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This article reviews anatomic considerations in penile and urethral surgery, with a particular emphasis on lymphatic anatomy. The historical evolution of techniques to reduce the unnecessary use and operative morbidity of inguinofemoral lymph node dissection are reviewed, with an emphasis on sentinel node (SN) biopsy and dynamic SN biopsy techniques., (Copyright 2010 Elsevier Inc. All rights reserved.)

Presence and magnitude of the inguinal nodal metastases are the most important determinants of oncologic outcome in patients with squamous carcinoma of the penis (SCP). Surgical removal of the inguinal lymph nodes provides an important staging and therapeutic benefit to SCP patients, while the methodology of appropriate patient selection for lymph node dissection continues to evolve. Compliant, motivated, and reliable patients with low risk of harboring metastatic inguinal lymph nodes can be managed with careful inguinal surveillance. In SCP patients whose primary tumors demonstrate pathologic features of aggressive disease, modified bilateral inguinal lymph node dissection should be performed and converted to classic ilioinguinal lymph node dissection if metastatic disease is confirmed on frozen sections. Patients with bulky inguinal metastases are unlikely to be cured by surgery alone. Integration of systemic therapy, especially in a presurgical setting, is an attractive strategy for management of patients with advanced SCP, and is currently being studied prospectively., (Copyright 2010 Elsevier Inc. All rights reserved.)

This article reviews the physiology of penile erection, the components of erectile function, and the pathophysiology of erectile dysfunction. The molecular and clinical under-standing of erectile function continues to gain ground at a particularly fast rate. Advances in gene discovery have aided greatly in working knowledge of smooth muscle relaxation/contraction pathways. The understanding of the nitric oxide pathway has aided not only in the molecular understanding of the tumescence but also greatly in the therapy of erectile dysfunction.

The circular fasciocutaneous penile flap meets all criteria for tissue transfer and urethral reconstruction. It reliably provides ample hairless tissue, usually 13 to 15 cm long, without compromising cosmesis or function. We find it ideal for long strictures in the distal or pendulous urethra, where the decreased substance of the corpus spongiosum may jeopardize graft viability. A second major advantage is its versatility: it can be used throughout the entire anterior urethra, from the membranous area to the meatus. In addition, the circular fasciocutaneous penile flap is easily combined with other tissue-transfer techniques when necessary, enabling one-stage reconstruction in the majority of cases. The flap may be tubularized for replacement urethroplasty or divided and used in two separate stenotic areas. Onlay reconstruction is preferable to flap tubularization and has provided a better initial and long-term outcome. The circular fasciocutaneous penile flap provides superior results even in patients with complex refractory strictures in whom previous attempts at anterior urethroplasty have failed. We believe its superiority resides in the transfer of well-vascularized tissue to the compromised area. Complications can be minimized by avoiding prolonged placement in the exaggerated lithotomy position and by meticulous attention to principle of reconstructive surgery.

The correction of strictures involving the fossa navicularis poses a distinct reconstructive challenge. Unlike surgical repair of strictures involving other urethral segments where the primary concern is restoration of urethral patency, management of fossa navicularis strictures also requires particular attention to cosmesis. Paramount to the success of any of the described procedures is the careful selection of nondiseased tissue for substitution. If the penile skin is healthy, the preferred urethral substitute is the fasciocutaneous ventral transverse island flap. The inherent characteristics of this versatile flap (i.e., well-vascularized predictable pedicle, nonhair bearing, negligible contraction) provide for an excellent time-tested glandular urethral substitute. In rare cases in which there is a suggestion of penile skin inflammation or scarring, extragenital tissue transfer techniques should be considered. Equally important is the need to substitute the entire length of diseased urethra, preferably as an onlay, preserving the dorsal urethral wall. Persistent proximal urethral disease will eventually result in further stricture formation. Finally, the choice of glanduloplasty is particularly important in achieving a cosmetically appealing outcome. A glans-cap repair is preferred because of the limited dissection required with this relatively simple and bloodless technique. Careful selection of the most appropriate combined urethral substitution and glans reconstruction techniques, as well as meticulous attention to surgical details, are mandatory for achieving a satisfactory functional and cosmetic outcome with fossa navicularis strictures.

Aesthetic procedures can increase the girth and visual length of the penis. Dermal-fat grafts increase penile circumference without the complications that result from fat injections. Release of the suspensory ligaments with skin advancement may increase flaccid penile length. Suprapubic lipectomy and Z-plasty of a penoscrotal web enhance penile appearance. Accurate diagnosis and meticulous technique are mandatory.

Modern tissue transfer techniques, often incorporating penile or scrotal skin islands based on a dartos fascia pedicle, have revolutionized urethral reconstruction. There are certain situations, however, that require a more creative and complex approach. The majority of these cases involve patients with panurethral stricture disease or those who have undergone multiple previous procedures for urethral stricture disease or hypospadias and their subsequent complications. In this article, the authors discuss the various aspects of these two conditions and outline several techniques for urethral reconstruction in these challenging patients.

