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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 20  |  Issue : 1  |  Page : 79-82

Staged total penile reconstruction using flap prefabrication and arteriovenous loop


1 CO, 12 Air Force Hospital, Gorakhpur, Uttar Pradesh, India
2 Department of Plastic Surgery, Command Hospital Air Force, Bengaluru, Karnataka, India
3 Department of Anaesthesia, Command Hospital Air Force, Bengaluru, Karnataka, India

Date of Web Publication9-Jul-2018

Correspondence Address:
Gp Capt Pallab Chatterjee
Department of Plastic Surgery, Command Hospital Air Force, Old Airport Road, Agram Post, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_14_18

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  Abstract 

Loss of penis due to injury or disease is physically and psychologically devastating to any male. While the technique of penile reconstruction continues to evolve in conjunction with the evolution of flaps in reconstructive surgery, the free tissue transfer using radial artery forearm flap (RAFF) in a single stage is recognized as the most preferred method at present. However, to avoid the complications often seen in such single-stage method, we used a novel two-stage technique for total penile reconstruction in two cases after penile loss. We prefabricated the neophallus in the forearm and constructed saphenofemoral arteriovenous loop in the groin in the first stage to allow all the suture lines to heal and provide for easy and reliable recipient vessels. The neophallus was transferred after 4 weeks and vessel anastomoses done conveniently in the groin with adequate sized vessels with robust inflow. Both the patients recovered well without any need for urinary diversion and quickly attained the ability to pass urine in standing position. We offer that the two-stage method of penile reconstruction using free RAFF is reliable, easy to perform and can avoid many of the complications seen with single-stage reconstruction.

Keywords: Arteriovenous loop, penile reconstruction, phalloplasty, radial artery forearm flap


How to cite this article:
Babu P, Chatterjee P, Ravi PR. Staged total penile reconstruction using flap prefabrication and arteriovenous loop. J Mar Med Soc 2018;20:79-82

How to cite this URL:
Babu P, Chatterjee P, Ravi PR. Staged total penile reconstruction using flap prefabrication and arteriovenous loop. J Mar Med Soc [serial online] 2018 [cited 2018 Dec 14];20:79-82. Available from: http://www.marinemedicalsociety.in/text.asp?2018/20/1/79/236246


  Introduction Top


Loss of penis due to injury or disease is devastating, both physically and psychologically, to any male as it is an organ that confers the gender and sexual identity. Every patient has his own story of suffering from pain, shame, and anxiety. This is multiplied many folds when it involves the cohort of serving soldiers who live in groups day and night without enjoying much privacy.

The technique of penile reconstruction, or, phalloplasty, has been evolving in conjunction with evolution of flaps in reconstructive surgery. The first phalloplasty done for the purposes of sexual reassignment was performed on another British Physician Laurence Michael Dillon in 1946 by Dr. Harold Gillies in thirteen stages, which is documented in Pagan Kennedy's book The First Man-Made Man.[1] Gillies and Harrison [1],[2] in 1948 reported a series of cases of war injury patients where random abdominal skin flaps were delayed, tubed and then transferred in various stages. This “tube within a tube” technique allowed placement of a baculum in the inner tube for stiffening and the outer tube provided the skin envelope. Patient often voided from proximal perineal urethrostomy.[1] In 1970s, Ortichochea described total penile reconstruction using gracilis myocutaneous flap and in 1980s Puckett et al. described the first ever free flap reconstruction of penis and various options were tried to look for the ideal donor flap.[3],[4] The radial artery forearm flap (RAFF) was first described by Chang and Hwang in 1984 for total penile reconstruction and has been found superior to all the other techniques.[5] The radial forearm flap has the advantage of providing thin, supple tissue as well as a long pedicle that is easily exposed and dissected. It allows the best recovery of sensation among various flaps used for penile reconstruction.[6],[7] The location of the donor site away from the groin also allows a two-team approach. The aim of this article is to highlight the role of plastic surgery techniques in functional reconstruction of the penis and a novel technique in creating suitable recipient vascular pedicle to enable a comfortable and reliable vascular anastomoses to neophallus.


