Reconstruction of the Penis Based on Type and Extent of Penile Malignancy

Squamous cell carcinoma accounts for more than 95% of the cases of cancer of the penis, yet penile cancer remains an uncommon malignancy constituting less than 1% of all malignancies in men from developed countries. The aim of treatment of penile cancer is to maximize organ preservation while achieving optimized oncologic outcomes. There are a multitude of surgical techniques and procedures to treat penile carcinoma that vary depending on the stage and grade of the penile malignancy.

Carcinoma In Situ, Ta, and T1 of the Penis

The first-line treatment option for carcinoma in situ (CIS) of the penis, erythroplasia of Queyrat, and Bowen disease is topical chemotherapy with imiquimod or 5-fluorouracil. In addition to topical agents, laser treatment, cryotherapy, circumcision, and photodynamic therapy may be used as alternative first-line treatment options. There are no randomized studies comparing organ-preserving and ablative treatment strategies from an oncologic standpoint, only retrospective studies with level 3 evidence or less; as ablative therapies require less reconstruction postoperatively given their inherent nature, the authors omit discussion of reconstruction following ablative procedures. Total or partial glans resurfacing as well as Mohs surgery may be offered as both a primary treatment option or as a secondary-line treatment of CIS and noninvasive disease that is refractory to topical or laser therapy. A discussion on glans resurfacing and Mohs surgery follows. Local recurrence of penile Tis, Ta, and T1 tumors has little influence on long-term survival, thereby justifying organ preservation whenever possible for these lesions.

Glans Resurfacing

The most common presenting location for malignant penile cancer is found on the glans and/or prepuce, with approximately 78% of the lesions detected at this location. Glans resurfacing is one of the few techniques used to treat noninvasive penile cancer that is confined to the glans. It is important to note, however, that up to 20% of patients initially diagnosed with noninvasive penile cancer will have invasive disease at final pathology. In one contemporary study of glans resurfacing, approximately 28% of patients treated with glans resurfacing required additional surgery for understaging of their disease or positive surgical margins at final pathology; however, the additional surgery was found not to compromise oncologic control.

Total glans resurfacing is performed by first marking the glans epithelium in 4 quadrants starting at the meatus and extending to the coronal sulcus in each quadrant. Next a perimeatal incision is made followed by a circumferential coronal incision in each quadrant; the epithelial tissue is then completely excised off the spongiosum in each quadrant allowing for a completely exposed glans. Next deep biopsies are taken from the spongiosal tissue in each quadrant. Following biopsies a split-thickness skin graft (STSG) is used to cover the glans ( Fig. 1 ).

( A ) The glans epithelium is marked in quadrants from the meatus to the coronal sulcus; ( B ) glans epithelium and subepithelial tissue completely dissected off the underlying spongiosum, starting from the meatus to the coronal sulcus for each quadrant; ( C ) a STSG is sutured and quilted using multiple 5-0 interrupted sutures.

( From Shabbir M, Muneer A, Kalsi J, et al. Glans resurfacing for the treatment of carcinoma in situ of the penis: surical technique and outcomes. Eur Urol 2011;59(1):144; with permission.)

Sexual function following glans resurfacing sheds light on the importance of this procedure and helps to serve as a reminder of the value of cancer survivorship objectives. In one study consisting of 10 patients who had undergone glans resurfacing for the treatment of erythroplasia of Queyrat, sexual function was evaluated at 6 months postoperatively. All patients who were sexually active preoperatively remained sexually active at 6 months postoperatively. In this specific study, all patients denied a negative change in the sensation of the tip of the penis or a negative change in their sex life.

STSG is a common technique adapted from plastic surgery and used by urologists commonly for reconstructive purposes covering major skin loss while providing satisfactory functional and cosmetic outcomes. STSG is highlighted throughout this article, as it has many applications in reconstruction of the phallus and scrotum following surgical treatment of these malignancies. It is important to note that advanced reconstructive techniques including STSG demand that medical comorbidities be optimized before surgical intervention. This requirement is especially true for smokers; current evidence from the plastic surgery literature suggest that a period of cessation no less than 2 to 4 weeks before surgery should be followed to optimize outcomes and wound healing.

