island flaps. Tunica vaginalis grafts give uniformly poor results in the urethra.
• Penile reconstruction favours an unmeshed thick (0.012–0.015 inch) STSG, which gives the best take and cosmesis (meshed/thinner grafts contract; FTSGs fail more often). Tunica vaginalis grafts are useful for small tunica albuginea defects of the corpora cavernosa.

Surgical Technique Generalities

Reconstruction aims to minimise tissue injury — bipolar cautery is often preferred (more confined field effects), and absorbable suture on a tapered needle is the rule in urethral surgery. Femoral neuropathy can follow lithotomy positioning (hip hyperabduction/hyperextension) or retractor injury. The femoral nerve (the largest branch of the lumbar plexus, from the anterior divisions of L2–L4) emerges between the psoas and iliacus and enters the thigh lateral to the external iliac artery; it provides sensation to the anterior thigh and medial leg and motor supply for knee extension.

Urethral Stricture Disease

The term "urethral stricture" refers specifically to anterior urethral disease — a scarring process of the urethral epithelium and the surrounding corpus spongiosum, termed spongiofibrosis. Because the posterior urethra is not surrounded by corpus spongiosum, its narrowings are not called strictures (pelvic-fracture injuries are PFUI; others are contractures or stenoses). A normal 30-Fr urethra has a 10-mm outer diameter.

Causes

• Acquired — trauma (the most common cause in developing countries; usually straddle trauma, often unrecognised until obstructive symptoms appear), iatrogenic instrumentation, lichen sclerosus (LS strictures are longer and carry a higher association with urethral cancer), and infection (gonococcal strictures, now less common; the role of Chlamydia/Ureaplasma is unclear).
• Congenital — rare; defined as a short, non-inflammatory stricture with no history or potential for trauma, in an infant before erect ambulation.
• Idiopathic — the most common cause in developed countries.

Diagnosis and Evaluation

The treatment plan depends on the stricture's location, length, depth, and density (spongiofibrosis). Patients usually present with obstructive voiding symptoms, UTIs (prostatitis, epididymitis), or retention, often after tolerating symptoms for a long time.

• Retrograde urethrography/VCUG define location and length.
• Ultrasound is the most accurate method for determining the graft length needed to repair an anterior stricture.
• MRI helps in PFUI with distorted pelvic anatomy but is not useful for anterior strictures except when urethral carcinoma is present.

Management

Four options: dilation, direct visual internal urethrotomy, urethral stent, and urethroplasty.

• Dilation — the goal is to stretch the scar without creating more scarring (bleeding means the stricture was torn, not stretched). Blind passage of filiforms is condemned. Efficacy is similar to internal urethrotomy in the short/mid term.
• Direct visual internal urethrotomy (DVIU) — incise the scar to healthy tissue so the lumen heals enlarged, usually at the 12 o'clock position (a deep distal incision risks entering the corpora cavernosa and causing ED); use normal saline irrigant. The most common complication is recurrence, and the success of later reconstruction is diminished by repeated dilations/urethrotomies.
• Urethral stent (UroLume) — must be placed only in the bulbar urethra (elsewhere it causes pain on sitting/intercourse); contraindicated after substitution urethroplasty (skin contact causes a virulent hypertrophic reaction) or with deep spongiofibrosis. (UroLume is off the market.)
• Open reconstruction (excision and primary anastomosis) — best results require total excision of the fibrosis, a widely spatulated ovoid anastomosis, and a tension-free repair in the lithotomy position; length is gained by mobilising the corpus spongiosum and detaching the bulbospongiosus from the perineal body. When the defect is too long for primary anastomosis, use a graft or flap (onlay, not tubularised). Avoid excision and primary anastomosis after prior hypospadias repair (the retrograde glanular blood supply may be absent).
  • Adverse events: permanent ejaculatory dysfunction in up to 20% (semen pooling, loss of force); temporary ED in up to 20% (resolves by ~6 months, with <3–4% permanent — roughly the rate after circumcision, higher with longer reconstructions); new penile curvature (from over-aggressive distal-bulbar excision); and rare loss of libido/anorgasmia (usually psychological).

Pelvic Fracture Urethral Injuries

This tab covers the reconstructive management of pelvic fracture urethral injuries (PFUI). (The acute trauma management is covered in the Trauma topic.)

Pathogenesis

PFUIs result from blunt pelvic trauma and accompany ≈10% of pelvic fractures. Distraction injuries are unique to the membranous urethra, most often occurring where the bulbous urethra departs the membranous urethra. (By contrast, straddle injuries usually involve only the bulbar urethra.)

Diagnosis and Evaluation

Define the precise anatomy before reconstruction. A cystogram shows the rostral displacement of the proximal urethra, the bladder outline, and bladder-neck competency — contrast in the prostatic urethra suggests an incompetent (open) bladder neck, while its absence suggests a competent (closed) one. However, the bladder-neck appearance on imaging does not reliably predict its ultimate post-reconstruction function, so videourodynamics can be used; a truly incompetent open bladder neck may warrant a continent stoma rather than urethroplasty.

