Phalloplasty: a valuable treatment for males with penile insufficiency

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

Aphallia - congenital absence of the penis: a systematic review

BACKGROUND

Aphallia is a rare congenital anomaly often associated with other urogenital anomalies. The management of aphallia cases for both the immediate and long-term treatment of patients with aphallia pose a major dilemma. Patients are at risk for psychosocial and psychosexual challenges throughout life.

METHODS

A systematic review was conducted on aphallia cases. We searched online databases until March 2023 for relevant articles and performed according to the PRISMA-P guidelines.

RESULTS

Of the 43 articles screened, there were 33 articles included. A total of 41 patients were analyzed qualitatively. Asia is the region with the most aphallia cases with 53% (n:22), while the United States is the country with the most most reported aphallia cases 31% (n:13). Most cases were identified as male sex (n: 40), and most cases were neonate with 68% (n:28) cases. Physical examination generally found 85% (N = 35) with normal scrotal development and palpable testes. The most affected system with anomalies is the genitourinary system with fistulas in 80% (n:29) cases. Initial management in 39% (n:16) of patients involved vesicostomy. Further management of 31% (n:13) included phalloplasty or penile reconstruction, and 12% (n:5) chose female sex. 17% (n:7) of patients refused medical treatment or were lost to follow-up, and 12% (n = 5) patients deceased.

CONCLUSION

Aphallia is a rare condition and is often associated with other inherited genitourinary disorders. In most cases, physical examinations are normal except for the absence of a phallus, and laboratory testing shows normal results. The initial management typically involves the vesicostomy procedure. Subsequent management focuses on gender determination. Currently, male sex is preferred over female. Due to the significant variability, the rarity of cases, and the lack of long-term effect reporting in many studies on aphallia, further research is needed to minimize bias.

Surgical tips in difficult penile prosthetic surgery: a narrative review

Penile prosthesis implantation continues to represent a reliable solution to address erectile dysfunction when oral medications fail, are not tolerated or are contraindicated, and most typically is associated with excellent satisfaction rates and durable results. Despite the dramatic improvements in the prostheses' design, in the surgical instruments and techniques over the years, certain categories of patients still pose a significant surgical challenge. The aim of the current review is to provide a quick and useful practical guidance based on our expertise in the identification and management of the difficult penile prosthesis implantation cases. A narrative review design was here preferred to fulfil our purpose. The search strategy included a range of terms, e.g. penile prosthesis, corporal fibrosis, infection, ischaemic priapism, Peyronie's disease, radical prostatectomy, pelvic surgery. Extensive corporal fibrosis after explantation of an infected device or after prolonged ischaemic priapism may represent the most difficult situations to deal with in penile prosthesis implantation surgery. Penile prosthesis implantation in patients with Peyronie's disease and in those who previously underwent radical prostatectomy also presents with an increased risk of complications. Experienced surgeons need to be able to recognise promptly and manage urethral perforation, cylinder crossover, tunical perforation and erosion, as these complications are more common when dealing with difficult penile prosthesis implantation cases. Applying penile lengthening techniques and principles can be useful in selected cases to ensure better postoperative satisfaction rates, especially in those patients who have experienced a more significant degree of loss of length preoperatively. High-volume-implanting surgeons should always be involved in complex cases to minimise the risk of complications. A thorough preoperative counselling can set realistic patients' expectations in this context, further contributing to postoperative satisfaction.

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes

OBJECTIVE

1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort.

METHODS

Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications.

RESULTS

Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%).

CONCLUSION

ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

Donor Site Defect Coverage of the Forearm with Dermal Substitute After Harvesting Radial Forearm Free Flap for Phalloplasty: Is MatriDerm® Worth the Effort?

