TRANSSCROTAL SIMPLE PENILE DEGLOVING: A NEW NON INVASIVE
APPROACH FOR CORPOROPLASTIES.
Raffaella Olivieri
Edoardo Austoni
Chair of Urology, Milan University (Milano), Italy.
Chief Prof.Edoardo Austoni
Uroandrological Reconstructive Center, Mangioni Hospital GVM (Lecco), Salus Hospital
GVM (Reggio Emilia),Villalba Hospital GVM (Bologna) Italy.
Corresponding Author:
Raffaella Olivieri
Uroandrological Reconstructive Center, Mangioni Hospital GVM (Lecco), Salus Hospital
GVM (Reggio Emilia),Villalba Hospital GVM (Bologna) Italy.
Via Leonardo da Vinci 46 Lecco
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Secretary Office: Milano +39 0248593400, Via Statuto 8 20121 Milano
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Personal Mobile: +39 3351992907
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email: segreteria@uroandrologiaricostruttiva.it
Key Words Albugineoplasty, Corporoplasty, Induratio Penis Plastica, La Peyronie’s disease,
Penile Surgery, Skin Degloving.
ABSTRACT
1
Background: The subcoronal approach is currently the most commonly used skin
degloving method for corporoplasty surgery. Although it is relatively easy and fully exposes
the corpora cavernosa, this approach is not free from unpleasant complications (subcoronal
lymphoedema and decrease of glans sensitivity); moreover, it often requires a pre- or
postoperative circumcision.
Objective: We report our experience with the Transscrotal Simple Penile Degloving
(TSPD) that is suitable for most corporoplasty procedures and verify the complications.
Design, Setting and Participants: This is a retrospective analysis conducted on 89
patients (pts) presenting with different penile diseases: Congenital curvature (26 pts);
Peyronie Disease (PD) and penile retraction/recurvatum (18 pts); PD and erectile dysfunction
and retraction/recurvatum (25 pts); Redo surgery for complex reconstruction of corpora
cavernosa (20 pts).
Surgical Procedure:
In the period from February 2008 through July 2010, the TSPD approach was carried out in
an sizable number of simple to complex albugineal surgery cases. The TSPD approach calls
for a 5 cm incision to be placed ventrally at the scrotal raphe on the penile base: penile
degloving is then easily carried out up to the subcoronal line. Care is exerted to avoid
damaging dartoic tissue. The dorsal neurovascular bundle is at than isolated, and the required
tcorporoplasty can be performed as per habitual practice. At the end of the procedure, the
penile shaft is regloved and a paracavernosal drain is placed infrapubically.
Results :
Any complications occurring during or after surgery have been analyzed. Patient
follow-up controls were performed on day 7, month 1 and month 3 post-surgery.
No pre- or postoperative circumcision procedures were required. No evidence of
postoperative preputial edema or penile skin necrosis. A mild loss of glandular sensitivity was
reported only by 4 patients (12.1% ) out of the 33 cases of apical grafting, who required
extensive glanular-cavernous disassembly.
Conclusion: TSPD reduces sub coronal complications rate of penile skin degloving
for corporoplasties. TSPD can be performed in most corporoplasty procedures and yields
optimal aesthetic/functional outcomes.
2
Take home message: Transscrotal Simple Penile Degloving may be advantageously
suggested in most corporoplasty procedures, it yields optimal aesthetic and functional
outcomes and is associated with lower complication risk rates.
MANUSCRIPT
Introduction
Ever since the introduction of corporoplasty procedures, surgeons would use one of
three different skin degloving methods:
1) the transperineal approach;
2) the transscrotal approach;
3) the subcoronal approach.
The evolution of reconstructive penile surgery and the subsequently introduced
albugineal surgery (necessary to achieve a true change incavernosal morphology) sometimes
combined with prosthetic implants, modifies the use of these approaches. Indeed, some
approaches were abandoned and/or chosen as route of choice for other indications:
1) The transperineal route was soon stopped being used for corporoplasties due to the limited
surgical view of the corpora cavernosa afforded, and was instead adopted for bulbar urethral
[1] and low-flow priapism surgery [2].
