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Keywords:

  • penis;
  • disassembly;
  • anatomy

Introduction

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference

Initially described by Perovic et al. [1]. for the correction of complex penile deformities as a consequence of Peyronie's disease, this technique is applicable also for penile reconstruction in patients with hypospadias, chordee, epispadias, venous impotence, dysmorphophobia and penile carcinoma.

The present paper concentrates on the application of the technique for the correction of complex penile deformities in patients affected by Peyronie's disease.

Planning and Preparation

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference

Patient Selection

Penile disassembly is indicated in patients with severe penile deviation under the glans penis or with a large plaque in the distal third of the shaft causing curvature of >60°, severe indentation or shortening.

A disease stable for at least 6 months is prerequisite for surgery and patients with a degree of erectile dysfunction are encouraged not to choose this technique, as postoperative worsening of erectile function is not uncommon when the corpora cavernosa are incised and grafted.

Recommended Equipment

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference
  • Scott retractor in case of additional penoscrotal approach
  • Plastic set
  • Light titanium needle holder
  • Polyglactin 910 (Vicryl™) 4/0 to repair perineal and circumferential subcoronal incision

Surgical Steps

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference
graphic

Figure 1 (a) A circumferential subcoronal incision is made and the penile skin is degloved. The dissection is obtained in the relatively avascular plane between the Buck's and Dartos fasciae. Dissection of the urethra off the tunica albuginea. (b) Two longitudinal paraurethral incisions of the Buck's fascia are made, one on each side of the urethra.

graphic

Figure 2 (a) Dissection is obtained in the avascular plane above the tunica albuginea of the corpora cavernosa. (b) The urethra is literally lifted off the corpora cavernosa. Particular attention is paid to remain in the plane between the corpus spongiosum and cavernosum, as on the ventral corporal aspect the tunica albuginea is composed only of two layers and therefore is particularly thin. The urethra is completely dissected off the corpora cavernosa down to its bulbous portion in order to gain extra length and elasticity.

graphic

Figure 3 Dissection of Buck's fascia containing the components of the dorsal neurovascular bundle. Dorsally, Buck's fascia is mobilised off the tunica albuginea using combined sharp and blunt dissection. This illustration shows the presence of communications between the cavernosal and dorsal arteries. This is a clear contraindication for total penile disassembly because the division of the communications may lead to the onset of postoperative arteriogenic erectile dysfunction. It is therefore paramount to preoperatively exclude the presence of these communications with a dynamic eco-colour-Doppler ultrasound of the penis after administration of prostaglandin E.

graphic

Figure 4 Buck's fascia has been completely dissected off the corpora cavernosa from the penile root to the glans groove. The deep dorsal vein can be seen running longitudinally in the middle of the neurovascular bundle, surrounded by one dorsal artery and one dorsal nerve on each side.

graphic

Figure 5 The urethra and Buck's fascia are completely dissected off the corpora cavernosa and are lifted with slings for demonstration purposes.

graphic

Figure 6 Dissection of the glans penis off the corporal tips. (a) The plane between the spongy tissue of the glans penis and the tunica albuginea is shown. A blunt dissection of the glans penis off the corporal tips is carried out with scissors. It is paramount at this stage not to damage the tunica albuginea or to leave any spongy tissue on the corpora cavernosa. During this manoeuvre special attention should be paid to prevent damage to the dorsal penile arteries that reach the glans laterally to the deep dorsal vein. (b) The complex glans–Buck's fascia and urethra are completely dissected off the corporal tips that are now completely denuded.

graphic

Figure 7 The penis has been completely disassembled. The Buck's fascia-glans-urethra complex is completely detached from the tunica albuginea of the corpora cavernosa.

graphic

Figure 8 Penile re-assembly. The glans cap is repositioned on the tip of the corpora cavernosa and is quilted in position with a 4/0 polyglactin 910 suture.

graphic

Figure 9 (a) Buck's fascia and the urethra are re-positioned respectively on the dorsal and ventral aspect of the corpora cavernosa and the initial two paraurethral incisions of Buck's fascia are closed with a running 4/0 polyglactin 910 suture to prevent postoperative mobilisation and haematoma formation. (b) Penile skin is re-approximated along the subcoronal circumferential incision with interrupted 4/0 sutures.

Postoperative Care

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference

A compressive dressing is applied postoperatively for 2 days to prevent haematoma and swelling formation and broad-spectrum antibiotics are administered for 7 days. Patients are discharged on postoperative day 1 and instructed to maintain the penis elevated for 2 weeks to minimise the risk of postoperative oedema formation and to refrain from sexual activity for 4–6 weeks.

Surgeon to Surgeon

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference

The following steps are paramount to achieve adequate results:

  • Adequate preoperative patient selection is mandatory. Patients with a pre-existing degree of erectile dysfunction or with documented communications between dorsal and cavernosal arteries should not be offered this procedure.
  • Complete exposure of the penile shaft is mandatory. A circumferential subcoronal incision guarantees the best exposure. If the penis is adequately degloved, a second penoscrotal incision is almost never necessary.
  • Avoid dissecting in the Dartos fascia. If the dissecting plane is between Buck's and Dartos, the blood supply to the prepuce is preserved and circumcision is not necessary, unless the patient has pre-existent preputial pathology.
  • Particular care should be paid during urethral dissection, as the ventral tunica albuginea is thinner and it is therefore relatively easier to lose the plain.
  • Plaque involvement of the neurovascular bundle can reduce its elasticity and may cause postoperative recurrence of the curvature. It is therefore paramount to excise as much of the plaque as possible, avoiding damage to the delicate neurovascular structures.
  • Drains are not necessary and a catheter is not useful during urethral dissection. A catheter can be left in situ postoperatively to prevent contamination of the dressing with urine.

Conclusions

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference

In experienced hands, total penile disassembly is a reproducible technique that guarantees excellent cosmetic and functional results in patients with complex penile deformities as a consequence of Peyronie's disease and preoperative good quality erections. This technique should be offered only for severe penile deviation under the glans penis or with a large plaque in the distal third of the shaft causing curvature of > 60°, severe indentation or shortening as in the Lue procedure or Nesbit plication would guarantee poor results in these cases.

Reference

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Recommended Equipment
  5. Surgical Steps
  6. Postoperative Care
  7. Surgeon to Surgeon
  8. Conclusions
  9. Conflict of Interest
  10. Reference