Buck's Fascia Research Articles

Modified prepuce unfurling for buried penis: A report of 12 years of experience

About 10 years ago, we started to correct buried penis using the technique of modified prepuce unfurling. We have made modifications in the years since our preliminary results were reported in 2002. One hundred and thirty-four patients received modified prepuce unfurling since 2000, with ages ranging from 2 months to 33 years. The surgical procedures included the removal of the narrowest part of the prepuce, dissection of the fibrotic tissue from the Buck's fascia, and unfurling the inner prepuce to cover the penis. Most patients had their procedures in day care service. No urinary catheter was needed. All patients were followed up for at least 2 months. Most patients had satisfactory results. All patients had the glans exposed after surgery, although one patient needed reoperation for prolonged edema and two patients had wound infections. Modified prepuce unfurling is a safe and effective method to correct buried penis.

Neurovascular bundle dissection for Nesbit procedure in congenital penile curvature patients: medial or lateral?

The objective of this study was to compare the outcomes of the modified Nesbit procedure using different techniques for dissecting the neurovascular bundle (NVB) to correct ventral congenital penile curvatures (CPCs). The bundle was mobilized using the medial and lateral dissection technique in 21 (Group 1) and 13 (Group 2) patients, respectively. In the medial technique, Buck's fascia is opened at the dorsal side of the penis, the deep dorsal vein is removed at the most prominent site of the curvature and a diamond-shaped tunica albuginea (TA) is excised from the midline of the penis. In the lateral technique, the bundle is mobilized using a longitudinal lateral incision of the Buck's fascia above the urethra at the 5 and 7 o’clock positions via a bilateral approach. The localization and degree of curvature was evaluated using the combined intracavernous injection stimulation test or from the patients’ photographs. The mean patient age and degree of curvature were similar between groups. The mean operation time was longer for Group 2 (P = 0.01). In Group 1, nine patients (42.8%) required one diamond excision, 10 (47.6%) required two diamond excisions and two (9.5%) required more than two excisions; in Group 2, six patients (46.2%) required two diamond excisions and seven patients (53.8%) required more than two diamond excisions (P = 0.019). The differences in penile shortening, penile straightening and numbness of the glans penis were not statistically significant. Medial dissection of the bundle for the modified Nesbit procedure reduces the number of diamond-shaped removals of TA and thus shortens operation time in comparison with its lateral counterpart.

Surgical Anatomy of Penis in Exstrophy-epispadias: A Study of Arrangement of Fascial Planes and Superficial Vessels of Surgical Significance

To study the anatomic arrangement of the fascial planes and superficial vessels in relationship to the laid-open urethral plate, glans, corpus spongiosum, and corpora cavernosa in the penis of patients with exstrophy or epispadias. Of 6 patients, 4 had classic exstrophy and 2 had incontinent epispadias. These patients had presented beyond adolescence without previous intervention and were selected for the present study. Using a 1.5-T magnetic resonance imaging scanner and compatible 3-in. surface coil, the epispadiac penises were studied using fast spin echo sequences and contrast-enhanced sequences. In 2 patients, angiography of the superficial vessels was also performed using multidetector row helical computed tomography. The imaging findings were also verified during the subsequent reconstructive surgery. A clear demarcation of the skin, dartos fascia, Buck's fascia, corpora cavernosa, corpus spongiosum, and the intraglanular planes were seen with the course of the blood vessels. The penile dartos received axial pattern vessels from the external pudendal vessels, with collateral branches from the dorsal penile artery as transverse branches at the shaft of the penis and preputial branches at the coronal sulcus. Buck's fascia sleeved the corpora cavernosa, enveloped the neurovascular bundle, and fused with the corpus spongiosum without crossing the midline. Intraglanular extension of Buck's fascia separated the intraglanular vascular arcade from the tip of the corpora. Parallel to the ventral midline, axial pattern vessels to the skin-dartos complex are present, with an additional supply to the prepuce from the terminal penile arteries. These findings can be used for designing the skin coverage. The subfascial plane between the tip of the corpora and the intraglanular vascular arcade and the plane of cleavage between the cavernosa-spongiosum interface can be used for efficient corporal urethral separation.

