Alex Vanni, MD

	As of 2014, World Health Organization estimates determined that 600 million people were obese. The number of obese people has doubled from 1980 to 2014, leading many urologists to become accustomed to operating on men who weigh over 300 or 400 pounds. As such, it is increasingly important for the urologic work force to be aware of the genitourinary repercussions of obesity. As the U.S. health system increasingly pushes to increase the value of health care, management of obesity-related conditions, such as buried penis, in a cost-effective manner becomes increasingly important.

	These videos illustrate the tissue handling, aesthetic, and functional considerations of optimizing outcomes in buried penis repair by experienced reconstructive surgeons. Commentary on each video is provided by Jeremy B. Myers, MD, associate professor in the division of urology at the University of Utah, and by 'Y'tube Section Editor James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

	Resection, reconstruction of massive lymphedema of the male genitalia

 illustrate their technique of resection and reconstruction of massive lymphedema of the male genitalia. They also present a case series of three men with massive lymphedema of the genitalia treated between 2014 and 2015.

 The authors demonstrate a technique for treatment of massive genital lymphedema, which can arise from previous inguinal or genital operations or from obesity. Highlights of their technique are relocation of the penis through the suprapubic fat pad to a more anatomic location and reconstruction of a neo-scrotum through flaps of lateral scrotum and perineum with areas unaffected by lymphedema. In addition, the authors show how a skin graft can be harvested from lymphedematous resected tissue and used with good results for penile skin grafting. Despite the horrendous nature of this problem, the results demonstrated in the video are very impressive.

Here, the surgeons illustrate how the excellent vascular supply of the penis and scrotum can be used to facilitate an optimal cosmetic outcome for buried penis repair. Further, their use of the resected tissue for a skin graft also minimizes morbidity for a patient population where postoperative complications are common and have the potential to be devastating.

	Correction of concealed penis with panniculectomy, penile skin graft

 depicts correction of concealed penis with panniculectomy and penile skin graft in a 63-year-old man with morbid obesity whose penis was completely concealed for 7 years.

 Dr. Vanni demonstrates repair of buried penis in a patient with morbid obesity. Their technique involves panniculectomy of the suprapubic fat pad with fixation of the fat pad to the deep tissue overlying the pubis. Reconstruction of the peno-scrotal and peno-abdominal junction is performed with a flap of redundant scrotum. The penile skin graft is applied with a bolster type of dressing. Their meticulous technique is evident throughout the video.

Dr. Vanni demonstrates how both removal of and fixation of the suprapubic fat pad are required to fix the penoscrotal junction in an optimal anatomic and functional location. The use of a bolster is a critical part of this surgery and greatly facilitates optimal wound healing and cosmetic appearance of the shaft skin. Although this may seem like a trivial portion of the operation, stabilization of grafted tissue in the morbidly obese patient is incredibly complex yet vital to an optimal outcome.

	Buried penis repair: Removal of suprapubic fat pad and split thickness skin graft

 demonstrates repair of buried penis in super-morbid obese men. The technique involves resection of the suprapubic fat pad entirely with reconstruction of lateral groin. Scrotectomy and reconstruction of the peno-scrotal and peno-abdominal junction is also shown.

 Here, we demonstrate repair of buried penis in super-morbid obese men. The technique involves resection of the suprapubic fat pad entirely with reconstruction of lateral groin. Scrotectomy and reconstruction of the peno-scrotal and peno-abdominal junction is also shown. The penile skin graft is taken from the resected suprapubic fat pad. We emphasize the type of body habitus, which is amenable to this repair and those patients that have a body habitus that need to be treated with a full abdominoplasty. Common wound complications are noted in one of the patients, and his healing is tracked over 2 months.

Here, Dr. Myers ablates the entire suprapubic fat pad with reconstruction from the lateral groin. This approach also includes a scrotectomy with reconfiguration of the peno-scrotal and peno-abdominal junction. Similar to Dr. Dugi and colleagues, Dr. Myers uses the resected suprapubic fat pad to harvest the skin graft. He also covers optimal patient selection for this approach, which is perhaps the most important component of a successful outcome in this patient population. Finally, the video covers common wound complications and their management, which are a common, if not inevitable component of this surgery.

	Limited panniculectomy for adult buried penis repair

 and colleagues demonstrate limited panniculectomy for adult buried penis repair in a 37-year-old male with Prader-Willi syndrome resulting in morbid obesity.

 Dr. Voelzke and colleagues demonstrate repair of buried penis. They very nicely emphasize the need to tack the suprapubic fat pad or “mons pannus” to the periosteum of the symphysis pubis. They also demonstrate the importance of not pulling down the peno-scrotal junction and peno-abdominal junction in order to expose the penis more. Exposing more of the penis is tempting since this is the objective of surgery, but will lead to a crevasse of very poor healing where the skin graft on the penis meets the abdomen and scrotum.

Here, the authors demonstrate the optimal balance between obtaining a normal cosmetic appearance and optimizing wound healing of the skin graft.

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These four videos depict expert techniques for buried penis repair.

Buried penis repair: Videos illustrate aesthetic, functional considerations

 a new video section of UrologyTimes.com, is a resource for urologists and other clinicians who focus on men’s health. ‘Y’tube covers surgical aspects of a variety of men’s health issues with the ultimate goal of accumulating a library of videos to serve as a reference. Here, three reconstructive urologists fellowship trained by Jack McAninch, MD, or Hunter Wessells, MD, illustrate the nuances of managing urethral stricture disease. Perhaps the most important aspects of these videos for the general urologist are the keys of precise setup, retraction, and exposure that facilitate meticulous tissue handling and precise suture placement. These videos serve as a reference that can be quickly reviewed before undertaking any of these procedures.

	This video demonstrates buccal mucosa graft urethroplasty for lengthy bulbar urethral strictures that are not amenable to excision and primary anastomotic urethroplasty. In addition, the video emphasizes sparing of the bubospongiosus muscle rather than division of the muscle.

Dr. Vanni shows the release of the bulbospongiosus muscle from the bulbar urethra and around the inferior aspect of the bulb, with gentle retraction of the muscle rather than midline division of the muscle. Although the evidence does not strongly support of an effect, proponents of this technique believe it decreases problems with post-void dribbling and ejaculatory dysfunction by preserving the function of the bulbospongiosus muscle. Despite natural worries about limiting exposure to the deep bulbar urethra, Dr. Vanni clearly demonstrates excellent exposure right up to the start of the membranous urethra.

	Another nice part of the video is Dr. Vanni’s use of a Gorget retractor to place stitches at the proximal urethral spatulation. The placement of sutures at the level of the bulbo-membranous junction can be very challenging and, as show in the video, this task can be facilitated by a retractor like the Gorget.

 Dr. Vanni illustrates the use of many of the nuanced tools and techniques that facilitate atraumatic tissue handling and exposure in reconstructive urology. He also illustrates how an atraumatic exposure of the entire bulbar urethra can be achieved without the need for complete division of the bulbospongiosus muscle. His meticulous tissue handling and excellent exposure allow for a precise anastomosis.

Excision and primary anastomosis anterior urethroplasty

Perineal urethrostomy for severe urethral strictures

Posterior urethroplasty for pelvic fracture urethral injury

This video demonstrates buccal mucosa graft urethroplasty for lengthy bulbar urethral strictures that are not amenable to excision and primary anastomotic urethroplasty.

Author | Alex Vanni, MD

Articles

Buried penis repair: Videos illustrate aesthetic, functional considerations

Urethroplasty: Bulbospongiosus sparing dorsal onlay bulbar urethroplasty