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40.2 Penile Reconstruction
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Fig. 40.1 Arteries and
nerves of the penis. The
skin has been removed on
the left side of the
illustration and the skin
and supercial fascia have
been removed on the right
side of the illustration.
(From Morrison SD etal.
[9], with permission from
Georg Thieme Verlag KG)
337
40.2 Penile Reconstruction
Penile preservation should always be attempted when there is partial amputation of
the penis since total phallic reconstruction is a very complex procedure that is better
left as a last resort. After a partial or subtotal loss, a penile stump of 2–3cm might
be lengthened by a conservative approach such as division of the suspensory ligament or excision of the suprapubic fat pad with a V-Y plasty of the lower abdominal
skin [12, 13]. Only when a patient has lost the major part of his penis leaving no
possibility for repair or preservation is phalloplasty required to replace the lost organ.
Penile reconstruction is indicated for cosmetic or functional purposes when there
are congenital anomalies (microphallus, ambiguous genitalia, bladder exstrophyepispadias complex), or when the anatomy of the penis has been disgured or
destroyed either by a natural disease (malignancy, severe Fournier’s gangrene) or by
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Fig. 40.2 Diagram
illustrating the skin, fascial
layers, cross section, and
vessels of the penis. (From
Biswas G etal. [10], with
permission from Georg
Thieme Verlag KG)
40 Treatment ofPenile Injury. II: Complex Procedures
trauma, be it accidental, or the result of an assault or self-inicted mutilation. In
many instances, it is a planned procedure being performed by expert surgeons who
have a good volume in the eld. However, in certain circumstances, it might prove
necessary as an emergency operation.
The triple goal of both glansplasty and phalloplasty include the creation of an
esthetic and sensate phalloid structure, the ability to have an erection and penetration, and the preservation of a normal micturition. Besides this triple goal, the
psychological aspect of penile reconstruction remains of paramount importance.
The Russian Surgeon Nikolai Aleksejevitch Bogoraz published the rst penile
reconstruction which was made of rib cartilage and an abdominal ap in 1936 [14,
15]. By the year 1948, he made a follow-up report of 30 patients who underwent
phalloplasty: there was successful urethral anastomosis in six cases, satisfactory
sexual activity in all, and even fathering ability in four of them. Skin sensitivity was
detectable in all the patients by 3–4months after the surgery and was complete after
1–2 years [14, 15]. During the same year (1948), Gilles and Harrison working
together on congenital aphallia developed Bogoraz’s technique and published separately a common work on a multi-staged technique of “tube within a tube” implying the creation of a neourethra within the neo-phallus [16, 17].
Since then, other donor sites have been used and beneted from the advent of
microsurgery. The ideal site doesn’t exist but the most preferable one should be
hairless, sensate, thin, pliable, providing sufcient tissues to allow tubularization,
and carrying a long pedicle. Gilbert and Winslow described ve necessary criteria
for an ideal phallic reconstruction in 1987. However, these criteria don’t take into
account the donor site morbidity [18, 19]:
– A single-stage reproducible procedure
– Creation of a neourethra enabling the patient to void in a standing position
– A phallus with erogenous and tactile sensibility
– Sufcient bulk allowing placement of a penile prosthesis, and henceforth a pen-
etrative sexual intercourse
– A satisfactory aesthetic result.
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339
Nowadays the gold standard donor site for neophalloplasty is the radial forearm
free ap (RFFF) also called radial artery free ap phalloplasty (RAFF) har-
vested from the non-dominant upper limb [20]. RFFF has rst been published by
Song et al. in 1982 [21], then by Chang and Hwang in 1984 who used also a
10–11cm segment of straight rib cartilage (from the union of eighth and ninth ribs)
that was xed to the corpora spongiosum of the penile stump [22]. Despite robbing
Peter to pay Paul as it will leave a large visible scar on the patient’s forearm, the
RFFF is favored by many surgeons for its cosmetic penile results and urinating
function. It must be borne in mind that after harvesting a radial artery-free
ap, the viability of the forearm will henceforth depend solely on the integrity
of the ulnar artery. Therefore the Allen test must be performed beforehand to
assess the patency of the palmar arch.
