Penile reconstruction DR VIPIN V NAIR

 INTRODUCTION
 ANATOMY
 INDICATIONS
 HISTORY
 PATIENT EVALUATION
 PROCEDURES
 METAIODIOPLASTY
 RECENT ADVANCES

 One of the most enduring dreams in
medicine and plastic surgery has been
The possibility to
replicate or replace
human organs lost
to disease or
trauma.

 Penile reconstruction
 Serves solution for a complex patient population
 But not without a series of issues.

 Percy, 1971 British comedy film about a penis
transplantation

 La dottoressa ci sta col
colonnello
 1980 commedia sexy
all'italiana about a penis
transplantation

 Negatively affects many
domains of one’s personal
life
Interpersonal
relationships
Self -
confidence
Psychological
well-being

SURGICAL
RECONSTRUCTION
PSYCHOLOGICAL
REHABILITATION

Procedures for various penile defects
Guide to chose the best suited surgical
modality

 Severe Congenital
abnormalities
 Urethra
 Penis

 Patients undergone penile
operations cosmetic and
functional deformities.
 But still crippled

 Aesthetically acceptable
 Competent neo-urethra
 Bulk /rigidity to allow for
intromission
 Sensate : tactile & erogenous
(orgasm)
 Voiding while standing
 Single stage
 Minimal scarring & disfigurement
 Little or no donor morbidity
Hage and De Graaf - 1993
Ideal requirements for phalloplasty
Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: Some
reflections on refinements of technique. Microsurgery. 1993;14:592–8.

 Russia first documented
phalloplasty
 Tubed abdominal flap
 Autologous rib cartilage
Bogoraz NA. On complete plastic reconstruction of a penis sufficient for coitus [in Russian] Sov
Surg. 1936;8:303–9.
•Prolonged hospital stays
•High flap failure rates
•Aesthetic and functional
results were suboptimal

 First female to male gender
reassignment procedure
 British physician, Laurence
Michael Dillon (born Laura
Maude Dillon)
 Who felt ‘not truly a woman’.
 Series of 13 operations.
Nair R, Sriprasad S. Sir Harold Gillies: Pioneer of phalloplasty and the birth of uroplastic surgery.
J Urol. 2010;183(4):e437.

 Popularized
 Neophallus with neo-urethra
 Cartilagenous graft as
stiffener
 Remained standard
technique for 40 years.
Nair R, Sriprasad S. Sir Harold Gillies: Pioneer of phalloplasty and the birth of uroplastic surgery.
J Urol. 2010;183(4):e437.

 Single stage scrotal flaps & cartilage
 Neo -urethra
 Sensate!
 Esthetically poor

 Single pedicle
infraumbilical flap
 Pre-constructed
skin-lined tunnel
 External pudendal
vessels
Snyder CC. Hermaphroditism. In BroadbentTR (ed):Transactions of the third international
congress of plastic surgery.Washington 1963. Amsterdam, Excerpta Medica, 1964 pp 912 – 20

 Gracilis
myocutaneous
flap
 Duration &
demand for
phallic stiffening
at patient’s
control
 Multiple stages
Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg. 1972;25:347–
66.

 Vertical midline
reverse bipedicle
tubed flap
 External pudendal
vessels
 Minimized scarring
2 stages
No neo-urethra attempted
Tube rolled inward wrapped
with skin graft
External stiffening device
Salgado CJ, Eidelson S, Madalon R, Sun Z (2012) Penile Reconstruction. Anaplastology

Salgado CJ, Eidelson S, Madalon R, Sun Z (2012) Penile Reconstruction. AnaplastologySalgado CJ, Eidelson S, Madalon R, Sun Z (2012) Penile Reconstruction. Anaplastology

 • The major advancement
 RFA free flap phalloplasty
 Prototypical flap
 Single stage
 Reliable
 Versatile
 Esthetically superior
ChangTS, Hwang WY. Forearm flap in onestage reconstruction of the penis. Plast Reconstr
Surg. 1984;74:251–8.

Single stage Urethrelphalloplasty
Technique of choice
Remains the standard method for comparison of all
other techniques done today
ChangTS, Hwang WY. Forearm flap in onestage reconstruction of the penis. Plast Reconstr
Surg. 1984;74:251–8.

