Scrotal Reconstruction Research Articles

ORIGINAL RESEARCH–INTERSEX AND GENDER IDENTITY DISORDERS: Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience

Metoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. Our aim is to describe our technique and highlight its advantages. Between September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed. Patients' personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data. The median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients. Metoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

Skrotum-Rekonstruktion nach Fournier-Gangrän mit uni- und bilateral gestielter rein muskulärer M.gracilis-Lappenplastik

Fournier's gangrene is still a major cause for the development of soft tissue defects of the perineum and is associated with a mortality of 40-67% of all patients. Along with the initial life-preserving treatment such as broad-spectrum antibiotics and multifold agressive surgical debridement, reconstruction of the body contour is of the utmost importance for these patients. An individual adjustment of treatment in every single case is required due to the wide variety of the resulting complex soft tissue defects and differing patient profiles. Most publications describe the use of musculo- or fasciocutaneous flaps for scrotal reconstruction. In this paper, we present two cases of successfully performed plastic reconstructions of the scrotum using a solely muscular gracilis flap to cover the exposed testicles, followed by a split-skin graft to cover the muscle. The plasticity of the muscle and the variability of flap design resulted along with the transplanted mesh-graft in an excellent outcome for the patient with respect to function, form and quality of life.

Scrotum reconstruction with the anterolateral (ALT) thigh flap

Scrotum reconstruction is challenging. Both the functional and cosmetic outcome are considered. Many reconstructive methods have been described, from burying the exposed testicles into a subcutaneous pocket to local musculocutaneous or fasciocutaneous flaps. We report our experience of treating three patients for scrotal reconstruction by using the anterolateral thigh island flap. Three patients received scrotum reconstruction with the anterolateral thigh island flap from 2003 to 2007. Two of them had Fournier’s gangrene and one had hidradenitis suppurativa. In two occasions a “true” perforator flap was used and in one a small muscle cuff of the vastus lateralis muscle was also included. All three flaps were successful. One patient had a proximal donor site wound dehiscence due to inadequate drainage. Simple conservative treatment resolved the problem. No patient had any functional donor site morbidity. We conclude that the anterolateral thigh flap is a valuable tool in reconstruction of the scrotum. It should be considered as a sound alternative within the available reconstructive procedures.

Thin-trimming of the scrotal reconstruction flap: long-term follow-up shows reversal of spermatogenesis arrest

To explore a method to decrease the arrest of spermatogenesis in patients undergoing scrotum reconstruction with a flap. A follow-up study on a patient whose scrotum had been reconstructed with a flap revealed the arrest of spermatogenesis. The flap was trimmed thin on two occasions, and the composition of the seminal fluid was followed up. The follow-up showed a decrease in the arrest of spermatogenesis after the flap was thin-trimmed. Thin-trimming the reconstruction flap can decrease the degree of spermatogenesis arrest in patients who have received scrotum reconstruction by thick flap.

Anterior Lateral Thigh Island Pedicle Flap in Total Scrotal Reconstruction-Three Cases Report

Scrotal skin defect may happen after trauma, infectious destruction, burn injury, malignancy and congenital anomalies. Numerous techniques were reported for scrotal reconstruction, especially after total loss of the overlying skin with testes exposure. We present our experience in scrotal reconstruction for three patients with total scrotal loss and testes exposure by the anterior lateral thigh flap in island fasciocutaneous pedicle flap. All flaps survived with no immediate or delayed complications. The anterior lateral thigh flap provided durable skin and thin soft-tissue coverage with good aesthetic results in 6 months follow up.

Rapid intraoperative tissue expansion can be used for scrotal reconstruction

Rapid intraoperative tissue expansion can be used for scrotal reconstruction

Scrotal Reconstruction Using Rapid Intraoperative Tissue Expansion: A Preliminary Report

Extensive scrotal skin loss can pose a difficult management problem. In most cases delayed scrotal approximation is feasible due to the redundancy of scrotal skin. However, large defects usually require reconstruction using flaps or grafts. We present a novel technique of scrotal closure using rapid intraoperative tissue expansion to manage select extensive partial scrotal defects. Between January 1996 and April 2006, 3 patients underwent delayed closure using rapid intraoperative tissue expansion for approximately 75% scrotal skin loss. Intraoperatively the residual lateral scrotal and medial thigh skin, and subcutaneous tissues were dissected, creating bilateral cavities for the placement of round 300 cc tissue expanders. Gradual inflation for a total of 20 minutes allowed adequate tissue expansion of the 2 thigh flaps, enabling tension-free scrotal closure. Each patient was followed for 12 months. The resulting reconstruction provided a tension-free, cosmetically appealing scrotum with complete testicular coverage. There were no perioperative or postoperative complications. Although rapid intraoperative tissue expansion has been successfully used for the closure of facial and extremity defects, to our knowledge it has not been described for genital skin loss. Our experience suggests that this relatively simple method is a viable addition to the reconstructive armamentarium in a select group of patients with extensive scrotal skin defects that are not amenable to scrotal approximation alone.

