Interesting Case Series Acquired Absence of the Penis - ePlasty

Interesting Case SeriesAcquired Absence of the PenisIan C. Hoppe, BA, and Matthew J. Trovato, MDDepartment of Surgery, Division of Plastic Surgery, New Jersey Medical School–UMDNJ, NewarkCorrespondence: hoppeic@umdnj.eduDESCRIPTIONA 45-year-old man presents with an acquired absence of the penissecondary to penile resection due to squamous cell carcinoma.NEXT

QUESTIONS1. What are the goals for phallic reconstruction?2. What options are available for reconstruction?3. What surgical repair is most appropriate?4. What is the long-term course for phallic reconstruction?BACKNEXT

DISCUSSIONSeveral goals should be kept in mind during phallic reconstruction.(1) A new urethra must be constructed that allows for functional voiding.(2) There must be enough tissue to allow for the insertion of aprosthetic device to permit sexual intercourse. (3) The final result mustbe aesthetically acceptable to the patient with (4) minimal loss of functionfrom donor sites. If possible, it is also desirable to (5) provideboth erogenous and protective sensation. From a surgeon’s perspective,(6) the reconstruction should be a single-step procedure.Many flaps are available for the reconstruction of the phallus. Pedicledoptions include abdominal, infraumbilical, groin, thigh, superficialinferior epigastric artery, and gracilis flaps. Microsurgical advanceshave made free flaps increasingly effective, including the radial forearmand lateral arm flaps. Osteocutaneous flaps have also been popularizedas of late, including the fibular and radial forearm osteocutaneous freeflaps. The radial forearm cutaneous flap is most desirable because of itsgood arterial supply and the abundance of skin available to create aneourethra and neophallus. The lateral border of this flap can be wrappedaround a Foley catheter using a tube-within-a-tube roll technique to allowfor an epithelialized urethra. The donor site can be easily coveredwith a split-thickness skin graft.BACKNEXT

Postoperatively, the Foley catheter should remain in place for up to 4weeks to allow for the neourethra to heal and to facilitate micturition.To monitor the patency of the microsurgical anastomoses, implantableDopplers may be placed on the anastomosed artery and vein. PencilDopplers can also be routinely used to monitor the perfusion of the flap.After the microsurgical anastomosis has taken, return of sexual functionshould become a priority. Several options for prosthetic implantsare available including rod-like implants and inflatable balloon-like implants.The long-term viability of these implants is dependent on thepresence of enough tissue and intact protective sensation.REFERENCES1. Selvaggi G, Elander A. Penile reconstruction/formation. Curr Opin Urol. 2008;18(6):589–97.2. Kim SK, Lee KC, Kwon YS, Cha BH. Phalloplasty using radial forearm osteocutaneous free flaps infemale-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62(3):309–17.3. Dabernig J, Shelley OP, Cuccia G, Schaff J, Haferkamp A, Djakovic N. Urethral reconstruction usingthe radial forearm free flap: experience in oncologic cases and gender reassignment. Eur Urol.2007;52(2):547–53.4. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial forearm flap really thestandard technique? Plast Reconstr Surg. 2009;124(2):510–18.BACK