Penile Defects Research Articles

Pelvic and Perineal Reconstruction.

After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction. Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap.

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.

(196) Advanced Surgical Management for the Ramifications of Neglected Penile Fracture with Pericardial Graft Reinforcement

Abstract Introduction Penile fractures occur when the tunica albuginea, a fibrous layer surrounding the corpora cavernosa, ruptures during sexual intercourse or masturbation. These incidents, although rare, are considered serious emergencies. Failure to address them promptly can result in complications such as erectile dysfunction, penile curvature, and hematoma. Unfortunately, cases often go unreported due to embarrassment or fear, resulting in delayed medical attention. Diagnosing penile fractures is mainly clinical, and treatment options depend on the timing of presentation. Objective To emphasize the importance of early medical attention and surgical intervention in the context of penile fractures, with the goal of preventing or reducing the occurrence of long-term complications. Methods A 55-year-old male developed a query penile fracture during intercourse. Initially, he experienced a popping sound with no visible signs of injury nor loss of erection. Two weeks later, he sought medical advice due a penile bump development accompanied by painful erections. Conservative management was provided with ice, non-steroidal anti-inflammatory drugs, and sexual abstinence. However, he later presented with a penile mass and curvature affecting his penetration during intercourse. A penile Doppler ultrasound revealed a fibrotic hematoma with a complex cystic lesion measuring 23.1 mm x 18.1 mm x 28.3 mm. The patient underwent a complex penile mass excision, tunica albuginea plication with pericardium graft reinforcement. The surgery involved excising scar tissue, removing the underlying fibrotic hematoma and cystic lesion, correcting the curvature, and reinforcing the weakened tunica albuginea with pericardium graft (Tutoplast, IOP Ophthalmics, Costa Mesa, CA, USA) (Figures 1–3). Histopathology reported grossly “a penile fibrotic mass with irregular dark brown firm cystic structure filled with yellow-tan necrotic tissue”. Microscopic description showed “a fibrous capsule with central hemorrhage and fibrin”. Results The patient had a successful procedure & uneventful smooth recovery. During 6 & 12 months follow-up, there was no long-term complications, he reported resolved curvature and satisfactory sexual intercourse Surgical treatment is recommended for penile fractures to achieve satisfactory results and restore sexual function. Various graft materials can be used to reinforce penile defects. Tutoplast (processed allograft tissue from cadaveric pericardium) has shown excellent results in Peyronie's curvature repair. The efficacy of bovine pericardium compared to Tutoplast in urologic surgeries is uncertain. In this particular case, Tutoplast was chosen due to its accessibility and the surgeons expertise in Peyronie's repair and penile prosthesis implantation. Conclusions This case report highlights the formation of a fibrotic hematoma resulting from delayed penile fracture presentation, which was managed through mass excision & correction of curvature. To date, there is no literature mentioning fibrotic hematoma formation as a consequence of neglected fracture presentation. Prompt medical attention with low threshold for early surgical intervention should be sought for suspected penile fractures to avoid potential long-term complications and improving their quality of life. Disclosure No.

(217) Revitalizing Penile Health: Advanced Surgical Approach for Treating Penile Mass Formation Resulting from Neglected Fractures, Enhanced with Pericardial Graft Reinforcement