Mohs Surgery for Carcinoma In Situ, Ta, and T1

Dr Frederic E. Mohs developed the surgical technique that bears his name in the 1930s while working on research as a medical student at the University of Wisconsin. Mohs micrographic surgery (MMS) is a technique that involves excision of tissue in layers with microscopic examination of the undersurface of the tissue to ensure a clear margin of resection. MMS allows for maximal tissue preservation by using microscopically ensured oncologic resection. MMS has been used in the treatment of penile cancer for more than 50 years. There have been several long-term studies that have evaluated the efficacy of MMS for penile carcinoma in terms of oncologic control and cosmetic outcomes. Brown and colleagues studied 20 patients with both penile CIS and invasive disease and followed these patients for an average of 3 years. They reported a 29% recurrence rate during that follow-up period, with one patient ultimately dying of metastatic disease and 4 patients developing lymph node involvement. In a more contemporary study with a longer follow-up of almost 5 years, Shindel and colleagues performed MMS on 41 penile cancers with a 32% recurrence rate. In total 25 of the cancers were CIS, 10 were invasive SCC, and 4 were Ta. Despite a high recurrence rate in patients treated with MMS compared with traditional surgery, the recurrence was effectively retreated and did not have an adverse effect on overall survival or tumor progression. It is important to note that only 13 of the defects created by MMS were amenable to primary closure; the remaining defects required skin grafts or tissue flaps. Overall MMS offers an excellent option in appropriately selected patients in minimizing sexual and urinary dysfunction postoperatively while achieving oncologic control. These patients must be agreeable, however, to vigilant long-term postoperative surveillance. Overall MMS allows for precise surgical approach, technique, and excision with a postsurgical bed that is microscopically free from tumor or dysplastic changes; but based on the surprisingly high rate of recurrence, this treatment approach has fallen out of favor now.

Treatment of invasive disease confined to the corpus spongiosum and glans includes total glansectomy with or without resurfacing of the corporeal heads; partial amputation is considered for patients who are unfit for reconstruction. Treatment of disease invading the corpora cavernosa or urethra (T2/T3) includes partial amputation with a tumor-free margin with reconstruction.

The armamentarium for the urologist in treating penile cancers in patients with T1, T2, or T3 disease includes total or partial glansectomy with reconstruction, wide local excision or partial penectomy with reconstruction, or total penectomy. Important considerations to best evaluate surgical outcomes include oncologic control, sexual function, cosmesis, psychosocial impact, and ability to void. Given these parameters, organ-sparing techniques and genital reconstruction have become paramount for patient satisfaction. A surgical margin of 5 mm is considered safe, but patients should remain under close follow-up.

Partial glansectomy can include wide local excision of any of the glandular tissue and includes glans resurfacing, MMS, and true partial glansectomy. Total glansectomy includes making a subcoronal incision with removal of all the glandular tissue distal to the corona while preserving the entire length of the mature corporal cavernosal tissue. Some smaller lesions treated with partial glansectomy may be amenable to primary closure; however, multiple reconstructive techniques exist including local flaps or free grafts. There exists considerable overlap in the usage of flap or grafting techniques regardless of primary excision technique (partial glansectomy, total glansectomy, or partial penectomy). Local flaps include rotational flaps from preputial skin, scrotal skin, or urethral tissue. In a recent study published by Yang and colleagues, 105 patients underwent glans-sparing excision of penile tumors less than 2.5 cm in diameter with either primary repair or preputial skin flap reconstruction. Skin flap reconstruction patients showed better 5-point satisfaction scale ratings in respect to orgasmic function, intercourse satisfaction, and overall satisfaction compared with primary repair patients at the 6-month follow-up. Free grafts include both buccal mucosa and STSG. However, Palminteri and colleagues suggest that the nonnative environment of buccal mucosa to an external recipient site of the glans penis or distal shaft make it an inferior choice in this situation and prefer STSG.

Partial penectomy includes removal of any penile tissue en bloc distal to a circumferential line of demarcation that preserves a negative margin. After deep frozen sections have been taken to ensure a negative margin, the corporal bodies are closed with a 2-0 absorbable suture. The corpora spongiosum and urethra are spatulated ventrally and a neo-meatus is created. Classic thinking suggests that a 3-cm stump should be the minimal length left to preserve the ability to void from a standing position and negate the need for a total penectomy with perineal urethrostomy. The current guidelines from the National Comprehensive Cancer Network state that, for high-grade T1 and T2 or greater tumors, more invasive approaches, such as partial or total penectomy, are warranted; however, in a highly motivated and reliable patient, glansectomy with negative tumor margin is acceptable if close follow-up is ensured. Again glanuloplasty can be performed with any of the aforementioned reconstructive techniques; however, Belinky and colleagues in the Journal of Urology describes 10 patients treated with partial penectomy and urethral flap glanuloplasty with good cosmetic outcome and no incidence of meatal stenosis. After standardized partial penectomy with prior release of the pendulous urethra from the specimen, the urethra is spatulated ventrally to the level of the neo-meatus and then sutured to the distal ends of the corporal bodies as a flap glanuloplasty ( Fig. 2 ).