Penile Fracture Due to Manipulation

A 24 year old young patient presented in the emergency department of Shaheed Monsur Ali Medical College Hospital, Uttara, Dhaka with swollen, curved and flaccid penis after forceful bending of his erect penis. The patient was anxious with normal vital sign. Rolling sign was positive. There was no bleeding at external urethral orifice, scrotum & testicle were found normal. On the above facts, penile fracture was diagnosed clinically. The penis was degloved upto the root of the penis & after evacuation of the haematomas, transverse tears were detected in Bucks fascia & tunica albugenia of the left corpus cavernosum, which were repaired by interrupted suture. In the post operative period sedative was given & recovery was uneventful. The aim of this case report is to increase the awareness of the condition which should be regarded seriously and treated expeditiously and to draw attention to its possible complications. DOI: http://dx.doi.org/10.3329/jss.v16i1.14448 Journal of Surgical Sciences (2012) Vol. 16 (1) : 44-46

V1584 TRANS-SCROTAL PLICATION FOR PEYRONIE'S DISEASE WITH SYNCHRONOUS PENILE IMPLANT

You have accessJournal of UrologyInfertility, Sexual Dysfunction and Testis1 Apr 2013V1584 TRANS-SCROTAL PLICATION FOR PEYRONIE'S DISEASE WITH SYNCHRONOUS PENILE IMPLANT Michael J. Belsante, Lee C. Zhao, J. Francis Scott, James R. Flemons, and Allen F. Morey Michael J. BelsanteMichael J. Belsante Dallas, TX More articles by this author , Lee C. ZhaoLee C. Zhao Dallas, TX More articles by this author , J. Francis ScottJ. Francis Scott Dallas, TX More articles by this author , James R. FlemonsJames R. Flemons Dallas, TX More articles by this author , and Allen F. MoreyAllen F. Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.3134AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Current standard management of Peyronie's disease with erectile dysfunction involves penile prosthesis placement with manual modeling. We report an alternative technique utilizing synchronous penile plication and inflatable penile prosthesis (IPP) placement. METHODS An artificial erection is induced with injectable saline and a penile tourniquet to identify the nature of the penile curvature. A 2 cm penoscrotal incision is made and mobilized over the convex aspect of the penile curvature. The dissection is carried down through dartos and Buck's fascia. The incision is then mobilized distally along the shaft to allow placement of multiple parallel plicating sutures (braided, nonabsorbable polyester) in the tunica albuginea until the curvature is completely corrected. IPP placement is then immediately performed through the same incision in a standard fashion. Patients were administered a postoperative survey to identify functional outcomes and patient satisfaction. RESULTS Sixteen patients have undergone synchronous penile plication with IPP placement. Preoperative penile curvature was a mean of 43 degrees compared with 4 degrees post-procedure. We achieved approximately 8 degrees of correction with each plication suture. Of the 10 patients who completed the survey, 90% described their penile curvature as much better and 10% as slightly better. No patients have had infection or have required reoperation. CONCLUSIONS Penile plication with concomitant IPP placement is an effective, safe, and controlled method for treatment of Peyronie's disease with erectile dysfunction. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e651 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael J. Belsante Dallas, TX More articles by this author Lee C. Zhao Dallas, TX More articles by this author J. Francis Scott Dallas, TX More articles by this author James R. Flemons Dallas, TX More articles by this author Allen F. Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Corpus cavernosum fracture: The ultrasound in the emergency diagnosis