Abstract Introduction Penile fractures are rare but serious emergencies caused by the rupture of the tunica albuginea during sexual activity. Prompt medical attention is crucial to prevent complications like erectile dysfunction, penile curvature, and hematoma. Delayed reporting due to embarrassment or fear can lead to further complications. Diagnosing penile fractures primarily relies on clinical examination, and treatment options depend on the timing of presentation. Seeking immediate medical help is vital to prevent long-term complications and ensure proper management. Objective To emphasize the importance of early medical attention and surgical intervention in the context of penile fractures, with the aim of preventing or reducing the occurrence of long-term complications. Methods This case report involves a 55-year-old male who experienced a penile fracture during intercourse. Initially, he had no hematoma, bruising, pain, or loss of erection. Two weeks later, he sought medical advice due to a penile bump and slightly painful erections. He was managed conservatively with ice, nonsteroidal anti-inflammatory medications, and abstinence from intercourse. Two months later, he presented to our clinic with complaints of a penile mass and curvature, affecting his erections and penetration. A penile Doppler ultrasound revealed a fibrotic hematoma with a complex cystic lesion measuring 23.1 mm × 18.1 mm × 28.3 mm on the right lateral mid-penile shaft. The patient underwent complex penile mass excision, tunica albuginea plication, and pericardium graft reinforcement. During the surgery, scar tissue and underlying fibrotic hematoma were removed (Figure 1). A complex cystic lesion on the right lateral mid-penile shaft was also excised (Figure 2). A tunica albuginea plication corrected the 30° left dorsal curvature. A pericardium graft (Tutoplast®, IOP Ophthalmics, Costa Mesa, CA, USA) reinforced the weakened tunica albuginea and covered the defect (Figure 3). Histopathology of the mass reported “a penile fibrotic mass, measuring 2 cm × 1.8 cm × 2.6 cm with an irregular dark brown firm cystic structure filled with yellow-tan necrotic tissue.” Microscopic description showed “a fibrous capsule with central hemorrhage and fibrin.” Results The patient had a successful procedure and smooth recovery. At 6- and 9-month follow-up, he expressed satisfaction with no complications or long-term side effects. Erectile function was restored, and penile curvature resolved, enabling satisfactory penetrative intercourse. Surgical treatment is recommended for achieving satisfactory results and restoring sexual function in penile fractures. Various graft materials can be used to reinforce penile defects. Tutoplast® (processed allograft tissue from cadaveric pericardium) has shown excellent results in Peyronie's curvature repair, but the efficacy of bovine pericardium remains uncertain. In this case, Tutoplast® was chosen for its accessibility and the surgeons' expertise in Peyronie's repair and penile prosthesis implantation, ensuring the best possible outcome. Conclusions This case report highlights fibrotic hematoma due to delayed penile fracture presentation, managed through mass excision and curvature correction. Currently, there is no literature available that discusses fibrotic hematoma formation from delayed penile fractures. Prompt medical attention crucial to avoid long-term complications. Early surgical management prevents erection loss, curvature, hematoma, or mass formation, improving quality of life for patients with penile fractures. Disclosure No.

Bipedicled Scrotal Flap for Penile Resurfacing.

Acquired penile defects can be secondary to various pathologic conditions, including infection, scar, or complications following urologic procedures. Penis defects with skin deficit carry a distinct challenge for reconstructive surgeons. Scrotal flaps can provide reliable coverage and can restore distinct qualities of native penile skin. A series of patients presented with a variety of acquired penile defects. Each of these patients underwent staged bipedicle scrotal flap surgery for coverage by the senior author. Eight patients underwent bipedicle scrotal flap reconstruction for penile defects with a skin deficit. All eight patients had satisfactory outcomes postoperatively. Only two of the eight patients had minor complications. For select patients presenting with underlying deficit of penile skin, bipedicle scrotal flaps prove to be a safe, reproducible, and reliable reconstructive technique for penile resurfacing. Therapeutic, V.

Fournier’s gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas’s NHS Foundation Trust

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Urethral duplication associated with complex chordee: a narrative review of literature and report of a case

