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Perineal Approach to the Penile Suspensory Ligament During Urethroplasty
0022-5347 /81/1254-0504$02.00/0 Vol. 125, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
PERINEAL APPROACH TO THE PENILE SUSPENSORY LIGAMENT DURING URETHROPLASTY ANDREI N. LUPU
AND
LARRIAN GILLESPIE
From the Department of Surgery, Division of Urology, UCLA School of Medicine, Los Angeles and Sepulveda Veterans Administration Hospital, Sepulveda, California ABSTRACT
The simple maneuver of inverting the penis into the perineum during urethral sleeve resection and urethroplasty permits direct access to the penile suspensory ligament. Division of the ligament can then be performed under direct vision with good hemostatic control.
~
Incision of the penile suspensory ligament may be necessary at times during dismembered urethroplasty involving the deep bulbar and/or membranous urethra. By providing greater mobility to the ventral aspect of the corpora it prevents undue tension on the urethral suture line and secondary ventral curvature of the penis. Herein we describe a simple maneuver that offers good exposure of the penile suspensory ligament through a midline perineal approach and permits local control of bleeding and incision of the ligament under direct visual control.
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ANATOMY
The penile suspensory ligament is an extension of the external oblique aponeurosis. It comprises 2 units. The first unit, which contains mostly elastic fibers, is attached to the linea alba and symphysis pubis, and provides dorsal support to the penis by insertion into the tunica albuginea on each side of the deep dorsal vein of the penis. The second unit, which contains mostly fibrous elements and is known as the ligament of Luschka, is attached to the pubis on each side of the symphysis and fans ventrally about the corpora and the urethra to provide ventral support in the manner of a sling. 1' 2 Branches of the external pudenda! veins criss-cross the area (fig. 1). TECHNIQUE
The urethra is approached through a midline perineal incision (fig. 2, A). After incision and lateral retraction of the
FIG.
L
Anatomy of penile suspensory ligament
A 8'Midline incision and lateral retraction of
bulbocavernosus m. Midline perineal inc1s1on
FIG. 2. A, urethral approach. B, urethral exposure
bulbocavernosus muscle (fig. 2, B) the urethra is freed from its dorsal attachments for the desired length (fig. 3, A). The penis and corpora are then inverted into the perineum (fig. 3, B). Accepted for publication August 1, 1980. 504
During the inversion the dorsal aspect of the penile skin assumes a caudad position. By cranial traction of the penile skin and caudad traction of the corpora, the suprapubic area and the suspensory ligament are exposed. Incision of the suspensory
PERihTEAL APPROACH TO PEl'lILE STJSP:El¾:SORY L:IGAJ1IEN'T DU'RING URETI-IFtOPLASTY
5G5
B The penis and corpora are inverted into the perineal opening exposing \he pemle suspensory l1gamenl
A The urethra is freed for \he desired length from its dorsal attachments
FIG. 3. A, urethral mobilization. B, inversion of penis into perineum
ligament and local hemostasis are achieved under direct visual control (fig. 4). DISCUSSION
Background. During transpubic repair of membranous urethral strictures, Waterhouse and associates divide the penile suspensory ligament after extending the abdominal incision to the base of the penis. 3 However, when urethroplasty is performed via the perineal route alone access to the suspensory ligament is cumbersome. Turner-Warwick divides the ligament blindly by inserting a knife into the suprapubic area through the perinea! opening. 4' 5 In our hands, this latter approach has resulted in incomplete division. of the ligament and in bleeding from injury to branches of the external pudendal veins, Rationale. Waterhouse and associates;' and TurnerWarwick4 mention that during dismembered urethroplasty the penile suspensory ligament should be divided. Although Tumer-W arwick states that ", .. additional length may be obtained ... if the peno-pubic suspensory ligament is relaxed" 4 neither author clearly explains why this maneuver should be undertaken. Partial mobilization of the urethra, which is an
FIG. 4. Incision of suspensory ligament
integral part of urethroplasty and division of the suspensory ligament, provides greater mobility to the ventral aspect of the corpora. A drop-back of the corpora of >2 cm. can, thus, be achieved. If the proximal aspect of the divided urethra is then advanced and pexed to the caudally mobilized corpora urethral gaps of >3 cm. can be bridged without tension on the suture line and subsequent ventral curvature of the penis. REFERENCES 1. Rouviere, H.: Anatomie Humaine, 7th ed. Paris: Masson & Co., vol.
2, p. 1015, 1954. 2. Testut, L. and Latarjet, A.: Traite d' Anatomie Humaine, 9th ed. Paris: G. Doin & Co., vol. 5, p. 332, 1949. 3. Waterhouse, K., Abrahams, J. I., Gruber, H., Hackett, R. E., Patil, U. B. and Peng, B. K.: The transpubic approach to the lower urinary tract. J. Urol., 109: 486, 1973. 4. Turner-Warwick, R.: Complications of urethral surgery in the male. In: Complications of Urologic Surgery: Prevention and Management. Edited by R. B. Smith and D. G. Skinner. Philadelphia: W. B. Saunders Co., chapt. 17, p. 336, 1976. 5. Turner-Warwick, R.: Personal communication.
