Annals of Pediatric Surgery, Vol 4, No 1,2, January-April 2008 PP 14-17 Original Article Correction of Penoscrotal Transposition by Modified Glenn-Anderson Technique Amin M. Saleh, Amr M. Abdelatif, Amira Waly Pediatric Surgery Unit, Faculty of Medicine, Zagazig University, Egypt. Abstract Background/ Purpose: Penoscrotal transposition may be partial or complete resulting in variable degrees of positional exchanges between the penis and the scrotum. Repair of penoscrotal transposition rely on the creation of rotational flaps to mobilize the scrotum down or transposing the penis to a neo hole created in the skin of mons pubis. Almost all known techniques make in complete circular incision around the root of the penis and this result in severe and massive edema of the penile skin that delay correction of the frequently associated hypospadias, and increase the incidence of complications. A modification of Glenn-Anderson technique was used to prevent the postoperative edema and allows early correction of associated hypospadias, and to decrease the incidence of potential complications. The results were compared with other reported techniques. Materials & Methods: Ten patients with incomplete penoscrotal transposition had been corrected by designing rotational flaps that push the scrotum back while the penile skin remain attached by small strip to skin of mons pubis.The early and late results were analysed. Results: All patients have had excellent cosmetic outcome. There have been minimal postoperative edema and no vascular compromise to penile or scrotal skin. Repairs of associated hypospadias were done in the same sitting in 2 patients, and 3-6 months after correction of penoscrotal transposition in the other 8 patients. Conclusion: The proposed modification of Glenn-Anderson technique minimizes post operative edema and improves healing with excellent cosmetic appearance. It allows one stage repair of associated htpospadias and reduce postoperative complications as urinary fistula, and flap necrosis. Index Word: Scrotal transposition, penis, hypospadias. INTRODUCTION enoscrotal transposition is a rare anomaly of the The aim of this study was to evaluate the results of P external genitalia characterized by malposition correction of incomplete penoscrotal of the penis in relation to the scrotum. In complete transposition and associated hypospadias transposition the scrotum covers the penis, which by a modification of Glenn –Anderson emerges from the perineum. In technique. incomplete transposition, which is more common, the penis lies in the middle of the scrotum. Both forms are often associated with a severe hypospadias.1 Correspondence to: Amin Saleh MD, Pediatric Surgery Unit, Faculty of Medicine, Zagazig University, Egypt. Tel: 0120080706. Email: [email protected] Saleh A. et al. PATIENTS AND METHODS The lines of incision were drawn around the root of the penis to elevate the two halves of the scrotum as Between 2004 and 2007, 10 patients underwent rotational flaps leaving the dorsal penile skin surgery for incomplete penoscrotal transposition connected to the skin of mons pubis. It is important to associated with hypospadias. Their ages ranged be sure that the designed incisions do not meet in the between 1 to 9 years. The hypospadias was classified mid line as in Glenn-Anderson technique 2 to leave a as subcoronal in 2 patients, penile in 3, penoscrotal in bridge of skin about 3-5mm separating the two 2, scrotal in 2, and perineal in 1. After release of the incisions and connecting the penile skin to the skin of chordee; 2 patients had proximal penile, 3 had mons pubis. So no circular incision was done around penoscrotal, 3 had scrotal and 2 had perineal the root of the penis as in other techniques, and penile hypospadias. skin remains connected and drained to skin of mons pubis. Two scrotal wings were thus created and Five patients had associated congenital anomalies in mobilized by subcutaneous dissection. The next step the form of incomplete testicular descent and inguinal was straightening of the penis and excision of the hernias (2 bilateral and 3 unilateral). chordee. The median scrotal raphe was incised along approximately half its length leaving the mobilized Surgical technique: (Figs 1-4) urethra entirely free. Fig 1. Incision were drawn around the root of the Fig 2. About 3-5mm bridge of skin separating the two penis to elevate the two halves of the scrotum incisions and connecting the penile skin to the skin as rotational flaps. of mons pubis. A B Figs 3a,b. The two scrotal wings were rotated infero medially and sutured together. 