Scrotal Skin Flap Research Articles

MANAGEMENT AND OUTCOME OF COMPLEX HYPOSPADIAS REPAIRS

Repeated attempts at surgical repair of hypospadias may leave the penis scarred, hypovascular and shortened. We report on the clinical outcomes of our repaired complex hypospadias cases, often referred to as hypospadias cripples. We evaluated the records of 137 children and young adults from January 1980 through December 2002 who were referred to us after multiple unsuccessful hypospadias repairs. The records of 11 patients were inadequate. The ages of the remaining 126 patients ranged from 14 months to 35 years. The number of prior surgical procedures ranged from 2 to 23. Of the 126 cases 98 (78%) were repaired in a single stage (group 1) and 28 (22%) underwent multistage repairs (group 2). Major complications occurred in 17 cases (17%) in group 1 and in 2 (7%) in group 2. Major complications included repair breakdown, stricture, diverticulum and multiple fistulas. Minor complications occurred in 9 (9%) cases in group 1 and in 4 (14%) in group 2. Minor complications included a single small urethrocutaneous fistula, skin tethering, inclusion cysts and glandular irregularity. Urethral substitution using skin grafts and/or bladder mucosa resulted in a high complication rate of 32% and 37%, respectively, whereas use of buccal mucosa resulted in a 15% complication rate. Preoperative psychological counseling and discussion with other parents or patients were helpful. We no longer use free skin grafts and/or bladder mucosa for urethral substitution. Waterproofing the urethral tube was performed using either a dartos or tunica vaginalis flap. When the quality of the tissues was poor or severely scarred a 2-stage repair was performed. When resurfacing the penis local skin flaps may be insufficient or unreliable, and rotation of scrotal skin flaps or burial of the penis in the scrotum (Cecil-Culp) offers dependable skin coverage.

Radiological evaluation of vaginal width and depth in male-to-female transsexuals by the use of magnetic resonance imaging.

Nowadays, the surgical treatment of male-to-female transsexuals is not rare, but few studies have reported on postoperative results. The aim of this study was to determine the role of magnetic resonance imaging (MRI) in the evaluation of the results of sex reassignment surgery (SRS) in male-to-female transsexual patients. Ten such patients (median age 28 years, range 21-47), who had undergone SRS using an inversion of combined penile and scrotal skin flaps for vaginoplasty, were examined with MRI after the operation. Turbo spin-echo T2-weighted and spin-echo T1-weighted images were obtained on sagittal, coronal, and axial planes with a 1.5 T superconducting magnet. The images were acquired on the sagittal, coronal and axial planes, by using TSE T2 weighted and SG T1 weighted images. MRI was performed within 2 weeks after the operation in six patients and after 1 year in the other four. In all cases, the images were obtained with and without an inflatable silicon vaginal tutor. The average neovaginal depth was 7.9 cm (range 6-10 cm). In four patients, MRI showed the presence of cavernosal rests, and in two there were remnants of the corpus spongiosus. In another patient, an abnormal anterior inclination of the neovagina was present. The average distance of the recto-vaginal septum was 4 mm (range 3-6 mm). No major complications were noted. Our study allowed not only a detailed assessment of the pelvic anatomy after genital reconfiguration, but also provided valuable information on possible complications.

Laparoscopic Technique for Secondary Vaginoplasty in Male to Female Transsexuals Using a Modified Vascularized Pedicled Sigmoid

Between 1995 and 2002, 53 primary sex reassignments in male to female transsexuals were performed at our division. The objective of this procedure is to mimic the female external and part of the internal genitalia both esthetically and functionally. In 11 of the 53 patients, a secondary vaginal lengthening had to be performed due to a short neovagina. This was achieved using a pedicled sigmoid segment, with an open approach in the first 2 patients and using a laparoscopic method in the following 9. This paper focuses on the laparoscopic technique, its benefits and potential complications. Where a primary vaginoplasty, combining inversion of the penile and scrotal skin flaps, yields unsatisfactory functional results, a secondary vaginoplasty using the pedicled sigmoid represents an elegant means to achieve functional improvement. Furthermore, we report a modified surgical approach to the conventional sigmoid transition.

