This article describes penile reconstruction after surgery. Patient considerations in reconstruction, reconstruction of varied urethral defects, general principles of urethroplasty, surgical techniques of urethral reconstruction, reconstruction of scrotal and testicular defects, reconstruction of the penile shaft, and timing of reconstruction are discussed. The use of local pedicled flaps in penile reconstruction, distant free tissue transfer in penile reconstruction, varied forms of prostheses, management of complications following penile reconstruction, postoperative care in penile reconstruction patient, and penile transplantation are described.
Patient considerations in reconstruction
The primary goal of penile reconstruction following oncologic resection is to create a neophallus that enables the patient to void while standing and to achieve vaginal penetration, that has erogenous and tactile sensibility, and that is cosmetically acceptable in shape, size, and color. In addition, surgeons should aim to perform penile reconstruction in a single-stage procedure that is associated with low donor-site morbidity. Success of such a complex endeavor depends on preoperative planning, which relies on a thorough evaluation of the patient that maximizes outcomes by guiding decisions regarding the method for reconstruction as well as elucidating possible challenges.
Because most recurrences and metastases following resection of penile carcinoma occur within 1 year of the initial resection, most surgeons await consideration of reconstruction until time has passed and the patient has been confirmed to be disease free. Other elements of patient and procedure selection are the patient’s baseline health status, social habits, and mental health status. The type of flap and the mechanism for providing rigidity should be determined with consideration of patient comorbidities such as diabetes, steroid use, obesity, and connective tissue disorders, all of which can influence the predicted outcomes. Tobacco use should be assessed because smoking has been shown to produce a thrombogenic, peripherally ischemic state with impaired wound healing and poor surgical outcomes. In particular, there is an increased risk of necrosing full-thickness skin grafts and local flaps in smokers. The exact duration of time between cessation of smoking and surgery required to prevent wound healing complications is unknown although commonly it is preferred that patients cease smoking for 2 to 4 weeks before their reconstruction. Summerton and colleagues state the importance of seeking psychological counseling before the penectomy; however, office evaluation before reconstructive surgery should address the psychosexual elements of possible procedural results, which may also influence the type of procedure selected. In addition, Khouri and colleagues state that patients must be prepared to undergo up to 6 operations within the first 12 months after phalloplasty as a result of complications and revisions, a possibility that should be discussed in frank terms with the patient. In selecting the type of penile reconstruction, additional variables exist such as donor-site hair distribution, scars, skin thickness, vascular supply, and vascular defects. Some surgeons use the Allen test, color duplex imaging, Doppler ultrasonography, and even angiogram studies for preoperative evaluation of pertinent vessels, given the vitality of understanding the vascular anatomy and viability of the vessels for successful outcomes. Some advocate application of antiscar ointment with associated massage beginning 3 months before the procedure to increase the dimension of the flap and facilitate closure of the defect.
Selection of the appropriate surgery reduces long-term problems in cosmesis, sexual function, and psychology. Although each reconstructive procedure has its unique benefits and drawbacks that should be tailored to the patient’s particular anatomy and general health status, patient preferences and postoperative goals should be discussed, because these help to guide preoperative planning as related to penile reconstruction.
Reconstruction of varied urethral defects
Because the primary urethral tumor is a rare condition, no large-scale experience exists about this topic. If possible, urethral tumors may require resection of the affected part of the urethra with the corpus spongiosum (partial urethrectomy) to offer the patient a treatment with curative intent. After urethral resection, normal voiding can be made possible by several reconstructive techniques replacing the resected urethra. These reconstructive techniques are based on the principles of urethroplasty for urethral stricture disease, but in urethral replacement, a whole new urethral tube must be created. To bridge the urethral gap, several techniques can be used:
- 1.
Anastomotic repair (AR)
- 2.
Augmented AR
- 3.
One-stage substitution urethroplasty
Free graft urethroplasty
Pedicled flap urethroplasty
- 4.
Two-stage urethroplasty.
