Flap Phalloplasty Research Articles

Functionality and Scar Evaluation of the Donor Site in Extended Radial Forearm Flap Phalloplasty: How Affected Is the Arm in Day-to-Day Life?

Background: The radial forearm flap remains the gold standard in phalloplasty in gender-affirming surgery due to its versatility and functional outcome, but the significant donor site morbidity and its impact on daily functioning and aesthetic perception remains understudied. This study provides valuable insights into the mid-term functional and aesthetic outcomes of the forearm in transgender individuals following radial forearm flap phalloplasty using widespread instruments for assessment scoring systems and for the evaluation of postoperative wound healing of surgical interventions in general. Methods: Between January 2013 and March 2018, a total of 47 patients underwent radial phalloplasty at AGAPLESION Markus Hospital, and 20 consented to participate in this cross-sectional, retrospective study evaluating functional and aesthetic outcomes post-radial forearm flap phalloplasty using standardized questionnaires (DASH, POSAS, and SBSES). A univariate median regression of each score was performed to determine the associations with selected variables, and correlation analyses between scores was performed using a nonparametric Spearman rank correlation. Results: Among the 20 participants, the median Quick DASH, DASH functionality, DASH sport and music, and DASH work scores indicated minimal to no functional impairment. Scar evaluations using the PSAS, OSAS, and SBSES scales showed overall patient satisfaction with minimal concerns regarding pigmentation and scar texture. Notably, an increase of 0.27 cm2 in wound surface area added one point to the DASH sport and music score (p = 0.037). Statistical analysis also demonstrated a significant correlation between functional and aesthetic assessment scores. Conclusions: The radial forearm phalloplasty donor site, evaluated by the PSAS, OSAS, and SBSES scales, leads to minimal or no functional impairment; however, the worsening of the DASH sport and music score with increasing wound surface reflects a direct relation between wound size and functional impairment.

Penile Reconstruction with Radial Forearm Free Flap—Present State of the Art

Abstract Background Patients with congenital or acquired penile defects face significant psychological trauma. Various methods for penile reconstruction have been described of which the free radial artery forearm flap using the tube-within-tube design is found to be the most commonly used. We have assimilated the best practices described at different times in our bid to standardize the technique and have strived to make it reproducible. The reconstructed phalluses with this method can withstand the test of time, allowing the patients to lead a normal life. Materials and Methods We conducted a retrospective review of the past 16 years and collected data for all radial forearm free flap phalloplasties. We have modified the design originally described by Biemer. The urethra is kept 1 cm longer than the shaft and the proximal 5 mm of the prospective urethra is not sutured to allow for spatulation of the urethral anastomosis. Results A total of nine patients were included out of which six patients had congenital malformations, two had traumatic injuries, and one had penile carcinoma. Six out of the nine patients had implants placed which were wrapped in fascia lata graft. One of these patients experienced displacement of the implant which needed to be repositioned. Three patients faced postoperative complications. All patients had tactile and erogenous sensation at the tip of the glans at the end of 1 year and all patients could micturate while standing. One patient's esthetic and functional outcome was compromised. One of the married patients has fathered a child through normal sexual intercourse. Conclusion Radial forearm phalloplasty done by this technique allows us to achieve consistently stable functional and esthetic outcomes. We firmly believe that this standardized protocol for penile reconstruction could be of great benefit to patients as well as to the treating reconstructive surgeon in their quest to achieve a completely rehabilitated patient.

A Study on Symptoms of Pelvic Floor Dysfunction in Assigned Female at Birth Patients Diagnosed with Gender Dysphoria Undergoing Vaginectomy.

A person diagnosed with gender dysphoria who was assigned female at birth (AFAB) may request a vaginectomy as part of gender-affirming treatment. The aim of this study was to investigate the impact of vaginectomy on symptoms of pelvic floor dysfunction (PFD). This is a cohort study on patient-reported symptoms of PFD in patients who were AFAB, diagnosed with gender dysphoria, and undergoing vaginectomy in a single surgical center. Patients responded to a questionnaire preoperatively and 1 year postoperatively. The questionnaire consisted of 33 questions, including a modified short-form version of the Pelvic Floor Distress Inventory (PFDI-20). Twenty-three consecutive patients were included in the study and 20 patients (87%) completed the 1-year follow-up. The preoperative median PFDI-20 score was 24 (0-114) compared with 32 (0-168) at the 1-year follow-up (P = 0.07). Patients who had previously undergone neophallus construction with a metoidioplasty (n = 15) had no significant change between the preoperative and the 1-year postoperative PFDI-20 score [median 17.5 (0-114) and 27.5 (0-145) (P = 0.65), respectively]; whereas those with a groin flap phalloplasty (n = 5) had a significant increase in reported symptoms [median 37 (10-95) and 124 (45-168), respectively (P = 0.04)]. Overall, vaginectomy could be performed without any major impact on symptoms of PFD. However, this seemed to be true mainly for patients with previous metoidioplasty, whereas patients with previous groin flap phalloplasty reported worsening of symptoms.

Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty

ObjectivesTo determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening. MethodsA retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of urethral lengthening. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. ResultsBetween November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. ConclusionsUrethral lengthening during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

(040) Anterolateral Thigh Flap Phalloplasty: Outcomes Following Genital Gender Affirmation Surgery

Abstract Introduction Genital gender affirmation surgery (gGAS) is a key part of the management of patients with gender dysphoria. The anterolateral thigh (ALT) free flap was proposed as an alternative to the more common radial forearm free flap (RFFP) phalloplasty due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap offers greater security of vascular supply for suitable patients, and if suitable and desired the flap can be formed with an integrated urethra, facilitating voiding while standing. Objective The aim of the study is to report the contemporary surgical and functional outcomes of ALT phalloplasty. Methods All individuals undergoing ALT flap phalloplasty for genital gender affirmation surgery (GAS) between 2009 and 2023 nationwide were included. Individuals were managed in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care version 7. Data were extracted from a prospectively collected single surgeon database and medical records. Functional outcomes were assessed by non-validated questionnaire. Statistical analysis included Mann-Whitney, chi-squared, Fisher’s exact and unpaired T tests. Results Surgical outcomes: A total of 87 patients were included in the study. More than half (45, 51.7%) had an integrated urethra. The median length of stay following surgery was six days (IQR 6-7). Eleven patients (12.6%) had a 30-day Clavien-Dindo 3b complication or greater. Three patients (3.4%) experienced total flap loss. A further three patients (3.4%) had partial flap loss. Three patients (3.4%) required a salvage phalloplasty later. Thirteen patients (out of 42, 31.0%) without an integrated urethra went onto have a free flap urethroplasty. Functional outcomes: Thirty-nine individuals (44.8%) completed the patient reported outcomes questionnaire. Most patients (77%) were generally satisfied with their phalloplasty. More than half (56%) with an erectile device used their phallus for penetrative intercourse, while one in five reported experiencing orgasm using their phallus alone. Following urethral lengthening, all respondents were able to void standing. There was no significant difference in mean satisfaction scores for those with an integrated urethra compared to those without (4.18/5 vs 3.82/5, p=.45), as well as between those with or without an erectile device, respectively (3.78/5 vs 4.10/5, p=.26). Conclusions This study is one of the largest single centre cohorts of ALT flap phalloplasty reported to date. It further supports the use of the ALT flap as one of the main genital GAS options for transmen. Over half of the patients studied had an integrated urethra, the gold standard for urethral lengthening. Patient reported functional outcomes were promising, with similar scores regardless of urethral lengthening or erectile device insertion. Disclosure No.

(184) Gender-Affirming Abdominal Phalloplasty

Abstract Introduction Phalloplasty can alleviate gender dysphoria in transgender individuals. Various techniques exist and selection of phalloplasty technique depends on patient preference, body habitus, and surgeon experience. Objective We demonstrate the creation of a neophallus using a pedicled abdominal flap using live surgical footage. Methods The patient was a 19 year old transmasculine individual who had been on gender-affirming hormone therapy for 3 years and desired a neophallus to align external appearance with his gender identity. The flap is designed using a fasciocutaneous flap based off the inferior epigastric and superficial circumflex iliac vessels, with innervation from the ilioinguinal nerve. Perfusion is assessed using fluorescence imaging prior to tubularization. Rotational flaps are used to cover the abdominal wound. Results The patient had an uneventful recovery after 48 hours of bedrest and was discharged on post-operative day 4 without complications. He has recovered well without any complications at 6 months postoperatively. Patients may elect to undergo next staged phalloplasty procedures with or without urethroplasty at least 6 months afterwards. Conclusions A pedicled abdominal flap phalloplasty is a safe and effective option for patients desiring a more easily concealed scar and fewer complications compared to alternative techniques. Disclosure No.

The pedicled Antero lateral thigh flap for gender affirming surgery: what is different? First case series outcomes of a single center from Turkey.