BackgroundUrethral duplication (UD) is reportedly rare. It is rarer in females. Knowledge on this anomaly comes from isolated report of cases. The aim of this review is to summarize information available on this anomaly thereby revealing gaps in knowledge, and to appropriately situate a recently managed case.MethodsPublications on UD in English language from 2001 to 2021 were searched for in the literature. Of importance were age at presentation, class of UD, nature of associated penile deformity and other structural anomalies. Available information was used to synthesize opinions after descriptive analyses using SPSS® version 21 (IBM Co., Armonk, NY, USA). In addition, a recently managed case of UD was reported and appropriately situated in the discourse.ResultIn all, 115 articles met the inclusion criteria. Majority (75.7%) were individual case reports, while the rest were retrospective review of case series. These provided a total of 269 reported cases. Of this lot, 38 cases were excluded because they either had no Effmann’s class or were not described well enough for an Effmann’s class to be assigned. Ultimately, 231 cases formed the basis for this review. Male to female ratio was 12:1. Types III and IIB had more females. Types IIA 2 (26.0%), IIA 2 “Y” (26.4%) and IA (22.5%) were frequently reported. About 61.8% males and 68.4% females had no associated defects. Isolated dorsal chordee was prevalent (7.1%), especially among type IA (16.7%) UD. Reported in 10.4%, vesicoureteric reflux may not be attributable always to high pressure voiding.A boy who presented at the age of 18 years with Effmann type IA UD and an associated complex chordee of the penile shaft was reported. The complex nature of the chordee adds to the challenge of explaining associated penile defects in UD.ConclusionUD is rare, but reported from all parts of the globe. There are a number of associated defects involving the external genitalia and other organs reported in UD in the male. The mechanisms of these defects are yet to be fully understood.

Urethra Reconstruction and Revision Urethroplasty in Pedicled Anterolateral Thigh Flap Penile Reconstruction.

Neophallic urethroplasty remains a significant challenge in penile reconstruction. Currently, there is no ideal recognized method. Through this article, we aimed to share our experiences of urethral reconstruction in the pedicled anterolateral thigh flap penile reconstruction using modified techniques and alternative flaps. In this single-center study from 2010 to 2020, 49 patients underwent penile reconstruction with a pedicled anterolateral thigh flap; 17 patients had a micropenis, 3 had iatrogenic defects, and 29 had penile defects after trauma. Different urethroplasty methods, complications, and revision methods were separately described. The tube-in-tube technique was used in 6 cases; the superficial iliac circumflex artery perforator (SCIAP) flap and pudendal-thigh flap were used in 26 and 11 cases, respectively, and the pedicled scrotal flap was used in 6 cases. Revision urethroplasty due to postoperative necrosis (n = 3), stricture (n = 8), and fistula (n = 2) were performed in 13 cases. The urethral complications (flap necrosis, urinary fistula, and stricture) were as follows: tube-in-tube, 66.7%; SCIAP flap, 46.2%; pudendal-thigh flap, 38.5%; and scrotal septum flap, 50%. After revision procedures, all patients could urinate while standing. The characteristics and requirements of patients should be considered before designing a surgical plan. The tube-in-tube technique is the first choice for reconstructing the penis and urethra in a single stage for thinner patients. For other patients, a different flap can be used as a substitute for urethral reconstruction. The SCIAP, pudendal-thigh, and pedicled scrotal flaps can be used to reconstruct the urethra. The tubed SCIAP flap and pudendal-thigh flap are reliable, simple, and suitable for revision urethroplasty.

Constructing a heparin-modified penile decellularized scaffold to improve re-endothelialization in organizational reconstruction.