General Principles of Urethroplasty
Preoperative preparation
The presence of urinary infection is one of the major causes of failure of urethral reconstruction, and for this reason it is advocated that the urine is sterile during reconstruction. It is advised to perform a urine culture the week before operation and to start with the appropriate antibiotics in case of infection 24 hours before operation.
Patient positioning
For tumors at the penile urethra, a common supine position is advised. When the tumor is situated deeper than the penile urethra, it is necessary to place the patient in the high lithotomy position. If there is any doubt about the extent of the urethral tumor, the patient should also be placed in the lithotomy position, which guarantees access to the penile and bulbar urethra.
Access to the urethra
Penile urethra
A circumferential incision about 0.5 cm below the glans is the best access to the penile urethra. This access provides an excellent and well-vascularized coverage of all sutures, grafts, or flaps at the end of the operation. Fistulation is uncommon with this incision. The tissue is incised and dissected perpendicular to Buck’s fascia, which can be easily identified because of its white aspect. The surgical plane following Buck’s fascia is virtually avascular and can be easily followed to the base of the penis without jeopardizing the vascularization of the penile skin.
Bulbar urethra
For exposure of the bulbar (and posterior) urethra, a perineal incision is necessary. Although an inverted-U or -λ incision has been described, a midline incision provides good access even to the posterior urethra and has the advantage of less postoperative pain. The subcutaneous tissue is incised until the level of the musculus bulbospongiosus. The bulbospongiosus is then incised at the midline and separated from the corpus spongiosum. The muscle can be fixated with 4 sutures at the perineal skin to provide good exposure.
Urinary diversion
After every reconstructive procedure of the urethra, a urinary diversion is mandatory. Leakage and extravasation of urine in a recently reconstructed urethra can cause significant complications. For one-stage urethroplasty and in the second stage of a 2-stage urethroplasty, the urinary diversion is important. In most cases, diversion can be assured by a 16- to 20-Fr urethral catheter or a suprapubic catheter. After 10 to 14 days (depending on the type of urethroplasty) a cystourethrogram is performed. In no or only minimal urinary extravasation, the urinary diversion can be removed. In significant urinary extravasation, the diversion is maintained and the examination is repeated after 1 week.
Reconstruction of varied urethral defects
Because the primary urethral tumor is a rare condition, no large-scale experience exists about this topic. If possible, urethral tumors may require resection of the affected part of the urethra with the corpus spongiosum (partial urethrectomy) to offer the patient a treatment with curative intent. After urethral resection, normal voiding can be made possible by several reconstructive techniques replacing the resected urethra. These reconstructive techniques are based on the principles of urethroplasty for urethral stricture disease, but in urethral replacement, a whole new urethral tube must be created. To bridge the urethral gap, several techniques can be used:
- 1.
Anastomotic repair (AR)
- 2.
Augmented AR
- 3.
One-stage substitution urethroplasty
Free graft urethroplasty
Pedicled flap urethroplasty
- 4.
Two-stage urethroplasty.
General Principles of Urethroplasty
Preoperative preparation
The presence of urinary infection is one of the major causes of failure of urethral reconstruction, and for this reason it is advocated that the urine is sterile during reconstruction. It is advised to perform a urine culture the week before operation and to start with the appropriate antibiotics in case of infection 24 hours before operation.
Patient positioning
For tumors at the penile urethra, a common supine position is advised. When the tumor is situated deeper than the penile urethra, it is necessary to place the patient in the high lithotomy position. If there is any doubt about the extent of the urethral tumor, the patient should also be placed in the lithotomy position, which guarantees access to the penile and bulbar urethra.
Access to the urethra
Penile urethra
A circumferential incision about 0.5 cm below the glans is the best access to the penile urethra. This access provides an excellent and well-vascularized coverage of all sutures, grafts, or flaps at the end of the operation. Fistulation is uncommon with this incision. The tissue is incised and dissected perpendicular to Buck’s fascia, which can be easily identified because of its white aspect. The surgical plane following Buck’s fascia is virtually avascular and can be easily followed to the base of the penis without jeopardizing the vascularization of the penile skin.