THE JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
PERINEAL APPROACH TO THE PENILE SUSPENSORY LIGAMENT DURING URETHROPLASTY ANDREI N. LUPU
AND
LARRIAN GILLESPIE
From the Department of Surgery, Division of Urology, UCLA School of Medicine, Los Angeles and Sepulveda Veterans Administration Hospital, Sepulveda, California ABSTRACT
The simple maneuver of inverting the penis into the perineum during urethral sleeve resection and urethroplasty permits direct access to the penile suspensory ligament. Division of the ligament can then be performed under direct vision with good hemostatic control.
~
Incision of the penile suspensory ligament may be necessary at times during dismembered urethroplasty involving the deep bulbar and/or membranous urethra. By providing greater mobility to the ventral aspect of the corpora it prevents undue tension on the urethral suture line and secondary ventral curvature of the penis. Herein we describe a simple maneuver that offers good exposure of the penile suspensory ligament through a midline perineal approach and permits local control of bleeding and incision of the ligament under direct visual control.
/~
//
ANATOMY
The penile suspensory ligament is an extension of the external oblique aponeurosis. It comprises 2 units. The first unit, which contains mostly elastic fibers, is attached to the linea alba and symphysis pubis, and provides dorsal support to the penis by insertion into the tunica albuginea on each side of the deep dorsal vein of the penis. The second unit, which contains mostly fibrous elements and is known as the ligament of Luschka, is attached to the pubis on each side of the symphysis and fans ventrally about the corpora and the urethra to provide ventral support in the manner of a sling. 1' 2 Branches of the external pudenda! veins criss-cross the area (fig. 1). TECHNIQUE
The urethra is approached through a midline perineal incision (fig. 2, A). After incision and lateral retraction of the
FIG.
L
Anatomy of penile suspensory ligament
A 8'Midline incision and lateral retraction of
bulbocavernosus m. Midline perineal inc1s1on
FIG. 2. A, urethral approach. B, urethral exposure
bulbocavernosus muscle (fig. 2, B) the urethra is freed from its dorsal attachments for the desired length (fig. 3, A). The penis and corpora are then inverted into the perineum (fig. 3, B). Accepted for publication August 1, 1980. 504
During the inversion the dorsal aspect of the penile skin assumes a caudad position. By cranial traction of the penile skin and caudad traction of the corpora, the suprapubic area and the suspensory ligament are exposed. Incision of the suspensory
PERihTEAL APPROACH TO PEl'lILE STJSP:El¾:SORY L:IGAJ1IEN'T DU'RING URETI-IFtOPLASTY
5G5
B The penis and corpora are inverted into the perineal opening exposing \he pemle suspensory l1gamenl
A The urethra is freed for \he desired length from its dorsal attachments
FIG. 3. A, urethral mobilization. B, inversion of penis into perineum
ligament and local hemostasis are achieved under direct visual control (fig. 4). DISCUSSION
Background. During transpubic repair of membranous urethral strictures, Waterhouse and associates divide the penile suspensory ligament after extending the abdominal incision to the base of the penis. 3 However, when urethroplasty is performed via the perineal route alone access to the suspensory ligament is cumbersome. Turner-Warwick divides the ligament blindly by inserting a knife into the suprapubic area through the perinea! opening. 4' 5 In our hands, this latter approach has resulted in incomplete division. of the ligament and in bleeding from injury to branches of the external pudendal veins, Rationale. Waterhouse and associates;' and TurnerWarwick4 mention that during dismembered urethroplasty the penile suspensory ligament should be divided. Although Tumer-W arwick states that ", .. additional length may be obtained ... if the peno-pubic suspensory ligament is relaxed" 4 neither author clearly explains why this maneuver should be undertaken. Partial mobilization of the urethra, which is an
FIG. 4. Incision of suspensory ligament
integral part of urethroplasty and division of the suspensory ligament, provides greater mobility to the ventral aspect of the corpora. A drop-back of the corpora of >2 cm. can, thus, be achieved. If the proximal aspect of the divided urethra is then advanced and pexed to the caudally mobilized corpora urethral gaps of >3 cm. can be bridged without tension on the suture line and subsequent ventral curvature of the penis. REFERENCES 1. Rouviere, H.: Anatomie Humaine, 7th ed. Paris: Masson & Co., vol.
2, p. 1015, 1954. 2. Testut, L. and Latarjet, A.: Traite d' Anatomie Humaine, 9th ed. Paris: G. Doin & Co., vol. 5, p. 332, 1949. 3. Waterhouse, K., Abrahams, J. I., Gruber, H., Hackett, R. E., Patil, U. B. and Peng, B. K.: The transpubic approach to the lower urinary tract. J. Urol., 109: 486, 1973. 4. Turner-Warwick, R.: Complications of urethral surgery in the male. In: Complications of Urologic Surgery: Prevention and Management. Edited by R. B. Smith and D. G. Skinner. Philadelphia: W. B. Saunders Co., chapt. 17, p. 336, 1976. 5. Turner-Warwick, R.: Personal communication.