Lotus petal flaps for scrotal reconstruction combined with Integra™ resurfacing of the penis and anterior abdominal wall following necrotising fasciitis

Necrotising fasciitis of the external genitalia following routine circumcision is uncommon. We describe reconstruction of the scrotum with local perforator flaps and a dermal regeneration template (Integra) to cover the penile shaft after debridement. Lotus petal flaps were originally designed to cover vulvo-vaginal defects, but in this instance integrated well with the remaining scrotal sac to produce a good volume neoscrotum for testicular cover. Integra creates an acceptable neodermis usually to cover areas of debrided full thickness burns. In this case, Integra adequately replaced the mobile dermal layer over Bucks fascia over the penis to create a pliable and cosmetically acceptable result with erectile capability.

Using the Pedicle Anterolateral Thigh Flap as an Optional Method in Fournier's Gangrene Wound Reconstruction

Fournier's gangrene is the progressive necrotizing infection of the perineum and genital fascia with gangrene of the overlying skin. The effective treatment includes aggressive debridements, broad-spectrum antibiotics, and intensive supportive care. Radical debridements often result in spermatic cord and testis exposure and need secondary reconstruction after infection controlled. How to achieve a cosmetic and functional reconstruction is a challenge. We provide our experience in scrotum reconstruction using the pedicled anterolateral thigh flap. From October 2005 to August 2006, there were seven patients who received pedicled anterolateral thigh fasciocutaneous flaps transfer for the complex perineal defects at the China Medical University Hospital. There were six male patients and one female patient, aged from 45 to 70 years old. The seven patients received one to three times wound debridements and were finally resurfaced with a pedicle anterolateral thigh fasciocutaneous flap transfer, to cover the scrotum, perianal, or lower abdominal skin defect. No cutaneous flap suffered from partial necrosis after transfer. There are two patients who received the split skin graft simultaneously with flap transfer for bigger abdominal defect. The size of the flaps ranged from 50 to 180 centimeter square and was supplied by single perforator. Post-operation wound healing and outlook is very good. Pedicle anterolateral thigh fasciocutaneous flap is a good surgical option in Fournier's gangrene reconstruction. The skin paddle can be adjusted geographically to match the critical defect and the pedicle length can be easily lengthened by ”pedicle extension technique”. The outlooks of the results are natural and less post-op morbidity were noted in our series.

Scrotum Reconstruction with Neurovascular Pedicled Pudendal Thigh Flaps

Scrotal defects resulting from many factors, including accidents, Fournier's gangrene, and gunshot injuries, present difficulties in management and reconstruction. Antibiotic therapy must be given to all patients, and if necessary vigorous debridement must be performed. Because of the abundant vascularity of the region, local wound dressing results in dramatically rapid recovery of the wounds. In unsuitable conditions that prevent primary closure of the scrotal skin, thigh flaps may be used. Proximally based neurovascular pudendal thigh flaps were used in 10 scrotal defects. Maximum dimensions of elevated flaps were 20 x 15 cm. All donor areas were closed primarily. Satisfactory results were achieved in all patients, especially in terms of sensitivity. Neurovascular pudendal thigh flaps are an excellent reconstructive choice for scrotal defects because of being sensate and having minimal donor-site morbidity.

Giant scrotal elephantiasis of inflammatory etiology: a case report

BackgroundScrotal lymphedema is rare outside endemic filariasis regions in Africa and Asia. It is of variable origin in the western world.Case presentationWe present a case of a 40-year-old European man with massive elephantiasis of the scrotum attributed to chronic inflammation of the lower urinary tract caused by urinary outlet obstruction and diabetes mellitus. The patient underwent subtotal scrotectomy saving penis, testes and spermatic cords and followed by scrotal reconstruction with adequate cosmetic and functional outcome.ConclusionIn this report we discuss a rare case of scrotal elephantiasis in an European patient, reflect on the etiology and the diagnostic and therapeutic approaches. Surgery can be successful even in giant scrotal elephantiasis.

Incarcerated Inguinal Hernia in the Presence of Fournier's Gangrene: A Novel Approach to a Complex Problem

Fournier's gangrene is an aggressive, polymicrobial soft tissue infection that specifically affects the genital and perineal region. Treatment requires early recognition, broad-spectrum intravenous antibiotics, and radical surgical debridement of all infected tissues. Optimal therapy may necessitate multiple debridements that leave the patient with large tissue defects that require skin grafting for scrotal and perineal reconstruction. The presence of other surgical emergencies, such as an incarcerated inguinal hernia, in the face of Fournier's gangrene presents a rare and challenging dilemma to the general surgeon. With the widespread acceptance of tension-free repair utilizing prosthetic mesh in uncomplicated hernia surgery, outcomes have been improved. However, surgical options for hernia repair may become limited in the face of a regional necrotizing soft tissue infection, for which mesh use in an open repair after debridement of infected tissues is generally contraindicated. In this report, the authors describe three consecutive cases of incarcerated inguinal hernia in the presence of concomitant Fournier's gangrene using a laparoscopic approach and natural biomaterial mesh for abdominal wall reinforcement.

