Scrotal Reconstruction Research Articles

Perineoscrotal reconstruction following fournier's gangrene using the upper medial thigh perforator flap

Background: Fournier's gangrene (FG) is a synergistic necrotizing fasciitis that involves the genitalia, perineum, or anal region and can be life threatening and generally necessitates urgent surgical intervention. It often causes scrotal defects that require reconstruction after surgical debridement. The reconstruction of these serious scrotal defects poses certain challenges for surgeons. In this study, reconstruction of scrotal defects caused by FG with medial circumflex femoral artery perforator (MCFAP) flap evaluated. Patients and Methods: Seventeen patients with FG reconstructed using a MCFAP flap, admitted to our hospital between February 2003 and March 2017, are included in this study. Reconstruction with MCFAP flap results, mean debridement number, comorbid diseases, and length of hospital stay are analyzed together. Patients with FG reconstructed using techniques other than MCFAP were not included in this study. Results: Eighteen MCFAP flaps were performed in 17 patients. The mean duration of operation was 2 h 55 min. Diabetes mellitus was the most common comorbid disease. The mean days of hospital stay were 19.9. Total flap loss was not seen in 17 patients. Donor area of the flap is closed primarily, by V-Y advancement flaps or by split-thickness skin grafts. Acceptable cosmetic results and scrotal contours were obtained in all patients. No major complications were observed. Conclusions: Using a MCFAP flap, a method that has minimal donor site morbidity, requires single session surgery, provides good skin quality and color similar to the scrotum, is an easy-to-perform process, proving to be a reliable flap for scrotal reconstruction.

Current Concepts in Scrotal Reconstructive Surgery

Scrotal reconstruction may be required in any setting where the patient sustains loss of a large area of scrotal or penile skin, as in repair of scrotal lymphedema and the adult acquired buried penis. Massive scrotal lymphedema and adult acquired buried penis are two conditions closely linked to obesity and are largely refractory to non-operative management. The demand for surgical repair of these conditions is increasing. The aim of this article is to provide an overview of the preoperative considerations, surgical techniques, and postoperative outcomes in the repair of scrotal lymphedema and adult buried penis. Scrotal lymphedema and adult buried penis are associated with significant medical comorbidities and can cause sexual and urinary dysfunction. Surgical repair requires a multidisciplinary approach. Skin grafts are often required. There is no consensus regarding optimal postoperative management of these surgical wounds. Consideration should be given to extended duration chemical prophylaxis of thromboembolic events. Though complications are common, patient quality of life is significantly improved following repair. The demand for surgical repairs of scrotal lymphedema and adult buried penis are increasing. Though patients have significant comorbidities and surgical repair may be complex, patient outcomes are good and quality of life can be greatly improved.

Scrotal reconstruction - A standard procedure for giant hydrocele repair

Scrotal reconstruction - A standard procedure for giant hydrocele repair

Evaluation of scrotal reconstruction with thigh flap

Background: Scrotal skin can be lost in many ways. Partial loss of scrotum is easy to manage but major scrotal skin loss represents a significant challenge to the reconstructive surgeon. Although many techniques have been established for the treatment of major scrotal defects, each technique has its own advantages and disadvantages in specific situations.Objective: The aim of this prospective study was to evaluate the outcome of thigh fascio-cutaneous flap for reconstruction of major scrotal loss with exposed testis.Methods: This prospective study was done for 5 years extending from January 2012 to December 2016. In this period we reconstructed major scrotal defects of eight patients with antero medial and pudendal thigh fascio-cutaneous flap in Burn and Plastic Surgery department, Khulna Medical College Hospital. Total eleven thigh fascio-cutaneous flaps were used for reconstruction of major scrotal defects.Results: The mean patient age was 41 years (range 24 to 62 years). The aetiology of scrotal loss was Fournier's gangrene in 4 cases and trauma in 4 cases. Three cases had bilateral and five cases had unilateral flap reconstruction. The flaps allowed sensate coverage and took well. Primary donor site closure obviated the need for skin grafts in most of the cases, Complications were flap tip necrosis (12.50%) and minor wound infection (12.50%) which were treated conservatively. Donor site scar was limited and acceptable. The flap had good aesthetic appearance except in one fatty patient where the flaps were bulky.Conclusion: The study concluded that thigh fascio-cutaneous flap is very reliable for coverage of major scrotal defects.Bang Med J (Khulna) 2017; 50 : 13-17

Scrotal reconstruction with superomedial fasciocutaneous thigh flap.