Management

Most PFUIs are short and amenable to mobilisation of the corpus spongiosum with a primary anastomosis. Mobilisation is done cautiously because the retrograde blood supply is tenuous in pelvic-fracture patients; meticulously detaching Buck's fascia increases corporeal compliance and limits the need for aggressive mobilisation. The proximal anterior urethra can be anastomosed to any posterior segment.

• Positioning — the exaggerated lithotomy/perineal approach, with boots positioned to avoid stretching the common peroneal (fibular) nerve (injury causes foot drop). Operatively, the ischiocavernosus is divided, the corpus spongiosum and bulbospongiosum are detached, the intracrural space is developed, and a spatulated, tension-free anastomosis (10–12 sutures) is made over a soft silicone stent. (The source's detailed step-by-step dictation is condensed here to its principles.)
• For a markedly rostrally distracted proximal urethra, be prepared to escalate: corpus-spongiosum mobilisation, intracrural-space development, sequesterectomy (removal of scar), corporeal rerouting, and infrapubectomy — the last risks penile shortening, erectile destabilisation, and pelvic instability/chronic pain.
• Postoperative care — urine is diverted by suprapubic cystostomy with the urethral catheter serving only as a stent; bed rest for 24–48 h, then ambulation. A voiding trial with contrast at 3–4 weeks checks for extravasation and patency before the suprapubic catheter is removed, with flexible endoscopy at ~6 months and 1 year.
• Outcomes — curative rates are in the high 90% range. Failures reflect ischemia of the mobilised proximal corpus spongiosum; duplex ultrasound predicts those at risk, and patients with bilateral internal pudendal obstruction may need penile arterial revascularisation before reconstruction. Erectile dysfunction is often a consequence of the injury itself.

Lichen Sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory, hypomelanotic, lymphocyte-mediated skin disorder that predominantly affects the genitalia — the prepuce, glans, urethral meatus, and fossa navicularis. In males it is associated with urethral strictures (via repeated instrumentation or pressure-voiding intravasation into the glands of Littre); in females, urethral stricture is uncommon. It was previously called balanitis xerotica obliterans.

Epidemiology

LS affects primarily middle-aged men (and can occur in boys), presenting mainly in the uncircumcised, and is the most common cause of adult meatal stenosis. (In male children, meatal stenosis is instead a consequence of circumcision causing ammoniacal meatitis.)

Risk Factors

The cause is undefined; proposed mechanisms include trauma, autoimmunity, genetics, and infection (Borrelia burgdorferi has been found in early disease). Affected patients are more likely to be active smokers with higher BMI, hypertension, diabetes, and coronary disease, and have longer strictures than non-LS cases.

Diagnosis and Evaluation

Symptoms include skin itching, bleeding, penile scarring with glanular adhesions, acquired buried penis, pain, dyspareunia, and painful erections; the lesion appears as a whitish plaque. Diagnosis is by biopsy. LS is capable of malignant transformation to squamous cell carcinoma in 2–8%, and 4–6% of penile SCCs have associated LS.

Management

• Dermatologic therapy reduces symptoms and progression. The 2023 AUA guideline recommends moderate- to high-potency topical steroids (clobetasol or mometasone); calcineurin inhibitors (tacrolimus) can regress external skin disease. (CUA 2019: 0.05% clobetasol propionate daily for 2–3 months.)
• LS-associated strictures tend to be longer and located in the penile urethra, making urethroplasty challenging. Because LS is a disease of genital skin, genital skin is not appropriate for reconstruction — oral mucosal grafting is the preferred tissue.
• Conservative therapy (topical steroid ± antibiotics, intermittent catheterisation) may suffice if the meatus is maintained at 14–16 Fr. Surgery is indicated for young patients with severe meatal stenosis; obtain a retrograde urethrogram first (long-standing meatal stenosis often masks proximal stricture disease). If only the foreskin is involved, circumcision may be curative.

Other Urethral Conditions

This tab groups the less common urethral problems: post-prostatectomy vesicourethral distraction defects, urethral hemangioma, male urethral diverticulum, and urethrocutaneous fistula.

Vesicourethral Distraction Defects

A complication of radical prostatectomy in which the bladder neck and urethra are distracted apart. Determining the defect length accurately is essential. Options include an indwelling suprapubic tube, endoscopic treatment, a continent catheterisable bladder augmentation (often a better choice than aggressive functional reconstruction), or diversion.

Urethral Hemangioma

A rare, usually persistent lesion — all reported cases have been benign. Management depends on symptoms, size, and location: asymptomatic lesions are observed (they can regress spontaneously), while symptomatic lesions must be completely excised to prevent recurrence (laser for small lesions, open excision for larger ones).