An aesthetically and functionally pleasing phalloplasty is most commonly performed by a free radial forearm flap. However, the problem with donor site morbidity on the forearm remains unsolved. The aim of this study was to evaluate if the use of a dermal template such as MatriDerm® on the donor site significantly decreases the incidence of complications based on the Clavien–Dindo classification, such as wound healing disorders and reoperation rate, and if it could shortens the duration of hospital stay. A case series analysis was conducted at our institution. A total of 21 patients divided into two groups undergoing the phallic construction after the Gottlieb and Levine design in a single center underwent the donor site defect coverage either by MatriDerm® and split-thickness skin graft from the thigh or by full-thickness skin graft from the groin area. The use of MatriDerm® and split-thickness skin graft showed to have a statistically significant impact on the rate of complications (p = 0.008). Complications that were treated conservatively as well as that require surgical revision were significantly lower in the MatriDerm® group than in the full-thickness skin graft group (p = 0.002). Complications occurred not only at the forearm but also at the groin, where the full-thickness skin graft was harvested. The large dimension of the free radial forearm flap used for phalloplasty resulted in a significant donor site morbidity, leading to wound healing disorders, reoperations, and extended length of hospital stay. Therefore, we consider the use of dermal templates such as MatriDerm® as worth the additional effort and costs in this patient collective.

Single versus two-stage phalloplasty for transgender female-to-male patients: a systematic review of the literature

Phalloplasty is the main treatment for gender dysphoria disorder. It is difficult to ascertain if staging of phalloplasty influences the rate of complications. We aim to describe and compare the rates of complication between single versus two-stage phalloplasty for transgender female-to-male patients. PubMed, Ovid Medline, EMBASE and SCOPUS databases were queried for studies reporting complications of female-to-male transgender patients who underwent phalloplasty. The keywords "phalloplasty", "female to male", "outcome", "complication" and synonyms in different combinations were used for the search. Only studies that could identify whether phallic shaft creation was performed in a single or two-stage procedure were included. From a total of 336 articles, 20 met the inclusion criteria. Sixteen studies reported complications associated with a single-stage phalloplasty and seven studies identified complications after a two-stage procedure. The most common complications found for both groups of staging were fistula, stricture and total/partial flap necrosis. Patients who underwent two-stage phalloplasty had higher complication rates (partial or total flap necrosis and fistulas), compared with the single-stage procedure (P<0.05). In conclusion, this systematic review identified the impact of staging in the rate of complications related to phalloplasty for transgender female-to-male patients; a two-stage phalloplasty has a higher rate of complications.

Phalloplasty in cis-men with penile insufficiency: evaluation of outcomes and surgical complications : Good ability to achieve orgasm, high urinary complication rate

Phalloplasty is the gold-standard treatment for cis-men with penile insufficiency, which is often secondary to congenital conditions. The study-objective is to evaluate the functional outcomes and surgical complications in this population. A retrospective database comprised of cis-men undergoing a phalloplasty at a tertiary referral center from 2004 to 2019 was created. Phalloplasty was performed with various flaps. The tube-within-tube-technique was used for urethroplasty when possible. Complications <30 days postoperative were categorized according to Clavien-Dindo. Functional outcomes were assessed by bladder emptying and ability to achieve orgasm. Thirty patients were included. Nineteen of them needed urethroplasty, the remaining 11 patients had a catheterizable stoma. Within 30 days postoperative, 3 patients (10%) developed partial-flap necrosis (Clavien-Dindo III), 1 patient (3.3%) developed graft failure (Clavien-Dindo III), 2 patients (6.6%) developed infected hematomas (Clavien-Dindo III) and 1 phalloplasty (3.3%) was complicated by hematuria (Clavien-Dindo II). In the long-term, 10 patients (33%) developed fistulae, 6 (20%) requiring urethroplasty. Seven patients (23%) had urethral strictures, all needing urethroplasty or urethrotomy. Sixteen patients (84%) emptied their bladder per urethra, the three remaining necessitated conversion to perineostomy. Median (IQR) Q_max on uroflow was 15.7 (11.9-19.2)mL/s with median (IQR) voiding volume of 259 (137-307) mL and median (IQR) residual volume of 11.5 (0-20) ml on ultrasound. All patients but 1 (97%) reported ability to achieve orgasm. RFFA and ALT result in phalli with great ability to achieve orgasm but urethral complications are frequent.

Outcomes of inflatable penile prosthesis insertion using a neotunica allograft in neophalluses of patients on the bladder exstrophy-epispadias complex spectrum

BACKGROUND

Men born on the bladder exstrophy-epispadias complex (BEEC) spectrum may undergo neophallus reconstruction with a variety of free flaps, most commonly radial forearm. In order to achieve erectile function, a penile prosthesis may be inserted following neophallus construction.