to describe the use of a superomedial fasciocutaneous thigh flap for scrotal reconstruction in open areas secondary to the surgical treatment of perineal necrotizing fasciitis (Fournier's gangrene). retrospective analysis of cases treated at the Plastic Surgery Service of Santa Casa de Misericórdia, São Paulo, from 2009 to 2015. fifteen patients underwent scrotal reconstruction using the proposed flap. The mean age was 48.9 years (28 to 66). Skin loss estimates in the scrotal region ranged from 60 to 100%. Definitive reconstruction was performed on average 30.6 days (22 to 44) after the initial surgical treatment. The mean surgical time was 76 minutes (65 to 90) to obtain the flaps, bilateral in all cases. Flap size ranged from 10cm to 13cm in the longitudinal direction and 8cm to 10cm in the cross-sectional direction. The complication rate was 26.6% (four cases), related to the occurrence of segmental and partial dehiscence. the superomedial fasciocutaneous flap of thigh is a reliable and versatile option for the reconstruction of open areas in the scrotal region, showing adequate esthetic and functional results.

Scrotal reconstruction by inguinal flap after Fournier’s gangrene: A case report and review of literature

Scrotal reconstruction by inguinal flap after Fournier’s gangrene: A case report and review of literature

Scrotal reconstruction and testicular prosthetics.

Scrotal surgery encompasses a wide-variety of surgical techniques for an even wider variety of indications. In this manuscript, we review our indications, techniques, and pit-falls for various reconstructive scrotal surgeries as-well-as surgical tips for placement of testicular prostheses. Penoscrotal webbing (PSW) is an abnormal, often-problematic distal insertion of scrotal skin onto the ventral penile shaft. There are several effective and straightforward techniques used to revise this condition, which include simple scrotoplasty, single- or double-Z-plasty, or the VY-flap scrotoplasty. Reconstruction is also commonly indicated following scrotal skin loss caused by infection, trauma, lymphedema, hidradenitis, and cancer. Although initial management of these conditions often involves scrotal skin removal, repair of expansive scrotal skin loss can be technically difficult and can be accomplished by using one of several skin flaps or skin grafting. Split-thickness skin grafting of scrotal defects can be accomplished easily, and provides durable results.

Idiopathic scrotal calcinosis: a rare case report and review of pathogenesis and surgical management

Scrotal calcinosis is an uncommon benign disorder of the scrotal skin characterized by multiple calcified intradermal nodules that occurs in the presence of normal calcium and phosphate metabolism. The pathogenesis of scrotal calcinosis is still controversial. Our Aim is to report this disease in 33-years-old man and review the pathogenesis and surgical management. We presented 33-years-old male patient with a 10 year history of painless scrotal nodules which gradually increased in size and number. Physical examination revealed multiple scrotal nodules with diameter of 5-10 mm, respectively. The nodules were firm and skin-colored. The nodules grow from small bud with chalky white exudative discharge but no history of vesicle, papule or any sign of inflammation. The patient’s symptoms were mild itching with no pain. He had no history of trauma, malignancy, or any metabolic disorder. His old brother had a history with the same complained. Laboratory findings including serum electrolyte and level of creatinine, urea, calcium and phosphorus, were within normal limit. The patient was performed biopsy before procedure showed dystrophic calcinosis appearance. We performed wide local excision of lesion with primarily closure with good postoperative outcome, with histopathology result calcinosis subcutaneous at region scrotum. Dystrophic scrotal calcinosis is a benign condition which can affect a patient’s quality of life. Irrespective of the etiology, surgical excision seems to be gold standart is required both for confirming the diagnosis as well as for treatment but occasionally may require complex scrotal reconstruction to provide a good clinical outcome with good patient satisfaction.

280 Scrotal Reconstruction Using Three Different Operative Methods in the Avulsion Injury of Penis and Scrotum

280 Scrotal Reconstruction Using Three Different Operative Methods in the Avulsion Injury of Penis and Scrotum

Reconstructive methods after Fournier gangrene

Fournier's gangrene is a variant of the necrotizing fasciitis restricted to the perineal and genital region. It presents as an acute life-threatening disease and demands rapid surgical debridement, resulting in large soft tissue defects. Various reconstructive methods have to be applied to reconstitute functionality and aesthetics. The objective of this work is to identify different reconstructive methods in the literature and compare them to our current concepts for reconstructing defects caused by Fournier gangrene. Analysis of the current literature and our reconstructive methods on Fournier gangrene. The Fournier gangrene is an emergency requiring rapid, calculated antibiotic treatment and radical surgical debridement. After the acute phase of the disease, appropriate reconstructive methods are indicated. The planning of the reconstruction of the defect depends on many factors, especially functional and aesthetic demands. Scrotal reconstruction requires a higher aesthetic and functional reconstructive degree than perineal cutaneous wounds. In general, thorough wound hygiene, proper pre-operative planning, and careful consideration of the patient's demands are essential for successful reconstruction. In the literature, various methods for reconstruction after Fournier gangrene are described. Reconstruction with a flap is required for a good functional result in complex regions as the scrotum and penis, while cutaneous wounds can be managed through skin grafting. Patient compliance and tissue demand are crucial factors in the decision-making process.

