Penile Lengthening in Bladder Exstrophy
Moneer K. Hanna, MD, FRCS1, Saman S. Talab, MD2, Sameer Mittal, MD1.
1New York Weill-Cornell, New York, NY, USA, 2Rutgers NJMS, Newark, NJ, USA.
BACKGROUND: As children born with bladder exstrophy and epispadias (BEE) transition to adolescence and adulthood, the external genitals acquire greater importance. The short phallus in BEE is partly due to an intrinsic corporal abnormality and partly due to pubic diastasis, the penile length is lost in traversing the distance between the pubic rami. The dorsal chordee may be due to corporal disproportion, and/or short urethral plate. Furthermore in some repeat surgery cases the iatrogenic scarring may contribute to the penile abnormalities. Herein we report on 32 patients who underwent secondary repair of the genitalia aiming at penile lengthening and correction of dorsal penile chordee.
METHODS: Between 1981 and 2015, 32 patients born with bladder exstrophy (29 pts.) and epispadias (3 pts.) were referred. Their ages varied between 12 and 29 years. Urinary tract status was: 23/32 had had bladder augmentation with a catheterizable channel and 9/32 underwent Mainz II urinary diversion. 7 patients underwent urinary and genital reconstruction at the same sitting, the other 25 patients had had prior urinary tract reconstruction by us. The urethra in all patients served as a conduit for seminal fluid. Penile lengthening (Johnston procedure) was performed in all patients. The corporal bodies were dissected and detached from the inferior pubic rami. The mobilization stopped short of the ischial tuberosity to avoid injury to the pudendal nerves and vessels as they emerge from Alcock's canal. In 9 patients with extensive scarring the periosteum was incised and subperiosteal dissection was performed to preserve the corporal wall and erectile tissue. The urethra was also dissected and was placed in the groove between the corpora prior to suturing them together. In 13 patients the urethra was augmented by a tubed graft (4 full thickness skin and 9 buccal mucosa) which terminated at the tip of the penis. In 19 patients the urethral meatus was hypospadiac. The dorsal penile curvature due to corporal disproportion was corrected by dermal grafting of the dorsal corporal walls in 16/32 patients.
RESULTS: Follow up varied between 1-12 years, all patients were followed by us for a minimum of one year. Postoperatively one patient developed a subcutaneous hematoma which required drainage and subsequently had an uneventful recovery. Another patient developed wound infection which resulted in distal break down and glans dehiscence. Recurrent scarring with keloid formation occurred in 3 patients and 1/3 developed a urethral stricture. All patients gained various degree of penile lengthening and 29/32 were satisfied with the surgical outcome.
CONCLUSIONS: After degloving the penis the dissection should start on the undersurface of the corpora up to their insertion in the pubic rami. Then proceed to medially and separate the corpora from the pubic ramus. In cases with excessive scarring, the subperiosteal dissection of the crura provided a virgin field and protected the erectile tissue and neurovascular bundle. Dry tubed grafts tend to contract and therefore are stented for several weeks followed by daily calibration recommended for six months to avoid stricture formation.
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