OBJECTIVE

In this study, we sought to describe the perioperative and clinical outcomes of inflatable penile prosthesis (IPP) insertion into neophalluses of patients along the BEEC spectrum.

STUDY DESIGN

Using a prospectively maintained institutional BEEC database, patients who had undergone both neophallus creation and IPP placement were identified for this study. Surgery was performed by two surgeons with expertise in IPP implantation. Operative details and postoperative outcomes and complications were collected with review of the medical record.

RESULTS

Overall, there were a total of 13 men who underwent neophallus reconstruction with subsequent IPP placement. Of these men, 76.9% (10/13) had experienced successful primary closure in childhood. One patient had corporal loss secondary to complete primary repair of exstrophy (CPRE) following a failed primary attempt. The average age at IPP placement was 23.2 years (SD ± 5.06). Mean OR time (n = 11) was 244.8 min (SD ± 46.2). 76.9% (10/13) of the cases used AlloDerm™ as a neotunica albuginea for support of the IPP. Three patients (23.1%) experienced complications all of which required revision surgery. Two of these complications were erosions in patients for whom AlloDerm™ was not used in the initial IPP placement.

DISCUSSION

The results of this study suggest that IPP placement in neophalluses of males on the BEEC spectrum have low perioperative and postoperative morbidity with successful outcomes. While the rate of complications is notably higher in this group compared to the native penis IPP literature, the use of AlloDerm™ or other allograft materials may help to narrow this gap.

CONCLUSIONS

IPP placement in neophalluses of men on the BEEC spectrum is successful in the majority of cases. Complications may be reduced with the use of AlloDerm™ in initial placement.

Microsurgical Phalloplasty in Nontranssexual Patients - Considerations After a Retrospective Single-center Analysis of 23 Cases

OBJECTIVE

To evaluate the outcome of a single-center series of penile reconstruction using the radial free forearm flap in rare indications.

MATERIALS AND METHODS

From April 1993 until September 2016, 23 nontranssexual patients underwent phallic reconstruction by the use of a neuromicrovascular free radial forearm flap in our clinic. Patient-specific characteristics, surgical techniques, complications, and outcomes were retrospectively evaluated and interpreted.

RESULTS

The indications for surgery were: disorders of sex development (34.8%), reconstruction after oncologic surgery (34.8%), automutilation (8.7%), iatrogenic (8.7%), microphallus (8.7%), and 1 case of priapism (4.3%). Two patients (8.7%) had a total flap necrosis and 2 patients (8.7%) had a partial flap necrosis; 3 out of these 4 patients were heavy smokers. Urinary fistulae and strictures were frequent but were successfully managed by urologists in all cases. There was no statistically significant correlation between smoking, comorbidities, number of venous anastomoses, and complications.

CONCLUSION

In departments experienced in microsurgery, the goals of penile reconstruction could also be achieved in patients with rare indications by the use of the neuromicrovascular free radial forearm flap. Despite the high rate of postoperative complications, penile reconstruction with the free radial forearm flap yields satisfying results. An intensive cooperation between the plastic-reconstructive team and the urological team is a prerequisite to achieve the best surgical result.

Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience

BACKGROUND

Urethral reconstruction in anterolateral thigh flap phalloplasty cannot always be accomplished with one flap, and the ideal technique has not been established yet. In this article, the authors' experience with urethral reconstruction in 93 anterolateral thigh flap phalloplasties is reported.

METHODS

Ninety-three anterolateral thigh phalloplasties performed over 13 years at a single center were retrospectively reviewed to evaluate outcomes of the different urethral reconstruction techniques used: anterolateral thigh alone without urethral reconstruction (n = 7), tube-in-tube anterolateral thigh flap (n = 5), prelaminated anterolateral thigh flap with a skin graft (n = 8), anterolateral thigh flap combined with a free radial forearm flap (n = 29), anterolateral thigh flap combined with a pedicled superficial circumflex iliac artery perforator flap (n = 38), and anterolateral thigh flap combined with a skin flap from a previous phalloplasty (n = 6). Seventy-nine phalloplasties were performed for female-to-male sex reassignment surgery. The others were performed in male patients with severe penile insufficiency.

