# A Preliminary Report on Combined Penoscrotal

Authors: John P. Brusky; Viet Q. Tran; Jocelyn M. Rieder; Sherif R. Aboseif
Journal: Advances in Urology
 (2008)

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## Abstract

Purpose. This paper aims at describing the combined penoscrotal and perineal approach for placement of penile prosthesis in cases of severe corporal fibrosis and scarring. Materials and methods. Three patients with extensive corporal fibrosis underwent penile prosthesis placement via combined penoscrotal and perineal approach from 1997 to 2006. Follow-up ranged from 15 to 129 months. Results. All patients underwent successful implantation of semirigid penile prosthesis. There were no short- or long-term complications. Conclusions. Results on combined penoscrotal and perineal approach to penile prosthetic surgery in this preliminary series of patients suggest that it is a safe technique and increases the chance of successful outcome in the surgical management of severe corporal fibrosis.


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## Body

## 1. Introduction

Corporal  scarring after infection
of a penile prosthesis or priapism greatly increases the difficulty of
subsequent prosthesis placement. Fibrosis shortens the penis and can obliterate
the cavernosal lumen, preventing easy passage of dilators or prosthetic
devices. In the case of extensive scarring, resection or cutting of scar tissue
with subsequent reconstruction of the corpora with graft materials is often
required. This adds additional complexity and time, and increases the
likelihood of complication.To simplify the procedure, we avoid
extensive excision of fibrotic tissue whenever possible. We have found with our
preliminary series of three patients that a combined penoscrotal and perineal
approach allows for a safe dilation of the corpora, even through densely
scarred tissue. Grafting of corporal defects is still possible when necessary.


## 2. Patients and Methods

From 1997 to 2006, a total of 3
patients with extensive corporal scarring were treated with placement of
semirigid penile prosthesis with a combined penoscrotal and perineal approach. All
patients had previous removal of infected penile prosthesis and corporal
scarring was anticipated. One patient had a history of three prior implants
which were removed for infection. In all patients, extensive corporal fibrosis
was encountered preventing easy proximal passage of the Hegar metal dilators.
In all cases, we felt that blind passage of the metal dilators was not possible
or safe, and that prosthetic implantation would not be possible without a
secondary approach. A combined penoscrotal and perineal approach was utilized
and successful placement of prostheses was accomplished in all patients.


## 3. Description of Technique

All patients are placed in a low
lithotomy position for easy access to the perineum and abdomen. The lower
abdomen is prepped in the event that autologous rectus fascia is needed for
corporal grafting. An extended 10-minute betadine scrub is utilized and the
anus is excluded from the draped field. A foley catheter is placed and the
surgeon changes his outer gloves. A longitudinal penoscrotal incision is made,
except when circumcision is planned, in which case a subcoronal incision with
degloving of the penis is performed. Liberal use of antibiotic irrigating
solution is utilized throughout the entire procedure.Longitudinal corporal incisions are
made with cutting current electrocuatery and2–0 vicryl stay sutures are placed
in the cut edges for retraction. Metzenbaum scissors are initially used to gently
dilate the corporal space. The corporotomies are extended proximally as
necessary. Excision of the corpora is avoided if possible. If the corpora can
be dilated easily, then a combined perineal approach is not necessary.If blind passage of the dilators
proximally is felt unsafe, then the perineal approach is also  used. A longitudinal perineal incision is
performed. The crus of each corpus
cavernosum is exposed; a ring retractor with hooks aids with
exposure. Longitudinal corporotomies are made and stay sutures are placed. We have found that the
proximal corpora are usually less scarred in these cases, and the true lumen is
more easily identified. With one finger in the corpora above,  a tonsil clamp is
passed from below and guided through the area of fibrosis by palpation. The
tips of the instrument are pointed away from the urethra to avoid injury (Figure1). Gentle spreading while withdrawing the instrument helps create the tract. A
6 French ureteral catheter may be placed through the tract to aid in its
identification and avoid creation of false passages. Progressively, larger metal dilators are then
passed through the tract, either from above or below, whichever proves easier.
An appropriately sized prosthesis is then placed. In cases of excessive
scarring, we recommend the use of a semirigid prosthesis. The corporotomies are
closed with running 2–0 absorbable monofilament suture. If there is excessive
tension while closing the corpora over the prosthesis, then a porcine acellular
collagen matrix or autologous rectus fascia graft is used to reconstruct the
defect.Figure 1
Combined perineal and penoscrotal approach facilitates passage of an instrument from above and below to allow adequate space to be created.


## 4. Results

Three patients with postinfection
fibrosis following prior removal of a penile prosthesis were implanted using
the combined penoscrotal and perineal approach. All patients had extensive
bilateral corporal fibrosis. Semirigid penile prostheses were placed in all
patients. To aid in closing corporal defects, autologous fascia was grafted in two
patients. Mean follow-up time was 91 months (range 15 to 129 months). To date
there have been no complications and no reoperations.


## 5. Discussion

Penile fibrosis may result from
untreated priapism, previous penile prosthesis removal, or intracavernosal
injection therapy. Severe fibrosis can greatly complicate the placement of
subsequent penile prostheses. The favored approach for severely fibrotic
corpora includes excision of fibrotic tissue and grafting with a variety of
materials as necessary to repair the defect. Others have advocated
corporoscopic resection of fibrotic tissue [1].In 1986, Herschorn et al. described a two-incision, combined
penoscrotal/subcoronal technique for facilitating placement of prostheses in
cases of severe distal corporal scarring [2]. Rajpurkar et al. described a minimal scar
excision technique through a perineal approach,  with a secondary subcoronal
incision when necessary for distal scarring [3].Our approach is somewhat different
in that we start with the more familiar penoscrotal approach on all patients.
The only initial difference is in patient positioning; a low lithotomy position
provides access to the perineum if needed. In most instances when scarring was
predicted, however, we were able to safely pass the prostheses proximally
without the need for a second incision. In these cases, the low lithotomy
position did not interfere with the purely penoscrotal approach.We find that the most difficult and
potentially dangerous step in prosthesis placement with corporal fibrosis is
proximal dilation. Blind dilation with excessive force may cause false
passages, crural perforation, or urethral injury. The pendulous corpora,
however scarred they may be, are more easily visualized and confidently
manipulated. Previously, operations have been aborted when proximal dilation
was not achieved. Identification of the true corporal lumen is often easier when
approached more proximally through a perineal incision. With corporal openings
both proximally and distally, a long pointed clamp is more easily passed
through the corpora with direct palpation of the instrument tip with the
opposite hand. Placing a ureteral catheter through the tract helps maintain
accuracy while dilating the tract with gentle spreading of a clamp or
metzenbaum scissors. Subsequent passage of metal dilators is then facilitated.In these difficult cases, we prefer
to use semirigid prostheses, although we believe that the same technique can be
applied for placement of inflatable prostheses. Summerton et al. used downsized inflatable
cylinders as tissue expanders in cases of severe fibrosis, later replacing them
with larger cylinders [4]. Regardless of the type of prosthetic placed
or the need for corporal excision or grafting, we based our preliminary result that using a
combined penoscrotal and perineal approach greatly increases the chance of
successful prosthetic placement.


## 6. Conclusion

Our preliminary result, based on
three patients, suggests that a combined penoscrotal and perineal approach to
penile prosthetic surgery is safe and increases the chance of successful
outcome in the surgical management of severe corporal fibrosis. We do intend to
enroll more patients to confirm these results.



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