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Perineal Approach for Urethral Surgery

Urologic Indications

In urology, a perineal incision is used to approach the bulbar or membranous urethra or prostate (Schreiter and Jordan, 2006).

Patient Positioning

Lithotomy position of the patient. Surgery of the membranous urethra or perineal approach to the prostate requires an extreme lithotomy position. With additional flexion of the lumbar spine, lifting of the buttocks (oblique positioning cushion), and increased hip joint flexion, the perineum can be aligned parallel to the floor. The legs are mounted in special holders. The padding of all the relevant pressure points is of paramount importance.

Surgical Technique of a Perineal Approach

• The assistant pulls the scrotum upward to stretch the skin of the perineum. Perform a median incision of the perineum through the raphe of the scrotum and perineum, depending on the location of the urethral disease. Alternative to a median incision, a lambdoid incision or perianal incision is possible.
• Use a Scott ring retractor after the division of the subcutaneous tissue (tunica dartos, fascia penis superficialis, and Colles' fascia). The scrotum is split into two halves along the septum testis.
• Divide the bulbospongiosus muscle strictly in the midline and mobilize the corpus spongiosum of the penis. Pull the bulbospongiosus muscle to the lateral with the hooks of the Scott retractor.
• Dissect the penile bulb from the central tendon for an approach to the membranous urethra.

Wound Closure:

Close the bulbospongiosus muscle with a running suture (e.g., vicryl 2-0). Adapt the subcutaneous tissue with interrupted sutures.

References

Schreiter, F. & Jordan, G. (ed.) Reconstructive Urethral Surgery
Springer Medizin Verlag Heidelberg, 2006

  Deutsche Version: Perinealer Zugang zur Harnröhre