( A ) Urethral release up to penoscrotal junction; ( B ) urethral ventral spatulation; ( C ) urethral suture to distal end of cavernous bodies; ( D ) final outcome; ( E ) 6 months postoperatively.

( From Belinky JJ, Cheliz GM, Graziano CA, et al. Glanuloplasty with urethral flap after partial penectomy. J Urol 2011;185(1):205; with permission.)

The importance of psychosocial and sexual outcomes for patients after glansectomy or partial penectomy cannot be overstated. A recent study by Gulino and colleagues documented good sexual outcomes with glansectomy and limited partial penectomy. In fact, 73%, 76%, and 71% of their 42 patients had rigid erections, retained normal orgasm and ejaculation, and preserved libido, respectively, at 6 months’ follow-up after surgery. Although good outcomes are attainable with primary excision and the reconstructive techniques mentioned earlier, adjunctive reconstructive techniques can and should be used to further enhance quality of life and limit the psychosocial impact of intervention. These techniques include suspensory ligament release, ventral phalloplasty, and suprapubic lipectomy. In a recent video published in the International Brazilian Journal of Urology , Wallen and colleagues document combined partial penectomy with ventral phalloplasty to preserve penile length. The video shows partial penectomy of an approximate 4-cm tumor with loss of only 2.5 cm of functional penile length after ventral phalloplasty ( Fig. 3 ). Suprapubic lipectomy and suspensory ligament release have long been used as adjuncts in cosmetic urology and have a role in post–partial penectomy patients as well.

Before and after images of partial penectomy patient with ventral phalloplasty performed at time of partial penectomy to maximize functional penile length.

Reconstructive Options Following Total Penectomy

In the treatment of disease that is locally advanced invading adjacent structures (T3/T4), total penectomy with perineal urethrostomy is the standard surgical treatment of T3 tumors. In more advanced T4 disease, neoadjuvant chemotherapy is advisable.

The standard of care for the treatment of advanced penile carcinoma T3 and T4 disease is a total penectomy with perineal urethrostomy often times accompanied or preceded by chemotherapy, particularly for T4 disease. The psychological effects of subtotal or total penectomy are often devastating on the quality of life of surviving patients as radical penile surgery affects sexual, voiding, and psychological well-being. Total phallic reconstruction was driven in part by the need in cancer survivors but also by trauma patients, disorders of sexual development, congenital anomalies, and female-to-male transsexual surgery. Perhaps no other need has greater advanced this field then genitoperineal transformation surgery in female-to-male transsexuals.

The origins of phallic reconstruction, however, were borne out of necessity on trauma patients with the first reported phalloplasty performed in 1936 by Russian surgeon Nikolaj Bogoraz. Bogoraz’s phalloplasty operation consisted of several stages, which began with the formation of bilateral tube pedicled grafts of the abdominal skin, then incorporated an 8-cm long segment of rib cartilage as a stiffner into the graft, and in a later stage reconstructed a portion of the urethra using a tubular scrotal flap. There were several surgical innovators that advanced the technique Bogoraz popularized, including Frumkin, Maltz, Gillies, and Harrison, by incorporating the tube within a tube concept of neo-urethral formation. It was the advent of microsurgical techniques that truly ushered in a new era of penile reconstruction lead by Dr Song and further popularized by Chang and Hwang with the use of the radial artery free flap, which has become the most common technique used today and is universally considered the standard technique for total phallic reconstruction. Since the introduction of microsurgical techniques and advancements in composite flaps, there has been a multitude of different approaches for total phallic reconstruction with more than 20 different types of flaps available. It is beyond the scope of the article to review each type of flap, free or pedicled; but instead the authors review the most common flaps and advancements in these techniques as they pertain to reconstruction following penectomy for cancer.

There are many types of both pedicled and free soft tissue flaps used for penile reconstruction. The most common types of flaps used are listed later. This list is not exhaustive but shows the number and type of the more common flaps used today. Local pedicled flaps for phalloplasty included extended groin skin flaps, rectus abdominis myocutaneous flap, the superficial inferior epigastric skin flap, anterolateral thigh flap, and the tensor fascia lata myocutaneous flap. Soft tissue flaps include radial forearm flap, dorsalis pedis flap, deltoid flap, lateral arm flap, fibular flap, tensor fascia lata flap, latissimus dorsi flap, radial forearm osteocutaneous free flaps, and scapular flaps ( Table 1 ).

