Surgical anatomy of Penis with special reference to hypospadias

1. Penile Anatomy
Dr. Faheem ul Hassan Andrabi
Fellow Pediatric Urology
Dr. Vinay Jadhav
Assist. Professor
Pediatric & Neonatal Surgery

2. Penis
A sign of pride and power before which even the veteran surgeons loose both.
S. F. Andrabi

3. External anatomy
The penis consists of an
attached root (radix)
a free, pendulous, body
(corpus) covered by skin

4. Skin
Skin is thin and loose
At the corona of the penis it is folded
to form the prepuce or foreskin

5. Skin
The internal preputial layer is
confluent with thin skin of glans
the frenulum, passes from the deep
surface of the prepuce to the glans

6. Root
The root of the penis consists of
two crura and the bulb,
crura are attached to the pubic arch and
bulb to perineal membrane respectively.

7. Root
The crura are continuation of corpora cavernosa, and the
bulb is the dilated posterior end of the corpus
spongiosum.

8. Root

9. Body
Body of the penis consists of erectile tissue,
the right and left corpora cavernosa and the
median corpus spongiosum

10. Corpora cavernosa
Form most of the body of the penis.
They share a common fibrous envelope, the tunica albuginea (TA)
TA forms a septum between corpora which deficient distally
The two corpora communicate distally

11. Corpora cavernosa
Ventral to corpora is corpus
spongiosus
dorsally between the corpora is
dorsal neurovascular bundle.
The corpora end distally within the
proximal aspect of the glans penis

12. Corpus spongiosum
The corpus spongiosum of the penis is traversed by the urethra
It is cylindrical, tapering distally, and surrounded by a tunica
albuginea.
Near the end of the penis it expands into the glans penis

13. Dartos Fascia
A loose areolar subcutaneous tissue, devoid of fat
contains the superficial blood vessels, nerves, and
lymphatics.

14. Buck’s Fascia
The deep fascia penis (Buck’s) binds the three bodies together
splits ventrally to ensheathe the corpus spongiosum,
It is closely adherent to the tunica albuginea.
Distally, it is attached to the coronal groove.
Proximally, it covers the crura and bulb

15. Fascia of Penis

16. Urethra

17. Suspensory ligaments of penis
Fundiform_________ Linea alba
Triangular_________ Pubic symphysis

18. Deep Arterial Supply
Internal Iliac Artery
Internal Pudendal Artery
Bulbourethral Artery
Cavernous Artery
Dorsal Artery

19. Deep Arterial Supply

20. Dorsal Artery of Penis Branches
Cortical branches____ Pierce Tunica Albuginea
Circumflex Branches___ Supply Corpus Spongiosum
Frenular artery_____ Supplies Glans

21. Deep Arterial Supply- Bulbourethral artery
runs through the deep transverse perineal muscle
to the penile bulb
It supplies the
corpus spongiosum
Bulbar urethra
bulbourethral gland.

22. Deep Arterial supply- Cavernosal artery
Passes through the perineal membrane
enters the crus penis on each side
runs the length of the corpus cavernosum
supplies the erectile tissue

23. Deep arterial supply- Courses of 3 arteries
Bulbar a.
pierces the urogenital diaphragm and bulbospongiosus muscle supply corpus
spongiosus
Urethral a.
also enters the bulb close to the bulbar.

24. Deep arterial supply- Courses of 3 arteries
The cavernosal artery
runs along the superomedial aspect of the crus, pierces the tunica
albuginea just before the two crura unite, and runs distally in the
center of the corpus cavernosum

25. Deep arterial supply- Courses of 3 arteries
Dorsal artery
runs distally lateral to the deep dorsal median vein and medial to the
dorsal nerve

26. Superficial arterial supply
Femoral artery
Deep EPASuperficial EPA
Dorsolateral & ventrolateral
Axial arteries

27. Superficial arterial supply

28. Superficial arterial supply

29. Superficial arterial supply
Axial branches give off cutaneous branches at the base of the penis
to form a subdermal arterial plexus, which extends distally to the
prepuce.

30. Superficial arterial supply

31. Superficial arterial supply

32. Superficial arterial supply
Behind the corona, the axial arteries send perforating branches
through Buck’s fascia to dorsal arteries

33. Superficial arterial supply

34. Superficial arterial supply

35. Prepucial arterial supply
the minute axial arteries supplying the outer prepuce layer fold by
360 º to terminate at the corona

36. Propucial arterial supply
incision along the coronal sulcus would not damage the arterial
supply of the prepuce in any way as the vessels terminate at this site

37. Venous Drainage
superficial drainage system
Prepuce Skin Subcutaneos tissue
Superficial dorsal vein 2
Left Saphenous vein

38. Venous Drainage
superficial drainage system

39. Venous Drainage
Intermediated venous drainage

40. Venous Drainage
Deep venous drainage

41. Lymphatic drainage
penile and perineal skin
 superficial inguinal nodes
glans
 deep inguinal and external iliac nodes.
Lymph vessels from the erectile tissue and
penile urethra
 internal iliac lymph nodes

42. Nerve Supply
Sympathetic
T11–L2
Parasympathetic
S2–4

43. Surgical Implications of arterial supply
It is necessary to keep intact at least one, and preferably two, of
the four branches of the external pudendal artery supplying the
penile skin.
The dorsolateral pair are the ones usually used for a pedicle.
Because the vessels are arranged axially, only longitudinal pedicles
can be raised.

44. Surgical Implications of arterial supply
Superficial fascia is indivisible, because it contains the blood
supply. It can support only one flap, although two flaps could be
formed side by side.
Closer to the corona prepuce has tenuous blood supply
A flap from the shaft will have a better blood supply than one from
the prepuce
Outer prepuce will have better blood supply than inner preputial
surface. This can be an important factor when a flap is to be placed
at a scarred site.

47. Key Points
The three main abnormalities in Hypospadias are
abortive foreskin
arrested urethra and
Deficient urethral spongiosum

48. Triangular defect
Its summit is formed by the proximal division of the corpus
spongiosum
The lateral sides by the two atretic pillars of spongiosum
And the base by the widely open glans.

49. Triangular defect
All tissues sitting inside this triangle are under-developed,
hypoplastic or dysplastic, although there is no histological
consensus to define these concepts

50. Key Points
Histological analysis has shown that the urethral plate in
hypospadias is well vascularized, with sinusoids of abortive
urethral spongiosum, and without scar tissue
These features may explain the successful use of incorporating the
urethral plate or abortive spongiosum into hypospadias
reconstruction

52. (1) tip of corpora cavernosa
(2) glans cap
(4) the tunica albuginea
(5) Buck fascia
(8) preputial dartos

53. Key Points
There is line of relative avascularity at dorsal midline with rich
vascularity on dorsolateral aspects
On ventral aspect, ventral penile branch of anterior scrotal artery is
not always present.

54. Key Points
intraglanular arcade of vessels is protected by the lamina propria
of the base of glans fused with the intraglanular extension of Buck
fascia

55. Key Points
Dorsolateral and dorsomedial branches run at the lateral aspect of
shaft in the area between 10- to 8-o’clock and 2- to 4-o’clock
positions
A rich collateral network is present at the base of glans cap over
the tip of corpora cavernosa with anastomosis between terminal
branches of superficial dartos vessels & dorsal penile artery

56. Penile anthropometry in North Indian children

57. Thank you
Thank you
Srinagar; Almond Blossoms
drfaheemandrabi@gmail.com