COMPLEX
PROBLEM
EMOTIONAL
SUPPORT
PHYSICAL
SUPPORT

 FIRST REQUIRES
PSYCHIATRIC
COUNCELLING
Depression
Suicidal
Ideation

Should not exclude
them from surgical
reconstruction
Deformity source
of psychological
distress

Resolve psychological problem
Before surgical treatment
Work collaboratively with a psychiatrist
throughout treatment

Sexual history
Premorbid length of penile shaft
Currently able to achieve orgasm.

Patient ’s tactile and
protective sensation in
penile remnant
Pudendal nerve
Ilioinguinal nerve
Genitofemoral nerve
ACCESS

Cultivate
Physician
Patient
Trusting
relationship
Help to realistic
patient
expectations
Imperative to
postoperative
success

 Patients are not likely to have the same sensation as they
did previously.
Length of
the penis
Penile
Sensations
Another
important issue

 Microsurgical reconstruction
Stops smoking
at least 4 weeks
before surgery
Abstains after
surgery.

 Remnant penile length
of min 2-3 cm
 Ability to urinate in a
standing position

 Penile length is
perceived
 Penile descent
 Increased convexity of
the penile base.

 Measures to augment penile length
 Sufficient to achieve a functional
phallus
 Severing the suspensory ligament
 V-Y plasty of the lower abdominal skin.
 An illusion of increased length

 Older patients
 Multipe comorbidities
 Dermal fat grafts or
 Hyaluronic acid
 Complications
 Scrotalization
 Hypertrophic scarring
 Low hanging penis
Alter GJ (1998) Penile enlargement surgery.Tech Urol 4: 70-76.

 Penile trauma
 Burns
 Excisional
debridement
 Good reliable
coverage
Split thickness skin
grafting

 Vacuum assisted
closure (VAC)

 Integra
 Bovine collagen +
silicon
 3 weeks post-
application

 Scrotal skin flaps
 Anterior and posterior
scrotal arteries
 Used in cases of
 Skin Deficiency
 Partial Penectomy defects
ZhaoYQ, Zhang J,Yu MS, Long DC Fu
nctional restoration of penis with partial defect by scrotal skin flap. J Urol 182: 2358-2361. 2009

urethral or
suprapubic
catheter
Concurrently
stents the
reconstruction
Prevent
strictures.
After 14
days,
cysto
urethrogram
Significant
extravasation,
repeat after 1
week
Urinary diversion
Key to success of reconstructive
procedures.

 Penis intact
 Amputated sharply
 Microsurgical
replantation
 Best outcome.

 Sensate
 Hairless
 Long pedicle
 Sufficient tissue to allow
tubularization
 Radial Forearm Free Flap
Fulfills these requirements
 The most commonly
used free flap for penile
reconstruction

 Chang and Hwang
 1984
 For total penile
reconstruction
ChangTS, Hwang WY Forearm flap in one-stage reconstruction of the penis. Plast Reconstr
Surg 74: 251-258;1984.

 Harvested from non-
dominant arm
 Contains :
 Radial artery
 Superficial and deep
venous systems
 Both antebrachial
nerves
 Skin and sc tissue from
forearm
 Rolled into a phallus as
a “Tube within aTube”

 Superior to all other
techniques
Garaffa G, Christopher NA, Ralph DJTotal Phallic Reconstruction in Female-to-Male
Transsexuals. Eur Urol 57: 715-722. (2010)
Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P,Van Landuyt K, et al. Penile reconstruction: is
the radial forearm flap really the standard technique? Plast Reconstr Surg 124: 510-518. (2009)

 Thin supple tissue
 Long pedicle
 Easily exposed and
dissected.
 Best recovery of
sensation
 Two -team approach.

 Two surgical teams
operate simultaneously.
 Urologist
 Resection
 Prepares the urethra
 Plastic surgeon
 Raises the flap on the
non-dominant forearm.

 Microsurgical
reconstruction  Anastomoses
 Femoral artery
 Great saphenous vein
 Inferior epigastric
vessels.

 Artery:
 CFA (end to side)
 DIEA
 Inter-positional vein
graft
 Vein:
 GSV
 DIEV
 SIEV

 Nerves:
 Medial and lateral
antebrachial nerves
 Tactile sensation
 Ilioinguinal
 Genitofemoral
 Erogenous sensation
 Nerve of the clitoris
 Dorsal penile nerve

Bone from the radius
harvested
provide extra rigidity of the
neophallus
Prophylactic plating -
decrease radius fractures
 Penile and testicular
implants
 After 12 months
 Sexual intercourse
following return of
protective sensation to
the penile tip.
Waits CA,Toby EB, Girod DA,TsueTT (2007) Osteocutaneous radial forearm free flap: long-term
radiographic evaluation of donor site morbidity after prophylactic plating of radius. J Reconstr Microsurg
23: 367-372.

