Scrotal Skin Research Articles

SCROTAL PILOMATRIXOMA: A RARE CASE REVEALED BY AN HYDROCELE

Pilomatrixomais a cutaneous tumor, originating from the hair matrix, mostly affecting pediatric population. We report a particularly uncommon location of pilomatrixoma: the scrotal skin. A 50-year-old man, without history, has developed a hydrocele . Most often, its preoperative diagnosis is not possible, because of its clinical polymorphism. The precise diagnosis is histological, by the revealing of mummified cells. The treatment is surgical, with only purpose to perform complete removal of pathologic tissue, allowing to decrease the rate of local relapse.

76. Robot-assisted Vaginoplasty: A Multidisciplinary Technique for Gender Affirmation

Background: Gender affirming trans female bottom surgery is critical in treating gender dysphoria but can result in complications such as stricture/stenosis development, neovaginal prolapse, and rectal injury. The authors describe a multidisciplinary robot-assisted technique incorporating a free peritoneal graft to alleviate these complications. Methods: Patients who met the World Professional Association for Transgender Health (WPATH) criteria for bottom surgery, underwent robotic-assisted penile inversion vaginoplasty with senior author (J.D.K), and had at least three months of follow-up were included in the study. Patients undergoing zero-depth vaginoplasty or revision vaginoplasty were excluded. The free peritoneal graft is harvested robotically and used as a strip of mucosal-like tissue for a more anatomic neovagina and sutured to scrotal skin grafts over a vaginal conformer. The construct is sutured to the remaining penile shaft skin and then then inverted and passed through the perineal body into the robotically-created space. The apex of the neovaginal lining created by the skin graft-peritoneal graft construct is then sutured to the peritoneal reflection with barbed suture in two layers intra-corporally via the robot. Results: Thirty-eight patients were included in our study. Average age at the time of initial consult was 31 years. All patients were on hormone therapy and 42% of patients had previously undergone top surgery. The average length of follow-up was 230 days. The most common complication was stricture/stenosis secondary to non-compliance with post-operative dilation protocol. Eight patients (21%) experienced stricture, four of which were managed with aggressive dilation. Three patients required surgical revision and one patient did not require any intervention. Seven patients (18%) experienced wound dehiscence with four patients requiring operative repair. Four patients (11%) developed labial banding/webbing that required revision. Other complications included one hematoma, one infection, and two episodes of post-operative bleeding. Eleven patients (29%) developed symptomatic granulation tissue during the healing process that was treated with silver nitrate application and resolved with time. Lastly, two patients (5%) had labial asymmetry that did not interfere with function, but who desired revision for cosmesis. Eighty-four percent of patients used Soul Source vaginal dilators (Sour Source Therapeutic, North Hollywood, CA) post-operatively and of those patients 53% could dilate with the orange dilator (the largest, 1 1/2 inch diameter), 13% with teal (1 3/8 inch diameter), 16% with blue (1 ¼ inch diameter) and 19% with purple (1 1/8 inch diameter). All dilators are 9 inches in length. Patients are cleared for sexual intercourse three months after surgery. Many patients had return of sensation to light touch of the neo-clitoris and were able to achieve organism through direct neo-clitoral stimulation. Conclusion: With experience and an interdisciplinary team, robotic-assisted vaginoplasty with free peritoneal grafting is safe and effective with a low complication rate and high neo-vaginal patency rate. Many patients report successful penetrative intercourse and the ability to achieve orgasm post-operatively.

MP20-11 A NOMOGRAM TO PREDICT VAGINAL DEPTH, BASED ON AVAILABLE PENILE AND SCROTAL SKIN, FOR PENILE INVERSION VAGINOPLASTY: A USEFUL TOOL FOR DECISION MAKING AND SURGICAL PLANNING

