| In recent years, with the fast development of national economy and living level,people’s pursuit of the quality of life is increasingly strong. Therefore, patients come toclinic because of penis deformity are increasing year by year. Penis is an important urinaryand reproductive organ for man who has been closely related to medical professionals andmen themselves. The length of penis plays a very important role in the physiological andpsychological for male. Clinical cases of small penis size, even a part of men with normalsize, wish for the penis enlargement through a certain way. Therefore, the penisreconstruction is one of the most challenging works in reproductive organ reconstruction.The major causes of penis deformity are congenital dysplasia, trauma, animal bites, penistumor resection and perineal burn scar contracture. As early as70s of20th centrary Kellyand Eraklis first reported to lengthen the penis by separating corpus cavernosum foot fromthe pubic. Suspensory ligament lysis was first applied in congenital epispadias or bladderextrophy, along with the suspension of ligament and the surrounding structures on the penisthoroughly, its operation to cause disease gradually extended to the various causes ofcongenital or acquired the penis (such as maldevelopment of penis, traumatic defect afterresection of carcinoma of penis, etc.). Suspensory ligament lysis is the most easily acceptedpenile elongation surgery by doctors and patients because of the rapid recovery, simplemethod, and small influence on postoperative erectile function.With the rapid development of modern iconography and computer image processingtechnology, there is a great breakthrough of diagnosis and treatment of small penis. Butbecause the penis and adjacent structures are complex and fine, so the treatment is difficult,even small error can cause great pain and dysfunction to patients. So recovering thestructure of the penis is the primeses to ensure the function, length, shape and appearance ofpenis. At present, some scholars have developed many methods to the penis plasty, characteris different, each have special. And the most important and the most serious complicationafter the penis lengthening is intractable prepuce edema of penis, the occurrence of whichwill seriously affect the operation effect and postoperative penile morphology. There is nodefinite conclusion of the mechanism of intractable prepuce edema of penis, and the currentreports said that that may be associated with intraoperative destroying of lymphatic andvenous circulation of penis. Penile veins can be divided into superficial, middle and deep3sets of vascular, superficial dorsal veins of penis was located in between the the dorsalsuperficial and the deep fascia of penis, merged into1-2trunk on the root of the penis, intoone side or both sides of the external pudendal vein respectively. Deep vein of penisreceives blood from penis glans, between deep fascia and tunica albuginea of penis, passthrough deep suspensory ligament of penis into the internal iliac vein on the base of thepenis. Penile venous reflux has been studied clearly. According to reports, superficial dorsalveins mainly drainage foreskin and skin blood of penis, so it should be kept as far aspossible in operation. As the superficial dorsal vein of penis is in the superficial fascia andBuck′s fascia, have1~3trunks synthesized by3~5small veins on the root of the penis,with anastomosis among trunks and traffic support between dorsal penile superficial veinand deep vein, so in the operation process it is easy to recognize and easy to avoid fromcutting off. Even if the need to cut off the ligation, because of widely anastomosing withdeep veins of penis,it also won’t cause serious problem of venous reflux.In the penis elengation surgery, lymphatic vessells are very easy to damage because\its anatomical features are not obvious and lymph traveling and distribution of penis arelack of understanding at present. So lymphatic vessells of penis can be damaged very easyduring the operation, or almost all the penis lymphatic drainage may be cut off, causingserious complications. In recent years, lymphatic research has been slow to progress,largely due to the lack of ideal lymphatic imaging method. There are few reports on itsdistribution, storage, reflux lymph nodes and other issues of penis lymph-vessels. It isdifficult to identify lymph-vessels by naked eye because lymphatic anatomy characteristicsare not obvious, and deformation and displacement problem on anatomy of soft tissue,therefore cannot accurately understand and describe the courser and distribution of penislymph-vessels by gross anatomy. In recent years, it is reported that by lymphatic endothelium specific immune marker can accurately mark lymph-vessels. The method iseffectively for the observation of single slice and small range of lymph-vessels. However,the process is complicated, and observation is not continuous, so it is not applicable if wewant to observe the penis overall lymphatic courser and distribution. Directlymphangiography, because it may cause fatal complications and difficult to operate, now isno longer routinely used. At present, there is no particularly good method for observing thedistribution and running