Bulbar urethra
For exposure of the bulbar (and posterior) urethra, a perineal incision is necessary. Although an inverted-U or -λ incision has been described, a midline incision provides good access even to the posterior urethra and has the advantage of less postoperative pain. The subcutaneous tissue is incised until the level of the musculus bulbospongiosus. The bulbospongiosus is then incised at the midline and separated from the corpus spongiosum. The muscle can be fixated with 4 sutures at the perineal skin to provide good exposure.
Urinary diversion
After every reconstructive procedure of the urethra, a urinary diversion is mandatory. Leakage and extravasation of urine in a recently reconstructed urethra can cause significant complications. For one-stage urethroplasty and in the second stage of a 2-stage urethroplasty, the urinary diversion is important. In most cases, diversion can be assured by a 16- to 20-Fr urethral catheter or a suprapubic catheter. After 10 to 14 days (depending on the type of urethroplasty) a cystourethrogram is performed. In no or only minimal urinary extravasation, the urinary diversion can be removed. In significant urinary extravasation, the diversion is maintained and the examination is repeated after 1 week.
Surgical techniques of urethral reconstruction
AR
This type of urethral reconstruction is the best technique because the diseased urethra is resected and replaced by its own healthy tissue without the interposition of foreign material. The good results are maintained in the long-term. The anastomosis must be made with 2 well-vascularized urethral ends without any tension. When these 2 basic principles are neglected, failure can occur. To assure a broad anastomosis, both healthy urethral ends are spatulated for about 1 cm. With this technique, the intrinsic elasticity of the urethra is used to bridge the gap: the urethra can be elongated about 20% of its original length. The urethra must therefore be mobilized by dissecting it away from the corpora cavernosa. To avoid chordee and shortening of the penis, this mobilization should not go beyond the penoscrotal angle distally. In an already impotent patient, this is of no importance and the urethra can be mobilized up to the glans. Proximally, the urethra can be mobilized up to the urogenital diaphragm. To free the bulbous urethra the centrum tendineum must be sectioned. Additional length can be gained by separating the corpora cavernosa and placing the mobilized urethra between them. In the absence of any residual tension, the anastomosis is started at the dorsal side of the urethra using 4 or 5 interrupted resorbable 4.0 sutures. Thereafter a 16-Fr urethral catheter is introduced to avoid adhesions at the level of the anastomosis. The anastomosis is further completed ventrally with another 4 or 5 interrupted resorbable 4.0 sutures. If the patient already has a suprapubic catheter, the urethral catheter can be removed after 5 days. If not, the urethral catheter is maintained for 10 days. Postoperative antibiotics are not necessary unless there is urinary infection.
In general, only 2 to 3 cm can be bridged with these maneuvers and only at the proximal bulbar urethra. Because surgical resection of the tumor requires a sufficient tumor-free margin and AR requires spatulation of the healthy urethral ends, AR is in most cases impossible. The only exception is leiomyoma of the male urethra, which most often occurs at the bulbar urethra. These tumors do not recur or metastasize. If the affected segment is short, resection and primary AR are sufficient to treat this condition.
Augmented AR
If an AR is attempted, but during the operation a tension-free anastomosis cannot be provided, a graft can be used to bridge the defect. This technique was initially described by Guralnick and Webster, whereby the urethral ends are spatulated at the dorsal side and the ends are sutured to each other. A graft is then fixed at the corpora cavernosa at the place of the defect and the urethral edges are sutured against this graft using a running suture on both sides. It is essential that the graft is placed against a well-vascularized graft bed.
One-stage Substitution Urethroplasty
This type of urethroplasty obtains the reconstruction of a new urethra within the same time as the urethral resection. Two major different types of substitution urethroplasty are described:
- 1.
Free graft urethroplasty:
To survive, the graft must be sutured against a well-vascularized graft bed. This is a problem in urethral replacement, because the corpus spongiosum is resected as well. Dorsally, the graft can be sutured against the corpora cavernosa but laterally and ventrally, a well-vascularized graft bed is lacking when creating a tube of a free graft. It has been shown that creating a tube of a free graft has disappointing results. For this reason, this type of urethroplasty is not indicated for urethral replacement.
- 2.