You have accessJournal of UrologyCME1 May 2022MP20-11 A NOMOGRAM TO PREDICT VAGINAL DEPTH, BASED ON AVAILABLE PENILE AND SCROTAL SKIN, FOR PENILE INVERSION VAGINOPLASTY: A USEFUL TOOL FOR DECISION MAKING AND SURGICAL PLANNING Shannon Smith, Nance Yuan, Michael Zaliznyak, Jenna Stelmar, and Maurice Garcia Shannon SmithShannon Smith More articles by this author , Nance YuanNance Yuan More articles by this author , Michael ZaliznyakMichael Zaliznyak More articles by this author , Jenna StelmarJenna Stelmar More articles by this author , and Maurice GarciaMaurice Garcia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To date, no nomogram exists to pre-operatively predict maximum achievable neovaginal depth before penile-inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth is determined by available skin and available anatomic space within the pelvis, and varies with surgical technique. Final achievable depth has been shown to be significantly important to patients. We created a nomogram to predict expected post-operative vaginal depth. METHODS: Retrospective review of all patients undergoing primary PIV at a single institution from June 2017 to February 2020 (n=46). Pre-op: Dorsal penile skin length was measured on stretch from the base to 1-cm proximal to coronal ridge. Midline scrotal skin length was measured on stretch from the penoscrotal junction to mid-scrotum, and mid-scrotum to mid-perineum. Intra-op: Length of the tubularized scrotal skin segment measured on a dilator. Immediate post-op: Final achievable vaginal depth measured with a dilator. Fourteen patients underwent PIV without the use of scrotal skin (PIV-SS) and 32 patients had PIV+SS. RESULTS: In patients who underwent PIV-SS, the final vaginal depth (13.3 cm+1.9) was 87% of pre-op measured penile skin length (15.3cm+3.0; 0.87+/-0.17). In patients who underwent PIV+SS, mean pre-op penile skin length was 11.1cm and pre-op midline scrotal length was 22.8 cm (+/-2.6 cm). This resulted in SS tube length of 12.3 cm (+/-3.2 cm). Mean final post-op vaginal canal depth was 15.6cm. Using the previous metric, where final vaginal depth was 87% of dorsal penile skin length, we calculated the SS contributed on average 5.9 cm to the final depth of 15.6 cm (15.6 – [0.87 * 11.1 cm]=5.9). The mean intra-op SS tube length was 0.62 (+0.13) of pre-op scrotal skin length. In 31 of 32 surgeries utilizing SS grafts, SS tube length was in excess of length necessary to achieve maximal vaginal depth, requiring trimming and discard. Given that in most cases there was an excess of SS, final post-op depth equaled the maximal vaginal depth that could be achieved. CONCLUSIONS: Our work suggests that preoperative penile shaft and SS length measurements can be used to predict final vaginal depth. SS grafts, when harvested and tubularized using optimal technique, appear to supply more skin than necessary to achieve maximal vaginal depth for the majority of patients. Our findings suggest that for most patients it should not be necessary to include additional tissue sources, such as peritoneum, to create a vaginal canal during primary vaginoplasty. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e321 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shannon Smith More articles by this author Nance Yuan More articles by this author Michael Zaliznyak More articles by this author Jenna Stelmar More articles by this author Maurice Garcia More articles by this author Expand All Advertisement PDF DownloadLoading ...

Correcting gender dysphoria –the anatomical changes with male to female gender reassignment surgery