 Forearm donor site
 covered with split-
thickness skin grafts or
full thickness skin
grafts from the groin.

 Post-Operative
 10 - 14 days in
hospital
 Bed rest for most of
this time
 Free flap monitoring
 Supra -pubic
catheter
▪ (~ 5 days)
 Foley 2 weeks

 Tattooing of the glans
 2 to 3 months latter to
improve the aesthetic
result.

 Erectile Prosthesis
 Erectile Prosthesis:
once sensation is
present at distal end (~
12 months)

 Testicular Implants:
 Scrotoplasty
performed at time of
phalloplasty
 Implants at time of
erectile prosthesis
 Glans:
 Tattooing any time
after 3 or 4 months

Primary option for phalloplasty
for most reconstructive surgeons
all over the world.
Gold standard for
phalloplasty with which other
flaps are compared.

 High number of initial urinary
fistulas
 Need stiffener or prosthesis
 Residual scar on the forearm
donor site
 Limitation in size of the
available forearm skin.
 Loss of phallic girth
 Tissue atrophy

 Osteocutaneous radial
forearm flap
 Reverse -flow island flap
 Transferred distant flap
while maintaining its
vascular connection with
the forearm.
 Pedicle divided 2 to 3
weeks later.
Mutaf M (2001) Nonmicrosurgical use of the radial forearm flap for penile reconstruction. Plast
Reconstr Surg 107: 80-86.

Osteocutaneous radial forearm flap
Radial recurrent FC flap
Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg. 2000 Apr;105(4):1361-70.
Mutaf M. A new surgical procedure for phallic reconstruction: Istanbul flap. Plast Reconstr Surg.
2000 Apr;105(4):1361-70.

 Sensate osteocutaneous
fibular flap
 1992 -Total phallic
reconstruction
Sadove RC, McRoberts JW (1992)Total phallic reconstruction with the free fibula
osteocutaneous flap. Plast Reconstr Surg 89: 1001.

Advantages
 Intrinsic rigidity
 Concealed donor site
 Long vascular pedicle.
 Increased bone stock
available obviates the
requirement for a penile
implant for intercourse.
Disadvantages
 Deceased sensibility
 Increased urethral
complications
 Permanently erect
penis that may cause
distress and social
embarrassment.

 Despite decreased
sensibility
 Better sexual intercourse
reported
Schaff J, Papadopulos NA (2009) A new protocol for complete phalloplasty with free sensate
and prelaminated osteofasciocutaneous flaps: experience in 37 patients. Microsurgery 29: 413-
419.

 Pedicled
 Free flap
 Increasing popularity
 For total phallic
reconstruction
Rubino C, Figus A, Dessy LA, AleiG, Mazzocchi M, et al. Innervated Island pedicled anterolateral
thigh flap for neo-phallic reconstruction in femaleto- male transsexuals. J Plast Reconstr
Aesthet Surg 62: e45-e49. (2009)

 Superior aesthetic
outcome
 Restoration of sensation
 Lateral femoral cutaneous
nerve to the pudendal or
dorsal penile/clitoral nerves.
 A major advantage over
the radial forearm
flap
concealed donor site.
An erectile prosthesis can
also easily be implanted

 Advantage
 Relatively inconspicuous
donor site without
compromising the size of
the neophallus.
 Erogenous and tactile
sensibility
 Inflatable prosthesis
allowed penetration during
sexual intercourse.
Upton J, Mutimer KL, Loughlin K, Ritchie J. Penile reconstruction using the lateral arm flap. J R
Coll Surg Edinb. 1987;32:97–101.

 Successfull
 Adults
 Children
 Good Penile size
 Very reliable flap
survival.
 Donor site primarily
closed

 Urethroplasty
 Later stage
 Buccal mucosa.
 Peculiar advantages of
reinnervated LDFF
(thoracodorsal nerve
anastomosed to
ilioinguinal nerve)
 ‘Paradox erection’
 Voluntarily contracting
the muscle
 Avoiding the use of a
stiffener.