The aim of this study is to share our preliminary outcomes of the pedicled Antero Lateral Thigh flap (ALTf) phalloplasty technique, which we presume to be the first reported case series of a single center from Turkey. A cross-sectional study, comprising all cases who underwent pedicled ALTf phalloplasty in our clinic, between January 2015 and December 2019, was designed. Demographic data, case characteristics and surgical details including complications were recorded. The mean age of our 26 cases was 30 (28-34) years. The mean penile length and diameter were 15.07 ± 0.98 cm and 3.9 ± 0.34 cm, respectively. Tactile sensation was evaluated by touching the radix, corpus and tip of the neo-phallus showing response in 17 (65.4%), 7 (26.9%) and 2 (7.7%) of the cases, respectively. In 14 (53.8%) of all our cases no complication was reported at all. However, in 12 (46.1%) cases, although no intraoperative complication occurred; postoperative complications were observed as Clavien-2 (3.8%), Clavien-3a (3.8%) and Clavien-3b (71%). Postoperative satisfaction rates were found 77.14% (38-94). Although relevant studies are limited, in addition to low complication rates and high satisfactory outcomes, by leading to a concealable donor site, the pedicled ALTf can be used as a preferred phalloplasty technique, especially in transmen with religious or cultural sensibility.

Planned Delay and Defatting of Transmasculine Anterolateral Thigh Flap Phalloplasty in High BMI Patients: A Retrospective Analysis of Complications

Planned Delay and Defatting of Transmasculine Anterolateral Thigh Flap Phalloplasty in High BMI Patients: A Retrospective Analysis of Complications

3D printing for an anterolateral thigh phalloplasty

BackgroundPhalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis.MethodsIn this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed.ResultsThe results gathered included the physician’s view on the model’s accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons’ undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility.ConclusionsThis study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.

Penile reconstruction following penile necrosis by radial forearm free flap phalloplasty

Penile reconstruction following penile necrosis by radial forearm free flap phalloplasty

Phallopoièse par lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme

The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

Chirurgie génitale de masculinisation des hommes trans

Genital surgery for masculinisation in the context of gender incongruence is characterised by the reconstruction of male genitalia using multiple surgical techniques -free flap phalloplasty, pedicled flap phalloplasty or metaoidioplasty- which this article aims to describe. A narrative review of the literature on these trans surgeries was carried out. Each technique has specific advantages and disadvantages, and does not produce the same results in terms of surgical risks, size of the reconstructed phallus, sensitivity, sexual function and urinary function. This surgical decision must therefore be shared with the person concerned, based on a clear understanding of their expectations and objectives. Long-term follow-up is recommended.

(137) Surgical Outcomes at a Single Institution of Infrapubic insertion of Malleable Penile Prosthesis in Transmen after Phalloplasty

Abstract Introduction Penile reconstruction has allowed transmasculine individuals to attain the aesthetic appearance of male genitalia, however a penile prosthesis is needed to achieve the ridigity and bulk for penetration. High complication rates have been reported with penile prosthesis placement after phalloplasty, with the rate of reoperation exceeding 40% following both inflatable penile prosthesis (IPP) and malleable penile prosthesis (MPP). We describe the experience of a single surgeon with the infrapubic approach for MPP placement after phalloplasty. Objective To review the surgical outcomes of the infrapubic approach to the insertion of the MPP after phalloplasty in transgender men. Methods The infrapubic prosthesis insertion after phalloplasty technique involves a horizontal incision anterior to the pubic symphysis, which allows dissection of the neophallus channel and the anchor site on the pubic symphysis. Surgical outcomes using the Spectra (Boston Scientific, Marlborough, MA) and Genesis (Coloplast, Minneapolis, MN) MPP were analyzed between October 2017 and May 2022. Complications were reviewed and categorized into erosions, infections, device malposition and malfunction, and less common events like necrosis. Results The infrapubic MPP technique was performed on 40 patients by a single surgeon; 35 patients had a prior radial forearm free flap (RFFF) phalloplasty, and 5 had a prior anterolateral thigh flap (ALT) phalloplasty. Of the 30 patients who have continued to follow-up, mean follow-up was 34.9 months. Complications were not mutually exclusive, with 7 implant detachments from the anchor site, 3 malpositions, 2 with pain/activity limitation, and 1 infection. Surgical revision was required in 12 patients (40.0%). There were no neophallus erosions, flap loss, seromas, nor urethral injuries. More complications occurred with the Spectra MPP (9/17 or 52.9%) compared to the Genesis MPP (3/13 or 23.1%). Conclusions Infrapubic MPP insertion in transmen after phalloplasty is associated with high prosthetic surgical revision rates. Fewer complications were identified in the Genesis cohort. Longer term studies with patient reported outcome measures are required for further evaluation. Disclosure No

(037) Contemporary Surgical and Functional Outcomes of Anterolateral Thigh Flap for Penile Reconstruction

