Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Penoscrotal Operations

This is a very brief introduction into most common urological operations. The list below is not exhaustive of all urological operations, but the procedures an SHO will more commonly encounter.

Penile Procedures

Circumcision

• Removal of foreskin for phimosis, recurrent balanitis, lichen sclerosis (BXO) or suspicious lesions
• Performed under LA or GA; day-case procedure
• Risks: bleeding, infection, cosmetic dissatisfaction, injury to meatus / glans, meatal stenosis due to BXO

Dorsal Slit

• Longitudinal incision made along the dorsal foreskin to release constriction
• Indication: symptomatic phimosis, failed paraphimosis reduction
• Faster and less invasive than circumcision; useful in unstable or high-risk patients
• Usually poor cosmesis
• If done in emergency setting can often be followed by elective circumcision

Penile Straightening Surgery

1. Nesbit / Plication
   • Shortening of the longer tunical side to correct curvature
   • Good for curvatures <60°
   • Risks: penile shortening, recurrent curvature; ED uncommon
2. Plaque Incision & Grafting
   • For severe (>60°) curvature, indentation or hourglass deformity
   • Tunical incision with graft placement
   • Higher risk of ED

Penile Cancer Surgery

• Includes: wide local excision, glansectomy, partial penectomy, total penectomy
• When patient undergo total penectomy they will require a perineal urethrostomy where urethra is brought out to the perineum (between scrotum and anus)
• This becomes the permanent urinary opening; patients void sitting down
• Requires ongoing monitoring for stenosis and routine perineal hygiene

Perineal urethrostomy

Split skin graft for glans reconstruction

Penile Prosthesis

• Surgical insertion of a device for refractory erectile dysfunction
• There are 2 types:

1. Inflatable Prosthesis
   • Pump in scrotum, cylinders in each corpora, fluid reservoir in abdomen → most natural appearance/function
   • Requires intact manual dexterity
2. Malleable Rods
   • Simpler, always semi-rigid
   • Lower mechanical failure risk as only has an implant in each corpora

• Risks: infection, erosion, mechanical failure, revision surgery
• Usually elective; high satisfaction rates

 

Testicular & Scrotal Procedures

Scrotal Exploration

• Performed urgently for acute scrotal pathology such as torsion or trauma
• If testis viable → bilateral orchidopexy
• If testis non-viable → orchidectomy + contralateral fixation
• Purpose of procedure - definitive diagnosis, treatment and prevention of recurrence

Orchidopexy

• For Torsion - fixation of both testes following detorsion. Prevents future torsion.
• For Undescended Testis - mobilisation and fixation of testis into scrotum
• Improves examination, reduces malignancy risk, protects fertility
• Usually day-case

Orchidectomy (Simple or Radical) +/- Testicular Prosthesis

1. Simple Orchidectomy
   • Simple Orchidectomy - removal of necrotic, atrophic, or severely infected testis
   • Often performed during emergency scrotal exploration
   • Usually scrotal approach
2. Radical Inguinal Orchidectomy
   • Standard operation for suspected or confirmed testicular cancer
   • Inguinal approach - avoids scrotal cancer seeding
   • Important for staging and onward oncology planning
   • Prosthesis can be inserted at same or later operation

Hydrocele Repair

• Excision or eversion of tunica vaginalis for symptomatic hydrocele
• Two main procedures – Lord's and Jaboulay's technique
• Alternative is Aspiration – but this is not usually definitive because of risk of infection and fluid will reaccumulate
• Day-case

Epididymal Cyst Excision

• Removal of symptomatic or cosmetically troubling epididymal cysts
• Day-case
• Specific risk: rarely fertility impact from epididymal tubule damage.

 

Male Fertility Procedures

Vasectomy

• Permanent male contraception by division/occlusion of vas deferens
• Usually LA, but can be done under GA in difficult cases; day-case
• Clearance only after two negative semen analyses (local policy varies)
• Risks: haematoma, infection, chronic scrotal pain, early/late recanalisation (failure)

Vasectomy Reversal (Vasovasostomy / Vasoepididymostomy)

• Microsurgical reconnection of the vas deferens to restore sperm flow
• Success inversely related to interval since vasectomy:

Interval since vasectomy	Patency rate	Pregnancy rate
<3 years	97%	75%
3–8 years	88%	50–55%
9–14 years	79%	40–45%
15–19 years	70%	30%
≥20 years	40%	<10%

• Sometimes requires vasoepididymostomy if obstruction is epididymal
• Patency does not guarantee pregnancy; sperm may take 3–6 months, sometimes up to 1 year, to return.
• Specific risks: failure, persistent azoospermia, epididymal blowout, late re-obstruction

Microsurgical Varicocele Ligation

• Treats varicocele-associated subfertility or scrotal pain
• Microsurgical inguinal/subinguinal varicocelectomy preferred (lowest recurrence + hydrocele risk)
• Alternative: IR embolisation
• Mechanism: multifactorial - reduced heat, oxidative stress and venous reflux effects

Varicocele

IR varicocele embolisation

Sperm Retrieval Procedures (for Azoospermia)

1. PESA – Percutaneous Epididymal Sperm Aspiration
   • Needle aspiration of epididymal tubules
   • Useful in obstructive azoospermia
   • Often combined with ICSI
2. TESA – Testicular Sperm Aspiration
   • Needle aspiration from the testis
   • Used when PESA fails or in non-obstructive azoospermia
   • Lower sperm yield than micro-TESE
3. TESE – Testicular Sperm Extraction
   • Open testicular biopsy to extract tubules for sperm retrieval
   • Works for obstructive azoospermia and some non-obstructive cases
4. micro-TESE – Microsurgical Testicular Sperm Extraction
   • Gold standard for non-obstructive azoospermia (NOA)
   • Operating microscope used to identify focal areas of active spermatogenesis
   • Highest sperm retrieval rate; lowest tissue trauma
5. Ejaculatory Duct Recanalisation / TUR-ED
   • Performed for ejaculatory duct obstruction causing azoospermia, low-volume semen, or painful ejaculation
   • Transurethral unroofing of ejaculatory ducts under endoscopic guidance
   • Improvement in semen parameters variable
   • Risks: retrograde ejaculation, haematuria, infection