2) The subcoronal route became the gold standard approach in Nesbit’s corporoplasty and in
the surgical management of Induratio Penis Plastica (IPP), because it allows for extensive
penile degloving with exposure of the corpora cavernosa up to the distal third segment and
pre-crural component [3-6].
3) The transscrotal route became the gold standard approach for prosthetic penile
implantation [7,8].
4) A combination of approaches, i.e., the subcoronal-transscrotal route (Austoni; 1992) [9]
and the subcoronal-infrapubic route (Lue,1993) [10] was widely applied in highly complex
surgery such as crural and distal albugineal substitution.
Nowadays, the subcoronal approach is used in most corporoplasty procedures,
because it is easy to perform and allows wide exposure of the corpora cavernosa, . However,
this approach has always been associated with two types of complications: high risks of
lymphoedema due to the the distal preputial lymphatic ducts inerruption and to the decrease
of glans sensitivity [11-13] . A pre- or postoperative circumcision may be performed to reduce
the ymphoedema, , however many patients do not accept this solution. Moreover,
3
circumcision followed by ample dartos dissection as for complex corporoplasty procedures,
may induce distal preputial ischemia,with risk of skin necrosis[14-16].
Transscrotal Simple Penile Degloving (TSPD) is suitable for different corporoplasty
procedures. The method is based on our previous experience with the subcoronal-transscrotal
approach .
Material and Methods
Patients
From February 2008 to July 2010 we performed the “Transscrotal Simple Penile
Approach” instead of the subcoronal and the subcoronal-transscrotal [18] approaches in all
cases of corporoplasty with or without prosthesis implantation or grafting for albugineal
remodelling.
Eighty-nine (89) pts underwent simple transscrotal degloving for a variety of penile
diseases:
1) Congenital penile curvature (Nesbit Procedure) [19] in 26 pts;
2) IPP associated with penile retraction and recurvatum (albugineal relaxing incision and
simple saphena grafting as per Austoni-Egydio’s technique) [20,21] in 18 pts;
3) IPP associated with erectile dysfunction, retraction and recurvatum (soft prosthesis
implantation and saphenous or biological dermal acellular grafting as per Perovich technique)
[22] in 25 pts;
4) Redo-Surgery for complex reconstruction of corpora cavernosa: 20 pts. In particular:
-8 pts presented with severe sepsis as a complication after pericavernous
enlargement (supralbugineal thickening) with Bio-Alkamid® filler injection. In
this case, a 2-step redo surgery was performed to remove all of the necrotic
material (that generally invades cavernous tissue and reaches subcutaneous and
cutaneous layers), and extensive dermal-epidermal penile skin graft.
Lengthening circular corporoplasty plus concomitant prosthesis implantation
were then carried out.
-12 pts presented with complications caused by previous surgery performed in
other Centers 5 pts with ED, 3 pts with proximal retraction of the graft and rebending, and 4 pts presenting with both conditions.
Methods:
The following standardized steps were performed in each patient, regardless of whether
surgery was primary or redo [Figure 1]:
4
- Combination of vasoactive injection and of subsequent intermittent saline infusion to
achieve a hydraulic erection thus avoiding the use of a tourniquet (reducing risks of DNVB
damage);
- Evaluation of penile recurvatum performed by visual angle assessment (Austoni) [20] or by
geometric measurement (Egydio) [23];
- In case of inflatable prosthesis implantation: proximal corporotomy on the ventral aspect of
the shaft;
- If needed, circumcision might be performed at this time –
- a 5 cm incision placed at the level of ventral scrotal raphe at the base of the penis;
- Full penile skin degloving is than easily performed up to the subcoronal line exerting care to
spare dartoic tissue;
- Use of double, bilateral paraurethral incisions for a safe isolation of the DNVB as per
standard practice
- Albugineal surgery with excision of ellipses for Nesbit procedure, or with single relaxing
incision for PD surgery .
- saphena vein or Acellular Dermal Matrix Intexen®) grafting for albuginea remodeling.
- hydraulic erection check after corporoplasty
- re-gloving and infrabupic drain .
Intraoperative, perioperative and postoperative complications have been analyzed and
pt follow-up controls were performed at day 7, month 1 and month 3 after surgery.