ObjectiveThe main objective of this work is to study usefulness of ultrasound (US) for the emergency diagnosis of the penile fracture. Material and methodsWe reviewed all the penile US studies registered in our Emergency Department between July 2007 and August 2009 with suspicion of a corpus cavernosum fracture. We compared US findings (subcutaneous hematoma, peri-albuginea hematoma, albuginea rupture and Buck's fascia rupture), and the clinical progress, with those of the surgery. We studied sensitivity, specificity, positive predictive value and negative predictive value of US in the diagnosis of rupture of the tunica albuginea. The epidemiological data of all the cases reviewed were collected. ResultsTwelve patients with a mean age of 37.8 years were reviewed. The most common cause of injury was sexual intercourse. A subcutaneous hematoma was found in nine patients, a peri-albuginea hematoma in eleven of the cases, and an albuginea rupture was seen in six of them. We found no Buck's fascia rupture. Seven patients underwent surgical treatment and in the remaining five patients, treatment was conservative. Clinical progress was good in all cases. US, as an emergency test to diagnose albuginea fracture gave 0.83 sensitivity, 1 specificity, 1 positive predictive value and 0.83 negative predictive value. ConclusionWe believe that US is a useful procedure in the diagnosis of acute penile fracture and that it could be proposed as the diagnostic method of choice to confirm the clinical suspicion of penile fracture. Identifying the exact site of a tear in the tunica albuginea facilitates the surgical procedure.

Congenital Megaprepuce: Surgical Approach

To describe surgical procedure and results of Congenital Megaprepuce (CMP) that consists in phimosis and megaprepuce; glans and corpora trapped into pre-pubic fat; incomplete micturition with typical "ballooning" aspect. Genitoplasty with penoscrotal separation (GPS) was performed at Pediatric Surgery Department of Hospital Nord - Marseille, between July and December 2010, in 5 uncircumcised children with CMP, by the same surgeon. Transversal incision at the ventral penoscrotal junction was used, with shaft bipartition and Buck's ventral fascia exposition. The inner layer of prepuce was resected while the outer layer was preserved for coverture of the penile shaft. The dorsal foreskin was medially and longitudinally incised to obtain adequate length of the dorsal shaft. The first middle dorsal suture was made using PDS 6.0 and completed in ventral direction with interrupted stitches. The urinary catheter was placed and hydrocolloid duoderm dressing used. Perioperative prophylactic antibiotic was given and pain control achieved with paracetamol and codeine. All patients presented urinary troubles before surgery. Skin penile coverage was complete in all patients with cosmetically and functionally satisfying results; no complication was observed at 12 months mean follow-up. CMP is a specific entity of "inconsistent penis." Surgical treatment should be discussed at diagnosis, resolving micturition troubles. GPS is a simple and reproducible procedure by experienced surgeons. Excellent cosmetic and functional results are obtained at mean follow-up, even if long-term results are required. GPS can be useful in other malformations of the penile shaft.

V1557 PERCUTANEOUS PLACEMENT OF PENILE PROSTHESIS

You have accessJournal of UrologyInfertility, Sexual Dysfunction, Trauma & Teaching Technique1 Apr 2012V1557 PERCUTANEOUS PLACEMENT OF PENILE PROSTHESIS Salvador Lima, Fabio Vilar, Hude Lucena Dias, Andrei Nunes, and Arnaldo Lemos Neto Salvador LimaSalvador Lima Recife, Brazil More articles by this author , Fabio VilarFabio Vilar Recife, Brazil More articles by this author , Hude Lucena DiasHude Lucena Dias Recife, Brazil More articles by this author , Andrei NunesAndrei Nunes Recife, Brazil More articles by this author , and Arnaldo Lemos NetoArnaldo Lemos Neto Recife, Brazil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1328AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The techniques for placement of penile prosthesis in general destroy the erectile tissue remaining in the dilation process commonly used because of the difficulty of uniformly separating the erectile tissue from Buck's fascia. METHODS The use of a set of coaxial dilators that have been adapted in the creation and expansion of an access path for percutaneous renal surgery inspired us to apply the same principle in the penile prosthesis placement technique. The first step of the technique is the introduction of a special metallic disk-shaped guide arrow sliding through the inner edge of Buck's fascia until the confluence with the glans. The introduction of sequential coaxial dilators allows the erectile tissue to be compressed to the opposite side in a uniform manner without destroying it. A fenestrated sheath allows safe introduction of the proximal shaft, that can be withdrawn without difficulty. RESULTS The use of this technique not only fastens the surgical procedure but also allows the preservation of remaining erectile tissue. Smaller caliber prostheses may eventually be used as the erectile tissue has a higher preservation perspective. We know that other techniques intended to preserve erectile tissue have been proposed however the technique of expansion does not ensure the preservation of erectile tissue. CONCLUSIONS The use of coaxial dilator in percutaneous implantation surgery of penile prostheses seems to represent a significant advance in the surgical procedure for treating erectile dysfunction since it simplifies the surgical technique and increases the chances to preserve the remaining tissue involved in the physiological mechanism of erection. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e631-e632 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Salvador Lima Recife, Brazil More articles by this author Fabio Vilar Recife, Brazil More articles by this author Hude Lucena Dias Recife, Brazil More articles by this author Andrei Nunes Recife, Brazil More articles by this author Arnaldo Lemos Neto Recife, Brazil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Para-meatus Skin Incision With Long Channel Technique for Midshaft Hypospadias Repair Without Penile Curvature