Lymphangiograms performed via the dorsal lymphatics of the penis demonstrate drainage into a specific lymph node center, the so-called sentinel lymph node, which is located close to the superficial epigastric vein between the latter and the superficial external pudendal vein. Anatomically, clinically, and pathologically, the sentinel lymph node is the first site of metastasis and often is the only lymph node involved. We recommend preliminary bilateral sentinel lymph node biopsy, with inguinofemoral dissection being performed only when this node is involved. If the biopsies are negative for metastases, no further surgical therapy is immediately indicated, and the patient needs to be observed closely with monthly examination for 1 year and examination every 2 months for 3 years. The clinical staging of cancer of the penis needs a new review for further evaluation of different modalities of treatment. Sentinel lymph node biopsy must not be used to determine whether node dissection is needed in patients with evident clinically positive nodes. Also, the concept of sentinel lymph node should not be applied in the management of patients who will not be available for frequent follow-up. If during physical examination, suspect lymph nodes are found other than the classic sentinel node, these lymph nodes must be removed for staging and subsequent treatment planned according to the histologic report.

The urethra is lined by transitional and stratified columnar epithelium. The urethra can be divided into both anatomic (prostatic, membranous, bulbar, and pendulous) and functional (anterior and posterior) segments. In the male, the anterior urethra is contained within the corpus spongiosum and penis. The urethra in the male and female is located within the urogenital triangle and pierces the superficial and deep perineal spaces of the pelvic floor. The urethra is surrounded by perineal and pelvic musculature that provide support and also form the urethral sphincter mechanism. Cancers of the anterior urethra preferentially drain into superficial inguinal lymph node channels. Those of the posterior urethra (prostatic, membranous, and bulbar segments in the male and the proximal two thirds of the urethra in the female) generally drain into pelvic lymphatic channels. A thorough knowledge of urethral and regional anatomy allows for complete tumor excision, optimal reconstruction, and in selected cases, restoration of urinary tract function.

Radical ilioinguinal lymphadenectomy remains the mainstay of treatment for certain genitourinary carcinomas either with the propensity for or with clinical evidence of metastases to the inguinal-pelvic region. The most frequent indication for this procedure in urologic practice is carcinoma of the penis, followed by carcinoma of the urethra, scrotum, and testis with scrotal invasion. This article reviews the anatomy of the inguinal and iliac region and presents a detailed discussion of the surgical technique and its most recent modifications.

A few clinical caveats relevant to penile neurovascular and lymphatic anatomy deserve special emphasis. First, it is clear from the work of Breza and others that the neurovascular anatomy of the penis differs from patient to patient, especially with regard to the arterial supply. It seems prudent to identify an accessory pudendal artery during pelvic lymphadenectomy and nerve-sparing prostatectomy in order to prevent a neurologically intact penis being left with an inadequate corporal blood supply. From an anatomic perspective, it appears that the sentinel lymph node biopsy might be useful in the management of superficial carcinoma of the prepuce or skin of the penis, as these areas drain to the superomedial zone of the superficial inguinal nodes, to which the sentinel node belongs. However, most tumors of the penis involve the glans. Thus, the sentinel node biopsy will not reliably predict nodal involvement for all clinical stage I lesions, as the lymphatics from the glans may bypass the superficial nodes to invade the pelvic nodes directly. Finally, it remains to be determined what impact, if any, the improved understanding of penile anatomy will have for the patient with carcinoma of the penis. The extent of dissection, both in partial penectomy and in nodal dissection, deserves careful consideration. Armed with a clearer understanding of the anatomy of the penis, the urologist can choose a plan of surgical treatment wisely.

Reportedly, 4 to 30 per cent of patients suffer impotence after prostatectomy. Some cases of neurovascular impotence can be attributed to the surgical technique. The author examines the incidence and mechanisms of such impotence and outlines the evaluation and treatment options.

Ritual circumcision of males has been practiced for millennia, but was limited to fewer than 20 per cent of the world's population. About a century ago, only the English-speaking countries adopted non-religious circumcision as a prophylactic or therapeutic panacea for myriad ailments. Since these "health" claims are now known to be unsubstantiated, the English-speaking countries either abandoned the practice or reduced the frequency of its performance; the only exception is the United States. This article examines the background for this enigma and suggests solutions.

Urethral injuries below the urogenital diaphragm may result from external trauma or instrumentation. The most severe complication is the development of a urethral stricture. Proper care of the acute injury will diminish this possibility. In the hands of an experienced perineal surgeon repair of the externally traumatized urethra should consist of urethral debridement, mobilization, spatulation, and primary anastomosis. If an experienced surgeon is not immediately available, a suprapubic tube should be placed after draining the perineum. When major injuries occur requiring life-saving procedures and immediate care of other problems, the urine should be diverted with a suprapubic tube and urethral repair carried out later.