SURGICAL ANATOMY

The penis is composed mainly

 two corpora cavenosa

 Single corpus Spongiosum
which contains the urethra

It has an

 attached part (root)

 a free part (body)

The root of penis

 consists of the two crura

 which are proximal parts of corpora cavernosa and re attched to the pubic arch & the bulb
of penis which is the proximal part of the corpus spongiosum; anchored to perineal
membrane.
The body of penis

 is covered entirely by skin Urethra

 is formed by the tethering of the two proximal free parts of the corpora cavernosa and the
related free part of the corpus spongiosum

Because the anatomic position of the penis is erect

 the paired corpora are defined as dorsal in the bodv of the penis
 the Single Spongiosum as ventral
 even though the positions are reversed in the nonerect (flaccid) penis.

 The corpus spongiosum expands to form the head of penis (glans penis), over the
distal ends of the corpora cavernosa.

The skin covering the penis

 very thin and dark in colour.

 It is loosely connected with the fascial sheath of the organ.
 At the neck it is folded to form the prepuce or foreskin which covers the glans
 and can be retracted backwards to expose the glans.

Frenulum

 On the under surface of the glans there is a median fold of skin called the frenulum
Preputial sac

 The potential space between the glans and the prepuce is known as the preputial sac.
 Also called as Tyson’s gland

Smegma

 On the corona glandis and on the neck of the penis, there are numerous small preputial
(sebaceous) glands which secrete a sebaceous material called smegma, which collects in
the preputial sac
PHIMOSIS
 It is inability to retract the prepuce over the glans.

Causes

1. Congenital

- The child has pinhole meatus and

- Ballooning of prepuce occurs when the child urinates.

2. Balanitis (inflammation of glans) and balanoposthitis (inflammation of

glans, prepuce and sac).

- Common in Diabetics.
  Patients with phimosis are more prone for recurrent infection, smegma collection and
carcinoma penis.

Problems due to phimosis

 Recurrent balanoposthitis
 Paraphimosis
 Ballooning of prepuceal skin
 Retention of urine
 Prepuceal calculi formation due to smegma collection in prepuceal sac
 Carcinoma of penis later

Treatment

 Circumcision
PAPARAPHIMOSIS
 Inability to place back (cover) the retracted prepucial skin over the glans is called as
paraphimosis.

 It causes ring like constriction proximal to the corona and prepuceal skin.
 As a result the glans will be swollen, oedematous with severe pain and tenderness.
 Often glans will undergo necrosis or becomes gangrenous.

 Paraphimosis is precipitated after sexual intercourse or iatrogenically after urethral

catheterisation.
Treatment

 Manual reduction of prepuceal skin is to be tried.

 Sedation and hyaluronidase injection in 10 ml saline into the constriction ring or multiple
needle punctures over the oedematous part, reduces the oedema and makes the
paraphimosis to get reduced.

 If not possible,

initial dorsal slit is made to relieve the oedema and compression.

Antibiotics and analgesics are given.

 Circumcision is done after 3 weeks.

CIRCUMCISION

Indications

 Religious
 Phimosis
 Paraphimosis after doing initial dorsal slit
 Balanitis and balanoposthitis (common in diabetics)
 Early carcinoma of prepuce or glans penis—both diagnostic as well as therapeutic
purpose
 Certain sexually transmitted diseases, e.g.herpes infection
Procedure

 In children, it is done under G/A.

 In adults, it is done under local anaesthesia.

 Alter cleaning and draping,

- LA [1% lignocaine (plain) injected circumferentially near the root of the penis is
given (ring block)
- Dorsal skin is cut up to the corona and later circumferentially and ventrally
- Care is taken to see that optimum (less) skin is cut ventrally to prevent occurrence
of Chordee
- Frenular artery is transfixed and ligated ventrally using chromic catgut
(2-0 or 3-0)
- Small bleeders are also ligated.
- Skin is apposed to the cut edge of corona using interrupted chromic catgut
sutures.

Postoperatively

 antibiotics and analgesics are given.