Scrotal reconstruction with modified pudendal thigh flaps

Scrotal skin loss can occur following trauma, Fournier's gangrene, post tumour excision, burns, etc. There are many techniques described in the literature including residual scrotal skin mobilization, skin grafts, pedicled and free flaps. The management is complex and challenging shown by the multiplicity of flaps and techniques described in the literature. We used a modified pudendal thigh flap to reconstruct scrotal defects in five patients. This study describes the vascularity of the flap, technique of elevation and the inset of the flap. The elevation and particularly the insetting make it different from other flaps raised on this vascular network for scrotal reconstruction. This pedicled flap is robust, reliable, resilient and produces a neo-scrotum that looks natural in appearance, offers good-quality skin cover and cushion to the testes as well as protective sensation.

Anteriorly based pudendal thigh flap for scrotal reconstruction based on the deep external pudendal artery (DEPA) flap

Background Major scrotal skin loss represents a significant challenge for reconstructive surgeons. Although many therapeutic methods have been established for the treatment of such defects, each technique has its own advantages and disadvantages. A posteriorly based pudendal thigh fasciocutaneous flap at the perianal region has been described for reconstruction of genital organs, but an anteriorly based pudendal thigh fasciocutaneous flap has not been described for scrotal reconstruction.

Surgical Treatment of Genital Manifestations of Lymphatic Filariasis: A Systematic Review.

Genital manifestations of lymphatic filariasis (genital LF) are a significant cause of disfigurement and disability in the developing world. Surgery is the standard treatment; however, definitive publications are lacking and best practice remains unclear. An exhaustive search strategy using keyword and subject headings was applied to Medline, EMBASE, Web of Science, CINAHL, and Scopus. Additionally citation lists, Google and Google Scholar, archives of relevant journals and websites were searched systematically. Studies with data on one or more human patient(s) who underwent surgery for genital LF were included. Articles were screened and data extracted by the first author with data verification by the second author. Fifty-seven studies were included: 18 series of ablative surgery, four series of non-ablative surgery and 35 case reports. Poor study quality, heterogeneous case definitions, lack of severity grading and limited follow-up precluded meta-analysis. Two series of simple hydrocelectomies performed in resource-limited settings reported early complication rates of 3.0-3.5 % using eversion and 5-7 % using excision, with recurrence of 7 % and 3-5 %, respectively. Complications were minimal for single-surgeon series and greater (12-18 %) when scrotal reconstruction was performed. There is little useful evidence for lymphatic bypass procedures in genital LF. Under-recognition of atypical manifestation of genital LF leads to potentially unnecessary surgeries. Surgery for genital LF is safe in resource-limited settings; however, more well-designed studies with better follow-up are needed. Research priorities include validation of case definitions and severity grading systems, and solutions to improve post-operative follow-up in resource-limited settings.

Editorial Comment

The postoperative genital appearance of repaired exstrophy patients, both male and female, remains an area needing surgical refinements. This includes the scrotum, which can be challenging to reconstruct in male exstrophy patients because of pubic diastasis. I applaud the authors for describing a new technique by which scrotoplasty can be accomplished in these patients, with acceptable cosmetic results based on preliminary data. 1 Dangle P.P. Billimire D. Schneck F. Grunwaldt L.J. Bilateral Circum-scrotal Z-plasties for Creation of Single Scrotal Sac in Cloacal Exstrophy With Widely Divergent Scrotal Sacs. Urology. 2015; 86: 808-810 Abstract Full Text Full Text PDF Scopus (1) Google Scholar Larger series using this technique will be necessary to determine whether the outcomes to date will hold true over time. Bilateral Circum-scrotal Z-plasties for Creation of Single Scrotal Sac in Cloacal Exstrophy With Widely Divergent Scrotal SacsUrologyVol. 86Issue 4PreviewSignificant number of patients with cloacal exstrophy variants present with poorly developed scrotum. Widely divergent hypoplastic scrotal sacs pose a technical challenge for scrotal reconstruction. We describe a technique of bilateral Z-plasty for the creation of single scrotal sac in a patient with widely divergent, hypoplastic scrotal sacs. Full-Text PDF ReplyUrologyVol. 86Issue 4PreviewCloacal exstrophy omphalocele-exstrophy-imperforate anus-spinal (OEIS) defects complex is rare with incidence of 1 in 200,000-400,000 pregnancies. Although the incidence of the associated scrotal anomalies is relatively high in patients with omphalocele-exstrophy-imperforate anus-spinal defects complex, very few cases are managed during individual's career. Full-Text PDF