Pedicled flap urethroplasty:
This is a one-stage urethroplasty in which a (pedicled) flap is used as a tube to reconstruct the urethra. A flap remains connected to the donor area with a vascular pedicle that provides vascularity to the flap. Flaps are thus not dependent on the vascularization of the surrounding tissues to survive and to defend themselves against infection. Harvested at the prepuce, the penile shaft or the scrotum, they can be used along the whole length of the urethra ( Fig. 1 ).
Penile skin flaps
During dissection of penile skin flaps, it is essential not to damage the vascular pedicle. It is essential to follow the avascular surgical plane along Buck’s fascia, which lies on the corpora cavernosa and spongiosum, to preserve all vessels of the subcutaneous tissue of the penis. The dissection must be performed far enough to allow mobilization of the flap without any traction. After harvesting the flap, a tube is made around an 18- to 20-Fr catheter using a resorbable running suture 4.0. It is important that the skin of the flap is healthy, without scar tissue, and that the vascularization is intact and not altered. This situation is not guaranteed if there have been previous interventions or lichen sclerosus.
Penile skin flaps can be harvested by several techniques:
Transverse island flap
The most distal part of the penile skin is used in a circular fashion. This technique was developed by Duckett in the treatment of hypospadias. In a noncircumcised man, the flap is taken at the inner surface of the prepuce. The dimensions of a transverse island flap are limited by the circumference of the penis and seldom exceed 10 to 12 cm ( Fig. 2 ).
Procedures for the person with hypospadias who has undergone numerous prior repairs and remains with residual strictures, fistulas, and chordee, in addition to those patients who have undergone prior radiation therapy with injured genitalia and impaired wound healing, represent a subset of complex problems that require transfer of extragenital tissues for successful resolution. Muscle-assisted full-thickness skin and buccal graft urethroplasty using gracilis, rectus abdominis, gluteus maximus, and free latissimus dorsi muscle transfers used for urethral and genital reconstruction has been successful in the past. These muscle flaps may be prelaminated with skin for the urethral component with muscle transfer 2 to 4 weeks later using the muscle to obliterate the dead space and aid in microbial clearance. Skin may also be placed for the urethral component at the time of inset. The gracilis muscle remains the workhorse of perineal reconstruction as it is the most readily available for transfer to the urethra and other perineal conditions.
Reconstruction of scrotal and testicular defects
Cancer of the penis that extends into the scrotum and bulky penile tumors may require the resection of scrotal skin. The resilient and vascular nature of the scrotum allows for primary closure of the scrotum even with skin losses of up to 50%, a figure that can be improved to 67% with tissue expansion of the remnant scrotum. Even so, reconstruction of the scrotum using grafts and flaps remains associated with the surgical treatment of advanced penile carcinomas. Given that tissue loss of the scrotum is frequently associated with Fournier gangrene ( Fig. 3 ), much of the literature surrounding scrotal reconstruction is based on experiences with this disease; however, techniques and lessons learned are directly applicable to urologic oncology patients who have undergone surgical resection or complete removal of the scrotum.
The primary concerns in repairing scrotal defects are to protect the testes and to obtain a closed wound. These objectives have been achieved with split-thickness skin grafts, subcutaneous thigh pockets, and various myocutaneous and fasciocutaneous flaps. Definitive reconstruction of the scrotum can be delayed for several weeks from the time the testicles are denuded. During this time, each testis is treated either with repeated wet dressing changes, thereby protecting the tissues from the increased systemic temperatures that can impair spermatogenesis, or with burial in an ipsilateral, medial, subcutaneous thigh pouch ( Fig. 4 ). Relocation of the testicles to a more anatomic position is supported by concerns about pain, adverse psychological outcomes, and thermoregulation. Wang and colleagues reported that spermatogenesis, which requires a temperature 2° to 8° lower than the abdominal environment, is significantly abnormal after 2 years of follow-up in cases of thick skin flaps and buried testicles. Consequently, these methods are not recommended for patients who desire to maintain fertility. In patients in whom the creation of a flap is deferred from the time of cancer resection, perioperative considerations should include minimizing the infection rate, with complete shaving of the remaining scrotum within the operating room as well as administration of a first-generation cephalosporin just before surgery. In addition, the spermatic cord or testicles are typically sutured together before reconstruction to minimize the surface area, facilitate closure, and prevent a bifid neoscrotum. Following the procedure, the scrotum should be elevated, and all patients should be advised that the neoscrotum may seem tight for 6 to 12 months until the testicles have expanded it fully.
