Complete Penoscrotal Transposition

• 25 Jun 2021 11:29:03 AM
• |Pediatic Urology

Dear All,

Recently there was a picture of Penoscrotal transposition was posted by Prasanna in Paediatric Urology Group of WhatsApp. We had one sentence answers from MS Ansari and Chandra Singh.

The condition being rare, I felt we should have some discussion on the subject and made a quick search of literature. Majority of the available literature concern Incomplete Penoscrotal transposition with many associated with Perineal Hypospadias.

I am providing two materials which are must read on the subject of Penile Transposition by Mohamed Fahmy* (2014 and 2017 - book Chapter). The Former I am providing the PDF as attachment while the latter, book chapter as a link.

https://link.springer.com/content/pdf/10.1007%2F978-3-319-43310-3_15.pdf  

I am providing an article on ‘Complete penoscrotal transposition: A three-stage procedure’ by Ivan Somoza* et al (2012, IJU)

https://www.indianjurol.com/article.asp?issn=0970-1591;year=2012;volume=28;issue=4;spage=450;epage=452;aulast=Somoza (PDF available)

https://www.indianjurol.com/temp/IndianJUrol284450-1451604_040156.pdf

Another article by Changhee Yoo, Kun Suk Kim* et al (2006, Korean J Urology) is also worth reading though PDF of the article is no longer available.

https://icurology.org/DOIx.php?id=10.4111/kju.2006.47.3.287 (No PDF available)

There are many articles addressing Incomplete verities of PSTs and those associated with Hypospadias and the procedures employed in their correction. I am not going int these at present.

I am sure our Pandits in the field will give us their valuable inputs with their experience.

With warm regards

Venu 

 

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Comments(7)

• 

  Amilal Bhat

  25 Jun 2021 05:01:34 PM

  PST gets much less attention. My views on  the classification and management is given  :-

  Penoscrotal transposition:

  Classification:  

  1. Congenital: Congenital disability with complete penoscrotal transposition to minor defect.

  2. Acquired (Secondary severe infection and scaring): Extensive scaring and debridement after Fournier gangrene may pull the scrotum below the scrotum. Repositioning of such scrotum is more complicated and challenging than congenital Penoscrotal transposition. 

  3. Iatrogenic:  Sometimes penis may have to be located below the scrotum to bridge the long urethral defect and achieve continuity of the urethra. Sometimes it is post-circumcision penis webbed.

  Congenital

  1 Penoscrotal transportation which is divided

  â–ª Complete (Extreme)

  â–ª Incomplete.

   B Minor, which is subdivided into:

  â–ª Bilateral (Symmetrical)

  2.Central Scrotalization of the median raphe.

  3.Wide penoscrotal distance or caudal penoscrotal transposition.

  I. Primary Webbing  

  A. Simple

  Grade 1 web extend up to proximal 1/3 of shaft of the penis.   

  Grade 2 web extend up to middle 1/3 of shaft of the penis.  

  Grade 3 web extend up to distal 1/3 of shaft of the penis.  

  Grade 4 Buried penis When the penis remains hidden and embedded under the suprapubic area this condition is called a buried penis

  B. Compound 

  Type 1. Web with pre-penile scrotum

  Type 2. Web with penile curvature

  Type 3. Broad web 

  II. Secondary webbed penis: Post circumcision in obese children or concealed penis 

   

  Management Scrotoplasty.

  Surgery for Penoscrotal Web

  Heineke-Mikulicz principle: A transverse penoscrotal junction incision is made centered at the expected penoscrotal angle. The horizontal incision mustn't be extended too laterally to cause a resultant narrowing at the base of the penis. This is then followed by a two-layer vertical closure of the defect, including subcutaneous sutures before the skin closure.   

  V-Y scrotoplasty. The V-Y scrotoplasty is a technique that allows lengthening of tissues via the formation of an inverted V-shaped flap. The centre of the V is the location of the maximal skin tension on the ventral shaft. The leg of the Y ends at the new penoscrotal angle. Traction sutures and skin hooks facilitate the design and raise of the skin flaps. This defect is then closed in forming a 'Y' configuration with a deep dermal plication stitch to relieve any excess tension.