Giant Scrotal And Penile Elephantiasis Of Idiopathic Etiology: A Case Report

Background: Scrotal lymphedema is condition though common in endemic filariasis regions in Africa and Asia but rare out side these region. It is of variable origin in the western world. Case presentation: We present a case of a 30-year-old man with massive elephantiasis of the scrotum and penis. The patient underwent subtotal scrotectomy saving penis, testes and spermatic cords and followed by scrotal reconstruction with adequate cosmetic and functional outcome. Conclusion: In this report we discuss a rare case of giant scrotal and penile elephantiasis, reflect on the etiology and the diagnostic and therapeutic approaches. Surgery can be successful even in giant scrotal elephantiasis.

Scrotal Reconstruction Following Fournier Gangrene Using the Medial Circumflex Femoral Artery Perforator Flap

Fournier gangrene can have devastating consequences. Often in the male, the testicles become exposed and demand both a functional and esthetic coverage. Local medial thigh cutaneous flaps usually still are available and have evolved to become a preferred solution. The medial circumflex femoral artery perforator (MCFAP) flap based on musculocutaneous perforators of the gracilis muscle represents yet another one of these options. As with all muscle perforator flaps, no muscle need be expended. A case report illustrates the role of the MCFAP flap for creation of a neoscrotum.

Reconstruction of wide scrotal defect using superthin groin flap

Introduction Grafts and flaps have been widely used to reconstruct scrotal defects due to Fournier’s gangrene. Controversy still exists concerning the use of grafts and flaps because of the low protection provided by the grafts and the high volume of the flaps. We describe the use of an expanded groin flap for scrotum reconstruction. Technical Considerations Three patients were treated for total scrotal tissue loss using this method. An expander was installed through an incision from the inferolateral aspect of the groin, and superthin flaps obtained after 3 weeks were dissected starting from the medial side. Care was taken during dissection, because the skin was thin on the lateral side, and dissection was performed in a subfascial fashion. Finally, the defect was covered with the lateral part of the expanded flap and the donor site was primarily closed. Conclusions To cover the testes, both the aesthetic and functional state should be taken into consideration. Therefore, a thin and durable cover is required for scrotal reconstruction. The expanded superthin groin flap possesses these features and is a good option.

Use of Tissue Expansion for Scrotal Sac Reconstruction After Scrotal Skin Loss

Use of Tissue Expansion for Scrotal Sac Reconstruction After Scrotal Skin Loss

Scrotal and Penile Reconstruction Using the Vacuum-Assisted Closure Device

Fournier's gangrene is a necrotizing, soft tissue infection that spreads along the deep external fascial planes of the perineum, scrotum (or vagina), penis, thighs and lower abdomen. Due to the rapid progression of the disease, patients are frequently left with a large integumentary deficit. Treatment of the skin defect has been described in a multitude of ways including split-thickness skin grafting, burying the testes in the thighs, thigh flaps and a variety of myocutaneous and fasciocutaneous flaps. Many of the previously described techniques have worked well for smaller defects and for closure of wounds but fall short of aesthetic reconstruction of sexual organs. Described here is a technique using split-thickness skin grafts, with foam dressings as the bolster. This was performed using the vacuum-assisted closure device (Kinetic Concepts Inc, USA). This technique creates a natural appearing scrotum that holds the testes away from the body, in a physiological manner, and surfaces the penis with a natural appearance, in a functional manner. The technique results in nearly 100% graft take and greatly decreases length of hospital stay.

Use of tissue expansion for scrotal sac reconstruction after scrotal skin loss

We describe a two-stage technique for scrotal sac reconstruction using tissue expansion, best described as a tissue expanded V- Y scrotoplasty. This technique has been used after extensive scrotal skin loss, providing excellent functional and cosmetic outcomes.

Idiopathic scrotal elephantiasis

Scrotal lymphedema (scrotal elephantiasis) is a condition that has historically been described in areas endemic to filariasis. We present a unique case of a 22-year-old man with idiopathic lymphedema isolated to the scrotum. After acquired causes of lymphedema were ruled out, the patient was treated with scrotectomy and scrotal reconstruction.

Scrotal and penile reconstruction using the vacuum-assisted closure device

Scrotal and penile reconstruction using the vacuum-assisted closure device