ABSTRACT Introduction & Objectives Increased Global acceptance of transgender communities, gender-affirming genital reconstructive surgery is becoming more prominent. Formalised education and training however has not quite entered the curriculum of many surgical training programs yet it remains imperative we have an understanding of modified anatomy in out patients. We demonstrate anatomical reconstruction during the transition between male to female anatomy. Methods Patient consent was obtained to take a series of photographs during gender affirming surgery from male to female. Results Contemporary patients receive both spinal and general anaesthesia prior to positioning in standard lithotomy. A perineal incision of approximately 10cm in the midline raphae exposes the corpora and spongiosum. A simple bilateral orchidectomy was performed at the level of the external inguinal ring. A neovaginal cavity was created by firstly dividing the bulbospongiosus attachments to the perineal body and the space is both blunt and sharply dissected. Further dissection is carried out in the avascular perirectal fat plant anterior to the Denonvilliers fascia. During this dissection a 18-22Fr urethral sound is used to apply downward traction on the rectum. A sterile ultrasound sleeve is placed in the rectum to allow bimanual palpation to confirm intact rectal mucosa. A circumferential incision proximal to the glans is performed to aide degloving of the penis. Bucks fasica is left intact and distal penile skin will later be used to form the clitoral hood. The dorsal neurvascular bundle is raised off the corporal bodies but an attachment to the glans remains. A triangular section of dorsal glans is preserved and dissected off the tips of corpora. The penile tissue is then disassembled separating the corpus spongiosum from the corporal bodies. The corpora are amputated at the level of the pubis, remaining erectile tissue destroyed and oversewn for haemostasis. The Urethra is shortened to an appropriate length to allow the dorsal aspect to align between the neoclitoris and neomeatus. The ventral aspect is spatulated to expose the neomeatus. The penile skin flap is invaginated within the neovaginal space and the skin incised to expose the neoclitoris and neomeatus. The penile skin is then anastomosed to the neoclitoris and neomeatus The distal end of the penile skin flaps is oversewn to create a blind ending tube and thus creating the neovagina. Labia Majora are formed by excising excess scrotal skin to create an appropriate contour. This form of neovagina is compared to methods that involve intestinal and peritoneal lining transfer. Conclusions We have outline the stepwise transition of male to female anatomy with a conventional contemporary technique. Creation of a neovagina with penile inversion has become common practice in gender affirming surgery. However there are other means of creating genitalia with alternative tissues, which subspecialised practitioners should be aware. Disclosure Work supported by industry: no.

V02-10 LONG TERM EVALUATION OF THE ARGUS-T® ADJUSTABLE MALE SLING: A PROSPECTIVE STUDY

You have accessJournal of UrologyCME1 May 2022V02-10 LONG TERM EVALUATION OF THE ARGUS-T® ADJUSTABLE MALE SLING: A PROSPECTIVE STUDY Rafael Zanotti, André Costa Matos, Felipe Pinho, Claudio Hideki Toi, Sergio Paolillo, Giovani Demartino, Marcel Takada, Bruno Hirata, and Luís Gustavo Morato de Toledo Rafael ZanottiRafael Zanotti More articles by this author , André Costa MatosAndré Costa Matos More articles by this author , Felipe PinhoFelipe Pinho More articles by this author , Claudio Hideki ToiClaudio Hideki Toi More articles by this author , Sergio PaolilloSergio Paolillo More articles by this author , Giovani DemartinoGiovani Demartino More articles by this author , Marcel TakadaMarcel Takada More articles by this author , Bruno HirataBruno Hirata More articles by this author , and Luís Gustavo Morato de ToledoLuís Gustavo Morato de Toledo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002528.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Male slings are attractive alternatives for the treatment of post prostatectomy urinary incontinence (PPI). In this study and accompanying video, our purpose is to report our findings of up to 12 years of follow up and the technical details that led us to our results. METHODS: From 06/2009 to 09/2021, 89 patients with PPI underwent male Argus-T® adjustable sling implantation. We prospectively recorded their data.Prior to implantation and during follow up, patients were acessed through clinical evaluation, 24h pad-test, ICIQ-SF and complications. Clinical and urodynamic variables were correlated to the need for readjustments. Success was defined by cure or improvement. The definition of objective cure was dry patient; of improvement, decrease >50% number of pads; of fail, decrease <50% number of pads. The definition of subjective cure was VAS >=8 and PGI-I “much better”; of improvement, VAS 6-7 and PGI-I “little better”; of fail, VAS <=5 or unchanged. RESULTS: The median follow up was 96 (13 - 144) months. In our series 22 patients (24,6%) had mild, 23 (26,1%) moderate and 44 (49,3%) severe incontinence. 20 patients (22,5%) had received previous radiotherapy and 18 (19,7%) previous urethral stricture treatment. Within the whole series, 75 patients (85,4%) achieved subjective success (74,4% cure + 11% improvement) and 71 (80,5%) objective success (65,9% cure + 14,6% improvement). Readjustments were necessary in 23 (25,8%) cases. Considering only the subgroups of patients who received previous radiotherapy and/or previous urethral stricture treatment, 66,7% needed readjustments. We found that these are predictor factors for the need of readjustments (p 0,001). Complications included: 2 cases of protusion of silicon arms to the scrotal skin; 2 of inguinal granuloma. 7 cases of urinary retention that resolved with indwelling catheter for 7 to 10 days. Device removal was necessary in 5 cases, 4 due to infection and 1 due to persistent urinary retention and severe pain. No cases of device components explantation were reported. Curiously, 3 of the 5 patients who had their devices removed remained dry, removal occurred about 2 years after surgery. CONCLUSIONS: We found similar success rates than previously published for this device, however adverse events are lower, especially regarding to sling removal. Previous radiotherapy and urethral stricture treatment are predictor factors for the need for readjustments. Adjustability benefits a significant number of patients who would have failed. Especially those with worse prognostic factors; maintaining the success rates of this group similar to the group without these factors. Argus-T has high and maintained success rate. Good outcomes can be achieved even for moderate to severe incontinence cases. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e113 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rafael Zanotti More articles by this author André Costa Matos More articles by this author Felipe Pinho More articles by this author Claudio Hideki Toi More articles by this author Sergio Paolillo More articles by this author Giovani Demartino More articles by this author Marcel Takada More articles by this author Bruno Hirata More articles by this author Luís Gustavo Morato de Toledo More articles by this author Expand All Advertisement PDF DownloadLoading ...