To report a new surgical technique for midshaft hypospadias repair without penile curvature. From September 2007 to October 2010, 21 patients, aged 13 months to 8.9 years, underwent single-stage hypospadias repair by 1 surgeon. The skin incision was created around the meatus, and a long channel beneath the urethral plate was created through the incision to the apex of the glans. The inner preputial flaps were tubularized into a neourethra, which was then transposed to the ventral channel through a ventrolateral tunnel beneath Buck's fascia. Most of the neourethra was covered by the intact soft tissue of the distal ventral penis. The proximal portion of the neourethra was covered by Buck's and dartos fascia around the skin incision, and the skin incision was closed longitudinally. The length of the urethral defect and channel and the postoperative complications were collected and analyzed. A total of 21 patients underwent single-staged hypospadias repair. The average length of the channel was 30 mm (range 25-35). The average length of the neourethra was 35 mm (range 30 to 40). The mean operative time was 60 minutes (range 50-70). The mean hospital stay was 12 days (range 10-14). With an average follow-up of 20 months (range 6-37), no postoperative complication was detected. This technique provides excellent short-term results for midshaft hypospadias without penile curvature and is a safe and simple solution.

Circumcision in Nesbit Corporoplasty: A Mandatory Time? Our Experience on 158 Patients

The Nesbit procedure is the most common surgical technique to correct congenital or acquired penile curvature. It is a common opinion that this surgical procedure has to be completed with a circumcision to prevent foreskin necrosis or phimosis. According to our experience we believe that some procedural "tricks" could strongly reduce that mechanical and ischemic trauma on the foreskin responsible for these complications. From 1988 to 2010 we selected 158 patients treated with Nesbit's corporoplasty. The procedure was recommended to patients who presented a penile curvature wider than 30° and reporting however some difficulty or pain at coitus, or to patients who complained about aesthetical problems (123 patients presented a La Peyronie disease and 35 presented a congenital curvature). Eleven patients underwent circumcision during surgery because of a pre-operative phimosis, or according to their own desire. Among the patients who did not undergo circumcision (147), paraphimosis was present in 3 patients. We reported only one case of curvature recurrence in a patient who had a sexual intercourse the day after surgery. We also had one case of hourglass effect in a congenital curvature. We believe that some tricks during Nesbit surgical procedure could prevent tissue and vascular trauma that give rise to tissue retraction, and consequently to phimosis and foreskin necrosis: a coronal incision to 0.5-1cm from the gland line would allow to let intact an adequate amount of reflection of skin (prepuce) bound of preputial skin reflection , maintaining good vascularity. The careful degloving with preparatory isolation of the dissection plan between dartos and Buck's fascia, can reduce vascular trauma of the fascia, minimizing bleeding and ensuring tissue vitality. Moreover, execution of only two hydraulics erections, after degloving and after correction, causes a minimal tissue stress. Circumcision must not be considered a mandatory time in Nesbit procedure: on the contrary, mandatory is the respect of the anatomical structures surgically attacked to avoid preputial resection.