RESULTS

Urethral complication rates (fistulas and strictures) were as follows: tube-in-tube anterolateral thigh flap, 20 percent; prelaminated anterolateral thigh flap, 87.5 percent; free radial forearm flap urethra, 37.9 percent; superficial circumflex iliac artery perforator urethral reconstruction, 26.3 percent; and skin flap from previous phalloplasty, 16.7 percent.

CONCLUSIONS

When tube-in-tube urethra reconstruction is not possible (94.2 percent of cases), a skin flap such as the superficial circumflex iliac artery perforator flap or the radial forearm flap is used for urethral reconstruction in anterolateral thigh phalloplasties. Flap prelamination is a second choice that gives high stricture rates. If a penis is present, its skin should be used for urethral reconstruction and covered with an anterolateral thigh flap. With these techniques, 91.86 percent of patients are eventually able to void while standing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Mystery and realities of phalloplasty: a systematic review

The neophallus creation is still a mystery and it remains challenging even today. In this article, we performed a comprehensive review of the literature regarding phalloplasty and penile reconstructive surgery between January 2008 and May 2016. In this review, we have included 15 research articles and the results of 276 patients were examined. Studies revealed several indications and when indications were reviewed, 191 patients were female-to-male transgender, 9 patients had disorder of sex development/micropenis, 16 had penile amputation/trauma, 9 had ambiguus genitalia, 40 had exstrophy and/or epispadias, 11 had other problems. As a result of this review, phalloplasty is a reliable and useful operation with good functional and aesthetical results.

Phalloplasty: A Review of Techniques and Outcomes

BACKGROUND

Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes.

METHODS

A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.

CONCLUSIONS

Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

Penile Allotransplantation for Complex Genitourinary Reconstruction

PURPOSE

Reconstruction of complex functional structures is increasingly being performed with vascularized composite allotransplantation. Penile transplantation is a novel vascularized composite allotransplantation treatment option for severe penile tissue loss and disfigurement. Three allogeneic human penile transplantations have been reported. We review these cases as well as penile transplant indications, preclinical models and immunosuppression therapy.

MATERIALS AND METHODS

We performed a comprehensive literature review for the years 1970 to 2016 via MEDLINE®, PubMed® and Google with the key words "penis transplantation," "penile rejection," "penile replantation," "penile tissue loss" and "penis vascularized composite allotransplantation." Relevant articles, including original research, reviews and nonscientific press reports, were selected based on contents, and a review of this literature was generated.

RESULTS

Three human allogeneic penile transplantations have been performed to date, of which 1 was removed 14 days after transplantation. The second recipient reports natural spontaneous erections and impregnating his partner. All 3 patients were able to void spontaneously through the graft's urethra. The complexity of the transplant is determined by how proximally the penile shaft anastomosis is performed and additional pelvic tissue may be transplanted en bloc if needed.

CONCLUSIONS

Penile transplantation is a technically demanding procedure with significant ethical and psychosocial implications that can provide tissue and functional replacement, including urinary diversion and natural erections. It is unclear how rejection and immunosuppression may affect graft function. Better models and more preclinical research are needed to better understand and optimize penile transplantation.

Phenotype, Sex of Rearing, Gender Re-Assignment, and Response to Medical Treatment in Extended Family Members with a Novel Mutation in the SRD5A2 Gene

Deficiency of steroid 5-alpha reductase-2 (5ARD2) is an inborn error of metabolism causing a disorder of sexual differentiation. It is caused by a mutation in the SRD5A2 gene in which various mutation types have been reported. Affected individuals have a broad spectrum of presentation ranging from normal female-appearing genitalia, cliteromegaly, microphallus, hypospadias, to completely male-appearing genitalia. We report an extended Emirati family with 11 affected members. The family displayed various phenotypes on presentation leading to different sex of rearing. Some family members were reassigned gender at various stages of life. The index case was born with severe undervirilization with bilaterally palpable gonads and was raised as male from birth. He had a 46,XY karyotype and a high testosterone/dihydrotestosterone ratio. Genetic investigation revealed a novel homozygous deletion of exon 2 of the SRD5A2 gene. Both parents were found to be carriers for the gene deletion. The patient had masculinizing surgery and a course of topical dihydrotestosterone. No beneficial effect of the hormone application was noted over 3 months and the treatment was discontinued. The findings on this kindred indicate that deletion of exon 2 in the SRD5A2 gene causes various degrees of genital ambiguity leading to different sex of rearing in affected family members. Gender reassignment may be done at various ages even in conservative communities like the Gulf region.