The goals of free flap phalloplasty should include a one-stage procedure, creation of a competent genitoperineal that allows patients to void while standing, restoration of erogenous and tactile sensation, a neo-phallus that allows for insertion of a prosthetic device or alternative to allow for sexual function, an aesthetic and cosmetically acceptable result in both the donor and graft site, and minimizing scarring and disfigurement with no loss of function of the donor site.

Radial Artery Free Flap Phalloplasty

Radial artery free flap (RAFF) is by far the most common flap used in total phallic reconstruction, with greater than 90% of reported cases using this technique. In a brief summary of the procedure described by Monstrey and colleagues, the plastic surgeon first dissects the radial forearm flap and constructs a tube within a tube phallus. The glans is then sculpted with a small skin flap and a full-thickness skin graft while the neo-phallus is still attached to the forearm by its vascular pedicle. The urethra stump is then prepared; and the receptor vessels are then dissected in the groin, often through a lower abdominal incision; and the RAFF is transferred from the forearm to the pubic area. The urethral anastomosis is performed first, then the radial artery is anastomosed microscopically in an end-to-side fashion to the common femoral artery, and the cephalic vein is anastomosed to the saphenous vein. An antebrachial nerve is microscopically anastomosed to the ipsilateral ilioinguinal nerve to allow for protective sensation, and another forearm nerve is connected to the dorsal nerve of the penis or pudendal nerves to allow for erogenous sensation ( Fig. 4 ).

( A ) Preoperative view of a 38-year-old man following total penectomy and bilateral inguinal node dissection for invasive squamous cell cancer 8 months previously. The patient has perineal urethra. ( B ) Left radial forearm osteocutaneous flap prelamination of neo-urethra. ( C ) Radial forearm osteocutaneous flap shown following flap harvest before pedicle division and transfer. ( D ) The patient at 4 months following total phalloplasty with radial forearm osteocutaneous flap and adjunctive palmaris longus tendon graft for coronoplasty.

( From Salgado CJ, Monstrey S, Hoebeke P, et al. Reconstruction of the penis after surgery. Urol Clin North Am 2010;37(3):396; with permission.)

Despite the RAFF as the most common technique used for phalloplasty, there is a paucity of prospective randomized controlled trials comparing flap techniques; therefore, it is not possible to prove one technique’s superiority over another. However, the RAFF has the most long-term data and largest data series to date in total phallic reconstruction and has proven to be a reliable technique. The RAFF has the theoretic advantage of maintaining the greatest degree of sensitivity to the phallus both in tactile sensation as well as erogenous sensation based on previous studies examining radial forearm flaps in oral reconstruction. Sensation of the RAFF phalloplasty is maintained via microsurgical anastomosis of the antebrachial nerves to the dorsal nerve of the penis or iliohypogastric and ilioinguinal nerves.

There are several drawbacks to the RAFF, the most common being donor site morbidity and the need for a secondary operation to allow for implantation of a penile prosthesis to restore sexual function. The RAFF used in phalloplasty surgery is typically larger than what is commonly used in head and neck reconstruction, thus there is greater concern for functional impairment and a cosmetically undesirable result of the donor site. However, in a long-term follow-up study of sex reassignment patients, there were few major long-term problems identified at the donor site, including no functional limitation, chronic pain, or cold intolerance. One of the most dreaded complications of any free flap phalloplasty is acute venous thrombosis of the anastomosis, which occurs with an incidence of 3%. Another dreaded vascular complication is acute thrombosis of the arterial anastomosis, which occurs soon after the anastomosis and is typically easily identifiable allowing for re-exploration and immediate revision and salvage of the phallus. The most common urologic complication of RAFF phalloplasty is urethral strictures and fistulas. Neo-urethral strictures, including meatal stenosis, occur in approximately 10% of the cases, whereas urethral fistulas occur in as many as 20% of cases. Despite the complication rates and donor site morbidity and scarring, the RAFF phalloplasty remains a reliable and reproducible technique and is the most common technique chosen for total phallic reconstruction.

Additional Flap Techniques

As previously stated, there are currently more than 20 techniques used in phallic reconstruction; the purpose of this article is not to review all of them but to highlight the most common and comment on the advancements in penile reconstruction. With this in mind, there have been recent flaps and advancements that deserve mention, namely, the osteocutaneous free flaps and the latissimus dorsi flap.