Physiology: Clinical implications for physicians and surgeons

SummaryRecent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck’s fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

Metachronous penile metastasis from rectal cancer after total pelvic exenteration

Despite its abundant vascularization and extensive circulatory communication with neighboring organs, metastases to the penis are a rare event. A 57-year-old male, who had undergone total pelvic exenteration for rectal cancer sixteen months earlier, demonstrated an abnormal uptake within his penis by positron emission tomography/computed tomography. A single elastic nodule of the middle penis shaft was noted deep within Bucks fascia. No other obvious recurrent site was noted except the penile lesion. Total penectomy was performed as a curative resection based on a diagnosis of isolated penile metastasis from rectal cancer. A histopathological examination revealed an increase of well differentiated adenocarcinoma in the corpus spongiosum consistent with his primary rectal tumor. The immunohistochemistry of the tumor cells demonstrated positive staining for cytokeratin 20 and negative staining for cytokeratin 7, which strongly supported a diagnosis of penile metastasis from the rectum. The patient is alive more than two years without any recurrence.

Partial Plaque Excision and Grafting (PEG) for Peyronie's Disease

Peyronie's disease is characterized by a fibrous inelastic scar of the tunica albuginea that often results in a penile deformity. Peyronie's disease may present as difficulty with penetration, or penetration that causes discomfort to the partner. Men with <12 months disease, progressive deformity, or painful erections may be considered candidates for non‐surgical therapy, although there is limited evidence of benefit with respect to deformity reduction. Non‐surgical therapies include vitamin E, colchicine, pentoxifylline, traction therapy, and vacuum therapy as well as intralesional injection with verapamil or interferon. Surgery is an option in specific instances. Surgical reconstruction is indicated for disease that is: stable for more than 6 months, with erect deformity that is painless, a compromised ability to engage in coitus secondary to deformity and/or inadequate rigidity, and when there is extensive plaque calcification. The partial plaque excision and grafting (PEG) procedure starts with the preoperative erection deformity angle measured. A circumferential degloving skin incision is fashioned, followed by longitudinal opening of Buck's fascia. The neurovascular bundle is elevated if the plaque involves the dorsal and/or lateral surface. The PEG surgical technique involves a single partial excision of the Peyronie's plaque centered over the area of maximum penile curvature and/or indentation, typically carried out to the 3 and 9 o'clock positions on the shaft bilaterally. With the penis on full stretch, stay sutures are placed at the four corners of the defect using 4–0 polydioxanone. The corners may be extended radially to enhance girth correction. The lateral longitudinal aspects of the defect should be equivalent, ultimately forming a rectangular defect.

La verge enfouie congénitale de l’enfant

Congenital buried penis in children is an uncommon and poorly known entity. The aims of this study were to report an original technique for correction of buried penis and to evaluate its results. It is a retrospective study of buried penis operated between November 1998 and May 2009. The acquired concealed penis and hypospadias were excluded from this study. The procedure includes several stages: degloving of the penis through a ventral anchor-like incision; division of the adherent layers surrounding the corpora cavernosa; anchorage of the Buck's fascia to the corporeal albuginea at the base of the penis; and ventral cutaneous coverage. The long-term results were evaluated by the parents and the surgeon according to anatomical, functional and aesthetic criterion. Twenty-five boys were evaluated. The mean age at surgery was 27 months (seven days-120 months). Two children required an additional plasty. Results were satisfactory in 24 cases (96%). One child required a redo procedure for unsatisfactory outcome. Of seven children with redundant skin (28%), three underwent a complementary cutaneous excision. Congenital buried penis remains a controversial issue. Our technique was simple and easily reproducible. Voiding difficulties, urinary tract infection or strong parental request were the main indications of this surgery in our experience.