characteristics of penis lymph-vessels. Therefore, it is necessary tofind a suitable method, which can accurately judge whether the lymph vessels and canaccurately locate the position of penis lymphangioma, and what’s more, can observe theoverall distribution and reflux lymph nodes of penis lymphangioma. Under theseanatomical basis and references, we can improve the method of operation, and preventserious injury on lymphatic causing by operation, sparing lymph-vessels as much aspossible in order to accumulate liquid reflux from tissue postoperatively, avoiding seriouscomplications of penile lengthening.Methods The study was divided into two parts.1. Select6cadavers of penis from healthy male adult fresh cadaver specimens, aftersoaking with10%paraformaldehyde, The specimen is divided into1cm thick tissue alongvertical direction of the penis, paraffin embedded. Do slice with5um thickness, interval ofconsecutive sections of5mm according to the original order from the glans start. Sectionsare immunohistochemical stained with lymphatic endothelium specific marker-D2-40.After staining the sections were scaned with full slice microscopic scanning equipment,magnification is400times. The results are output into computer. Penis lymph-vessels arefound and marked under the appropriate magnification, then output the marked pictures inBMP form, and use MIMICS three-dimensional medical reconstruction software toreconstruct penis lymph–vessels, the reconstruction results were observed and analyzed oncomputer.2. Select7healthy adult males and6patients who have small penis and willing to havepenile lengthening surgery as the research object, scan the pelvic region by magneticresonance after injecting magnetic resonance imaging contrast agents hypodermical in theprepuce of penis. The results of the scan is transfered into MIP format and import into MIMICS to reconstruct penis lymph-vessels which distribution, the walking and return, etccan be observed.Results1. Lymph-vessels were distributed to from the start of the glans to the basis of penis.Lymph-vessels can be observed which diameter ranged from50-80um to about1.8mm.The luminal endothelial showed immunohistochemical staining positive as reddish brown,no red blood cells within the lumen, while vascular endothelial cell shows negative inimmunohistochemical staining. The number of lymphatic vessels in the first third is in largequantity and it has extensive anastomosis. Lymph-vessels are different in distributionamong individuals before the first3/4of penis. However, there are only3-4lymph-vesselsat the last1/4of the penis in all specimens. These lymph-vessels are located on both sidesof dorsal of penis and midline, lymph-vessels diameter is between0.6-1.8mm, there are noother lymph-vessels to the root of the penis.2. Lymph-vessels were distributed to from the start of the glans to the basis ofpenis.Lymphatics of the glans and prepuce are interlinked, while there is no traffic branchbetween penile skin and corpus cavernosum. Penis lymph-vessels cannot be clearlyobserved in the first half of the penis, but to the last half of penis lymph-vessels can beclearly seen with the help of the contrast agent filling in the lumen. Lymph-vessels, asmany as3-4pieces, are concentrated on back side of the penis at the root of penis.Lymph-vessels located in the central of the penis are continue to walk backwards along thecorpus cavernosum until the first bend of penis, while lymph-vessels at midline turn tolateral right-anglly, stopping at the bilateral inguinal lymph nodes.Conclusion1. Methods used in this study have superiority of both specificity and accuracy aslymphatic immunohistochemical staining, and also wholeness as lymphangiography. Thisstudy precisely describes the penis lymphangioma position and walking, distribution,storage and return, becomes a supplement for vascular system anatomy of penile. In someway, this study provides anatomical basis for mechanism of intractable edema of theforeskin after penis lengthening surgery, and for the future operation incision design to the prevention of complications in penis lengthening operation.2. Using methods of indirect MR lymphangiography and3D reconstruction can clearlyand accurately show the distribution, walking and reflux of penis lymph-vessels withsimple, little pain, no serious complications operation, which is a safe and effective methodto observe the lymph-vessels of penis. We can know from MR lymphangiography resultsthat, if improper operation incision and inappropriate isolated and location cutting off thesuspensory ligament, It may cause serious damage to the penis lymphangioma, thusaffecting the prepuce lymphatic return, causing serious complications such as edema ofprepuce. Using the MR lymphangiography as preoperative examination for patients withpenile lengthening surgery, we can know conveniently and intuitively of penislymphangioma distribution, with or without lymphatic dysfunction and anatomic variationand other special circumstances. Which has important significance on preoperationassessment of patients, personalized operation scheme developing; avoiding injuringlymph-vessels to reduce severe postoperative complications occurred. |
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