Bilateral Circum-scrotal Z-plasties for Creation of Single Scrotal Sac in Cloacal Exstrophy With Widely Divergent Scrotal Sacs

Significant number of patients with cloacal exstrophy variants present with poorly developed scrotum. Widely divergent hypoplastic scrotal sacs pose a technical challenge for scrotal reconstruction. We describe a technique of bilateral Z-plasty for the creation of single scrotal sac in a patient with widely divergent, hypoplastic scrotal sacs.

Sex reassignment surgery

Transsexualism, or gender incongruence, presents a state in which a person's assigned sex at birth conflicts with their psychological gender. It is classified in International Classification of Diseases as F64. Treating these persons require multidisciplinary approach, including psychiatrist, endocrinologist, gynecologist, urologist, plastic and reconstructive surgeon. Genital reconstruction is the final step in transition, and can be performed when all other conditions required by World Professional Association for Transgender Health (WPATH) are accomplished. Female to male sex reassignment surgery Several surgical procedures can be done in female to male transsexuals, including mastectomy, removal of female genitalia, metoidioplasty, scrotoplasty with implantation of testicular implants, as well as total phalloplasty. The current operative technique of metoidioplasty comprise the following steps: vaginal removal, the release of the ventral chordee and clitoral ligaments, straightening and lengthening of the clitoris, urethroplasty by combining buccal mucosa graft and genital flaps and scrotoplasty with insertion of testicle prostheses. The goal is to perform all these procedures in one stage, and that makes our team famous worldwide. Metoidioplasty results in excellent cosmetic outcome with completely preserved sensitivity and sexual arousal, enables voiding while standing, but without ability to penetrate due to small size of the neophallus. Considering these advantages, including low complication rate, patients often choose this option. For those who require bigger phallus which enables implantation of penile prosthesis, several surgical techniques have been reported using either available local vascularized tissue or microvascular tissue transfer. However, none of them satisfy all the goals of modern penile construction, i.e. reproducibility, tactile and erogenous sensation, a competent neourethra with a meatus at the top of the neophallus, large size that enables safe insertion of penile implants, satisfactory cosmetic appearance with hairless and normally colored skin. We developed a new technique using the musculocutaneous latissimus dorsi free transfer flap, which mostly satisfies the requirements noted above. It has many advantages, such as its workable size which enables prosthesis implantation, long neurovascular pedicle and minimal functional loss after removal, as well as small phallic retraction. Total phalloplasty using latissimus dorsi flap, including total removal of female genitalia, reconstruction of the neourethra to reach the top of the glans, glans and scrotal reconstruction, implantation of testicular implants and penile prosthesis, is performed in 2 or 3 stages, presenting very complex and demanding surgical procedure with longer postoperative recovery period. Male to female sex reassignment surgery Several feminizing surgical procedures are performed in male to female transsexuals, including facial, neck, breast and genital surgery. Genital reconstruction comprises vaginoplasty, introitoplasty, clitoroplasty, labioplasty and urethroplasty. There are two substantial tissues for vaginal replacement: skin and bowel. For transgender patients penile inversion vaginoplasty presents the best option. Procedure starts with bilateral orchidectomy. The penis is dissected into its anatomical components and corpora cavernosa are completely removed. Glans with neurovascular bundle is used to create clitoris with preserved sensation, while skin of the penis is inverted, as a pedicled flap preserving blood and nerve supplies to form a fully sensate vagina. Urethra is reconstructed as in a female. Available and hairless flap, elasticity of penile skin, preserved erogenous sensation, good cosmetic and functional outcome, are the main advantages of this technique. After penile inversion skin flap, and in cases of failed surgery, sigmoid colon technique presents the method of choice in male to female reassignment surgery. Beside aesthetic and functional result, psychosocial and psychosexual outcome of these procedures are necessary in achieving a good quality of life for these patients.