Simplified Surgical Approach to Congenital Megaprepuce: Fixing, Unfurling and Tailoring Revisited

Megaprepuce is a congenital penile malformation that includes phimosis and severe ballooning of the internal prepuce. We combined the main technical details of 2 previously reported surgical techniques to simplify the surgical approach. We report the key points of this revisited surgical correction for megaprepuce and the long-term results. Penile reconstruction was performed between March 2004 and March 2009 in 26 children 2 to 19 months old (median age 6) with congenital megaprepuce. Surgical repair consisted of limited preputial resection of the phimotic ring, wide dissection of the outer prepuce to the base of the penis, fixation of the proximal outer prepuce to Buck's fascia to create a new penoscrotal junction, and unfurling and wide tailoring of the inner prepuce in the ventral midline to resurface the whole elongated penile shaft. A bladder catheter was left in place for 5 or 6 days. Only patients with at least 6 months of followup were included in analysis. All patients underwent surgery on an outpatient basis. Operative time was between 50 and 85 minutes. Median followup was 17.6 months (range 6 to 59). Two patients had slight dehiscence of the ventral suture, which healed spontaneously without a scar. In 1 patient transient urethral meatal stenosis developed. The final cosmesis result was adequate in all patients. It is possible to correct megaprepuce and achieve an adequate genital aspect with a simple approach of resurfacing the penis with the unfurled, tailored inner prepuce.

Tissue Engineering Penoplasty With Biodegradable Scaffold Maxpol-T Cografted Autologous Fibroblasts for Small Penis Syndrome

In this study, we investigated the safety and efficacy of a poly acid-co-glycolide biodegradable scaffold (Maxpol-T) coated by autologous fibroblasts (AF) for penile girth enlargement in small penis syndrome (SPS). Eighty patients with SPS were enrolled in a clinical study at 2 medical centers; 69 patients completed the study protocol. Scrotal skin was harvested under local anesthesia, and AFs were cultured and seeded on a Maxpol-T scaffold; the cografted scaffold was implanted under the Buck's fascia of penile shaft via a circumcising incision. Patients were followed up at 1, 3, and 6 months to evaluate penile girth changes. Patient satisfaction was assessed via Visual Analogue Scale and scored on the International Index of Erectile Function-5 (IIEF-5). Mean preoperative penile girth in the flaccid and erect state was 8.18 ± 0.83 cm and 10.26 ± 1.22 cm, respectively. At the 6-month postoperative follow-up, mean penile girth in the flaccid and erect state was increased to 12.19 ± 1.27 cm and 13.18 ± 1.31 cm, respectively (P < .001 for change in both flaccid and erect state). Sixty-five patients (94.2%) reported satisfaction with the procedure. Among them, 4 cases (5.8%) were dissatisfied, 7 cases (10.1%) were satisfied, 26 cases (37.7%) were very satisfied, and 32 cases (46.4%) were extremely satisfied. All men maintained IIEF-5 scores of more than 22. Complications included prolonged subcutaneous edema in 3 patients (4.3%) and pinpoint erosion at the suture area in 3 patients (4.3%). Implantation of autologous fibroblasts seeded on a Maxpol-T collagen scaffold holds promise as a safe and novel technique for penile girth enhancement in patients with SPS.

Recuerdo y actualización de las bases anatómicas del pene

The knowledge of penile anatomy is basic to perform a proper diagnosis and direct the most adequate treatment of the various diseases that may appear: urethral stenosis, erectile dysfunction, congenital or acquired penile curvature, etc.; being its anatomical knowledge essential for a proper surgical management. The penis is the male organ involved in both voiding and sexual functions: the body of the penis is composed by three erectile bodies, (i.e the deep structures): the corpora cavernosa and the corpus spongiosum, this last surrounding and covering the urethra. Buck's fascia is in relation to the deep structures of the penis. The superficial fascia, dartos, is made up from a more areolar tissue and is in relation to skin and vessels. The vascularization of the deep structures comes from the common penile artery, a branch of the internal pudendal artery. Penile blood drains through three venous systems: superficial, intermediate and deep systems. Pudendal nerves are in charge of the sensitive and motor somatic innervations. Cavernosal nerves are a combination of parasympathetic and sympathetic afferent fibers, corresponding to the nerves of the autonomic system of the penis.

