Campbell’s Chapter 33
By
Peter Tran
Garden City Hospital
4/22/2009

Basic Principles of Reconstructive Surgery
◦ Grafts/Flaps



Specific conditions requiring reconstructive
repair
Penetrating trauma to the penis
Urethral stricture disease

The term tissue transfer implies the
movement of tissue for purposes of
reconstruction.
◦ Can be as a graft or flap

The term graft implies that tissue has been
excised and transferred to a graft host bed,
Take requires 96 hours and occurs in two
phases.
◦ The initial phase, imbibition, takes about 48 hours.
◦ The second phase, inosculation, also requires about
48 hours and is the phase in which true
microcirculation is re-established in the graft.

If a graft is a split-thickness unit, that graft
carries the epidermis and the part of the
superficial dermis.
◦ Tends to brittle and less durable

If a graft is a full-thickness unit, it carries the
covering and the superficial dermis or lamina
with all the characteristics attributable to that
layer. It also carries the deep dermis or deep
lamina.
◦ fastidious in its vascular characteristics

Buccal mucosal grafts have optimal vascular
characteristics

The term flap implies that the tissue is
excised and transferred with the blood supply
either preserved or surgically re-established
at the recipient site.
◦ Random Flaps
 A flap without a defined cuticular vascular territory.
◦ Axial Flaps
 there is a defined vessel in the base of the flap
 3 types
 direct cuticular axial flap
 musculocutaneous flap
 fasciocutaneous system
Figure 33-2 Random flap. The arterial perforators have been interrupted, and flap survival depends on
the intradermal and subdermal plexuses.
Figure 33-3 Axial flaps. Large
vessels enter the base of the
flaps. Survival depends on these
vessels and on the random distal
vascularity. A, Peninsula flap. The
vascular continuity and the
cutaneous continuity in the flap
base are intact. B, Island flap. The
vascular pedicle is intact; the
cuticular continuity has been
divided. These axial vessels are
unsupported (dangling). C,
Microvascular "free" transfer flap.
The free flap cuticular and
vascular connections are
interrupted at the base of the flap.
Vascular continuity is
reconstituted in the recipient area
by a microsurgical anastomosis.
(A to C, from Jordan GH, et al:
Tissue transfer techniques for
genitourinary reconstructive
surgery. AUA Update Series
1988;7:lesson 10.)
Figure 33-4 A, Musculocutaneous
flap. Musculocutaneous perforators
from the artery to a muscle
vascularize the skin and overlying
subcutaneous fat. They may be
transferred as free flaps but are
usually transferred locally, left
attached to the vascular pedicle. B,
Fasciocutaneous flap. Perforating
blood vessels from rich plexuses
on the superficial and deep aspects
of the fascia connect to perforator
vessels that communicate with the
microvasculature of the overlying
paddle. In genital reconstruction,
these flaps are based on the dartos
fascia of the penis or are free flaps
from the forearm. (A and B, from
Jordan GH, et al: Tissue transfer
techniques for genitourinary
reconstructive surgery. AUA Update
Series 1988;7:lesson 10.)
Figure 33-6 Sagittal section of
the pelvis. The urethra is
subdivided into the following
sections: 1, fossa navicularis; 2,
pendulous or penile urethra; 3,
bulbous urethra; 4, membranous
urethra; 5, prostatic urethra; 6,
bladder neck. By common usage,
the divisions of the fossa
navicularis, pendulous urethra,
and bulbous urethra compose
the anterior urethra; and the
divisions of the membranous
urethra, prostatic urethra, and
bladder neck compose the
posterior urethra. (Modified from
Devine CJ Jr, Angermeier KW:
Anatomy of the penis and male
perineum. AUA Update Series
1994;8:11.)

Five sphincters are recognized
Figure 33-9 Illustration of the vasculature to
the genital skin. A, The superficial external
pudendal vessels arborize to become the
fascial blood supply contained in the dartos
fascia of the penis. B, The scrotal artery is a
terminal branch of the deep internal
pudendal artery. This artery is thought to
arborize in the tunica dartos of the scrotum
and Colles' fascia of the perineum. The
perineal artery continues lateral to the groin
crease onto the thigh and extends toward
the groin.

The penis is drained by three venous
systems: superficial, intermediate, and deep
◦ The superficial veins contained in the dartos fascia
on the dorsolateral aspects of the penis unite at its
base to form a single superficial dorsal vein. The
superficial dorsal vein usually drains into the left
saphenous vein.
◦ The intermediate system contains the deep dorsal
and circumflex veins, lying within and beneath
Buck's fascia.
◦ The deep drainage system consists of the crural
and cavernosal veins.