A single-stage reconstruction on giant scrotal lymphedema: a case report

Introduction: Scrotal lymphedema is a rare condition characterized by the swelling of the scrotal skin due to deterioration in lymphatic drainage. Although not life-threatening, chronic lymphedema is disabling with significant physical and psychological morbidity and complications, including impaired hygiene, urinary incontinence and immobility. This report aimed to describe the diagnosis and treatment of giant scrotal lymphedema. Case Presentation: A 23-year-old man presented with a gradually enlarging scrotum. Physical examination of the genitalia shows that the patient’s penis was difficult to identify, and testes were completely impalpable due to the thickness of the scrotal skin. There were neither inguinal lymph node enlargement nor other skin lesions on the scrotum. The scrotum was homogenous, with a measured dimension of 35 cm x 28 cm x 20 cm anterior to posterior. Laboratory evaluation, including complete blood count, complete metabolic panel, human immunodeficiency virus, sedimentation rate, and antibodies to strongyloides, schistosomes, and filaria, were within normal limits. The penis and testes were normal-sized and clearly demarcated from computed tomography scan, buried within the hardened scrotal soft tissues, with no signs of testicular tumor or any pelvic lymph node enlargement. Conclusion: Scrotal lymphedema is a rare condition characterized by the swelling of the scrotal skin due to deterioration in lymphatic drainage.

Rare Metastasis of Rectal Cancer to Scrotal Skin: A Case Report, and Literature Review

Background: The most common manifestations of metastatic colorectal cancer are found in the liver, lung, bone, and brain. Cutaneous metastasis is rare in rectal cancer, and it indicates a widespread disease and a poor prognosis. Case presentation: In this report and review we present a 58-year-old man who diagnosed with rectal cancer (RC) and underwent abdominoperineal resection. The patient developed a skin lesion (indurated erythema) on his scrotum four months later. Histopathological examination revealed adenocarcinoma with lymphovascular invasion. Discussion: The primary causes of mortality in people with RC have been reported to be disease dissemination and recurrence. Cutaneous metastasis to the scrotum happens seldom, accounting for less than one percent of the total surface area of the body. Conclusions: Even if an RC patient has been asymptomatic for a long time, skin involvements must be considered by clinicians. So, giving specific attention to all skin nodules, non-healing ulcers, and chronic indurated erythema is essential. Early detection relies heavily on patient engagement.

Arterial supply to the scrotum: A cadaveric angiographic study.