 Santanelli and Scuderi
 Phalloplasties
 Female to male transsexuals
 Good success rates
 Safe
 Sensate flap
 Less conspicuous donor scar.
Santanelli, F., Scuderi, N. Neo-phalloplasty in Female-to-MaleTranssexuals with the Island
Tensor Fasciae Latae Flap. Plast. Reconstr. Surg., 2000, 105: p. 1990.

 Thoraco dorsal artery
perforator flap has
been used for phallic
reconstruction  Advantages
 Concealed donor site
 Large reservoir of tissue
Lin CT, Chen LW (2009) Using a free thoracodorsal artery perforator flap for phallic
reconstruction--a report of surgical technique. J Plast Reconstr Aesthet Surg 62: 402-408.

 Pedicled suprapublic
abdominal wall flap
 Good cosmetic result
 Ability to achieve sexual
intercourse with the aid
of a penile implant
 Limitation
 High rate (75%) of urinary
complications.
Bettocchi C, Ralph DJ, Pryor JP (2005) Pedicled pubic phalloplasty in females with gender
dysphoria. BJU Int 95: 120-124.

 Important part of the patient's wishes
 An aesthetic and normal looking penis.
Horton CE, McCraw JB, Devine CJ Jr, Devine PC. Secondary reconstruction of the genital area.
Urol Clin N Am 1977 4:133 – 41

 UrinaryTract
 Stenosis
 Fistula
 Flap failure (partial or
complete)
 Wound healing
problems
 Implant extrusion or
failure
 Donor:
 Decreased sensation
 Prolonged swelling
 Decreased function
(usually self-limited)
 Poor scarring
Hu ZQ, Hyakusoku H, Gao JH, Aoki R, Ogawa R, et al. (2005) Penis reconstruction using three
different operative methods. Br J Plast Surg 58: 487-492.

 Development of biological
substitutes Potentially restore
normal function.
 Use synthetic or natural matrices
labeled scaffolds.
 When used alone,
 some scaffolds can facilitate the
body’s natural ability to regenerate
by directing new tissue growth
Chen KL, Eberli D,Yoo JJ, Atala A (2010) Bioengineered corporal tissue for structural and
functional restoration of the penis. Proc Natl Acad Sci U S A 107: 3346-3350.

 Scaffold seeded with cells
 Resulting construct
implanted into the patient
 Restore the structure and
function of damaged
tissues and organs.

Fu Q, CaoYL (2012)Tissue engineering and
stem cell application of
urethroplasty: from bench to bedside. Urology
79: 246-253.
Efstathiou E, Gardikis S, Giatromanolaki A,
Kambouri K, Sivridis E, et al. (2012)
Effect ofVEGF on Angiogenesis in Pedicle
Penile Skin Flaps:An Experimental
Study of Urethral Reconstruction in Rabbits.
Eur J Pediatr Surg.
SongYS, Lee HJ, Park IH, KimWK, Ku
JH, et al. (2007) Potential differentiation
of human mesenchymal stem cell
transplanted in rat corpus cavernosum
toward endothelial or smooth muscle
cells. Int J Impot Res 19: 378-385.
Nolazco G, Kovanecz I,Vernet D, Gelfand RA,
Tsao J, et al. (2008) Effect
of muscle-derived stem cells on the
restoration of corpora cavernosa smooth
muscle and erectile function in the aged rat.
BJU Int 101: 1156–1164.

 2008 North Carolina
 Anthony Atala et all
 Transplanted bioengineered
penises onto 12 rabbits.
 All mated and four produced
offspring.
Mohammadi, Dara (4 October 2014). "The labgrown penis: approaching a medical milestone".
The Observer. Retrieved 16 March 2015.

 First successful penis
transplant
 21yearold
 Urologist
 André van der Merwe
 Plastic surgeon
 Frank Graewe.
 University of Stellenbosch in
South Africa.
 9 hour procedure
 Used microsurgery
Gallagher, James (13 March 2015). "South Africans perform first 'successful' penis transplant".
BBC News. Retrieved 15 March 2015.