The second most used are the suprapubic, the bular osteofasciocutaneous
ap, and pedicled anterolateral thigh aps (ALT) which have the advantages of
leaving a scar in an anatomically hidden site and having a natural skin pigmentation
approaching that of the perineum. Other donor sites are less commonly used including the ulnar forearm free ap, latissimus dorsi free ap, scapular free ap, thoracodorsal artery perforator ap, bird-wing abdominal ap, upper arm aps, and
supercial circumex iliac artery perforator ap [12, 13, 20, 23, 24]. Some authors
recommended a combination of two techniques to achieve better cosmetic and functional results [25].
Designs of the neophallus are also multiple: The tube-within-a-tube design (the
most popular), the shaft-only design with no included neourethra, the composite
design (separate donor sites for the urethra and shaft), the shaft-only phalloplasty
combined with the construction of a urethra using a separate graft [13, 23, 24].
The technique of RFFF can be summarized in ve points [13, 19, 22, 23, 26, 27]
(Figs.40.3, 40.4, 40.5, 40.6, and 40.7a–c):
– Harvesting obliquely toward the hairless ulnar aspect of the forearm a 17×17cm
strip using the tube-within-a-tube technique (4 cm for the neourethra and
13cm for the neophallus shaft), i.e. two skin paddles rolled in opposite direc-
tions, and containing a dermal vascular supply between them for the urethral
skin paddle. An additional skin ap is used to create a glans-like corona.
– Urethral anastomosis.
– Microsurgical end-to-side or end-to-end anastomosis between the radial artery
and a branch of the femoral artery, either the deep inferior epigastric artery,
the circumex femoris lateralis, or the profunda femoris artery.
– Microsurgical end-to-end anastomosis of the cephalic vein and the deep epigas-
tric vein or the greater saphenous vein.
– Connection of the medial cutaneous nerve of the forearm to the ilioinguinal or
iliohypogastric nerve for protective sensation, and connection of another nerve
to the dorsal penile nerve for erogenous sensation.
The patients are under antibiotic prophylaxis for 2days (Intravenous cefuroxime), the aps are monitored hourly postoperatively to detect early ischemic
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40 Treatment ofPenile Injury. II: Complex Procedures
ab
Fig. 40.3 Outline of the radial forearm free ap phalloplasty on the arm. The ap is designed to
include the lateral and medial antebrachial cutaneous nerves as well as the radial artery and veins
and the cephalic vein (a); representation of the ap following inset (b). (From Khavanin N and
Redett RJ [19]. Creative Commons Attribution 4.0 International License)
Fig. 40.4 Markings of the radial forearm free ap in situ within the forearm. The outline of the
ap, including the markings for glansplasty, is made in black. The courses of the radial artery (red)
along with its two venae comitantes (paired blue) and the cephalic vein (single blue) are marked
out as well. (From Khavanin N and Redett RJ [19]. Creative Commons Attribution 4.0 International
License)
ab
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Fig. 40.5 The ap is divided into three sections prior to tubularization: the outer skin envelope of
the neophallus; the de-epithelialized portion, which separates the skin and urethra; and the ulnarsided skin paddle, which serves as the neourethra (a); the ap is tubularized over a 16-French Foley
catheter (b). (From Khavanin N and Redett RJ [19]. Creative Commons Attribution 4.0 International
License)
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Fig. 40.6 During the
glansplasty, the distal ap
is de-epithelized and curled
onto itself to reproduce the
corona. A full-thickness
skin graft is harvested from
the groin and placed below.
Before the return of
sensation to the
neophallus, this can be
further rened with
tattooing if the patient so
wishes once the wounds
have healed. (From
Khavanin N and Redett RJ
[19]. Creative Commons
Attribution 4.0
International License)
40 Treatment ofPenile Injury. II: Complex Procedures
changes, and the patients are kept on bed rest for about 10days with an indwelling
urethral catheter.