Complications

 Reactionary haemorrhage due to slipping of ligature from frenular artery and dorsal vein
 Infection
 Stricture urethra near the external meatus in children
 Chordee due to removal of excess skin on the ventral aspect
 Rarely priapism can occur

Hollister Bell cap technique (Plastibel device):

 This specially devised plastic cap can be fitted over the glans penis and prepuce is rolled
Over it.
 A tight ligature is tied over it near base of the prepuce.
 In 7 days skin and prepuce sloughs off and sheds with the cap.
 Bleeding will not occur due to thrombosis of prepuceal vessels.

Technique can be used for

 religious circumcision
 balanoposthitis without phimosis.

Contraindicated in

 Phimosis
 Paraphimosis
Circumcision by guillotine

 It is a method done by pulling and stretching the prepuceal skin beyond the glans and
cutting the prepuce.
 Should be condemned and not be done as injury to glans is common.

 It is practiced in religious circumcision.

 Monopolar cautery should not be used in circumcision,

BALANOPOSTHITIS
  It is inflammation of glans and prepuce

 Inflammation of prepuce is posthitis

 Inflammation of the glans is balanitis

Causes

 Diabetes mellitus
 Candidiasis
 Veneral diseases like syphilis, herpes.

It can cause

 Phimosis
 carcinoma penis.

Clinical features:

 Pain
 Swelling
 discharge.

Treatment:
  Antibiotics.
 Circumcision.
 The diabetes is controlled.

CHORDEE (CORDEE)
  It is a fixed bending of glans penis, more obvious during erection.

Types

 Ventral.
 Dorsal.

Causes

 Hypospadias,
where urethra opens more proximally than normal
(ventral cordee).
 After circumcision,
if more skin Is cut over the ventral aspect
(ventral cordee).

In epispadias dorsal cordee occurs.

Treatment

 Chordee due to hypospadias is corrected during staged procedure.

In chordee following circumcision,

 initially stilbestrol 6 mg daily is given.

 Later chordee is corrected surgically by excising fibrous tissue
 later doing skin grafting.

More often they require surgical Intervention.

PRIAPISM
It is persistent, painful erection of penis.

 Corpora cavernosa are filled with blood due to defective venous drainage.
 Glans and corpus spongiosum are not involved.

Causes

 Idiopathic thrombosis of corpora cavernosa

 Idiopathic thrombosis of prostatic venous plexus
 Sickle cell disease
 Leukaemia
 Secondary deposits in corpora cavernosa
 Spinal injury or diseases

It can be

1. ischaemic (low flow)

2. non-ischaemic (high flow)
3. stuttering/intermittent.

Investigations

 Relevant for specific causes.

  Doppler duplex US scan is done.
 Arteriogram often with embolization is often done

Treatment

 Doppler guided aspiration

 intracavernous injection of adrenergic agonists like phenylephrine are nonsurgical
methods.

 Anastomosis between corpora cavernosa and saphenous vein.

 Anastomosis between corpora cavernosa and corpus spongiosum.
PEYRONIE’S DISEASE
(Induratio-penis Plastica)

 It is development of fibrous tissue plaque on the covering of corpus cavernosum and later
involving its full extent resulting in induration of corpus.
 It is a slowly progressive disease

 uncertain aetiology
may be
- Due to old trauma
- often associated with Dupuytren’s contracture
Retroperitoneal fibrosis
plantar fascitis.

 Initial active phase has

- painful erection
- with changing deformity of penis.

 Later quiescent phase has

- disappearance of painful erection
- with development of deformity which is painless.
  Later erectile dysfunction
 penile shortening occurs.
 Indurated plaque is noticed in the penis.

Treatment

 Some cases resolve spontaneously.

Drugs

 Steroids.
 Vitamin E.
 Potassium amino benzoate 12 mg/day.
 Tamoxifen 20 mg daily.
 Terfenadine and fexafenadine
 Colchicine therapy.
 Intralesional injection of verapamil 10 mg once in weeks-12 injections.