To determine the dominant arterial supply to the scrotum. Experimental anatomic study. Intact male canine cadavers (n=10). Barium sulfate was injected into the internal iliac artery (n=7) or into the pudendoepigastric trunk (n=3). The perineal, scrotal, and prescrotal skin was sharply dissected from cadavers and radiographed. Angiograms were subjectively reviewed by 3 investigators. Angiograms were completed successfully in all 10 dogs, with no difference between frozen and fresh cadavers. The dominant blood supply to the scrotum was consistently identified as arising from the ventral perineal arteries, originating from the internal pudendal arteries, coursing ventrally and cranially toward the caudal scrotum before terminating as the dorsal scrotal arteries (n=7). The blood supply to the cranial scrotum was more limited (n=3) as only the cranial border of the scrotum was perfused by the ventral scrotal arteries. Based on this anatomic perfusion study, the dorsal scrotal arteries appear to supply a larger area than the ventral scrotal arteries. These results provide evidence to justify further consideration of a scrotal flap using the caudal perineal skin as the main cutaneous pedicle to reconstruct defects located on the caudal, medial, and lateral thighs in dogs. Such a flap should be based on the caudal blood supply and the base of this flap should be located caudal to the scrotum to preserve its main blood supply.

Clinical aspects and management of scrotal calcinosis

Scrotal calcinosis is a benign idiopathic cutaneous calcinosis characterized by the presence of calcified nodules of the scrotal skin. The aim of the study is to report the clinical, histological and therapeutic aspects. This was a prospective descriptive study from 2014 to 2020 in the department of urology. Patients were included, aged at least 15years, consulting for nodules of the scrotal skin whose clinical and paraclinical assessment concluded to scrotal calcinosis. The variables studied were clinical, paraclinical, therapeutic and evolutionary. Informed consent of the patients and anonymity in the use of scientific photographs were observed. In 6years, 8 cases of scrotal calcinosis were diagnosed and operated on, i.e. 1.3 per year. The average age of the patients was 36.2years. The average age of the lesions was 4.2years, the general condition was good (n=8). The unsightly appearance (n=5), pruritus (n=2), recommendation of the spouse (n=2), psychological trauma (n=5), and fear of cancerous degeneration (n=3) were the reasons for consultation. The lesions were scattered or in clusters. Serologies were positive: HIV (n=2), chlamydia (n=4) and syphilis (n=3). Treatment was surgical (n=8). Histological analysis concluded to scrotal calcinosis. The average hospital stay was 2days. The mean time to complete healing was 19.6days without recurrence. Scrotal calcinosis is a benign, rare idiopathic pathology. The treatment is surgical.

Acute necrotizing pancreatitis complicating as Fournier’s gangrene

Scrotal involvement is extremely rare complication of acute necrotising pancreatitis. It presents as scrotal swelling and skin color change, which mimics the presentations of testicular torsion, epididymitis, and testicular tumor. Early diagnosis can significantly reduce the associated mortality both with necrotising pancreatitis and Fournier gangrene. Thorough clinical examination along with abdominopelvic Computed Tomography provides a useful means of diagnosing this complication. Here, we are presenting a case of acute necrotising pancreatitis with collection in left pararenal space tracking all the way to reach the left inguinal canal till the root of scrotum, being managed successfully after early diagnosis with early debridement and application of vacuum assisted drainage.

Penile Flap Inversion Vaginoplasty in Transgender Women: Contemporary Morbidity and Learning-Curve Analysis From a High-Volume Reconstructive Center.

ObjectivesNumbers of PIV are rising. The aim of this study is to analyze the surgical learning-curve (LC) on the grounds of perioperative complications.Patients and Methods108 PIVs, performed by a single surgeon between 2015 and 2018 have been analyzed. Learning-curve analysis was based on three factors: operating time, vaginal depth and complications.ResultsThe median FU was 6.3 months. Median age at surgery was 36 years, median time of hormone treatment was 36 months. The median CI was 0.3 and the median BMI was 25 kg/cm3. Median CCI® was 8.08. 40.7% of the patients developed short-term complications, more than half of which were Clavien I. Overall only 1.9% had Clavien IIIb complications. There were no Clavien IV or V complications. 17.6% of patients had wound infections, 13% wound dehiscence, 9.3% introitus strictures, 13.9% suffered from atrophy of the neovagina, i.e. loss of depth or width, and 8.3% from meatus urethrae strictures. Duration of hormonal therapy, BMI and CI had no impact on surgical outcome. Age had a significant impact on CCI®, as younger patients had a higher risk for complications. Use of scrotal skin and surgeries performed had a significant influence. LC analysis via CUSUM analysis showed that after 32 surgeries, the PIV is performed safely.ConclusionThe PIV is a safe GAS-technique, associated with minor complications leading to low rates of revision surgery. Younger age, the use of scrotal skin and surgeon's experience has significant impact on complications. Duration of hormonal therapy, circumcision and BMI has no impact on complications.