Radial and Fibular Osteocutaneous Free Flaps

These techniques were first described in 1993 with the inherent advantage of intrinsic rigidity of the flap allowing for sexual activity without the need for a prosthesis. The fibula free flap provides vascularized bone that is longer than the radial forearm osteocutaneous flap, thereby optimizing sexual outcomes; it is typically associated with reduced donor site morbidity. The disadvantages of the osteocutaneous flaps include a higher rate of urethral complications, including fistula and stricture; a permanently erect phallus; and less erogenous and tactile sensation of the neo-phallus. The largest follow-up study for male patients treated with an osteocutaneous free fibular flap phalloplasty includes 18 patients with an average follow-up of 5.5 years. The results of the follow-up study show no significant osseous resorption; good functional results, both urinary and sexual; and high patient satisfaction. Long-term follow-up studies for radial forearm osteocutaneous flaps have shown softening of the neo-phallus, with approximately 20% of the patients seeking a corrective procedure at a mean of 2 years postoperatively ; refer to Fig. 4 for surgical images of a radial forearm osteocutaneous flap.

Total phallic reconstruction using a musculocutaneous latissimus dorsi (MLD) flap was first described by Perovic and colleagues in 2006 used in children as an alternative to the RAFF. The group later published their results with this technique on adults necessitating total phallic reconstruction with the intention of providing a flap that allowed for creation of a larger neo-phallus with lower donor site morbidity then the RAFF. The MLD phalloplasty requires 4 stages in order to provide a functional neo-phallus that is capable to use for intercourse.

The advantages of the MLD are related to the larger size graft resulting in creation of a larger phallus and the limited donor site morbidity. The donor site can be closed directly in most patients without the need for additional tissue grafting, and clothing generally conceals its site. The disadvantage of the MLD flap is that it requires 4 stages, 2 of which require urethroplasty with buccal mucosa harvest as part of stage one of the urethroplasty.

Penile Prosthesis in Phalloplasty Patients

A significant advancement in phalloplasty patients concerns the insertion of a penile prosthesis in an effort to restore sexual function. Penile prosthesis implantation in phalloplasty patients remains a challenging procedure for the implant urologist but has long-term data proving its safety and efficacy. The prosthesis is inserted at least 1 year after the phallic reconstruction in order to allow for maximal nerve sensation, including cutaneous sensation, to develop. Previous studies on transsexual patients have shown that by 1 year, genital sensitivity and tactile sensitivity was regained ; to the authors’ knowledge there are no such studies that exist on postpenectomy patients. This 1-year wait time is necessary to allow for sensation of the phallus to ensure both the erogenous enjoyment of the prosthesis as well as to ensure somatic sensation to help maintain the safety of the phallus in the event of extrusion or erosion. Both semirigid penile implants as well as inflatable penile implants have been used in the neo-phallus; both single cylinders as well as bilateral cylinders have been used.

The technique described by Zuckerman and colleagues for insertion of a penile prosthesis in a neo-phallus begins with bilateral incisions overlying the ischial tuberosities ( Fig. 5 ). In postpenectomy patients in which the proximal corpora remain, the standard technique is to open the proximal corpora and use them as the anchoring site of the prosthesis; this approach can be either penoscrotal or via bilateral incisions over the ischial tuberosities. Alternatively if the proximal corpora have been excised, the inferior pubic rami can be exposed and used as sites to anchor the prosthesis. The neo-phallus shaft is dilated distally in the standard fashion as with a typical implant with Metzenbaum scissors, Hager sounds, Brooks dilators, or a combination thereof. After appropriate sizing with the Furlow device, the implant is chosen and encased in polyethylene terephthalate creating a neo-tunica. The neo-tunica covering allows not only fixation of the cylinders to the proximal corpora or inferior pubic rami but also protects against extrusion of the device through the glans of the neo-phallus by creating an added buffer between the implant and the skin. The cylinders are then placed in a standard fashion with the aid of a Keith needle and Furlow passer if an inflatable penile prosthesis is chosen, otherwise standard implantation of a semirigid implant commences at this point. After seating of the implant, the proximal end of the neo-tunica is sutured to the proximal corpora or inferior pubic ramus. If an inflatable device is chosen, the pump and reservoir need to be placed. The pump is placed in the scrotum through one of the perineal incisions after blunt creation of a subdartos pouch. The reservoir is placed via a lower abdominal counterincision.