Surgery is needed in many cases

1. Excision and plication to opposite side- Fitzpatric operation.

2. Multiple incisions over the fibrous plaque and temporal fascia bridging—Gelhard’s
operation.
3. Excision of fibrous plaque and corporotomy is covered with overlay flap like tunica
vaginalis flap (Lockhart’s)/dermal flap (Devine and Horton’s).
 4. Intracorporeal penile prosthesis placement.

RAM’S HORN PENIS

 Filarial involvement of penis
 where it becomes
thick
distorted
resembles horn of a ram.
CARCINOMA PENIS
 It is commonly squamous cell carcinoma
 but melanoma
adenocarcinoma from Tyson’s gland
basal cell carcinoma
secondaries may also occur.

Aetiology

 Chronic balanoposthitis
 phimosis
 Sexually transmitted diseases.
 Leukoplakia of glans.
 Long-standing genital warts.
  Paget’s disease of penis.
 Erythroplasia of Querat is persistent rawness of glans penis
 Condyloma acuminata (by human papilloma virus)
 Balanitis xerotica obliterans.
 HIV infection—HPV-16.

‣ Circumcision during infancy confers total immunity against carcinoma penis.

‣ It is common in Asia and Africa.

Pathology

 Infiltrating type occurs in a pre-existing leukoplakia.

 It often presents as indurated area.

 Papillferous type eventually attains

- a large size
- fungating foul smelling lesion
- which often gets infected.

 Ulcerative type
 - glans penis is the most common site
- 80% are of low grade tumours.

Spread

1. Through lymphatics,
 it spreads to the horizontal group of inguinal lymph nodes
 which become nodular and hard.
 Lymph nodes on both sides can get involved.

 Later, externas iliae group are involved (above and on medial aspect of the inguinal
ligament).
 Once inguinal lymph nodes are fixed,

- it causes severe excruciating pain

- lymphoedema.

 Fixed lymph node status indicates the advancement of the disease.

 It may erode into the femoral vessels causing torrential haemorrhage and death.
 Fungation can occur.
2. From glans,it also spreads to Cloquet lymph node which is located in femoral canal

3. Carcinoma from shaft of penis

 can spread directly to the externa iliac lymph nodes.
 It spreads proximally to the body of penis causing induration.
 Urethral meatus may get involved causing alteration in urinary stream.
 It is a locoregional malignant disease.
 4. Blood spread is rare.

Clinical Features

 In an adult, recent onset of phimosis should raise the suspicion of carcinoma penis.

 Lesion is painless initially

 but later becomes painful due to secondary infection
 often accompanied by discharge which is foul smelling, purulent and irritating.
 Altered urinary stream.
 Fungation and induration everted edge, often extending into the body of penis.
 Palpable hard nodular inguinal Jymph nodes on both sides may be present.
 External iliac lymph nodes may be palpable.

 After infection

- Pain
- Oedema
- Tenderness
- Redness

Investigations
  Wedge biopsy from the lesion shows squamous cell carcinoma with epithelial pearls.

 FNAC of lymph nodes (No open biopsy for lymph nodes).

 Ultrasound abdomen, to look for involvement of external iliac lymph nodes.

 SLNB-Cabana sentinel node is located above and medial to the junction of saphenous
and femoral vein.
- It is the first node to get involved in carcinoma penis.
- So this Sentinel Lymph Node Biopsy (SLNB) after isosulphan blue dye injection
in to the primary is done to decide for the necessity for ilioinguinal block issection

Broder’s grading

1. Very well differentiated (75% epithelial pearls)

2. Well differentiated (50-75%)
3. Moderately differentiated (25-50%)
4. Undifferentiated (<25%)

Staging of Carcinoma of Penis

Jackson’s staging of carcinoma penis

Stage 1 - Tumour involving only 90% five-year glans/prepuce/both survival
Stage 2 - Tumour extending into 709% body of penis
Stage 3 - Tumour having mobile 50% inguinal nodes
Stage 4 - Tumour spreading to 5% adjacentstructures/fixed node

Treatment

 If growth involves the glans without extending into the proximal part of shaft of the penis
- partial amputation of the penis is done.
- A length of 25 cm stump is retained.
- Clearance of 2 cm from the proximal extended part of the tumour is needed.
- Advantage is proper streaming of the urine is possible.

