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Perineal Approach for Urethral Surgery

Urologic Indications

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

Preoperative Patient Preparation

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

Surgical Technique of an Perineal approach

• The scrotum is pulled upward by the assistant to stretch the skin of the perineum. Median incision of the perineum through the raphe of the scrotum and perineum, depending on the location of the urethral disease. As an alternative to a median incision, a lambdoid incision or perianal incision can be done.
• A Scott ring retractor is inserted after division of the subcutaneous tissue (tunica dartos, fascia penis superficialis and Colles' fascia). The scrotum is splitted into two halves along the septum testis.
• The bulbospongiosus muscle is divided strictly in the midline and the corpus spongiosum of the penis is developed. The bulbospongiosus muscle is pulled to the lateral with the hooks of the Scott retractor.
• For access to the membranous urethra, the bulb of penis is dissected from the central tendon.
• Wound closure: closure of the bulbospongiosus muscle with a running suture vicryl 2-0. Closure of 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