 Botched circumcision aged 18.
 As of 13 March 2015
 Recovered function in the organ
▪ Urination
▪ Erection
▪ Orgasm
▪ Ejaculation
 But sensation is expected to take two years to return
fully.
Associated Press (13 March 2015). "Penis transplant successfully performed in South Africa". CBC News.
Retrieved 13 March 2015.
Gallagher, James (13 March 2015). "South Africans perform first 'successful' penis transplant". BBC News.
Retrieved 15 March 2015.
Johnson, John (12 June 2015). "Penis transplant patient has major news for skeptics". Fox News. Retrieved
18 August 2015.

 Thomas Manning, 64
 Bank courier from
Halifax,
Massachusetts.
 15-hour May 8 and 9.
 Deceased donor.
“I want to go back to
being who I was ”
 Thomas Manning, 64

 Female to male gender reassignment surgery
S.V. Perovic and M.L. Djordjevic. Metoidioplasty: a variant of phalloplasty in female transsexuals
BJU International,Volume 92 Issue 9, December 2003

 Technically simpler than
phalloplasty
 Costs less
 Fewer complications.
Metoidioplasty as a Single Stage Sex Reassignment Surgery in FemaleTranssexuals: Belgrade
Experience (Journal of Sexual Medicine,Volume 6 Issue 5, Oct 2008)
 Phalloplasty better
sexual penetration

 Testosterone replacement therapy
 Enlarges clitoris
 Average size of 4–5 cm

 Patient prep
 Skin surrounding enlarged
clitoris is incised on the
underside and the lateral
crura
 Urethra extended using
mucosal tissues from
 Vaginal area or
 Inside the mouth/cheeks
 Catheter facilitate healing
-3 weeks

 Surgeon separates the enlarged
clitoris from the labia minora
 Severs suspensory ligament
 Lower it to the approximate
position of the penis.

 Neopenis
 With skin by cutting the labia minora and
wrapping around the tissue and secured with
stitches
 Scrotoplasty
 Vaginectomy
 Hysterectomy
 Oophorectomy

 Dribbling
 Spraying of urine
 Urethral strictures
 Fistula
 Rejection testicular prostheses
Metoidioplasty as a Single Stage Sex Reassignment Surgery in FemaleTranssexuals: Belgrade
Experience (http://www3.interscience.wiley.com/journal/121489446/abstract) by Miroslav L.
Djordjevic, Dusan Stanojevic (Journal of Sexual Medicine,Volume 6 Issue 5, Oct 2008)

 Selvaggi G, Monstrey S, et al. Donorsite morbidity of the
radial forearm free flap after 125 phalloplasties in gender
identity disorder. Plast Reconstr Surg. 2006;118(5):1171–7.

Garaffa G, Christopher NA, Ralph DJ.Total phallic reconstruction in female
to male transsexuals. Eur Urol 2010; 57 (4): 715–722
This series confirms the reliability of RAFF phalloplasty in female to male
transsexuals

 Garaffa G, Raheem AA, Christopher NA, Ralph DJ.Total
phallic reconstruction after penile amputation for
carcinoma. BJU Int 2009; 104 (6): 852–6.
 This is the largest series reported of penile reconstruction with
RAFF after amputation for penile cancer.

Hoebeke PB, Decaesteker K, Beysens M et Al. Erectile implants in female to male
transsexuals:our experience in 129 patients. Eur Urol 2010; 57 (2): 334–4).
This series, the largest in the literature on the topic, confirms that penile prosthesis implantation
in phalloplasty is possible but complication rate is high

 Song C,Wong M,Wong CH, OngYS.
Modifications of the radial forearm flap phalloplasty
for female-to-male gender reassignment. J
Reconstr Microsurg. 2011 Feb;27(2):115-20.

 Efstathiou E, Gardikis S, GiatromanolakiA,
Kambouri K, Sivridis E, et al. (2012) Effect of
VEGF on Angiogenesis in Pedicle Penile Skin
Flaps:An Experimental Study of Urethral
Reconstruction in Rabbits. Eur J Pediatr Surg.

 Penile reconstruction
 Complex endeavor
 Requires close cooperation between the plastic surgeon and urologist
 Not only the surgical, but also psychological aspects of treatment
will determine success or failure of therapy.
 Regardless of the method of reconstruction,the goals of surgery
remain the same.
 Create functional and aesthetic phallus
 Ability to void standing
 Achieve sexual function.
 In future, tissue engineering and stem cell technology may have an
important place

Penile reconstruction DR VIPIN V NAIR

Penile reconstruction DR VIPIN V NAIR

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