Penile Embryology and Anatomy

Knowledge of penile embryology and anatomy is essential to any pediatric urologist in order to fully understand and treat congenital anomalies. Sex differentiation of the external genitalia occurs between the 7and 17 weeks of gestation. The Y chromosome initiates male differentiation through the SRY gene, which triggers testicular development. Under the influence of androgens produced by the testes, external genitalia then develop into the penis and scrotum. Dorsal nerves supply penile skin sensation and lie within Buck's fascia. These nerves are notably absent at the 12 o'clock position. Perineal nerves supply skin sensation to the ventral shaft skin and frenulum. Cavernosal nerves lie within the corpora cavernosa and are responsible for sexual function. Paired cavernosal, dorsal, and bulbourethral arteries have extensive anastomotic connections. During erection, the cavernosal artery causes engorgement of the cavernosa, while the deep dorsal artery leads to glans enlargement. The majority of venous drainage occurs through a single, deep dorsal vein into which multiple emissary veins from the corpora and circumflex veins from the spongiosum drain. The corpora cavernosa and spongiosum are all made of spongy erectile tissue. Buck's fascia circumferentially envelops all three structures, splitting into two leaves ventrally at the spongiosum. The male urethra is composed of six parts: bladder neck, prostatic, membranous, bulbous, penile, and fossa navicularis. The urethra receives its blood supply from both proximal and distal directions.

Genital self-mutilation

We present a case report of a 22-year-old Nigerian student who presented to the accident and emergency unit of a Nigerian Teaching Hospital with a history of self-inflicted genital injury following a suicide attempt. He had background history of predisposition to depressive illness, a current diagnosis of a major depressive disorder, and had had two attempted suicidal episodes in the last 3 months prior to this event. The clinical finding shows a patient with sad affect, feeling of hopelessness, and worthlessness; however, the vital signs remained fairly stable. At examination under anesthesia, the testes were exposed and the right already self-castrated. The penis was degloved to the level of the Buck's fascia with intact corpora cavernosa and urethra. He had surgical excision of the hanging self-castrated right testis with debridement and primary closure of the genital laceration. He was promptly reviewed by the psychiatrists who co-managed appropriately.

Simple, Safe, and Satisfactory Secondary Penile Enhancement After Near-Total Oncologic Amputation

After oncologic penile amputation, the penile stump may prove of insufficient length, causing poor personal hygiene and scrotal excoriation and an inability to void while standing. In these cases, penile enhancement by uncovering its subcutaneous parts may offer a simple and satisfactory solution.From August 2003 to August 2007, penile enhancement was performed in 6 patients with a mean age of 63 years (range, 51-69 years) and only 1 cm (range, 0-1.5 cm) of remaining penile length when standing up.The skin on the penile stump was used to recreate a neoglans. The subcutaneously covered penile shaft was dissected deep to Buck's fascia up into the deep suspensory ligament. Ventrally, the bulbospongeous muscle was laid bare over 1 to 2 cm. After resection of pubic subcutaneous fat, the pubic and scrotal skin edges were anchored to the suspensory ligament, bulbospongious fascia, and tunica albuginea. The resulting bare surface of the penile shaft was covered by a skin graft.Partial neoglandular skin slough was observed in 2 patients and could be treated conservatively in both. Penile lymphedema was observed in the 1 patient whom had previously undergone radiotherapy. This was treated by secondary subcutaneous resection and skin tightening. At a mean follow-up of 2.5 years (range, 1-5 years), the cosmetic appearance was acceptable in all patients and their penile length ranged from 7.5 to 9 cm. All were able to void while standing without soiling themselves.