BackgroundDue to the unique anatomy and complex function of the penis, the reconstruction of penile defect is fraught with great challenges. The current standard methods are limited by numerous complications and insufficient donor sites. While functional vascularized penile tissue engineering offers a novel way to address this problem, revascularization remains the primary concern.MethodsIn this study, a penile scaffold with associated modifications was constructed. The performance of decellularized penile scaffolds (DPSs) was improved by conjugation with heparin (HEP) and reseeding with human umbilical vein endothelial cells (HUVECs). There were three groups according to the modifications, including native DPSs, HEP-DPSs, HEP-HUVECs-DPSs. After perfusing with 1% Triton X-100/0.1% ammonium hydroxide solution, the cellular components were removed. Subsequently, the covalent binding of heparin in the DPSs was performed with 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide/N-hydroxysuccinimide, followed by reseeding with HUVECs. Scaffolds were implanted into the backs of rats and the implanted tissues were harvested at 1, 2, 3, and 4 weeks. Then hematoxylin and eosin (H&E) staining and immunofluorescence assays were performed to assess the degree of angiogenesis.ResultsThe native DPSs retained the extracellular matrix and heparinized modification. The H&E results indicated that more HUVECs covered the inner surface of tubular structures in the HEP-DPSs group compared to the native DPSs group. The number of vessels in the HEP-HUVECs-DPSs was significantly increased compared to the control scaffolds at all time points.ConclusionsThese results suggested that, compared to the native DPS, heparin-conjugated scaffolds provided a superior environment for the growth of HUVECs and the modified methods provided a perspective for overcoming the obstacles in tissue engineering of transplantable penile tissues and the establishment of a functional vasculature.

Is the Snodgrass technique suitable for different types of hypospadias? Single-center experience

Background: Hypospadias is a congenital penile defect and Tubularized Incised Plate (TIP) urethroplasty is a widely accepted option to repair this defect. Our experience about the outcome of hypospadias repair by this technique is discussed. Methods: This is a retrospective analytical study consisting of 80 cases, conducted between May 2017 to December 2019 at the Department of Pediatric Surgery, Maternity, and Children’s Hospital Dammam. All the cases with anterior, middle, and posterior hypospadias, who underwent Snodgrass TIP urethroplasty, were included in the study. The same surgeon performed all the operations. The follow-up period lasted for 2 years, after surgery and the final outcome of the procedure was recorded, based on the observations. Results: The age range of the patients varied between 1 to 9 years. Anterior hypospadias constituted 64 (80%) cases followed by middle hypospadias 13 (16.25%), and posterior hypospadias 3 (3.75%). By type, glanular hypospadias was the most common 30 (37.5%), followed by sub-coronal 19 (23.75%), coronal 15 (18.75%), mid-penile 11 (13.75%), proximal penile 2 (2.5%) and penoscrotal hypospadias 2(2.5%). Scrotal hypospadias was the least common type, 1 (1.25%). Overall complications that required re-intervention occurred in 16 (20%) cases. Urethrocutaneous fistula (UCF) which occurred in 7 (8.75) cases was the most common complication, followed by meatal stenosis in 4 (5%) and glans dehiscence and urethral stricture 2 in each (2.5% each). Total repair disruption was the least common complication that was noticed in 1 (1.25%) case. Functional and cosmetic results were judged as satisfactory. Conclusion: For hypospadias repair, TIP urethroplasty is the procedure of choice for anterior hypospadias with excellent results. It is also quite suitable with middle hypospadias and acceptable for posterior hypospadias for selected cases. The overall complication rate is low and also offers very good functional and cosmetic results.

Significance and Surgical Options for Nontranssexual Phalloplasty: A Retrospective Single-Center Analysis of 166 Patients.

This study aimed to evaluate the long-term outcomes of phalloplasty and explore the clinical significance and selection of methods for penile reconstruction. The same surgical team performed primary phalloplasty in 166 nontranssexual patients using different surgical approaches between September 2000 and September 2020. All patients had at least 6 months of follow-up. Surgical techniques, complications, and outcomes were retrospectively recorded. A total of 166 patients with indications such as penile trauma (n = 68 [41%]), amputation injury (n = 15 [9%]), iatrogenic (n = 13 [8%]), penile aplasia (n = 54 [32%]), genital ambiguity (n = 15 [9%]), and Peyronie disease (n = 1 [0.6%]) underwent different techniques of phalloplasty. Four patients (2.4%) had total flap necrosis, and 17 (10%) had partial flap necrosis. The total urethral complications rate was 32.5% (54 of 166); however, all the patients were able to void while standing after successful corrective surgery. Individualized selection of appropriate penile reconstruction methods tailored to the cause of penile defect, patients' personal needs, thickness of donor site, and the blood supply of the flap are conducive to achieving satisfactory treatment results, reducing complications, and improving patient satisfaction. We believe that a scapular flap has certain advantages in nontranssexual patients, whereas other flaps also have their own indications.