Long-term outcome of male genital reconstruction in childhood

Hypospadias, epispadias with or without exstrophy, and disorders of sex development are among the most common anomalies of genitalia that occur during childhood. Considering the tremendous effect of genitourinary reconstruction on adult life, the evaluation of the long-term results of different techniques of genitoplasty in pediatrics is of the utmost importance. After reviewing the literature, the authors summarize the available long-term outcomes of genitoplasty in childhood, specifically focusing on the cosmetic, psychosocial, psychosexual and functional results, and emphasize that, contrary to the widely available data on early outcomes of genital reconstruction in the pediatric population, very few well described controlled studies have evaluated the long-term effect of genitoplasty in puberty and adulthood, in the sense that the surgeon should describe the peroperative findings in more detail and also be more structured in evaluating the postoperative result at follow-up visits. Finally, the authors conclude that more attention should be paid to the impact of these techniques on cosmetic aspects and psychosexual development in these patients after puberty, as they play a crucial role in their adult quality of life.

Key discussions from the Working Party on Disorders of Sex Development (DSD) evaluation, Foundation Merieux, Annecy, France, March 14-17, 2012

Four topics from the DSD Working Party, a meeting to provide information regarding future studies, reported here are the complexities of hypospadias, surgical treatment of virilized genitalia of 46,XX DSD individuals, advances in phalloplasty and psychological, social and sexual outcomes.

Long-term evaluation of donor-site morbidity after radial forearm flap phalloplasty for transsexual men

INTRODUCTION

Phalloplasty using the radial forearm flap is currently the most frequently used technique to create the neophallus in transsexual men (formerly described as female-to-male transsexual persons). Although it is considered the gold standard, its main disadvantage is the eventual donor-site morbidity in a young, healthy patient population.

AIM

The study aims to examine the long-term effects of radial forearm flap phalloplasty in transsexual men and to evaluate aesthetic outcome, scar acceptance, bone health, and daily functioning.

MAIN OUTCOME MEASURES

Scars were evaluated with the patient and observer scar assessment scale, the Vancouver Scar Scale, and self-reported satisfaction. Bone health was assessed using dual X-ray absorptiometry and peripheral quantitative computed tomography, and daily functioning using a physical activity questionnaire (Baecke). These measurements were compared with 44 age-matched control women.

METHODS

This is a cross-sectional study of 44 transsexual, a median of 7 years after radial forearm flap phalloplasty, recruited from the Center for Sexology and Gender Problems at the Ghent University Hospital, Belgium.

RESULTS

We observed no functional limitations on daily life activities, a pain-free and rather aesthetic scar, and unaffected bone health a median of 7 years after radial foreram flap phalloplasty. Over 75% of transsexual men were either satisfied or neutral with the appearance of the scar.

CONCLUSIONS

Transsexual men, despite scarring the forearm, consider the radial forearm flap phalloplasty as worthwhile.

Phalloplasty in complete aphallia and ambiguous genitalia

The most common indications for phalloplasty in children include aphallia, micropenis/severe penile inadequacy, ambiguous genitalia, phallic inadequacy associated with epispadias/bladder exstrophy and female to male gender reassignment in adolescents. There are many surgical options for phalloplasty; both local pedicled tissue as well as free tissue transfer. The advantages of local tissue include a more concealed donor site, less complex operation and potentially faster recovery. However, pedicled options are generally less sensate, making placement of a penile prosthesis more risky and many children with bladder exstrophy have been previously operated upon making the blood supply for local pedicled flaps less reliable. This Here the authors discuss free tissue transfer, including the radial forearm, the anterolateral thigh, the scapula and latissimus, and the fibula free flaps, as well as local rotational flaps from the abdomen, groin, and thigh. The goal of reconstruction should be an aesthetic and functional (ability to penetrate) phallus, which provides tactile and erogenous sensation, and the ability to urinate standing. Ideally, the operation should be completed in one to two operations with minimal donor site morbidity. There are advantages and disadvantages of each of flap and thus the choice of donor site should be a combination of the patient's preference and surgeon's ability to produce a consistent result.