Although the denuded testicles are more commonly covered with meshed split-thickness skin grafts that are aesthetically satisfactory, conform well to irregular defects, and enable the drainage of exudate, thus improving the success of the graft take to nearly 100%, with 95% skin survival in extended defects, these grafts cannot be used if the tunica vaginalis is affected or if there is no granulation tissue. Furthermore, grafts have the disadvantages of being insensate, demanding a long and time-consuming period of wound care, and potentially adhering to the testes to cause contractures that hinder the cremasteric reflex. In addition, the incidence of testicular torsion and vascular compromise in healed grafts is not uncommon and patients need to be aware of these occurrences. Skin grafts are not recommended in defects so large as to expose the spermatic cords because a greater amount of procedural difficulty is associated with the increasing size of the defect. Because local flaps are the preferred option for providing testicular coverage when the remnant scrotum is insufficient, alternatives have been extensively developed over the years; options for testicular coverage use pedicled flaps, which can be completed safely in single-stage repairs. These flaps tend to avoid the complications of skin grafting such as skin maceration and breakdown secondary to fecal and urinary contamination. In addition, the complicated postoperative care and the duration of anesthesia that are required for free-flap repairs are obviated with the use of a pedicled flap for scrotal reconstruction.
Reconstruction of the scrotum and perineum may be accomplished with vertical rectus abdominis myocutaneous flaps and is the flap of choice of the authors for perineal defects ( Fig. 5 ). Many flaps, however, are based on tissue from the perineum, groin, or lower extremities as opposed to the abdomen, and Hallock describes a medial circumflex femoral artery perforator flap that is based on the musculocutaneous perforators of the gracilis muscle. This technique is suggested as an improvement on the medial thigh fasciocutaneous flap and is regarded as superior to the sensory anterolateral thigh (ALT) flap, which is typically based on discrete perforators and requires a more extensive dissection. Hallock’s technique uses a nonhirsute donor site and spares one lower extremity from violation; however, it results in an insensate neoscrotum that may be attached to the medial thigh, thereby begging a second-stage procedure. Hsu and colleagues illustrate the use of the well-established gracilis myofasciocutaneous advancement flap for cases of scrotal and perineal skin loss. This graft is elevated with a robust portion of the perigracilis fascia, and the associated skin incision is simply repaired with a V-to-Y primary closure. Kayikçioğlu advocates a short gracilis flap with a more proximal skin island to minimize problems caused by the traditional pedicle base location, which is 8 to 10 cm from the pubic tubercle, and the bulky nature of the original flap. In the short gracilis flap procedure, the main pedicle, derived from branches of the medial femoral circumflex artery and vein, is ligated and the motor nerve transected with the aim of inducing muscle atrophy. Despite these maneuvers, the flap is left as a peninsula or an island. A disadvantage of such myofasciocutaneous flaps is the sacrifice of normally functioning muscle tissue in a setting in which bulk is an unnecessary flap feature. Thus, attention has been directed to developing thinner fasciocutaneous flaps. One such flap is the neurovascular pedicled pudendal thigh flap that Karacal and colleagues described for use in scrotal reconstruction. With this technique, the superficial perineal artery supplies a posterior flap from the level of the scrotoperineal junction. The flap, used for defects with a mean area of 300 cm 2 , includes the deep fascia of the thigh and the fibrous tissue covering the adductor muscles, leaving a donor defect that can be closed primarily. The superficial perineal nerve is incorporated into the flap, eliminating numbness in spite of the associated denervation of the genitofemoral and ilioinguinal nerves. In cases of pelvic radiation, however, this flap is not always reliable. A novel technique published by Payne and colleagues is the use of local perforator lotus petal flaps that are based on the internal pudendal arteries. In this method, the skin flaps are raised from the gluteal folds and rotated 90° to create a neoscrotum. Maharaj and colleagues have used the Singapore flap, which was