Geometrical Model of Free Skin Graft for the Optimization of Glans Reconstruction after Partial Penectomy

Abstract Introduction and Objective The management of penile carcinoma is very disabling and mutilating, bur early treatment can be curative. Our group systematically performs oncological management with immediate penile reconstruction and preservation of the organ (partial penectomy, resurfacing, or glansectomy) when feasible. Due to the low incidence of penile carcinoma, it is difficult to achieve experience in penile reconstruction using free grafts in a standardized and reproducible way. Therefore, we herein present the results of the use of an inanimate model to identify the most efficient geometric way to procure and apply a free skin graft to reconstruct the penis. Methods A preclinical inanimate model of the penis was developed to simulate the surgical reconstruction using a free skin graft. Six different geometric skin-graft models were created and tested. For each of them, we measured graft's surface area as well as the discarded surface after placing the graft on the penis for reconstruction. We also measured the amount of suture lines required for reconstruction. All of these measurements in the six different models were compared. Results Based on the six models, we identified that the longitude of the graft must measure the same as the maximum perimeter of the glans in order to have a square that enables the complete coverage of the penile defect. The total graft area for the first 4 models was of 40 cm2; for models 5 and 6, it was of 60 cm2. The average discarded area of the graft was of 18.135 cm2 (range: 12 cm2 to 30 cm2). Models 4 years 6 were the ones with the least discarded tissue: 12 cm2. The average amount of suture lines to secure the different model grafts was 7.3 (range: 5 to 12). The models that required the least amount of suture lines were number 1 and 4, with a total of 5 suture lines. Conclusions The double trapezoid is the most efficient model to reconstruct the glans after organ-sparing oncological management. Our results contribute to establish a more standardized and predictable technique to reconstruct the penis.

Reconstruction of soft tissue penile defects due to trauma using inguinal flaps

Background: We present a case of using the external pudendal artery (EPA) flap to cover the soft tissue defects of the penis following multiple trauma with penis shrinkage, corpus spongiosum and urethral injuries. Case report: A 54-year-old male patient was admitted to the hospital with multiple injuries: complex trauma with extensive scrotal and perineal skin loss, soft tissue defects of the penis with corpus spongiosum and urethral injuries, complex and open forearm fracture. The patient underwent emergency surgery to remove scrotal skin, Burry the testis in the subcutaneous pouches in the thigh, Foley sonde was placed over the bladder above the pubic bone and amputate the right hand.After that, the patient was operated on using foreskin flaps to cover corpus spongiosum defects and reconstruct the urethra. However, after about 10 days, the foreskin flap was infected and then necrotic resulting in the soft tissue defects of the penis exposing the urethral.Therefore we decided to perform surgery using the external pudendal artery (EPA) flap to solve that problem. We put sonde foley to shallow urethra and let urine pass out. The cosmetic and functional results of this foreskin-flap have been good. There was no infection, the length of the penis was maintained. The urinary stream has been normal with no urine leakage after surgery. Conclusion: The external pudendal artery flap is a good option for the treatment of patients with penile soft tissue defects. Due to its simplicity, short operation time, easy dissection, good aesthetic outcome. Therefore the external pudendal artery flap is an optimal choice for the treatment of cases of genital soft tissue defects (scrota and penis).