Simultaneous total corporal reconstruction and implantation of a penile prosthesis in patients with erectile dysfunction and severe fibrosis of the corpora cavernosa

INTRODUCTION

Implantation of a penile prosthesis in severely scarred corporal bodies represents a great challenge as fibrosis can compromise dilatation and subsequent closure of the corpora cavernosa and limit size, type, and function of the device.

AIM

The aim of this study is to report our experience of simultaneous corporeal reconstruction and penile prosthesis implantation in patients with severe penile contracture consequence of diffuse fibrosis.

METHODS

Between March 2006 and February 2010, 18 patients with severe penile contracture and coporeal fibrosis underwent simultaneous corporeal reconstruction and placement of a penile prosthesis.

MAIN OUTCOME MEASURES

Surgical outcome and complications have been recorded during postoperative follow-up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified erectile dysfunction index of treatment satisfaction questionnaire.

RESULTS

Although the dilatation of the corpora was extremely difficult due to the severe fibrosis, a penile prosthesis has been implanted in all patients. A malleable penile prosthesis has been inserted in four patients and a three-piece inflatable device in the remainder. After an average follow-up of 26 months (range 6-36), revision surgery was required in four patients (elective exchange to three-piece inflatable device in three patients and upsizing of the implant in one patient). Although all patients were able to achieve penetrative sexual intercourse, four patients were partially dissatisfied because of significant penile shortening.

CONCLUSION

In expert hands, simultaneous penile prosthesis implantation and corporal reconstruction of severely scarred corpora yield satisfactory results. Patients must be warned that complication rate in presence of severe fibrosis is significantly higher than in virgin cases and that downsized cylinders might be required due to the contracture of the tunica albuginea.

Urethroplasty for strictures after phallic reconstruction: a single-institution experience

BACKGROUND

Treatment recommendations for strictures after phalloplasty are lacking.

OBJECTIVE

Our aim was to evaluate the outcome of urethroplasty for strictures after phalloplasty and to provide treatment recommendations based on this experience.

DESIGN, SETTING, AND PARTICIPANTS

One hundred and eighteen urethroplasties were performed in 79 patients. Mean patient age was 37.6 yr. Mean follow-up was 39 mo.

INTERVENTION

Different types of urethroplasty were used: meatotomy, Heineke-Mikulicz principle (HMP), excision and primary anastomosis (EPA), free graft urethroplasty (FGU), pedicled flap urethroplasty (PFU), two-stage urethroplasty (TSU), and perineostomy followed by urethral reconstruction (PUR).

MEASUREMENTS

Stricture recurrence was defined as the need for additional instrumentation or surgery.

RESULTS AND LIMITATIONS

Mean stricture length was 3.6 cm. Stricture location was at the meatus, phallic urethra, anastomosis, fixed part, and different locations in 18, 28, 48, 15, and 9 urethroplasties, respectively. Stricture recurrence was observed in 44 urethroplasties (41.12%). Stricture recurrence rate for meatotomy, HMP, EPA, FGU, PFU, TSU, and PUR was 25%, 42.11%, 42.86%, 50%, 40%, 30.3%, and 61.9%, respectively.

CONCLUSIONS

The main stricture location after phalloplasty is the anastomosis between the phallic and the fixed part. Urethroplasty for strictures after phalloplasty is associated with a relatively high recurrence rate.

TRIAL REGISTRATION

EC UZG 2007/434.

Endoscopic incision of short (<3 cm) urethral strictures after phallic reconstruction

INTRODUCTION

Urethral stricture formation is a frequent complication after phallic reconstruction, but little is known about the treatment. Endoscopic cold-knife incision has long been applied for short urethral strictures. Can this treatment be used for strictures in the phalloplasty patients as well?

