Total Phallic Reconstruction Using the Radial Artery Based Forearm Free Flap After Traumatic Penile Amputation

Abstract

Introduction Although genital injuries in civilian centers are rare, the scenario is completely different in the battlefield. If the penile distal stump is not adequate for primary reimplantation or it cannot be found, then delayed penile reconstruction needs to be considered. Aim To report a single-center experience with total phallic reconstruction using radial artery based forearm free flap (RAFFF) after penile traumatic loss. Methods We retrospectively reviewed the clinical records of 10 patients who underwent total phallic reconstruction with the use of the RAFFF from September 2001 through August 2015 after traumatic amputation of the penis. Main Outcome Measures Patients' baseline features, surgical outcomes, complications, and satisfaction are reported. Results The average age at the time of penile reconstruction was 36 years (range = 27–52 years). The causes of penile loss were self-amputation owing to an acute schizophrenic episode (n = 2), road traffic accident (n = 3), blast injury (n = 3), donkey bite (n = 1), and Fournier gangrene (n = 1). The average time from the trauma to reconstruction with the RAFFF was 7 years (range = 2–15 years). The urethral stump was adequate for primary anastomosis, with phallic neourethra construction in six patients. The remaining patients had complete avulsion of the penis and were voiding though a perineal urethrostomy. In consequence, they required a two-stage urethroplasty. An acute arterial thrombosis of the microsurgical anastomosis occurred in two patients and was managed successfully with immediate exploration. A neourethra stricture and fistula occurred in one patient, which needed revision. All patients who underwent complete urethral reconstruction could void and ejaculate from the tip of the phallus. After a median follow-up of 51 months (range = 1–114 months), all patients were satisfied with the size, cosmetic appearance, and sensation of the phallus. Six patients underwent inflatable penile prosthesis implantation and could engage in penetrative sex. However, revision surgery was needed in three patients (infection, n = 2; mechanical failure, n = 1). Conclusion Despite the high incidence of postoperative complications and the possible need for multiple operations, in expert hands and in large-volume centers, penile reconstruction with the RAFFF after traumatic loss of the penis yields excellent results and allows patients to regain sexual and urinary functions.

Mystery and realities of phalloplasty: a systematic review

“…Falcone et al [23] All patients were fully satisfied and urinary functions 2 patients had acute arterial thrombosisof the microsurgical were normal anastomosis, 3 patients had urethral fistula, 1 patient developed stricture, no complications about the donor site.…”

“…Song et al [22] 19 Female-to-male transgender Radial forearm free-flap Falcone et al [23] 10 2 self-amputation (schizophrenic episode Radial forearm free-flap 3 traffic accident, 3 blast injury, 1 donkey bite, 1 fournier gangrene Papadopulos et al [24] 32 Female-to-male transgender Osteofasciocutaneous fibular flap Bird-Wing abdominal phalloplasty technique for 4 patients who had disorder of sex development and severe penile deficiency. The neophallus remained viable and survived in all patients and also there was no problem about the donor site.…”

“…There were good aesthetic results but unfortunately there were 2 comlete flap loss. Falcone et al [23] reported 10 patients with several indications. Two patients had self-amputation due to schizophrenic episode, 3 had traffic accident, 3 had blast injury, 1 had donkey bite and 1 had fournier gangrene.…”

Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery

“…For this reason surgeons have developed innovative strategies to anchor the cylinders to the pubic bone and to prevent distal extrusion. All authors agree that all complications from previous stages of the phallic construction must have been corrected prior to PP implantation, and that tactile sensation should have returned in order to achieve a better surgical outcome [1][2][3]12,13].…”

“…The ideal goal of total phallic construction is the creation of a cosmetically acceptable and sensate phallus with an incorporated neourethra. Indeed, it should allow the patient to void in the standing position in a male fashion, and should have enough bulk to house a stiffener to guarantee the adequate rigidity for penetrative sexual intercourse [1][2][3][4][5][6][7][8][9].…”