Erectile dysfunction in patients undergoing multiple attempts at hypospadias repair: Etiologies and concerns

One-third of adult patients presenting for the repair of persistent penile defects after failing multiple hypospadias repair attempts during childhood will complain of erectile dysfunction (ED). The goal of this paper is to identify possible etiological causes of its onset. Five selection criteria were used for entrance into the study: 1) Patients had to have failed≥three prior hypospadias repair attempts. 2) Present for evaluation between 18 and 40 years of age. 3) No known congenital or medical anomaly could be present that could have predisposed to erectile dysfunction. 4) Sexual history inventory for men (SHIM-5 score) completed. 5) All patients with moderate to severe ED (SHIM scores≤16) underwent psychological screening; individuals with good quality spontaneous or self-stimulated erections, experiencing major life events, or had documented psychological problems were excluded from the study. One hundred consecutive patients meeting these criteria were assessed. We evaluated multiple factors to discern if they were associated with the onset of ED: the initial location of the urethral meatus, if a corporoplasty was performed, the type of corporoplasty used, if the urethral plate was divided or resected, the use of a ventral corporal graft, the total number of open reparative procedures performed before referral, the number of direct visual internal urethrotomies (DVIU) performed, the length of a urethral stricture at the time of the referral and whether lichen sclerosus was present. Statistical evaluations used chi-square analysis, two-tailed t-tests, or a logistic regression model where indicated, p-values < 0.05 were considered significant. 37% (37/100) of our patients complained of moderate to severe ED (SHIM score ≤16). Statistical analysis comparing patients with ED to those without ED (63%:63/100), revealed patients with ED were older, median age 34yrs (range 20-40) vs 26yrs (range 18-40) p=0.0212, had undergone division of the urethral plate 70.3% (26/37) vs 47.6% (30/63), p=0.0276, had placement of a ventral corporal graft, 24% (8/33) vs 1.5% (1/67), p=0.0003 or had undergone repetitive DVIU's to manage urethral stricture disease, median number 4 (range 0-15) vs 0 (range 0-6), p<0.0001, see table. The early onset of ED in patients that failed multiple attempts at hypospadias repair in childhood is associated with advancing age, division of the urethral plate, and prior ventral corporal grafting. Especially significant is the association of ED to the use of repetitive internal urethrotomy to manage urethral stricture disease.

Utility of Groin Flap in Penile Reconstruction

Background: Reconstruction surgery for skin and soft tissue defects of the penis would ideally secure sufficient volume, be safe in procedure, and involve a simple surgical technique. Among the wide variety of techniques that have been employed, the groin flap-based technique is considered a relatively simple option for volumetric reconstruction. In this retrospective study, the authors report cases of penile reconstructive surgery using a groin flap.Methods: We performed a retrospective chart review of patients with penile defects treated in our department. Reconstructive surgeries were carried out using pedicled groin flaps. Charts were reviewed to investigate duration of the surgeries, recovery and follow-up periods, and bulkiness at one and 10 months after surgery. Patients were observed postoperatively for complications, urination, and erectile function.Results: Six patients hospitalized from March 2009 to September 2013 for penile defects underwent surgery in our department. All patients recovered without any flap loss. The most common complication after surgery was wound dehiscence. Circumferences of penile shafts were measured at 1 and 10 months after surgery, and penile bulkiness at rest were found to be maintained at &gt;86%. There were no patients with contracture, and in all patients, urination and erectile functions were satisfactory.Conclusion: Reconstructing penile defects using groin flaps was found to be favorable in terms of volumetric reconstruction and postoperative patient satisfaction. Furthermore, the surgery and recovery periods are short, and rates of complication and donor site morbidity are also low.

Scrotal Tissues: The Perfect Material for Urogenital Reconstruction.