  Case Reports Top


Case 1

A 28-years-old unmarried serving soldier presented with an ulceroproliferative growth on the penis of 6 months duration that was diagnosed as a case of carcinoma penis with no lymph nodal spread. He underwent subtotal penectomy which left only 1 cm of the penile stump. The patient was well counseled about the possible outcomes and morbidities associated with the procedure. On review after a convalescence period of 8 weeks, the patient was evaluated, and the operative wounds were found to be well healed. However, the patient was severely depressed and totally withdrawn. Apart from the loss of sexual function, his inability to pass urine in standing position and forcible sitting to pass urine to prevent spillage was very embarrassing and distressing. He was found to be highly disturbed psychologically due to the loss of the important vital organ. Local examination revealed healed scar with a perineal urethral opening and a very short penile stump. Histopathology report showed clear margins and repeat scanning revealed no spread either locally or to the lymph nodes. The patient was counseled, and various reconstructive options were discussed. Considering his young age and marital status, reconstruction using free RAFF was planned.

Case 2

A 24-years-old unmarried male presented with history of a major road traffic accident with polytrauma. He sustained fracture of pelvis and extensive perineal soft-tissue injuries including total penile and scrotal loss. He had undergone wound debridement and primary closure of wounds at the primary center. On presentation, all his wounds were healed well and had a posterior perineal urethrostomy. Reconstructive options were discussed with the patient and decision was taken to do staged reconstruction using free RAFF.

In both the patients, to ensure the reliable vascular basis of the neophallus and to provide good vascular inflow, the decision was taken to prefabricate neophallus in the forearm and create saphenofemoral arteriovenous (AV) loop in the groin so as to get a good recipient pedicle in the first stage. Penile prefabrication and AV loop creation were done in the first stage. Four weeks later, the matured neophallus was transferred to perineum. The cut ends of the loop formed the recipient vessels and there was adequate pedicle length for a tension-free vascular and urethral anastomoses. Wounds healed uneventfully and urinary catheter was removed after 3 weeks.

Stage 1

Prefabrication of neophallus

Penis, anatomically, is a “tube within a tube,” the inner one being the urethra and the outer one the soft-tissue cover. Radial artery and the subcutaneous veins were marked on the skin from wrist to proximal forearm preoperatively. The anatomical territory of RAFF also is marked. The flap is raised in the subfascial plane till the proximal third of the forearm. The flap is refashioned to form a new penis of adequate size to match the expectations of the patient [Figure 1]. The urethra, being the inner tube and the most functional part of the penis, is located overlying the artery along its course. The adequate width of skin is designed to accommodate a 16F urinary catheter when it is tubed. 3 mm width of skin on either side of the urethra is de-epithelized to get a three-layer closure of urethra to prevent fistula formation. The rest of the flap is wrapped around the urethra to form the body of the penis. The distal part of the flap is refashioned to form the glans and sutured. A 16F silicone Foley catheter was positioned in the new urethra. The donor site was skin grafted and dressed. This prefabricated penis was left attached to the radial vascular pedicle and the proximal skin and subcutaneous tissue for subsequent transfer to the perineum. The lubricated silicone catheter was moved frequently to ensure patency of neourethra while the wounds were healing.
Figure 1: Prefabrication of neophallus in forearm. (a) Markings for radial artery forearm flap. (b) Flap raise based on radial artery and cephalic vein. (c) Incisions for neourethra for “tube within tube.” (d) Neophallus prefabricated on forearm with continued blood supply

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Creation of saphenofemoral arteriovenous loop

The long saphenous vein was harvested from Lt thigh clamping all tributaries for a length of 15 cm. This vein was turned upward and anastomosed to femoral artery by end to side anastomosis [Figure 2]. The loop of vein was positioned in subcutaneous tissue of the suprapubic region and fixed with Prolene suture for subsequent identification and dissection. The patency of the fistula was monitored by hand-held Doppler while it matured over the next 4 weeks in the postoperative period.
Figure 2: Creation of saphenofemoral arteriovenous loop. (a) Long saphenous vein disconnected from below. Femoral artery exposed. (b) Saphenofemoral arteriovenous loop created by end-to-side anastomosis. (c) Positioning arteriovenous loop in groin