15 Vol 4, No 1,2, January- April 2008 Saleh A. et al. Complete mobilization and fixation of the testes were straightening into a button hole designed in the skin of performed in all patients. Herniotomy was performed mons pubis. in 5 patients (3unilateral and 2 bilateral) through the Complications after surgery for penoscrotal same scrotal approach. transposition include urethral and testicular injury, The two scrotal wings were rotated infero medially urinary fistula, flap necrosis, and penile edema. Circular and sutured together with 4-0 absorbable sutures. incision at the root of the penis partially compromises lymphatic drainage which may interfere with healing of The repair of associated hypospadias was done by the neourethra.10 3 tubularized incised plate (TIP) urethroplasty in the Observation of patients corrected by Glenn Anderson same sitting in 2 patients, and 3-6 months after technique showed gross edema that persists for long correction of penoscrotal transposition in the other 8 periods (6-9 months), and after resolution leaving the patients. penile skin dusky and darkly pigmented and appears as the scrotal skin. In this neo designed modification of Glenn Anderson RESULTS technique the preserved strip of skin on the dorsum of the penis provides a good vascular bed for venous and Satisfactory anatomical, cosmetic and functional lymphatic drainage, so no gross edema developed after results were obtained in most of the patients. The operation as seen in other techniques and simultaneous follow up periods ranged from 6 to 18 months. correction of associated hypospadias can be done Complications included urethral stenosis and urethral without increasing complications. fistulas in 1 patient (10%) that was successfully treated with repeated dilatations, no additional Arena et al11 reported 38% complications in their work, surgical correction needed in any of the corrected Glassberg et al12 reported 50% complications and patients. Koyanagi et al13 reported 48% complications. All of them use the same technique in the correction of In this technique, no circumferential incision of the penoscrotal transposition. In this series there were 10% skin around the penile base was done, and penile skin complications in the designed modification of Glenn is connected and drained to skin of mons pubis. There Anderson technique. was minimal post operative edema that did not compromised wound healing and disappeared in few days after surgery. CONCLUSION Preservation of strip of skin at the root of the penis DISCUSSION connecting penile skin to skin of lower abdomen during Penoscrotal transposition was first reported by Appleby correction of penoscrotal transposition reduce in 1923.4 Patients with penoscrotal transposition often postoperative edema and lower complications with have accompanying urological abnormalities such as better cosmetic appearance. chordee, hypospadias and vesicoureteric reflux. Mcllvoy and Harris first performed surgery to move the penis into a more cranial position through a REFERENCES subcutaneous tunnel beneath the prepenile scrotum.5 1. Parovic S, Vuadinovic V. Penoscrotal transposition with hypospadias: One stage repair J Urol. Forshall and Rickham used a different technique in two 148:1510-13,1992. patients in whom the cranially located scrotal flaps 2. Glenn JF, Anderson EE. Surgical correction of were elevated, rotated medially and caudally, and incomplete penoscrotal transposition. J Urol. 6 sutured beneath the penis. This method was also used 110:603-5,1973. by Glenn and Anderson.7 The technique was later modified by Dresner in 1982.8 Mark and his colleagues9 3. Snodgrass W. Tubularized incised plate urethroplasty for distal penile hypospadias. J Urol. 151:464, 1994. presented a radically divergent view of penoscrotal transposition. They stated that the penis and not the 4. Appleby LH. An unusual arrangement of the external scrotum is mal positioned. They transfer the penis after genitalia. Can Med Ass J. 13:514-6,1923. Annals of Pediatric Surgery 16 Saleh A. et al. 5. Mcllvoy DB, Harris HS. Transposition of the penis and 10. Germiyanoglu C, Ozkardes H, Altug U et al. scrotum: case report. J Urol. 73:540-3,1955. Reconstruction of penoscrotal transposition. Br J Url. 73:202-3,1994. 6. Forshall I, Rickham PP. Transposition of penis and scrotum. Br J Urol. 38:250-2,1956. 11. Arena F, Romeo C, Manganaro A, et al. Surgical correction of penoscrotal transposition associated with 7. Glenn JF, Anderson EE. Surgical correction of hypospadias and bifid scrotum: our experience of two incomplete penoscrotal transposition. J Urol. stage repaire. J of Pediat. Urol. 1:289-94,2005. 110:603-5,1973. 12. Glassberg K.I., Hansbrough F. Horowitz M: The 8. Mark E, Kolligian, Israel F, et al. Correction of Koyanagi-Nanomura 1-stage Ducket repair of severe penoscrotal transposition: Anovel approach.J Urol. hypospadias with and without penoscrotal 164:994-7,2000. transposition. J Urol. 160:114-1107,1998. 9. Dresener ML. Surgical revision of scrotal 13. Koyanagi T, Nonomora K, Yamashita T et al. One engulfment.Urol Clin North Am. 9:305-10,1982. stage repair of hypospadiase: is there no simple method universally applicable to all types of hypospadias? J Urol. 152:1232-123,1994. 17 Vol 4, No 1,2, January- April 2008 .