Aesthetic scrotal reconstruction following extensive Fournier’s gangrene using bilateral island pedicled sensate anterolateral thigh flaps: A case report

Achieving an aesthetic appearance of the scrotum after extensive Fournier's gangrene is a reconstructive challenge. Testicular coverage is often prioritized over scrotal cosmesis due to the comorbidities typically seen in this patient population. We describe our treatment of a young, healthy male with extensive Fournier's gangrene, with loss of the scrotum. Bilateral neurotized anterolateral thigh flaps were used to achieve a sensate and aesthetically acceptable result.

Anatomical and functional outcome after bilateral scrotal flap in penile reconstruction

Abstract Background: Injection of alloplastic material underneath the penile skin for penile augmentation causes many complications such as inflammation, infection, ulceration, and pain during sexual activity. One of the treatments for complications after these penile augmentation procedures is surgical excision of the foreign body granuloma followed by penile skin coverage with bilateral scrotal flaps. There are no prior prospective studies published about anatomical and functional outcomes. Objective: To study the anatomical and functional outcome of one-stage bilateral scrotal flap reconstruction in patients after surgical removal of paraffinoma from penile shafts. Methods: Patients who suffered from complications of penile foreign body granuloma were treated by surgical excision and reconstruction with bilateral scrotal flaps. The penile lengths and circumferences when flaccid and erect were recorded preoperatively and postoperatively. The patients were interviewed using questionnaires and satisfaction scored to determine their sexual experiences were recorded before and after surgery. Results: Thirteen patients were enrolled in this study. The mean follow-up time was 23.5 (11.5-40.5) weeks. The mean erectile length and the maximal circumference were 11.8 (9-15) cm, 14.5 (11.5-17) cm preoperatively, and 11.7 (10-14) cm, 11.8 (10-13) cm postoperatively. Satisfaction scores of sexual activity is 6.84 (0-9) preoperatively, and 8.38 (5-10) postoperatively. Conclusion: One-stage bilateral scrotal flap coverage is a good option for penile skin reconstruction. This technique can achieve satisfactory results both anatomically and functionally.

Early scrotal approximation after hemiscrotectomy in patients with Fournier’s gangrene prevents scrotal reconstruction with skin graft

We report the outcomes of an early loose closure of the scrotum with a modified U-stitch to minimize use of split thickens skin graft for patients with hemiscrotal tissue loss after surgical debridement. From January 2006 to August 2011, 28 male patients presented with Fournier's gangrene, requiring major urological surgical care and scrotal debridement at Denver Health Medical Center. Surgical outcomes were compared between patients receiving a novel U-Stitch approximation and those treated by traditional management. The mean age of the patients was 47.1 ± 10.2 years. In total 8 patients (2.2%) developed bacteremia and 3 (0.1%) had methicillin-resistant staphylococcus aureus (MRSA) infection. There was conversion from the U-Stitch approximation patients to traditional management. U-stitch patients required less hospitalization than patients requiring split-thickness skin graft (STSG) due to loss of >50% of the total scrotal tissue (11 vs. 35 days, p = 0.081). The U-stitch demonstrated non-inferiority to traditional treatment. Immediate loose scrotal wound approximation with efficient surgical debridement for Fournier's gangrene may prevent testis exposure facilitating local wound treatment, decreasing the length of hospital stay in patients with Fournier's gangrene involving the scrotum. Future randomized trials may validate these findings.

Scrotal reconstruction: a review and a proposed algorithm

Scrotal reconstruction is a difficult problem following infection, trauma or tumour resection. The focus of classic reconstructive options remains occlusive and aesthetic with little regard for testicular function. The important factors in choosing the right reconstructive option for our patients are age, testicular functional requirements and best aesthetic outcome. We reviewed contemporary options available for reconstruction of the scrotum and their effects on testicular function in an effort to provide an algorithm for scrotal reconstruction. We performed an extensive online search using OVID SP, OVID, Medline, PubMed, CINAHL Plus and Cochrane Library database using keywords “scrotal, scrotum and reconstruction”. The introduction of axial pattern analysis of flaps has led to a flourish of innovative and novel coverage techniques to achieve aesthetic and gross reproductive function. With the emergence of new technology, however, spermatogenesis has moved to the forefront of the field, and a new paradigm shift in reconstruction needs to follow. New studies have re-orientated best practice to include this in the reconstructive ladder, and here, we provide a useful algorithm for scrotal reconstitution that will help reconstructive surgeons in choosing the right option for their patients.