Abstract Introduction The radial forearm free flap phalloplasty is the most commonly used flap for penile reconstruction. The anterolateral thigh (ALT) free flap was proposed in 2006 as an alternative due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap was proposed the same year thus offering greater security of vascular supply for suitable patients. Previous reports have highlighted higher rates of flap loss and low rates of integrated urethra. Objective The aim of the study is to report the contemporary surgical outcomes of ALT phalloplasty. In addition, the functional outcomes of the ALT flap phalloplasty are reported for the first time. Methods All patients undergoing ALT flap phalloplasty were included in the study between 2009 and 2021. Data were extracted from a comprehensive prospective database and the medical records. Functional outcomes were assessed by non-validated questionnaire. Results Seventy-six patients underwent ALT flap phalloplasty with a mean follow-up of 34 months (SEM ± 3.05). Median age of the patients was 32 (IQR 26 – 46) and body mass index was 24 (SEM ± 0.61). A significant minority had a previous phalloplasty (22%). In addition, 7% of patients had other co-morbidities including diabetes and peripheral vascular disease. Over half of all flaps (n=41) were designed with an integrated urethra and 6.6% (n=5) required free flap transfer. The average length of stay was seven days (SEM ±0.47). Post-surgery, five (6.6%) patients experienced total flap loss, with a further three (3.9%) experiencing partial loss. Urethral complications were common with eleven (26.8%) patients developing fistulae and three (7.3%) developing strictures. Fifty-three (69%) patients completed the functional outcomes questionnaire. Forty-three (81%) were generally satisfied with their phalloplasty, while thirty-four (65%) felt they had a good cosmetic outcome. Twenty-eight (53%) had sensation in at least half of their phallus. Eight (17%) experienced troublesome post-micturition dribbling. Conclusions Presented is one of the largest cohort of patients following genital gender affirmation surgery using the ALT flap phalloplasty. Over half of all patients successfully had an integrated urethra (gold standard for urethral reconstruction). Functional outcomes (an important determinant for the choice of a flap) are reported for the first time showing 81% of patients are satisfied despite a challenging cohort with almost a quarter of patients undergoing salvage following previous failed phalloplasty. Disclosure No

(199) Anterolateral Thigh Flap Phalloplasty for Micropenis

Abstract Introduction Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps. Objective The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. Methods A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder. Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. Results The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. Conclusions Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further esthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Disclosure No

(520) The Use of Gracilis Muscle Flap in Radial Forearm Free Flap Phalloplasty to Decrease Urethral Fistula Rate: Initial Outcome

Abstract Introduction `- Chang and Hwang, in 1984, described the technique of Radial Forearm Free Flap Phalloplasty (RFFFP). It is now considered to be the standard surgery for phallic reconstruction. Urethral fistula is the most common complication reported in RFFFP and may reach up to 60-70%. Most commonly, the fistula site is at the anastomosis between the native urethra and the neo-urethra. Objective `- to study the impact of gracilis muscle flap wrapping around the native urethra/neo-urethral anastomosis on decreasing the fistula rate. Methods `- A prospective study was conducted at our urology department, from January 2018 till December 2020. - Patients presenting with a micropenis (Stretched penile length <7 cm) underwent RFFFP with gracilis muscle flap wrapping. - The free-flap was harvested from the non-dominant forearm. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein, and the medial and lateral antecubital nerves with the ilio-inguinal and the dorsal penile nerves respectively. - A pedicled gracilis muscle flap was then wrapped around the neo-urethera/native urethral anastomosis to assess its possible role in decreasing the postoperative urinary fistula rate. Results `- Nineteen patients were included in the study with a median age of 26 years (16 - 43) and a BMI of 24 (22-25). The median hospital stay of 14 days (14 - 21) and the median follow-up was 11 months (4 - 13). The median cold ischemia time was 90 mins (70 - 100), estimated blood loss was 500 cc (400 - 500) and operative time was 11 hrs (10 - 12). - A viable phallus was achieved in 13 patients (overall free flap survival 68.4%). - Of the successfully viable phallus cases, 8 cases (42.1%) were complicated by complete disruption of the urethra and the remaining five cases (26.3%) had complete urethral tube. - One case of them developed a fistula at the neo-urethera/native urethral anastomosis, one case had a distal fistula and one case had a ring stricture at the site of anastomosis. - The gracilis muscle flap prevented urethral fistula formation in 4 out of 5 cases (80%) with complete urethral tube. Conclusions `- The use of pedicled garcilis muscle flap wrapping around the neo-urethra/native urethral anastomosis during RFFP might be helpful in reducing the urinary fistulae rates at this site. However, larger comparative studies are needed. Disclosure No