MATERIALS AND METHODS

Thirty-two endoscopic urethrotomies were done in 22 patients with a phalloplasty. Only noncomplicated strictures shorter than 3 cm were considered appropriate for endoscopic incision. The stricture was treated by a cold-knife incision. The urethral catheter was maintained for at least 2 weeks. Follow-up was done every 3 months during the first year and annually thereafter. Comparing failures with successful cases, prognostic factors for success are assessed.

RESULTS

Median follow-up is 51 months (range, 8-95 months). In 14 patients, no previous intervention was done. Mean stricture length is 1 cm (range, 0.5-2.5 cm). Endoscopic incision was successful in 14/32 cases (43.8%). First incision was successful in 10/22 cases (45.5%), a second incision was successful in 4/7 cases (57.1%), but three or more incisions were never successful (0/3). The only significant difference between failures and successful cases is the interval between phalloplasty and endoscopic incision (32 vs. 9.9 months; p = 0.00008).

CONCLUSIONS

Endoscopic incision for short (<3 cm) urethral strictures after phallic reconstruction can solve the problem in about half of the cases. Three or more incisions seem to be useless. Endoscopic incision is significantly better when performed with a long-term interval after phalloplasty, indicating that a well-healed phallic urethra is more prone to a successful endoscopic incision.

Use of forearm free-flap phalloplasty in bladder exstrophy adults

OBJECTIVE

To assess the long-term outcome and cosmetic results of forearm free-flap phalloplasty for correcting micropenis associated with bladder exstrophy in men.

PATIENTS AND METHODS

From 1992 to 2000, six men with bladder exstrophy and unsatisfactory penile appearance underwent phalloplasty at our institution. The mean (range) follow-up was 113 (62-153) months. The surgical procedure consisted of a modified radial free-flap phalloplasty and prosthesis implantation. One-stage urethroplasty was electively performed according to the patient's voiding pattern. Early and late complications were recorded and quality of life after phalloplasty was assessed.

RESULTS

The mean (range) age was 21.2 (17-26) years and flap survival was 100%. Two incontinent patients underwent immediate perineal urethrostomy. One sepsis occurred, requiring the removal of the penile prosthesis and a cutaneous continent urinary diversion; this patient was the only one to complain about the outcome. Two anastomotic urethral strictures were conservatively treated by endoscopic urethrotomy and only one patient underwent subsequent urethral self-dilatations. Five patients were very satisfied with the cosmesis of the neophallus and three patients reported having regular sexual intercourse.

CONCLUSIONS

Although short, this series indicates the low incidence of early complications and the excellent long-term satisfaction with forearm free-flap phalloplasty in bladder exstrophy. Phalloplasty has potential indications when adult exstrophy patients are dissatisfied with the cosmetic appearance of their external genitalia or have unsatisfactory sexual intercourse.

Penile reconstruction/formation

PURPOSE OF REVIEW

To evaluate current reviews and assess scientific validity of the recent literature on penile reconstruction after trauma, penile reconstruction in gender reassignment surgery, concealed penis, and aphallia.

RECENT FINDINGS

Technical advances in penile reconstruction have been highlighted. The few long-term follow-up studies available confirm the difficulty of such surgery, in terms of complications and the limits of the final achievable outcomes. The surgery necessitates several steps and a high number of revisions. Scientific progress in penile reconstruction seems slow, with a lack of controlled studies, high rate of loss to follow-up (especially in sex reassignment surgery) and a lack of validated assessment measures. However, a few recent studies are making the problems clearer, especially in patient selection and the avoidance of raising false expectations in patients.

Reconstructive surgery for severe penile inadequacy: phalloplasty with a free radial forearm flap or a pedicled anterolateral thigh flap

Objectives. Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy. Methods. Eleven males (age 15 to 42 years) were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4-49 months). Aesthetic and functional results were evaluated. Results. There were no complications related to the flap. Aesthetic results were judged as "good" in 9 patients and "moderate" in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications (stricture and/or fistula). Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion. Conclusion. In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.