Male Urethral Diverticulum

• Congenital — from incomplete urethral development; a prostatic urethral diverticulum may be a large remnant of the müllerian duct, associated with defects of diminished virilisation.
• Acquired — from urethral injury causing an intraspongiosal hematoma.

On evaluation, a catheter tip tends to catch in the diverticular opening, so the tip must be directed toward the true lumen. Most diverticula need no treatment unless very large; large ones accumulate urine and cause recurrent UTI or post-void "incontinence." Endoscopic unroofing relieves voiding symptoms (with subsequent post-void dribbling), and open repair excises the redundant urethra.

Urethrocutaneous Fistula

A complication of urethral surgery, periurethral infection (inflammatory strictures or treatment of a urethral growth), or urethral carcinoma — be cautious in a patient with a fistula or periurethral abscess without chronic obstructive symptoms, as this may be the hallmark of urethral carcinoma. Management is directed at both the defect and its underlying cause: complex posterior fistulae often need omental interposition, and radiation greatly magnifies the difficulty (tissue interposition is the rule, and diversion may be safest).

Foreskin & Penile Conditions

This tab covers the common foreskin disorders — balanitis, phimosis, paraphimosis, and circumcision — and a few other penile conditions.

Balanitis and Phimosis

Balanitis is inflammation of the glans, usually from poor hygiene (failure to retract and clean under the foreskin). Balanoposthitis is a severe form in which a tight phimotic band retains inflammatory secretions, creating a preputial cavity abscess. Phimosis — the inability to retract the foreskin — can result from repeated episodes of balanitis.

Paraphimosis

Painful swelling of the foreskin distal to a phimotic ring when it remains retracted too long. Reduction: apply gentle, steady pressure to decrease the swelling, then push on the glans with the thumbs while pulling the foreskin forward with the fingers. If it has been present for many hours to days, reduction may be impossible and an emergency dorsal slit or circumcision is required.

Circumcision

In adults, circumcision is done under local anaesthesia (a dorsal penile nerve block at the base plus circumferential infiltration); a sleeve technique is favoured in men and older boys. In brief, a preputial cuff is marked and incised through the dartos to Buck's fascia, a second coronal-margin incision is made (with optional frenuloplasty), the intervening sleeve of skin is removed, and the edges are reapproximated after hemostasis. Complications are uncommon — the most common immediate one is hematoma; transient glans hyperesthesia is usual, and minor skin separation may heal by secondary intention.

Other Penile Conditions

• Buried penis — the penile shaft skin is lost to severe inflammation and the penis becomes trapped in the penopubic/scrotal area; patients are often profoundly overweight and frequently diabetic.
• Reactive arthritis — the classic triad of arthritis, conjunctivitis, and urethritis; the urethral involvement is usually mild and self-limited.
• Amyloidosis — a rare urethral disease that should be considered in any urethral mass, presenting with hematuria, dysuria, or urethral obstruction.

Penile Reconstruction & Curvature

This tab covers penile curvature (chordee), total penile (phallic) reconstruction, failed hypospadias repair, and reconstructive aspects of genital trauma.

Penile Curvature

"Chordee" means curvature — a relative asymmetry of the erect penis from reduced compliance of one aspect of the tunica albuginea or foreshortening of an erectile body. It is congenital (ventral, lateral, or dorsal — characteristically with a large erect penis) or acquired (almost always from trauma during intercourse).

Acquired curvature that is not Peyronie's disease is thought to follow a subclinical penile fracture: disruption of the outer longitudinal layer of the tunica albuginea during buckling (the inner circular layer staying intact), or disruption of both layers with Buck's fascia preserved. Patients note a pop during intercourse, then painful erections, then (usually dorsal) curvature. Global cavernosal veno-occlusive dysfunction is usually not a complicating factor.

Total Penile Reconstruction

Forearm flaps are the most common method for total phallic construction. Disadvantages include an obvious donor-site deformity, possible cold intolerance in the donor hand, and problematic hair if the forearm is hirsute. Rigidity for intercourse is provided by an external or implanted prosthesis, which is never implanted until ≥1 year after construction — protective sensibility must first be demonstrated in the flap.

Failed Hypospadias Repair

A hypospadias repair may fail from inadequate correction of chordee or an inadequate urethra — with a resulting stricture, fistula, or diverticulum.

Genital Trauma

(Acute management is covered in the Trauma topic.) Penetrating injuries may involve the urethra, the corporeal bodies, or both — with bullet injuries, projectile velocity matters (high-speed rounds may pass through superficial structures with little cavitation). Degloving injuries (penile/scrotal skin stripped from deeper structures) bleed little; the tissues are allowed to demarcate before reconstruction with grafts. Genital burns are managed by careful, repeated debridement (exploiting the penis's unique vascularity) rather than aggressive excision, and genital lymphedema (e.g. after pelvic radiation) can be reconstructed with a split-thickness skin graft.