Multiparametric ultrasound in torsion of the testicular appendages: a reliable diagnostic tool?

Torsion of the testicular appendages represents the most common cause of an acute scrotum in prepubertal boys. Itssonographic appearances on gray-scale US and color Doppler US have already been presented in several studies. The aim ofthis analysis was to expand those already established techniques with strain elastography and thus present typical features ofthis entity on multiparametric US. Retrospective analysis of all patients presented to the urologicaldepartment with an acute scrotum between January 2018 and July 2020 identified eleven patients 6-17 years old (mean, 11.1years), discharged with the diagnosis torsion of the testicular appendages that were examined with a high-end ultrasound device.Results: On gray-scale US all patients showed a round lesion with heterogenous echotexture adjacent to the upper poleof the testis/epididymis with a diameter of 4 to 11.1 mm (mean, 7.7 mm). Scrotal skin thickening and a concomitant hydrocelewere found in 9 (81.8%) and 7 (63.6%) cases, respectively. On color Doppler images, all torsed appendages were avascularand in 9 (81.8%) patients we observed hyperemia of the adjacent epididymis. Strain elastography showed increased tissuestiffness in all documented images. Torsion of the testicular appendages has a set of features on multiparametricUS. Awareness of this features can facilitate diagnosis of torsion of the testicular appendages and reduce unnecessary surgicalscrotal exploration or unwarranted antibiotic treatment.

A New Modified Bipedicle Scrotal Skin Flap Technique for the Reconstruction of Penile Skin in Patients with Paraffin-Induced Sclerosing Lipogranuloma of the Penis.

We introduce a new modified penile skin reconstruction technique to treat paraffin-induced sclerosing lipogranuloma of the penis. From 2017 to 2020, 49 patients underwent the procedure. Complete removal of the lipogranuloma-involved penile skin was performed. A subcutaneous tunnel was then created between a horizontal scrotal incision and a proximal penile circumferential incision. The denuded penis was pulled through the tunnel, and a subcoronal and longitudinal dorsal penile suture line was made. An inverted V-shaped incision was made on the scrotum on the ventral side of the penis, followed by longitudinal closure. Outcomes and complications of the procedure were retrospectively studied. The long-term effect of surgery on sexual function and overall satisfaction was measured using a patient-reported questionnaire, which was completed by 30 patients. The overall complication rate was 26.5%. Clavien-Dindo grade 1, 2, 3a, 3b, 4 and 5 complications occurred in the postoperative period 5, 0, 8, 1, 0 and 0 times, respectively, in 13 patients. Surgery was successful in 27 (90%) patients according to the patient-reported questionnaire. Erectile dysfunction, pain/tension during erection, premature ejaculation and penile lymphedema were observed in 2, 3, 1 and 1 patients, respectively. All patients reported sexual intercourse ability. The type of penile skin reconstruction after the removal of sclerosing lipogranuloma of the penis is controversial. The reconstruction technique presented herein is an effective single-stage treatment option with a high success rate in patients with sclerosing lipogranuloma of the penis with intact scrotal skin.

Scrotal Reconstruction Using a Free Ulnar Forearm Flap: A Case Report

Scrotal defects requiring reconstruction may occur after trauma, cancer, or infection. To maintain good testicular function, the ideal scrotal temperature should be slightly lower than the abdominal temperature. However, large local flaps that are enough to cover the testes cannot be used in all patients. A 74-year-old man presented with scrotal and perineal tissue defects after undergoing debridement for Fournier's gangrene due to rectal carcinoma-induced perforation. The scrotal skin defect was reconstructed using a 22 × 10-cm-free ulnar forearm flap. The postoperative course was uneventful, and at the 14-month follow-up examination, the scrotal skin was found to be thin and pliable. Moreover, the donor site on the left forearm was in an acceptable state and no hand dysfunction due to contracture was observed. Based on our observations, we recommend that the free ulnar forearm flap might be an effective option for scrotal reconstruction, causing little donor site morbidity.