Value of magnetic resonance imaging in the evaluation of sex-reassignment surgery in male-to-female transsexuals.

We investigated the value of magnetic resonance imaging (MRI) in the evaluation of sex-reassignment surgery in male-to-female transsexual patients. Ten male-to-female transsexual patients who underwent sex-reassignment surgery with inversion of combined penile and scrotal skin flaps for vaginoplasty were examined after surgery with MRI. Turbo spin-echo T2-weighted and spin-echo T1-weighted images were obtained in sagittal, coronal, and axial planes with a 1.5-T superconductive magnet. Images were acquired with and without an inflatable silicon vaginal tutor. The following parameters were evaluated: neovaginal depth, neovaginal inclination in the sagittal plane, presence of remnants of the corpus spongiosum and corpora cavernosa, and thickness of the rectovaginal septum. The average neovaginal depth was 7.9 cm (range = 5-10 cm). The neovagina had a correct oblique inclination in the sagittal plane in four patients, no inclination in five, and an incorrect inclination in one. In seven patients, MRI showed remnants of the corpora cavernosa and/or of the corpus spongiosum; in three patients, no remnants were detected. The average thickness of the rectovaginal septum was 4 mm (range = 3-6 mm). MRI allows a detailed assessment of the pelvic anatomy after genital reconfiguration and provides information that can help the surgeon to adopt the most correct surgical approach.

Dartos flap interposition in the surgical repair of rectourethral fistulas.

Multilayer closures are important techniques in urethral fistula repair. We report our experience with dartos flap interposition in the repair of rectourethral fistula. A tip of a V-shaped scrotal skin flap is mobilized and de-epithelialized to develop a dartos flap. Two patients with a rectourethral fistula underwent fistula closure covered with this dartos flap. The surgical repair was successful in both cases and neither patient showed any late complication. A scrotal dartos flap is well vascularized and easy to mobilize. We believe this technique is helpful in preventing postoperative complications following complex posterior urethral surgery.

Pedicled scrotal island skin flap in the treatment of anal basal cell carcinoma

Basal cell carcinoma of the anus is extremely rare, accounting for only 0.1% of anorectal malignancies. We report the reconstruction of the anus with a biaxial pedicled scrotal island myofasciocutaneous flap following excision of an anal basal cell carcinoma, and conclude that this technique may be valuable in the reconstruction of the anal region.

The first cut is the deepest? Medicolegal aspects of male circumcision.

The first cut is the deepest? Medicolegal aspects of male circumcision.

CONCEALED PENIS IN CHILDHOOD: A SPECTRUM OF ETIOLOGY AND TREATMENT

Purpose Concealed penis is an uncommon condition due to poor skin fixation at the base of the penis, cicatricial scarring after penile surgery and excessive obesity. The condition varies in severity and several surgical options are available, such as excision of previous scarring, degloving the penile shaft, reconstructing the penile shaft skin with flaps, fixing the penile skin at the penopubic and penoscrotal angles, and removing excess suprapubic fat. Materials and Methods We reviewed the records of 43 patients treated for concealed penis from 1993 to 1998. We categorized the cases as type 1-congenital concealed penis, type 2-concealed penis due to scarring from previous surgery and type 3-complex cases involving excessive obesity. Cases were reviewed in regard to surgical techniques and outcomes. We identified 18 type 1, 18 type 2 and 7 type 3 cases. Mean age of type 1 patients at surgery was 12.4 months with 1 patient presented at age 7 years. None had previously undergone penile surgery. All patients underwent complete penile degloving. To reconstruct the penile shaft flaps or Z-plasties with penile skin were used in 12 patients and scrotal skin flaps were used in 2. In 12 patients the penile skin was fixed at the penoscrotal and penopubic angles to maintain penile length and in 2 excess fat was excised. Mean age of type 2 patients at surgery was 19.8 months. All had previously undergone surgery, including hypospadias in 1 and circumcision in 17. All patients underwent complete penile degloving and the cicatricial scar that trapped the penis was excised. Penile skin flaps and Z-plasties were used in 12 cases, scrotal skin flaps were used for reconstruction in 2 and skin grafting was done in 1. In 10 patients the penile skin was fixed with sutures to maintain penile length. Mean age of type 3 patients at surgery was 15.8 years. Of the 7 boys 6 had previously undergone penile surgery. All required extensive scar excision and complex reconstruction involving penile skin flaps in 3, scrotal flaps in 5 and penile skin fixation in 6. Excessive suprapubic fat was removed in 5 patients, of whom 3 underwent liposuction. Results Surgical results were uniformly good in type 1 patients except in 1 who was believed to have excessive suprapubic fat. Results were good in 14 of the 18 type 2 patients, although 2 retained excessive suprapubic fat and 2 had some unsightly scarring. No type 1 or 2 patient required additional surgery. Of the 7 type 3 patients 6 had a good result and required no additional surgery. One patient has recurrent concealed penis after 2 procedures and awaits additional surgery. Conclusions Concealed penis has a varied etiology and requires a flexible surgical approach. The common surgical options in all cases include complete penile degloving, excising the scarring due to previous surgery, removing excess suprapubic fat, reconstructing the penile skin with local flaps, and fixing the penile skin at the penopubic and penoscrotal angles.

Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients?

When inversion of the combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has not led to functional results, rectosigmoid colpopoiesis offers an immediate solution to a complicated and difficult problem. However, open colocolpopoiesis involves major surgery, and it may be associated with substantial extended morbidity and hospitalization, short- and long-term unfavorable results, and extensive scarring of the abdomen. To reduce this associated morbidity, we employ a laparoscopically assisted approach and a total laparoscopic rectosigmoid colpopoiesis. This procedure has been performed safely in the series presented herein, with no apparent compromise in the adequacy of the dissections. We conclude that our patients benefited from this procedure, and we advocate considering a total or partial laparoscopic approach whenever secondary rectosigmoid colpopoiesis is indicated in male-to-female transsexuals.

Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals.

When inversion of combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has become impossible or has not led to functional results, alternative vaginoplasty techniques should be considered. Colocolpopoiesis involves major surgery and often leads to disappointing long-term results. An Abbé-McIndoe vaginoplasty applying split-thickness skin grafts often does not provide favorable results in the scarred area encountered after complications of skin flap inversion surgery. Because thicker skin grafts show less tendency to shrink, the use of a full-thickness skin graft has been advocated for vaginoplasty in females. In this paper, we present our technique of successful secondary vaginoplasty applying full-thickness skin grafts in six male-to-female transsexuals. In patients with sufficient groin and abdominal skin to spare, a miniabdominoplasty allows for acceptable donor site scarring combined with correction of the abdominal skin surplus. In flat-tummied patients, the conventional abdominoplasty will allow for sufficient skin to be harvested to ensure successful secondary vaginoplasty. Abdominoplastic vaginoplasty has been proven to provide a good alternative whenever a laparotomy is not favored or is contraindicated in secondary cases.

Extended use of scrotal septal island skin flap for the repair of penile hypospadias.

In this article, one-stage repair of complicated cases of penile hypospadias when there is no penile skin available for safe reconstruction is described. An island of the most median hairless part of the scrotal skin around the median raphe was used as a skin flap based on its scrotal septal pedicle with an extended and free arc of rotation for repair of distant urethral defects. The bilaterally stretched, most median area of scrotal skin is almost hairless. This well-vascularized flap was used in reconstruction of 18 patients with recurrent, complicated, proximal, and distal penile hypospadias from January 1989 through July 1993. Of these, 17 patients were post pubertal and 1 was prepubertal. A maximum of 5 years and a minimum of 8 months follow-up showed no hair growth problems. Complications were sacculation of the reconstructed urethra in 1 patient, meatal stenosis in 1 patient, and urethral fistula in 1 patient. Technique refinements and encouraging results as well as complications are discussed.

Perineally-based scrotal skin flap to cover the inguino-scrotal defect resulting from radical removal of scrotal mesothelioma.

Perineally-based scrotal skin flap to cover the inguino-scrotal defect resulting from radical removal of scrotal mesothelioma.