V11-03 PENILE RECONSTRUCTION FOR CONGENITAL MICROPENIS WITH THE ANTEROLATERAL THIGH PEDICLED FLAP

You have accessJournal of UrologyCME1 Apr 2023V11-03 PENILE RECONSTRUCTION FOR CONGENITAL MICROPENIS WITH THE ANTEROLATERAL THIGH PEDICLED FLAP Aurélie Schirmann, Nim Christopher, David Ralph, and Wai Gin Lee Aurélie SchirmannAurélie Schirmann More articles by this author , Nim ChristopherNim Christopher More articles by this author , David RalphDavid Ralph More articles by this author , and Wai Gin LeeWai Gin Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps.The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. METHODS: A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder.Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. RESULTS: The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. CONCLUSIONS: Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further aesthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Source of Funding: None declared © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e999 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aurélie Schirmann More articles by this author Nim Christopher More articles by this author David Ralph More articles by this author Wai Gin Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

30 Years of Experience in Musculocutaneous Latissimus Dorsi Flap Phalloplasty with Reinnervation: Optimal Principles.

We performed a retrospective review of patients who underwent shaft-only, two-stage or one-stage latissimus dorsi flap phalloplasty with or without reinnervation at a single institution from 1991 through 2020. Patients with a minimum of 1 year of follow-up were included. Data on the patient's demographics, the procedure, and the results of the operation were maintained. In total, 592 latissimus dorsi flap phalloplasties were performed during the entire study period. Of the phalloplasties, 494 (83.5%) were performed for gender-affirming surgery, of which 470 were performed for transgender patients and 24 for intersex patients. Twenty-five patients (4.2%) had congenital malformations, 17 (2.9%) had oncologic resections, and 56 had posttraumatic loss (9.5%). Latissimus dorsi flap total phalloplasty with reinnervation is currently one of the few methods that can solve not only an aesthetic problem, but also a functional one without the use of an endoprosthesis if the level of reinnervation and muscle contraction is sufficient.

PD06-05 MANAGEMENT OF SERIOUS COMPLICATIONS AND TISSUE LOSS FOLLOWING HYPOSPADIAS SURGERY

You have accessJournal of UrologyCME1 Apr 2023PD06-05 MANAGEMENT OF SERIOUS COMPLICATIONS AND TISSUE LOSS FOLLOWING HYPOSPADIAS SURGERY Tenny Zhang, Peter Cai, Ashraf Gamal, Cairo Egypt, and Moneer Hanna Tenny ZhangTenny Zhang More articles by this author , Peter CaiPeter Cai More articles by this author , Ashraf GamalAshraf Gamal More articles by this author , Cairo EgyptCairo Egypt More articles by this author , and Moneer HannaMoneer Hanna More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003230.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite the high re-operation rates after proximal hypospadias repairs, surgeons have rarely reported disastrous complications of hypospadias surgery. Herein we report on 16 patients who sustained partial or total glandular or penile loss after hypospadias surgery and were referred to us for further management over the last 40 years (Figure 1). METHODS: Operative details of the primary surgery were not available in the majority of cases as six cases were from Egypt, one from Portugal, and one from Iraq. Forty-four percent (7/16) of the index operations utilized epinephrine mixed with local anesthetic. The surgical repairs we performed included Bevan-DeCastro phalloplasty (4), forearm flap phalloplasty (1), and penile lengthening by cutting the suspensory ligament (6) followed by resurfacing using either rotational scrotal flap (3) or staged Cecil-Culp repair (3) (Figure 2). Four patients underwent contouring of the glans penis. One patient declined treatment. RESULTS: Significant penile lengthening was achieved in all patients ranging from 5 to 8 cm (75-150% of the preoperative penile length). Phalloplasty was technically successful in all patients however we deferred urethroplasty in the four Bevan-DeCastro repairs to a later date during adolescence when forearm flap phalloplasty and penile prosthetic implant are practical. All five phalloplasty patients had acceptable cosmetic result in the absence of erectile function. CONCLUSIONS: Partial or total glandular or penile loss subsequent to hypospadias repair is a rare and disastrous complication. Subsequent surgical repair provides some value in improving outcomes. We discourage the use of epinephrine injections during hypospadias repairs and emphasize the importance of leaving the glans exposed to allow for postoperative visual examination and early recognition of vascular compromise. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e157 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tenny Zhang More articles by this author Peter Cai More articles by this author Ashraf Gamal More articles by this author Cairo Egypt More articles by this author Moneer Hanna More articles by this author Expand All Advertisement PDF downloadLoading ...

Phalloplastie par Lambeau perforant thoracodorsal « tube in tube »

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.