Background:Correction of male urogenital pathology of different severity is complicated by the anatomical aspects of the penis. Skin texture, internal structures, and perfusion dynamics of the urogenital area make it a difficult area to reconstruct. We provide our experience with axial scrotal flaps for correction of penile defects of different severity and believe that these local flaps offer sufficient tissue characteristics for proper restoration of this complex region.Methods:Forty-eight patients were divided into 3 groups depending on penile defect genesis and severity. Axial scrotal flap reconstruction was used for the correction of defects in all cases, when necessary in combination with other flaps.Results:Axial scrotal flaps for total and subtotal penile reconstruction serve as valuable material for reconstruction of the urogenital area, and are to be combined with other flaps for restoration of bulk tissues. Localized defects of the penis and urethra reconstructed by axial scrotal flaps provide excellent aesthetic results with minimal scaring, stable perfusion dynamics, and high satisfaction rate.Conclusions:Scrotal tissues provide an excellent reconstruction material for penile defects because of their highly similar tissue structure as that of the penis. Scrotal axial flaps do not provide excess bulking in the postoperative period and are recommended for reconstruction of urethral and localized penile defects. Multistage surgery is recommended in cases of severe tissue damage, in combination with other flaps (inguinal, thoracodorsal, and radial).

Penile and scrotal defects post-Fournier gangrene: reconstructive options and challenges in resource limited settings

Introduction: Penile and scrotal defects following necrotizing fasciitis (Fournier gangrene) of the perineum in males can be a source of great morbidity and psychological concern to the patients inflicted with such a problem. In severe cases, it can result in mortality. Reconstruction of extensive defects/ulcers can be challenging in resource limited settings due to limited availability of tools such as doppler ultrasound/stethoscope, loupes, and operating microscopes for microsurgical procedures. Fournier gangrene is usually managed by the urologists in most centers in collaboration with the plastic surgeons for reconstruction of more extensive defects. Objective: The aim of the study was to review the penile and reconstructive options deployed for post-Fournier gangrene patients over a 3-year period (April 2017 to March 2020) in a tertiary hospital setting highlighting options utilized, indications for the respective options, and challenges encountered. Methodology: Case notes of Fournier gangrene patients offered penoscrotal reconstruction by the urology and plastic surgical teams within the period were retrieved, reviewed, and relevant data useful in achieving the above objectives extracted for analysis. Clinical photographs of some of the patients were included for illustration. Results: Twenty patients (20) that met the inclusion criteria were reviewed. Fourteen (70%) had defects involving both the scrotum and the penis, five (25%) involved the scrotum alone, while one (5%) had defect on the penis alone. Four (20%) had diabetes mellitus, three (15%) had HIV infection, and two (10%) had hypertension. Seventy percent (14) of the patients had secondary wound repair by direct closure, 5% (one) had split skin grafting alone, 5% (one) had a combination of split skin grafting and local advancement flap, and 20% (four) required the use of available locoregional flap [three being bilateral scrotal advancement flaps and one being bilateral pudendal thigh (Singapore) flap]. Healing was satisfactory in all the patients although two of them (10%) had surgical site infection whereas one (5%) had mild wound dehiscence, but all healed within 2 weeks. Conclusion: Post-Fournier gangrene defects can be reconstructed using several options, the choice of which is dependent on the size of the defect, elasticity of residual scrotal skin, status of defined locoregional pedicles, availability of modern diagnostic and operating equipment, and expertise of the surgeon. Collaboration between the urologists and the plastic surgeons is recommended for optimal outcome.

Complete Human Penile Scaffold for Composite Tissue Engineering: Organ Decellularization and Characterization

Reconstruction for total penile defects presents unique challenges due to its anatomical and functional complexity. Standard methods suffer from high complication rates and poor functional outcomes. In this work we have developed the first protocol for decellularizing whole-organ human penile specimens for total penile tissue engineering. The use of a hybrid decellularization scheme combining micro-arterial perfusion, urethral catheter perfusion and external diffusion enabled the creation of a full-size scaffold with removal of immunogenic components. Decellularization was complete as assessed by H&E and immunohistochemistry, while quantification of residual DNA showed acceptably low levels (<50 ng/mg). An intact ECM was maintained with histologic architecture preservation on H&E and SEM as well as preservation of key proteins such as collagen-1, laminin and fibronectin and retention of growth factors VEGF (45%), EGF (57%) and TGF-beta1 (42%) on ELISA. Post-decellularization patency of the cavernosal arteries for future use in reseeding was demonstrated. Scaffold biocompatibility was evaluated using human adipose-derived stromal vascular cells. Live/Dead stains showed the scaffold successfully supported cell survival and expansion. Influence on cellular behavior was seen with significantly higher expression of VWF, COL1, SM22 and Desmin as compared to cell monolayer. Preliminary evidence for regional tropism was also seen, with formation of microtubules and increased endothelial marker expression in the cavernosa. This report of successful decellularization of the complete human phallus is an initial step towards developing a tissue engineered human penile scaffold with potential for more successfully restoring cosmetic, urinary and sexual function after complete penile loss.