  Z scrotoplasty:  A vertical incision is given, and two wings of the Z are created having the parallel angles 60 degrees on the proximal and distal ends of the incision. The two flaps created by these three incisions are approximated in such a way to elongate the coverage over the ventral shaft and creating the penoscrotal angle.  The length of all three incisions should be equal to avoid asymmetry from twisting penile skin. It is also vital to develop wide-based flaps to avoid flap necrosis.    In severe cases, multiple Z-plasty incisions may be required sequentially to augment the repair, and excess skin may be resected along the median raphe.

  II. Management of Penoscrotal transposition (PST)

  The management should start with a multidisciplinary approach taking care of other associated anomalies and parents' involvement in the treatment plan of a newborn. Early institution of treatment is ideal for preventing the psychological trauma to the child and parents at earliest, but this should not be done at the cost of evading through evaluation protocol. Patients of severe penoscrotal transposition should be evaluated for other associated VACTERL anomalies. A staged repair is often needed as the pathology is associated with hypospadias or other anorectal malformations.  Objectives in Complete PST management are to locate the penis in normal position, correction of chordee, urethroplasty, glanuloplasty and scrotoplasty. In severe form of penoscrotal transposition, there may not be the hypospadias, but urethra is usually short, so these patients also require urethroplasty with scrotal correction transposition. Repair may be staged or can be done in single stage provided the goals mentioned above are achieved. In cases with perineal hypospadias with chordee and bifid scrotum may be staged in two or three.  Orthoplasty in the first stage, urethroplasty or scrotoplasty in the second stage, and scrotoplasty or urethroplasty in the third stage.  In two-stage orthoplasty and /or scrotoplasty in the first stage, and urethroplasty glanuloplasty and scrotoplasty in the second stage. The basic principle in all type of scrotoplasty is to preserve blood supply and lymphatics of the penis to prevent complications like penile skin necrosis and lymphoedema

• 

  Chandra Singh J

  26 Jun 2021 07:37:17 PM

  Thank you Prof.Amilal for those valuable inputs. In PST associated with severe hypospadias, I have always prefer staged repair, for fear of compromising on the vascularity. In the Korean article referenced by Prof.PVG, they have reported no complications, though there seems to be no connecting bridge to the skin of dorsal penis. What has been your experience in single stage repair?  Would you recommend any techniques to optimize the results?

  
  

• 

  Chandra Singh J

  26 Jun 2021 10:03:08 PM

  Thank you Prof.Amilal for those valuable inputs. In PST associated with severe hypospadias, I have always prefer staged repair, for fear of compromising on the vascularity. In the Korean article referenced by Prof.PVG, they have reported no complications, though there seems to be no connecting bridge to the skin of dorsal penis. What has been your experience in single stage repair?  Would you recommend any techniques to optimize the results?

  
  

• 

  Dr. Prasanna Venkatesh M K

  10 Jul 2021 05:49:16 PM

  Thank you Prof Amilal Bhat  and Prof Chandra Singh for your valuable comments. This is indeed a rare  anomoly, and cause significant distress to the parents. I agree that these repairs have to be carried out by multi disciplinary teams and it would be better if staged.

  
  

  Thank you Prof PVG Sir, for bring this topic onto the group for discussion

• 

  PANKAJ JOSHI

  04 Aug 2021 01:58:51 PM

  Excellent discussion and thank you teachers for enlightening.

  This is a complex subject.

  We get referrals for failed Hypsoapdais where many a times the penoscrotal transposition is uncorrected.

  Genital aesthetics is a priority .

  Presenting  photos of such patients where we corrected the urethra and transposition in one stage.

  
  

  
  

  

• 

  Dr. Anil Takvani

  04 Aug 2021 08:33:35 PM

  Dear Pankaj, 

  
  

  Thanks for adding excellent photos of two cases...

• 

  Dr. Anil Takvani

  05 Aug 2021 08:27:35 PM

  Dear Pankaj, 

  
  

  Thanks for adding excellent photos of two cases...