Results
A median follow-up period of 11.4 months showed the following findings for all patients:
- No pre- or postoperative circumcision were required
- Postoperative bandages were normally adopted
- No cases of postoperative preputial oedema were reported;
- Loss of glandular sensitivity was complained only for patients who had undergone apical
extensive mobilization of the glans: 4 pts (12.1%) out of 33
- No cases of penile skin necrosis ;
- Redo surgery was performed in 12 pts after previous surgery performed in other centers: 5
pts with ED, 3 pts with proximal retraction of the graft and re-bending, and 4 pts presenting
with both conditions. In all cases, the full transscrotal penile degloving was easily performed
5
Discussion
After an extensive 2-year experience with transscrotal simple penile degloving, the
subcoronal degloving approach is no longer considered a routine part of corporoplasty in our
experience.
. The need for circumcision has thus decreased (circumcision is performed only in
concomitant presence of phimosis and upon consent released by the patient).
In our patients the transscrotal simple penile access was demonstrated not to cause
ischemia while achieving a complete degloving of the corpora cavernosa up to the glans with
perfect preservation of fascial planes. Moreover, the absence of subcoronal incisions avoids
circumferential interruption of the distal preputial lymphatic ducts and any lymphoedema that
might be caused by this procedure.
The preoperative visual evaluation (Austoni) [20,24] or geometric measurement (Egydio)
[23] of the recurvatum allows to establish in advance the precise dimension of the graft.
After TSPD , the Isolation and dissection of the DNVB and urethra can be performed as
per normal practice: two bilateral paraurethral incisions are placed to detach Buck’s fascia
from the albuginea without risk of damaging any single parts of the bundle. Albugineal
surgery with grafting and albugineoplasty follows current standardized and well known steps
(Austoni, Egydio, Lue) [9,10,20,21]. This approach allows carrying out without any problem
the same standardized procedures for albugineal surgery [20]:
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Bilateral paraurethral dissection of Buck`s Fascia;
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Intraoperative hydraulic erection test;
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Albugineoplasty with cavernous remodelling and grafting;
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Prosthesis implantation,
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Hemostasis with Buck’s fascia reconstruction: in this surgery this step is important
since it ensures that skin easily slides over the corpus cavernosum, thus allowing natural
hemostasis;
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infrapubic placement of paracavernous drain.
In case of prosthesis implantation, the transscrotal simple penile degloving approach
provides a full exposure of the corpora cavernosa and of the crura up to the ischial tuberosity
and allows to perform corporotomies on the ventral aspect of the shaft, away from the
neurovascular bundle. This type of exposure becomes particularly useful in case of severe
fibrosis of the crura when the full opening of this segment of the corpora is necessary.
In such conditions, prosthesis implantation calls for multiple cavernotomies that will then
be expanded and adjusted to accommodate the prosthesis. When the albuginea is insufficient
6
to contain the prosthesis, porcine acellular dermis matrix (InteXen®) grafts will be used to
cover the albugineal defect [Figure 6].
When redo surgery is required, for example after an extensive dermal-epidermal penile
skin graft necessary because of complications associated with pericavernous filling, the
importance of this approach is even greater since penile scars caused by grafting or cutaneous
flaps make subcoronal degloving unfeasible [Figure 7]. The transscrotal simple penile
degloving approach allows to dissect Buck’s fascia, the corpora cavernosa and the urethra at
level of middle third and crural site, without damaging the previous grafts. Therefore this
approach allows to carry out a true lengthening corporoplasty (relaxing circular incision,
InteXen® graft and three-piece inflatable prosthesis).
The transscrotal simple penile degloving approach offers excellent outcomes in terms of
aesthetics and has the added benefit of being non invasive.
Conclusions
We believe that the transscrotal simple penile degloving, (which represents an
evolution of previous mixed subcoronal-transscrotal approach), may replace the well known
subcoronal approach in most corporoplasty procedures, offering excellent aesthetic and
functional results.
Abbreviation
Pts: patients
IPP: Induratio Penis Plastica
DNVB: Dorsal Neuro-Vascular Bundle
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