Urethroplasty with a bilayered poly-D,L-lactide-co-ε-caprolactone scaffold seeded with allogenic mesenchymal stem cells.

Reconstructive surgery for urethral defects employing tissue-engineered scaffolds represents an alternative treatment for urethroplasty. The aim of this study was to compare the therapeutic efficacy of the bilayer poly-D,L-lactide/poly-ε-caprolactone (PL-PC) scaffold seeded with allogenic mesenchymal stem cells (MSCs) for urethra reconstruction in a rabbit model with conventional urethroplasty employing an autologous buccal mucosa graft (BG). The inner layer of the scaffold based on poly-D,L-lactic acid (PL) was seeded with MSCs, while the outer layer, prepared from poly-ε-caprolactone, protected the surrounding tissues from urine. To track the MSCs in vivo, the latter were labeled with superparamagnetic iron oxide nanoparticles. In rabbits, a dorsal penile defect was reconstructed employing a BG or a PL-PC graft seeded with nanoparticle-labeled MSCs. In the 12-week follow-up period, no complications were detected. Subsequent histological analysis demonstrated biointegration of the PL-PC graft with surrounding urethral tissues. Less fibrosis and inflammatory cell infiltration were observed in the experimental group as compared with the BG group. Nanoparticle-labeled MSCs were detected in the urothelium and muscular layer, co-localizing with the urothelium cytokeratin marker AE1/AE3, indicating the possibility of MSC differentiation into neo-urothelium. Our results suggest that a bilayer MSCs-seeded scaffold could be efficiently employed for urethroplasty.

Commentary to ‘Topical estradiol increases epidermal thickness and dermal collagen of foreskin prior to hypospadia surgery – randomized double blinded controlled trial’

Summary Introduction The use of preoperative topical testosterone stimulation prior to hypospadias correction aims to increase penile size and achieve better surgical results. Topical estradiol has been shown to improve the quality of skin in other sites, but its use in boys with hypospadia has not yet been elucidated. Objective This study aims to evaluate the primary effects in epidermal thickness and collagen distribution of estradiol compared to testosterone and placebo in skin of prepuce before hypospadia surgery. Matherials and methods Patients were randomized into three groups according to the topical hormone used: TG: Testosterone ointment; EG: Estradiol ointment; CG: Neutral base ointment. Fragments of foreskin were excised, fixed and then sectioned for histology. For each sample, epidermal thickness and dermal collagen expression was measured by specific computer analysis, P-values of Results Thirty-three patients with a mean age of 4.01 ± 2.92 years were included. Hypospadia classification was similar in all three groups. Mean epidermal thickness and collagen type I expression in EG were greater than those of the other groups. Collagen type III expression was similar in all groups. Discussion Foreskin has a fundamental role in many techniques of hypospadias surgery and can be used either as a graft or a flap in the correction of the penile defect. Increase of epidermal thickness and dermal collagen observed in the present study has already been related to use of estradiol in other skin sites, but not yet in foreskin. Further studies are needed to evaluate the real significance of these findings in boys with hypospadias. Conclusion Use of topical estradiol before hypospadias surgery lead to greater epidermal thickness and increases dermal collagen expression in foreskin. Download : Download high-res image (376KB) Download : Download full-size image