Phallus dilation through bilateral perineal incisions.

( From Zuckerman JM, Smentkowski K, Gilbert D, et al. Penile prosthesis implantation in patients with a history of total phallic construction. J Sex Med 2015;12(12):2487; with permission.)

As with any penile implant surgery infection, erosion into the urethra, extrusion from the skin, and mechanical failure are all possible complications of either type of implant, semirigid or inflatable. A recent study of penile implants in patients with a neo-phallus demonstrated a 6% intraoperative complication rate, including a cystotomy and a vascular flap injury. The postoperative revision rate was 23.0%, with a 9.7% infection rate. At 5 years’ follow-up, approximately 80% of the patients were sexually active. The largest series of penile implants in patients with a neo-phallus demonstrated a slightly higher infection rate of 12% and noted a significantly higher incidence of 41% for removal and revision. Both studies used semirigid implants as well as inflatable implants but moved to preferring inflatable implants as the surgeons gained experience in placing penile implants in a neo-phallus. It is important to note that in the largest study only female-to-male transsexuals were included.

Tissue Engineering in Phallic Regeneration

Regenerative medicine is the process of replacing or regenerating human cells, tissues, or organs with the goal of restoration of structure and function. There are in essence 3 different conceptual approaches for tissue engineering: autologous or allogeneic stem cells obtained from a biopsy and expanded in vitro, implantation of biological materials to assist tissue repair, and implantation of matrices that are seeded with stem cells. Several trials have shown the potential of tissue-engineered corpus cavernosum as an alternative for surgical total phallic reconstruction. Based on these studies, entire corporal bodies have been created using acellular corporal matrices seeded with autologous smooth muscle and endothelial cells in animals. These studies have led to bioengineered corpora allowing male rabbits to successfully mate with female rabbits. Although predominately the studies have been conducted in animals, there are studies of human corpus cavernosal, endothelial, and smooth muscle cells, which have formed vascularized corporal bodies when implanted in vivo ex situ.

Despite the dramatic advancements being made in tissue engineering, the promise of phallic reconstruction using stem cells does not as of yet have clinical utility in humans but remains a promising technology in the future.

Penile Transplantation

There are only 2 reports of penile transplantation in the medical literature. The first reported penile transplant was in 2006 in Guangzhou, China. The recipient was a 44-year-old man that suffered a traumatic event resulting in penile amputation. Following the appropriate medical and psychological workup, the 15-hour surgery was performed. The recipient was able to urinate after Foley catheter removal on postoperative day number 10 and showed no signs of rejection or infection. Unfortunately, because of extreme psychological distress of the patient and his wife, he requested the transplanted penis to be removed. The second reported case of a penile transplant was performed in South Africa in 2014 following a traumatic amputation. The 21-year-old recipient underwent a 9-hour procedure and has recovered successfully with restoration of both urinary and sexual function.

Both of these cases highlight the feasibility and success of a penile transplant, but more research is currently being investigated in an effort to improve outcomes for recipients. In both cases of penile transplantation, only the dorsal arteries, nerves, and veins were microscopically anastomosed. The cavernosal arteries and the bulbourethral arteries were not reapproximated directly. The cavernosal arteries are responsible for erection, but it is technically difficult to perform this anastomosis, as it requires excision and shortening of the native corpora in order to visualize the vessels and perform the anastomosis. Surgeons at Johns Hopkins University have investigated this issue and have shown that it is possible to revascularize a penile transplant with anastomosis of the dorsal, cavernosal, and external pudendal arteries in cadaveric trials that were complete with perfusion studies after anastomosis. The cavernosal artery anastomosis was accomplished by gaining additional length of the donor penile allograft cavernosal arteries allowing for an anastomosis and less excision of recipient corporal tissue to expose the vessels. In addition to the cavernosal arteries, the external pudendal arteries were anastomosed via a groin incision to allow for improved perfusion of the penile shaft skin. The perfusion studies showed that corporal inflow was significantly improved compared with studies with solely dorsal artery anastomosis, suggesting improved results of erectile function with cavernosal artery anastomosis. No attempts were made during these studies to perform a bulbourethral anastomosis because of the size and shorter course of these arteries. Penile transplant offers an exciting alternative to flap phalloplasty and will likely be implemented in the next 12 months in the United States, mainly for patients with postwar traumatic amputation; however, this technique can be used in postpenectomy patients for malignancy as well. At the time of this article submission, Johns Hopkins School of Medicine was the only center in the United States that formalized a penile transplant program and was actively awaiting their first patient.