Urethral Hemangioma
◦ Benign
◦ management depends on the size and location of
the lesion
◦ Laser Tx

Reiter’s syndrome
◦ Urethral involvement is usually mild, self-limited,
and a minor portion of the disease.
 No Tx needed.
◦ Also known as circinate balanitis
◦ perineal urethrostomy and excise the entire distal
urethra for severe disease

Lichen-Sclerosus(BXO)
◦ most common cause of meatal stenosis
◦ lichen sclerosus appears as a whitish plaque that
may involve the prepuce, glans penis, urethral
meatus, and fossa navicularis
◦ Diagnosis is made through biopsy
◦ For mild disease
 Topical steroids and abx
◦ For severe disease or young patients
 RUG
 staged buccal graft reconstruction, at least in the short
to mid term, seems to provide superior durable results


Urethral fistulas may be a complication of
urethral surgery or develop secondary to
periurethral infection associated with
inflammatory strictures or treatment of a
urethral growth.
Treatment of a urethral fistula must be
directed not only to the defect but also to the
underlying process that led to its
development.

Tx
◦ Conservative
 Stenting/Catheter
◦ If conservative measures fail, wait 6 months to
allow complete resolution of the inflammatory
process


Meatal stenosis in a boy appears to be a
consequence of circumcision that then allows
subsequent meatitis from a wet diaper
pressing for prolonged periods against the
glans penis.
Tx
◦ Meatotomy

Chordee – penile curvature caused by
tethered superficial tissue or scarred urethra.

Amputation is the
ultimate
penetrating penile
injury.
◦ If the patient
presents acutely with
the amputated distal
part of his penis,
microvascular
replantation is the
favored approach.



Wounds should be dressed in sterile salinesoaked bandages.
A delay of approximately 24 hours is
sufficient to define the extent of the damage.
Most degloving injuries can then be managed
acutely with immediate reconstruction by the
application of split-thickness skin grafts.
◦ The shaft is covered with a sheet graft of splitthickness skin.
◦ The testes are sutured together in the midline,
fixed in their anatomically correct position, and
covered with a meshed split-thickness skin graft.


Ability to reconstruct the damage caused by
genital burns often depends on how well the
normal structures have been maintained after
the acute injury.
Careful debridement is the rule in acute
management of genital burns
◦ Can’t replace corporal tissue.
◦ Will typically need flaps/grafts performed under
multiple stages

Urethral stricture refers to anterior urethral
disease, or a scarring process involving the
spongy erectile tissue of the corpus
spongiosum (spongiofibrosis).
◦ Contraction of this scar reduces the urethral lumen

posterior urethral "strictures" are not included
in the common definition of urethral stricture
◦ Posterior urethral stricture is an obliterative process
in the posterior urethra that has resulted in fibrosis
and is generally the effect of distraction in that area
caused by either trauma or radical prostatectomy.

Etiology
◦ Trauma/inflammation that results in scarring
 GC, straddle injury, iatrogenic, LS-BXO

Diagnosis/Evaluation
◦ Most patients present with obstructive voiding
symptoms/UTI’s/retention.
◦ Important to determine the location, length, depth, and
density of the stricture (spongiofibrosis).
 RUG (dynamic?)/cysto/US

Tx
◦ Goals
 Cure vs. conservative management?
◦ Urethral dilation
 Oldest and simplest
 goal is to stretch the scar without causing further bleeding/scarring
 Balloon dilation prefered
◦ DVIU
 The urethrotomy procedure involves incision through the scar to healthy
tissue to allow the scar to expand (release of scar contracture) and the
lumen to heal enlarged.
 Competition between wound contraction and epithelialization.
 Success rate low: 20-35%.
 Better with stricture < 1.5cm and not associated with severe spongiofibrosis
(75%)
 Leaving indwelling catheter or on self-dilation program does not prevent
recurrence.

Tx
◦ Urethral Stents (removable/permanent)
 Majority of experience from Europe and UK
 Best used for short bulbar stricture with minimal
spongiofibrosis.
 Open surgery still offer better long-term results
 Unique complications
 Placed only in bulbar urethra.
 Pain on sitting and intercourse, perineal pain.
 Two or more overlapping stents can migrate, leaving a
gap, where stricture recurrence can occur.
 Not to be used in urethral distraction injuries or straddle
injuries where significant fibrosis is present.
◦ Lasers
 Data shows mixed results

Excision and Reanastomosis
◦ the most dependable technique of anterior urethral
reconstruction is the complete excision of the area of
fibrosis, with a primary reanastomosis of the normal
ends of the anterior urethra.
◦ Important points
 the area of fibrosis is totally excised; the urethral
anastomosis is widely spatulated, creating a large ovoid
anastomosis; and the anastomosis is tension free.
 success of this procedure relies on vigorous mobilization of
the corpus spongiosum
 The more proximal the stricture the more likely
reanastomosis can be performed, otherwise tissue transfer is
required.