The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes of Transgender and Gender-Diverse People.

Transgender and gender diverse individuals may seek gender-affirming medical care, such as hormone therapy or surgery, to produce primary and/or secondary sex characteristics that are more congruent with their gender. Gender-affirming medical care for transmasculine individuals can include testosterone therapy, which suppresses circulating estrogen and can lead to changes in the vaginal epithelium that are reminiscent of the post-menopausal period in cisgender females. Among transfeminine individuals, gender-affirming medical care can include vaginoplasty, which is the surgical creation of a vulva and neovaginal canal, commonly using penile and scrotal skin. The effect of gender-affirming medical care on the vagina of transmasculine individuals and on the neovagina of transfeminine individuals is poorly characterized. This review summarizes what is known of the epithelium and local microbiota of the testosterone-exposed vagina and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps for future research.

Mathieu vs urethral plate tubularization in circumcised Megameatus intact prepuce repair: A prospective randomized comparative study.

The objective of this study is to evaluate and compare urethral plate tubularization vs Mathieu in circumcised Megameatus intact prepuce (MIP) repair. Many techniques were described for MIP, which account for 5% of hypospadias cases and usually diagnosed at time of, or even after circumcision. Forty-six circumcised MIP cases were prospectively enrolled in this prospective study, which was carried out in April 2017 and March 2020. Patients were randomly allocated into two groups. Group one operated by simple urethral plate tubularization and group two by the Mathieu technique. Hypospadias objective scoring evaluation (HOSE) scores, success rate, operative time, and the need for relaxing incision or scrotal flaps for skin closure were compared. Forty-three circumcised cases (22 in group one and 21 in group two) completed at least 6 months of follow-up. Ages ranged from 12 to 39 months (mean 18.06 6 6.35) in group one and from 10 to 32 months (mean 19.5 6 7.14) in group two. There was no significant difference between cases with accepted outcome based on HOSE scores (14) of the two groups (P value ¼ .942). Three fistulae and one meatal stenosis were the complications in group one (18.2%). In group two, two patients complicated with fistula (9.5%) (P value ¼ .674). Significant differences were present only in the operative time (P ¼ .001) and in the need of relaxing incision or scrotal skin flaps (P ¼ .012) both were more in group two. Mathieu and tubularized incised plate urethroplasty both are good options for circumcised MIP repair.

Reconstruction of Scrotal Skin Defects Using Bilobed Pudendal Flap.

Due to its unique cosmetic appearance and functioning, scrotal skin offers a major clinical challenge in terms of reconstruction. Thus, successful reconstruction of scrotal skin should include both provision of pliable texture and protection of testicular functions. Skin grafts and flaps are important options for such reconstruction; however, they both have unique features that bring about specific limitations and specific problems. In the light of the negativities related to the widely used skin grafts and flaps, this study aims to discuss the use of bilobed pudendal flap-a simple, uniform, and pliable tissue-for the first time in the related literature for the reconstruction of scrotal skin defects caused by Fournier's gangrene. This study was performed using the single-step method of scrotal skin reconstruction on eight patients who had developed scrotal skin defects and underwent reconstruction by using three-dimensional bilobed pudendal flaps (defect and reconstructive tissues planned on different planes) from December 2016 to August 2019. No complication such as infection, bleeding, hematoma, partial or complete flap loss, scar contraction, urinary problem, erectile dysfunction or discomfort, or sensation loss was observed in seven out of eight study patients. The only complication to have developed in one patient was minimal dehiscence, which was then corrected by restoration. Repair of scrotal skin defect using a three-dimensional bilobed pudendal flap enabled an elastic scrotal repair acceptable in sensorial and visual terms.