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Stage 2

Microvascular transfer of prefabricated penis

Proximal dissection was done in the forearm to get the additional length of radial artery and the median basilic vein [Figure 3]. The suprapubic dissection freed the AV fistula loop which was divided in the middle to get an arterial end and venous end to serve as recipient vessels. Thickening of vessel wall occurred due to arterialization of saphenous vein in the AV loop. The prefabricated penis was disconnected from forearm and end-to-end anastomoses performed by microsurgical techniques. Urethral anastomosis was performed without any tension by spatulating the neourethra and the native urethral end over a 16 F silicone Foley catheter. Vessel anastomoses were technically easy due to good caliber and thickness of the recipient vessels. To restore tactile and erogenous sensation, the medial and lateral antebrachial nerves were identified, preserved, and anastomosed to the ilioinguinal and dorsal penile nerves. Patency of anastomotic site was ensured, and soft-tissue closure was done in layers.
Figure 3: (a) Neophallus disconnected from forearm. (b) Neophallus after microvascular transfer. (c) Preoperative appearance after penectomy for cancer. (d) Postoperative at 4 weeks. Patient is able to pass urine in standing position

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Postoperative course

The viability of transferred neophallus was conveniently monitored by observing visible pulsation with every pulse owing to strong inflow from femoral artery. Case 1 needed revision of the venous anastomosis at 48 h due to venous congestion caused by a kink at the anastomotic site. Case 1 also required repair of urethral fistula that developed at 6 week postoperative period after final transfer due to hair growth at the suture line. This complication was avoided in Case 2 with use of endoscopic removal of hair in neourethra at regular intervals before they could become problematic. In both cases, no urinary diversion was used, and the urethral catheter was removed successfully at 2 weeks' postoperatively to allow for micturition in standing position with good forward stream.


  Discussion Top


To replicate or replace a lost human organ due to trauma or disease is one of the most challenging tasks in plastic surgery. Although the majority of the larger series of published articles on penile reconstruction consist mainly of gender reassignment surgeries, the indications could be any loss or absence of the organ due to trauma, burns, sepsis, or tumor.[8] The ideal requirements for phalloplasty as addressed by Hage et al. in 1993 are to provide an aesthetically acceptable phallus in a single stage procedure, creation of a competent neourethra enabling voiding while standing, return of both tactile and erogenous sensibility, bulky enough to accommodate a stiffener and with minimal scarring with no functional loss in the donor area.[9]

Many different techniques have been tried over the years to achieve these goals beginning with random pattern flaps from abdomen [1] and pedicled flaps such as groin flaps and anterolateral thigh flaps [10] but were associated with prolonged hospital stays and high failure rates with suboptimal results.

With the introduction of Chinese flap design for penile reconstruction in 1984 by Chang and Hwang,[11] RAFF has become the preferred option for most of the surgeons across the world and this is considered by many as the gold standard for phalloplasty now.[5],[11],[12] The ulnar portion of the flap is relatively hairless and may be used to form the urethra. However, with urethra being the most functional part of the phallus, the skin overlying the radial artery which has the maximum vascularity is probably a better option for neourethra fashioning. The urethral part of the flap can be extended distally and reshaped to form the glans. Proximal extension of the urethral part may help in getting additional length of urethra for a tension-free anastomosis. The major advantage of this flap is the fact that it can be customized to individual requirements especially in total avulsion injuries.[13],[8]

Major drawbacks with this flap are urethral obstruction due to growth of hair inside the neourethra, need for stiffener and residual scar on the forearm. Doornaert et al. with the largest series of phalloplasties using RAFF describe this as a reliable, psychologically and cosmetically pleasing and capable of attaining satisfactory sexual function when performed in a minimum of two stages.[12] Although it can be performed in single stage, the complication rates related with flaps may go up to 25% and urethroplasty related complications up to 64%.[14]

Various modifications of the flap have been described to reduce the complications and include prefabrication of the neourethra by using a tubed graft.[15] Biemer in 1988 described the technique of centering the urethra in the flap overlying the radial artery to improve the vascularity of this segment of the skin but that takes away the advantage of hairless ulnar skin of the Chinese flap design.[16] The continuity of neourethra into the glans segment eliminates the chance of meatal stenosis when glans is designed by refashioning the distal part of the flap.[17] A two-stage phalloplasty by prelamination of urethra by a full thickness skin graft within the radial forearm flap has also been tried but has high fistula rates ranging from 15% to 22% and 32% urethral stricture rates.[18] Osteocutaneous version of forearm flap obviates the need for incorporation of a stiffener at a later date for enabling sexual function but is technically more intricate to accomplish.[19]

The two-stage technique for total penile reconstruction in our case conferred the following advantages:

  1. Allow complete healing of suture lines of the prefabricated neophallus to avoid minor/major wound healing problems
  2. Ensure reliable fashioning and healing of neourethra such that no urinary diversion was required at the time of definitive transfer and requirement of catheterization for a short period
  3. Make the vascular anastomoses reliable and easy by allowing the AV loop to mature for 4 weeks. The anastomoses were carried out comfortably in the groin without any constraints of pedicle length available and need for difficult dissection and vessel preparation as with the use of deep inferior epigastric vessels
  4. Provide robust blood supply to the neophallus from femoral artery which ensured uneventful healing.