Modified Vascularized Pedicled Scrotal Flap for Complex Hypospadias

Surgical correction of complex hypospadias defects is a problem. A 1-stage technique using a scrotal septum pedicled skin flap was used in 7 patients with inadequate preputial skin and scarred ventral penile skin unsuitable for satisfactory repair. The results were satisfactory in 5 patients. Distal urethral stricture developed in the remaining 2 patients and 1 of them had a subcoronal urethrocutaneous fistula. Minor hair growth was noted in 1 patient. The pedicled scrotal septum flap is recommended in selected cases of complex hypospadias, particularly when other methods fail.

De-epitlielialized scrotal flap in repair of urethrocutaneous fistula and hypospadias

Eight cases of closure of urethrocutaneous fistula and 15 cases of urethroplasty for hypospadias are reviewed. Most of the fistulas were present in the penoscrotal level. Fistula and hypospadias opening were closed by re-enforcement using a de-epithelialized scrotal skin flap. Of 8 patients with fistula, there was no recurrence, and 3 procedures were performed without urinary diversion or urethral stent. Of 15 patients with hypospadias, there was no fistula formation in the original urethral opening area but a fistula distal to the original urethral opening developed in 3 patients. This technique is satisfactory in repairing complicated as well as noncomplicated urethrocutaneous fistula and can be done without urinary diversion or urethral stent. It appears to be useful in reducing fistula formation following urethroplasty in hypospadias or urethral fistula repair.

Correction of penile curvatures caused by unsuccessful hypospadias repair using the scrotal septum pedicled skin tube principle combined with corporoplasty and a modified meatoglanuloplasty.

Scrotal septum pedicled skin tube urethroplasty combined with a modified meatoglanuloplasty and corporoplsty were used in 2 adults. They had three previous hypospadias repair attempts in their childhood, leaving them with a meatus near the glans but with severe ventral penile curvature. Scrotal septum pedicled skin flaps used for the repair, by providing natural vascularization and offering more flexibility, allow the surgeon to reconstruct long urethral defects. The cosmetic and functional results of this combined technique are satisfactory. This principle can also be applied in adult hypospadias cases with deficient preputium in which the midanterior scrotum contains a shiny non-hair-bearing skin.

The use of scrotal septal neurovascular pedicle island skin flap in one-stage repair of hypospadias.

A scrotal septum neurovascular pedicle skin flap was successfully used in one-stage repair of hypospadias in 30 patients with encouraging results. The hairless median scrotal skin flap, with the scrotal septum attached, rich in neurovascular plexus and with the flap tip continuous with the external urethral orifice, is ideal material for creating a new penile urethra without interference to its blood supply. Operative technique and clinical analysis are detailed.

Scrotal and Penile Lymphedema: Surgical Considerations and Management

From 1971 to 1981, 6 patients with scrotal and penile lymphedema There treated with total excision of the scrotal and penile skin. Split thickness skin grafts were used to cover the penis and form a neoscrotum. Of the patients 2 men had primary idiopathic lymphedema, while 4 had secondary lymphedema resulting from foreign body injections or trauma with subsequent chronic infection.Surgical considerations using split thickness skin grafts versus posterior lateral scrotal skin flaps are compared.

Island patch urethroplasty: effects on urinary flow and ejaculation.

Seventeen patients had a single-stage operation for urethral stricture. To avoid recurrence (which occurred in 2 patients) the urethra should be opened not only through the stricture but well beyond the pathological cavernous tissue. In 3 patients it was not possible to reconstruct the bulbocavernosus muscle over the bulb. This resulted in urethral pouching which did not interfere with micturition, except for after-dribbling, but prevented forceful ejaculation and the semen leaked slowly for several minutes. Excision of the apex of the scrotal skin flap to the island patch seems to prevent marginal skin necrosis.

Scrotal flap urethroplasty in the treatment of carcinoma of the penis.

Another use for the scrotal skin flap is described. It is an ideal method for dealing with carcinoma of the penis and prevents meatal stricture. It may be used to provide permanent urethrostomy in cases of chronic complicated urethral stricture where other types of operative treatment are unacceptable to the patient. It is recommended for use in situations where follow-up is difficult.

Reconstruction following iatrogenic burn of the penis

An iatrogenic third degree burn of the penis resulted from the use of a circumcision clamp and an electrosurgical unit for circumcision. The penis was reconstructed by means of a pedicle scrotal skin flap.