 Partial amputation of penis with bilateral ilioinguinal lymph node block dissection is
called as Young ‘s operation.

 If tumour involves the proximal part of the body of penis or if it is anaplastic/poorly

differentiated tumour
- total amputation of penis is done with perineal urethrostomy.
- Problems with perineal urethrostomy are scrotal ammoniacal dermatitis
- stricture at urethrostomy site.

 Dermatitis is prevented by asking the patient to urinate in sitting position lifting the
scrotum upwards.
 Stricture needs dilatation.
 Total scrotectomy with orchidectomy is done along with total amputation of the penis---
Sir Piersey Gold operation.
- It prevents frequent dermatitis of the scrotal skin because of the perineal
urethrostomy and also reduces the sexual desire.
  In case of carcinoma in situ,
- T lesion of glans penis or well differentiated tumour in young individual,
circumcision and curative radiotherapy to the penis can be given using radio-
active tantalum wire implantation (6000 cGy in 7 days) or by wearing radium
penile mould continuously or intermittently (6000 cGy in 7 days) or by linear
accelerator external beam radiotherapy (6000 cGy in 5 weeks).
- Involvement of nodes in these patients is less than 10%.

 When lymph nodes are involved and are mobile

- bilateral ilioinguinal nodal dissection is done.

 Primary inguinal block is doing block dissection within 4 weeks of surgery for primary
tumour.
 Secondary inguinal block is doing block dissection after 4 weeks of surgery for primary
disease.
 Only 50% of palpable inguinal nodes are involved by metastatic spread.
- So often a course of antibiotic is given and waited for 4-6 weeks.

Complications of ilioinguinal block dissection are

 flap necrosis
 lymphoedema of lower limb
 femoral blow out
 infection
 lymphorrhoea
 haemorrhage.
•If primary tumour is poorly differentiated, and if tumour of T2 or above, chances of inguinal
nodal spread is more than 50% and so a prophylactic inguinal nodal dissection is done.
•Often,involvement of inguinal nodes may be due to infection.
 So a trial of antibiotic therapy is given for 4-6 weeks to reduce the size of the inguinal
node
 Removal of iliac nodes does not alter the outcome.
 It is done to confirm the spread, so that further therapy can be planned and prognosis can
be predicted.

Postoperative

Radiotherapy
 radiotherapy to inguinal region is often given.
 In advanced fixed inguinal nodes palliative external radio- therapy is given.
 It is to palliate pain, fungation and anticipated erosion in femoral Vessels.
 Topical 5 FU cream or imiquimab or Mohs surgery or llimited wide excision or Nd:YAG
laser photoirradiation is useful in carcinoma in situ.

Chemotherapy:
 5 FU; methotrexate
 Bleomucin
 cisplatin
 vincristine MBP/VBM combinations are used.
Bleomycin is a radiosensitiser and so beneficial if RT is planned later.

Role of radiotherapy

 Carcinoma in situ
 Small lesion less than 2 cm
 Lesion confined to glans
 small lesion in young individual
 Advanced inoperable disease
 Palliation to inoperable inguinal nodes in groin
 Postoperative RT

Complications of inguinal block dissection

 Haemorrhage
 Lymphorhoea
 Lymphoedema Infection
 Flap necrosis—common
BUSCHKE-LÖWENSTEIN
TUMOUR
 It is verrucous carcinoma of penis (5-15% common).
 It is a curable malignancy.
 It is locally destructive, locally invasive.
 It is often large, exophytic, dry, verrucae-like growth.
 Neither spreads through lymphatics nor blood.
 After biopsy and confirmation, surgical excision or partial amputation is the treatment of
choice
 Radiotherapy should be given
 Virus etiology is proposed – HPV -6 and 11
 Systemic interferon alpha therapy and Nd:YAG laser therapy is successful