  Conclusion Top


Total penile reconstruction using free tissue transfer is a challenging procedure that requires meticulous technique and great attention to detail. As Hage et al. remarked, the development of phalloplasty techniques have paralleled the evolution of plastic surgery.[20] Even though the two-stage method using RAFF and AV loop as described does take greater time for the final result as compared to the single-stage procedure, we believe that it is more reliable, technically easier to perform, gives aesthetically pleasing results and probably the preferred option by the surgeons encountering such cases infrequently.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nair R, Sriprasad S. Sir Harold Gillies: Pioneer of phalloplasty and the birth of uroplastic surgery. J Urol 2010;183:e437.  Back to cited text no. 1
    
2.
Rashid M, Tamimy MS. Phalloplasty: The dream and the reality. Indian J Plast Surg 2013;46:283-93.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg 1972;25:347-66.  Back to cited text no. 3
    
4.
Puckett CL, Reinisch JF, Montie JE. Free flap phalloplasty. J Urol 1982;128:294-7.  Back to cited text no. 4
    
5.
Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg 1984;74:251-8.  Back to cited text no. 5
    
6.
Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol 2010;57:715-22.  Back to cited text no. 6
    
7.
Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, et al. Penile reconstruction: Is the radial forearm flap really the standard technique? Plast Reconstr Surg 2009;124:510-8.  Back to cited text no. 7
    
8.
Rashid M, Sarwar SU. Avulsion injuries of the male external genitalia: Classification and reconstruction with the customised radial forearm free flap. Br J Plast Surg 2005;58:585-92.  Back to cited text no. 8
    
9.
Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: Some reflections on refinements of technique. Microsurgery 1993;14:592-8.  Back to cited text no. 9
    
10.
Puckett CL, Montie JE. Construction of male genitalia in the transsexual, using a tubed groin flap for the penis and a hydraulic inflation device. Plast Reconstr Surg 1978;61:523-30.  Back to cited text no. 10
    
11.
Descamps MJ, Hayes PM, Hudson DA. Phalloplasty in complete aphallia: Pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2009;62:e51-4.  Back to cited text no. 11
    
12.
Doornaert M, Hoebeke P, Ceulemans P, T'Sjoen G, Heylens G, Monstrey S, et al. Penile reconstruction with the radial forearm flap: An update. Handchir Mikrochir Plast Chir 2011;43:208-14.  Back to cited text no. 12
    
13.
Garaffa G, Raheem AA, Christopher NA, Ralph DJ. Total phallic reconstruction after penile amputation for carcinoma. BJU Int 2009;104:852-6.  Back to cited text no. 13
    
14.
Fang RH, Lin JT, Ma S. Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery 1994;15:349-52.  Back to cited text no. 14
    
15.
Leriche A, Timsit MO, Morel-Journel N, Bouillot A, Dembele D, Ruffion A, et al. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int 2008;101:1297-300.  Back to cited text no. 15
    
16.
Biemer E. Penile construction by the radial arm flap. Clin Plast Surg 1988;15:425-30.  Back to cited text no. 16
    
17.
Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg 1993;92:276-83.  Back to cited text no. 17
    
18.
Dabernig J, Schumacher O, Lenz C, Rickard R, Turner A, Dabernig W, et al. Modern concept for treatment of the female-to-male transsexual. Urologe A 2007;46:656-61.  Back to cited text no. 18
    
19.
Koshima I, Tai T, Yamasaki M. One-stage reconstruction of the penis using an innervated radial forearm osteocutaneous flap. J Reconstr Microsurg 1986;3:19-26.  Back to cited text no. 19
    
20.
Hage JJ, Bloem JJ, Suliman HM. Review of the literature on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J Urol 1993;150:1093-8.  Back to cited text no. 20
    


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