(245) Outcomes of Penile Reconstruction for Salvage of Penile Gangrene

Abstract

Abstract Introduction The most catastrophic complication of penile implant surgery results in either total/partial loss of the penis to such an extent that salvage penile reconstruction or phalloplasty is required. Penile gangrene (or necrosis) is rare and is associated with several patient factors (smoking, diabetes) and surgical factors (sliding technique, revision or a subcoronal incision). Irreversible ischemia with tissue loss will ensue if the prosthesis is not removed immediately. Nevertheless, subsequent corporal fibrosis and penile length loss may preclude an adequate functional penile length. In this situation, total penile reconstruction would be the only option to restore the ability for sexual intercourse and to void while standing. Objective The aim of this series is to assess the risk factors that predispose a select group of patients that require phalloplasty following penile gangrene and their surgical and functional outcomes following reconstruction. Methods All patients following phalloplasty for penile necrosis were identified from a comprehensive prospective database. Potential risk factors for penile necrosis were identified and the type and outcomes of reconstruction summarized. Functional outcomes were assessed by non-validated questionnaire. Results Thirteen patients with a median age of 57 years (range 27-68 years) required phalloplasty following penile necrosis with no incidence of flap loss. Reasons for erectile dysfunction were diabetes (37.5%), Peyronie’s disease (31%) and pelvic trauma (25%). The most common identifiable risk factors was diabetes (60%), followed by smoking (53%), adjunctive procedures like sliding technique or grafting (40%), revision surgery (27%) and infection with delayed explantation (27%). All patients had more than one risk factor for penile necrosis. Penile reconstruction was achieved with the radial artery forearm free flap (62%) and the anterolateral thigh flap (38%). All flaps were designed with an integrated urethra requiring anastomotic urethroplasty. Urethral complications occurred in 46.2% of men (fistulae and strictures) requiring surgical repair (Clavien 3b) while 2 had partial skin graft loss from the donor arm that improved with dressings and antibiotics (Clavien 2). Following phalloplasty, all responders had sensation (46% could orgasm with the neophallus) and 86% were able to void while standing. Most men were satisfied with the esthetic outcome (92%). The questionnaire response rate was 67%. Conclusions Penile necrosis following penile prosthesis insertion is rare and occurs in the presence of risk factors, particularly diabetes and smoking. Penile prosthesis surgery should be considered carefully in this cohort of patients especially for revision surgery or where adjunctive procedures are planned. Infection requires immediate explant of the device. Phalloplasty has good surgical and functional outcomes should reconstruction be required although there is a significant risk of surgical complications. Disclosure No