To enhance the rigidity of a neophallus that contains no cartilage or bone and
ensure sexual penetration, a prosthesis is usually implanted at least 1year after the
surgery, when the patient is likely to have acquired a phallic sensation [12].
Complications of phalloplasty include hematoma, wound dehiscence, soft nonfunctioning phallus, infection, arterial or venous thrombosis (4% and 19%, respectively) mostly in smokers, necrosis (2–10% of cases), urethral stricture or stula
(24–42% of cases), phallic loss (1.7% of cases), etc. [12, 23, 24, 27].
When an erectile device has been implanted, further specic complications may
be observed, including infection of the device, erosion, and mechanical failure, with
an occurrence rate of 11.9%, 8.1%, and 22.2%, respectively [12].
Patients’ satisfaction is high, being about 84–97%, with phallic sensation present
in up to 86% and sexual function achievement varies between 60 and 100% [12,
23, 27].
40.3 Penile Transplantation
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343
a
b
c
Fig. 40.7 (a) Flap outlined on the left forearm. The central strip will be tubed for urethral recon-
struction. Skin distally (at the wrist) is planned for glans reconstruction in this patient. The stippled
skin is included and then de-epithelialized to provide an augmentation effect. (b) The radial forearm ap tubed in-situ to form a neo-urethra, with glans distally. The fascia is sutured separately
around the neo-urethra to provide a “waterproong” layer. The radial forearm free ap donor site
will be covered with a full-thickness skin graft, harvested from the left groin. (c) Semi-erect positioning after successful micro-anastomosis. The reconstructed glans is pink, a sign of wellvascularized free-ap tissue. (From Dabernig J etal. [26], with permission from Elsevier)
40.3 Penile Transplantation
Penile allograft transplantation is still in its infancy since the rst case attempted in
China in 2006 which was technically successful but the penis had to be explanted
after 2weeks reportedly due to the psychological distress of the recipient [28]. The
surgery implied anastomosis of the urethra, corpus spongiosum, corpora cavernosa,
and sutures of the deep dorsal vein, dorsal artery, dorsal nerve, and supercial dorsal vein.
The rst successful operation was performed in South Africa in 2015 with longterm results as the patient maintained the ability to micturate and regained sexual
potency (erection, orgasms, and ejaculations) [29]. This success was followed by
another case in 2017in the same institution and by the rst case in the United States
in 2016 [30–33].
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40 Treatment ofPenile Injury. II: Complex Procedures
More recently a young boy who had sustained a blast injury to the abdominal
wall and perineum underwent “en-bloc” transplantation of the penis, scrotum, and
lower abdominal wall in the USA in 2018 with a successful result at a 1-year follow up [19, 33, 34].
In a cadaveric experience, Tuffaha etal. demonstrated that the three main arteries
to be anastomosed in penile transplantation are the cavernosal artery which supplies the corpora cavernosa, the dorsal artery which perfuses the glans and the
corpus spongiosum, and the external pudendal artery which perfuses the shaft and
surrounding skin [35] (Fig.40.8a–c).
Fig. 40.8 (a) Perfusion territories observed from the dorsal, cavernosal, and external pudendal
arteries. (From Tuffaha SH et al. [35], with permission from Wolters Kluwer Health). (b)
Illustration depicting cadaveric penile transplantation. Sup: supercial. (From Tuffaha SH etal.
[35], with permission from Wolters Kluwer Health). (c) The recommended strategy for vascularizing penile allografts. (Left) Midshaft or distal shaft transplantation: dorsal and cavernosal arteries. (Center) Proximal shaft: dorsal, cavernosal, and external pudendal arteries with skin bridge.
(Right) Proximal shaft with a surrounding defect: dorsal, cavernosal, and external pudendal arteries with additional skin to resurface the defect. (From Tuffaha SH etal. [35], with permission from
Wolters Kluwer Health)
a
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b
c
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40 Treatment ofPenile Injury. II: Complex Procedures
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