originally used in vaginal reconstruction, as a testicular sling, dissecting from the posterior perineum along the groin crease to the medial thigh as deep as the subfascial layer. The flap is elevated and then tunneled under the remaining bridge of skin between the groin crease and the scrotum. The donor site is closed primarily after the flap is secured to the edges of the defect. In search of a functionally and aesthetically ideal outcome for reconstructing a wide scrotal defect, Atik and colleagues used a skin expander for 3 weeks at a location 5 cm inferolateral to the anterior superior iliac spine. The area of expansion extended toward the lateral aspect of the groin where the subcutaneous fat tissue is notably less than in the peri-inguinal region. The flap, based on the superior circumflex iliac artery with nerve input from the lateral cutaneous femoral nerve, was dissected subfascially, tunneled subcutaneously to the scrotum, and sutured to the defect. The donor site was closed primarily and the capsule that had formed around the expander prevented any adhesion of the testes to the flap. The result of this procedure was a superthin neoscrotum with an average, uncomplicated hospital stay of 33 days. Various other flaps that use similar principles to these procedures have been described, with a more recent emergence of technical modifications that are based on advancements in technology and engineering. For instance, fibrin sealant intended to prevent fluid accumulation in reconstruction with split-thickness skin grafts and flaps has had success as a tissue glue for genital skin reconstruction. New tools to aid the surgeon in scrotal reconstruction will be developed as science and technology continue to advance.
The need for testicular reconstruction associated with penile cancer is rare. The testicles have an independent blood supply compared with the surrounding tissue, and thus, even with extensive debridement, they can be completely exposed and remain viable. Nonetheless, for damage to the testicle that requires repair, free grafts of tunica vaginalis are superior to synthetic grafts, which have a high infection rate, often requiring orchiectomy. Serial Doppler ultrasonography can be used to assess the testicles following repair, and testicular volume can be monitored.
Many options exist for scrotal reconstruction following resection or complete excision of the scrotum in association with surgical procedures aimed at eradicating local penile carcinoma. With the application of basic principles and the individualization of therapy based on the size of the defect and patient desires such as continued spermatogenesis and cosmesis, an appropriate technique can be selected and used in a single-stage procedure.
Reconstruction of the penile shaft
Patient Evaluation
History
The evaluation of the patient requiring penile reconstruction begins at the time the surgeon greets the patient. Typically the patient who has suffered from the loss of any portion of his penis finds himself in a desperate frame of mind and at times does not fully understand your reconstructive plan. It is therefore imperative to obtain informed consent of your proposed procedures and to enquire about previous psychiatric history because often these patients have some form of depression. A significant percentage of patients may even have attempted to injure themselves because of the loss of their penis. This situation should not exclude them from being a surgical candidate; this deformity has caused some patients to commit suicide.
A questionnaire may be given to the patient before the consultation to include a more detailed sexual history and desired goals. These goals are then reviewed by the surgeon and a picture of the patient’s expectations may be evaluated to determine if they are realistic or not. If a questionnaire is used then directed questions need to be made to elicit your defects and to formulate the operative plan. Ask if the patient is able to urinate voluntarily or not and whether it is via a perineal or penile urethrostomy. Is the patient able to have an orgasm currently and in what manner (eg, by penetration, masturbation)? Is the tactile sensation necessary for the patient to obtain an orgasm and are nerves such as the pudendal, ilioinguinal, and iliohypogastric sensate or not? When was the last time the patient was able to obtain an orgasm and has he been able to obtain one following the extirpation procedure? These are all important questions and the surgeon must feel comfortable asking them, because often the questionnaire may not elicit the answers.