Grafts
◦ 4 types used for urethral reconstruction
 FTSG, bladder epithelial, buccal mucosal, rectal
mucosal

Use of flaps
◦ mobilized on either the dartos fascia of the penis or
the tunica dartos of the scrotum
 3 important points
 the nature of the flap tissue, the vasculature of the flap,
the mechanics of flap transfer, and use on non-hirsute
skin
Figure 33-33 A dorsal transverse island of penile skin applied to a stricture of the urethra. The flap has been elevated
on the dartos fascia, and a lateral incision has been made into the urethra. The flap is secured in place (right). (From
Jordan GH: Management of anterior urethral stricture disease. In Webster GD, ed: Problems in Urology. Philadelphia,
JB Lippincott, 1987:217.)
Figure 33-34 Penile longitudinal skin island. The
incisions to be made to mobilize the flap are
demonstrated in the inset. The heavy line is the
primary incision made full thickness through the
dartos fascia and superficial Buck's fascia lateral to
the corpus spongiosum. A, Dissection elevates the
dartos fascial flap well past the corpus spongiosum
in the midline. B, A lateral urethrostomy placed to
face the flap has opened the entire length of the
stricture. C, The skin paddle of the flap has been
developed by making the incision outlined by the
dotted line (inset) and undermining the skin lateral
to it. The medial edge of the flap has been fixed to
the edge of the stricturotomy. D, The flap is inverted
into the defect. E, A watertight subepithelial suture
line has been completed with a running absorbable
monofilament suture. The skin will be closed with
subcutaneous sutures and interrupted cutaneous
sutures. (A to E, from Jordan GH: Management of
anterior urethral stricture disease. In Webster GD,
ed: Problems in Urology. Philadelphia, JB Lippincott,
1987:214.)
Figure 33-35 A ventral transverse
skin island is elevated on the penile
dartos fascia, inverted to the area of
the perineum where flap onlay is
accomplished. A, The skin island is
elevated on the dartos fascia. B, The
appearance of the flap transposed to
the area of the perineum for onlay in
a proximal bulbous urethral stricture.
Figure 33-37 Ventral skin island for
long bulbous stricture. The skin
paddle of the flap is developed on the
ventral midline of the penis and can
be extended around the penile shaft
at its distal end. A, The paddle of the
flap has been incised and its pedicle
elevated. This pedicle includes Buck's
fascia and dartos fascia, denuding the
tunica of the corpus spongiosum and
the corpora cavernosa. The pedicle
(the dartos fascia bilaterally) is based
on the superficial external pudendal
vessels and the internal pudendal
vessels in the scrotum. Development
of this pedicle allows the flap to be
moved to any area of the urethra. B,
The flap has been passed through a
tunnel beneath the scrotum developed
by dissection along the corpus
spongiosum. A laterally placed
urethrostomy has opened the urethral
stricture. C, The deep edge of the flap
is secured by the suture techniques
previously described. D, Anastomosis
of the flap has been completed. The
pedicle can be seen extending
beneath the scrotum. (A to D, from
Jordan GH, McCraw JB: Tissue transfer
techniques for genitourinary surgery,
Part III. AUA Update Series 1988;7.)
Figure 33-38 Illustration of reconstruction in a patient
with a long anterior urethral stricture with a relatively
short narrow-caliber section (technique of augmented
anastomosis with circular skin island). A, A circular
skin island is elevated on the dartos fascia. The patient
is positioned flat on the table. B, The skin island onlay
is begun, the rest of the flap is placed into the perineal
dissection, and the penis is closed; the patient is then
repositioned in the lithotomy position. C, The flap is
retrieved through the perineal dissection. The narrowcaliber section is excised, and the urethra is spatulated
on the dorsum. D, The onlay is completed, and the
floor strip anastomosis is closed. E, Schematic of the
surgery. (A to E, from Stack RS, Schlossberg SM, Jordan
GH: Reconstruction of anterior urethral strictures by
the technique of excision and primary anastomosis.
Atlas Urol Clin North Am 1997;5:11-21.)
Figure 33-39 Collage of techniques for reconstruction of the fossa navicularis and meatus. A, Technique after Blandy
in which a random penile skin island is advanced into a meatotomy defect. B, Technique after Cohney in which a
transversely oriented random flap is advanced into the meatotomy defect. C, Technique after Brannen in which a
midline random flap is advanced into the meatotomy defect. This technique was an attempt to improve the cosmetic
result of prior procedures. D, Technique after De Sy in which a ventral longitudinal skin island is advanced into the
meatotomy defect. The skin island is developed by deepithelialization of a portion of the longitudinal flap. (After
Jordan GH: Management of anterior urethral stricture disease. Probl Urol 1987;1:199-225.)