Scrotal calcinosis in a patient treated with isotretinoin: a rare entity

Scrotal calcinosis is a rare disorder characterized by multiple papules or nodules of calcification in the scrotal skin. The pathogenesis of this disease is poorly understood. The condition presents as several brown to yellowish asymptomatic nodules on the scrotum. Excision followed by scrotal reconstruction is the treatment of choice. It leaves a good cosmetic result with low chances of recurrence. Newer treatments, such as ablative lasers, have been proposed with very good results. We describe the case of a 28-year-old patient with a history of severe acne treated with oral isotretinoin that presented for scrotal nodules. On laboratory examination, hypercalcemia was found with normal phosphorus, parathyroid hormone, and vitamin D hormone levels. Hypercalcemia was linked to his isotretinoin therapy. Serum calcium concentrations normalized after cessation of isotretinoin and hydration. Because the patient refused surgery, a biopsy of the lesion confirmed the diagnosis of scrotal calcinosis. Then the patient was referred to a cosmetic laser center to treat his condition.

Extended Ulaanbaatar Procedure with Preputial Skin Graft for Proximal Hypospadias.

Two stage urethroplasty for proximal penile hypospadias is time consuming, expensive and; traumatic both for parents and phallus. On the other hand, single stage procedure technically demanding. We would like to describe Extended Ulaanbaatar Procedure (EUP) which is not a two stage procedure. Rather, might be called as 'extended single stage' procedure. In EUP we have done orthoplasty along with urethroplasty with preputial skin graft at same sitting as primary procedure keeping urination diverted through proximal hypospadiac meatus as "controlled fistula" which was closed after six months as secondary procedure. We operated on 35 patients of proximal penile hypospadias with moderate to severe chordee. Chordee was excised till correction of curvature. Two distracted cut ends of native plate was bridged with preputial skin graft (PSG) in between. Following that, silastic tube was placed over glandular plate as scaffold, on both cut ends of native plate and PSG. All the urethral plates and PSG were buried with tunica vaginalis flap before glanuloplasty. After six months, proximal "controlled fistula" was closed with scrotal dartos fascia and skin to join distal to proximal urethra. Vertical meatus in glans was found in 32 patients. One patient had glans dehiscence, two patients had medium sized fistula, another two patients had stenosis in neourethra and six had suture track fistula. Twenty-nine patients had satisfactory curve with good flow in uroflowmetry as per nomogram at sixth month of follow up. In classic Ulaanbaatar procedure authors do distal urethroplasty and glanuloplsaty in 1st stage following orthoplasty to avoid repeat trauma in glans in repeat procedures. Left over urethroplasty in classic Ulaanbaatar was done in 2nd stage. However, in EUP; we did urethroplasty for full length following orthoplasty as primary procedure. This procedure is less invasive than two staged as we avoided repeat degloving and repeat dissection on operated tissues. Urethroplasty done as primary procedure shunned the need of repeat degloving, decreased the period of morbidity, stay, and cost of surgery. We also avoided problems of urination through not matured, long, neo-urethra. Similarly complications i.e disruption, stenosis in neo-urethra can be managed utilizing the advantages of urinary diversion.

Phalloplasty With a Free Scapular Flap Improves Postoperative Sensation in Penile Reconstruction.

Objective We aimed to evaluate both the long-term surgical outcomes and patient-reported outcomes of free scapular flap (FSF) phalloplasty. Method The same surgical team performed phalloplasty in 66 patients using a FSF between March 2000 and September 2018. All patients had at least 24 months of follow-up. The surgical techniques used, complications observed, and surgical and patient-reported outcomes were retrospectively described. Results A total of 66 patients with indications of penile trauma (n = 19), micropenis (n = 42), and self-amputation (n = 5) underwent FSF phalloplasty. Two patients (3%) had total flap necrosis and 1 (1.5%) had partial flap necrosis. The urethral complication rate was 18.2% (12/66 patients). All patients were able to void while standing after revision procedures or urethroplasty. We found that an FSF is a reliable donor site for penile reconstruction. Conclusion The FSF phalloplasty creates an esthetically pleasing penis and allows voiding while standing. Most patients can engage in sexual activity. The main drawbacks of using this method are that patients experience different degrees of sensory recovery, and patients undergoing surgery with the "tube-in-tube" technique may find they are be limited by the thickness of the flap. However, by making full use of residual tissue, such as the micropenis glans or scrotal skin, patients can obtain good tactile and erogenous sensation. We believe that using an FSF complements the existing phalloplasty techniques.