The patient needs to be aware that you will do whatever you can within your surgical capabilities to perform a successful reconstruction, accomplishing as many of the desired goals as possible. Commonly more than one operation is necessary to accomplish your reconstructive goals and the patient needs to be as committed as you are to the process. A patient who desires only one quick operation is often not a good surgical candidate, because revision surgery is often required to accomplish all goals. In addition realistic expectations should be sought. A patient who states that his erect penis was 25 cm long preoperatively and desires this result postoperatively should be referred to the Kinsey Institute study and one in the Journal of Urology showing that the top 1% of patients have penises at most 22.5 cm in length when erect, with the top 10% measuring just more than 15.5 cm in length. The average penile length is 15 cm when erect.
Patient-controlled factors such as smoking and diabetes need to be addressed and a commitment from the patient to cease smoking or control his blood sugars if he is diabetic is vital. Hemoglobin A 1C should be evaluated and an endocrinologist should be consulted to ensure there is hypoglycemic control. Urine nicotine levels should be measured to ensure that the patient (if a smoker) has ceased smoking. Although smoking is considered by some surgeons to be a contraindication for surgery, if the patient abstains for a minimum of 3 weeks then surgery may be entertained. The patient should be aware of the increased risks of surgery if he has a previous smoking history. Surgical scars and prior history of trauma should be addressed because this dictates the use of flap tissue for the reconstruction. A detailed medical and surgical history should be taken so that any complicating factors to the proposed reconstruction may be addressed before surgery.
Physical examination
The patient should be in a gown for easier access for examination of the genital and perineal region. A lithotomy position is beneficial, particularly for the patient with a perineal urethrostomy, so that the abdominal and perineal regions are visualized together. The patient is often best evaluated in the surgical position in which he will be placed during surgery. Patient hygiene should be observed. The importance of good hygiene for any patient undergoing genitoperineal surgery cannot be overemphasized. If a partial penectomy has been performed and a remnant portion of penile shaft exists then measurement should be made with tape from the pubic symphysis to the distalmost aspect of the glans penis. This measurement should be recorded in the flaccid and erectile state if the patient is potent. Circumference in the midshaft axis should also be measured and recorded. Tactile sensation is evaluated at the distalmost aspect of the penis, midshaft, and at the pubic base. This sensation is evaluated in the perineum as well because this is particularly important in the patient with a perineal urethrostomy.
Suprapubic fat excess is recorded because a simpler buried penis operation may correct the patient deformity and achieve the patient’s goals. Previous infections and associated microbes are recorded so that they may be treated with perioperative antibiotics. Surgical scars are also noted and appropriate preoperative studies obtained to ensure adequate arterial inflow and venous outflow of the surrounding vasculature. One must ensure that the recipient vessels are suitable for free tissue transfer and that any local flap option maintains flap vessel patency if it is an axial pattern flap.
Goals in penile reconstruction:
- •
Allow patient to void through reconstructed penile urethra conduit
- •
Allow patient to have intercourse with new penis
- •
Allow patient (if possible) to have orgasm during sexual intercourse
- •
Allow patient to have sensitivity to distal shaft/glans
- •
Create an aesthetically pleasing phallus
- •
Avoid infection and other complications if possible.
Timing of reconstruction
When is Reconstruction Necessary?
The penis is an exceptionally composite organ with several and complex roles (transport of urine through a flaccid organ, transport of semen through an erected organ, allowing intercourse, essentiality for sexual function); it thus has a psychosexual effect on the man. When the penis is absent or inadequate, surgery is unable to replace it totally, recreating an anatomically and functionally normal organ with adequate sensation, erection, and capability to convey sperm and urine. Recently, there has been increasing interest in phallic substitution in adults and some fascinating procedures have been introduced that may partially reproduce an efficient penis. Many of these procedures were introduced in the treatment of female-to-male gender dysphoria as the main indication for phalloplasty. These technical proposals give new perspectives in male reconstructive surgery in infants, children, and adolescents affected by congenital penile malformations or early acquired serious penile deficiencies. Severe penile insufficiency or absence of a penis is a devastating condition for men, with significant psychological and physical effects. Although uncommon, they are challenging lesions to treat. As well as congenital conditions in which the penis has failed to develop, traumatic events, medically necessary penile amputations, and failed reconstructions of congenital anomalies are the main reasons for penile insufficiency ( Box 1 ).
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
