Review of microsurgical posterior urethral reconstruction

Posterior urethra reconstruction can be a challenging proposition for both patient and surgeon. The vast majority of urethras can be successfully reconstructed with either anastomosis or grafting. However, there are some patients who have recurrent urethral strictures that require more complex reconstruction. There is some speculation that microsurgical penile revascularization may allow subsequent graft reconstruction with lower stricture rates, but this is not yet proven. For the most tenacious urethral strictures, free tissue transfer may be required. The free radial forearm flap is well suited for urethral reconstruction, and the free anterolateral thigh flap may also have a role for these patients. This article will review urethral trauma and strictures and microsurgery's role in reconstruction of the posterior urethra.     

Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps

The free radial forearm flap is a very common material for penile reconstruction. Its major problems are donor-site morbidity with large depressive scar after skin grafting, urethral fistula due to insufficiency of suture line for the urethra, and need for microvascular anastomosis. A new method using combined bilateral island SCIP flaps for the urethra and penis is developed for gender identity disorder (GID) patients. The advantages of this method are minimal donor-site morbidity with a concealed donor scar, and possible one-stage reconstruction for a longer urethra of 22 cm in length without insufficiency, even for GID female-to-male patients. A disadvantage is poor sensory recovery.     

Penile circular fasciocutaneous flaps to reconstruct complex anterior urethral strictures

The circular fasciocutaneous penile flap meets all criteria for tissue transfer and urethral reconstruction. It reliably provides ample hairless tissue, usually 13 to 15 cm long, without compromising cosmesis or function. We find it ideal for long strictures in the distal or pendulous urethra, where the decreased substance of the corpus spongiosum may jeopardize graft viability. A second major advantage is its versatility: it can be used throughout the entire anterior urethra, from the membranous area to the meatus. In addition, the circular fasciocutaneous penile flap is easily combined with other tissue-transfer techniques when necessary, enabling one-stage reconstruction in the majority of cases. The flap may be tubularized for replacement urethroplasty or divided and used in two separate stenotic areas. Onlay reconstruction is preferable to flap tubularization and has provided a better initial and long-term outcome. The circular fasciocutaneous penile flap provides superior results even in patients with complex refractory strictures in whom previous attempts at anterior urethroplasty have failed. We believe its superiority resides in the transfer of well-vascularized tissue to the compromised area. Complications can be minimized by avoiding prolonged placement in the exaggerated lithotomy position and by meticulous attention to principle of reconstructive surgery.     

Phalloplasty and urethroplasty in children with penile agenesis: preliminary report

PURPOSE: Female gender has been assigned to 46,XY newborns affected by aphallia, possibly resulting in subsequent gender dysphoria. Prenatal and postnatal effects of the androgens on the brain and sexual orientation cannot be modified later. Therefore, patients affected by aphallia should be raised as males. Because definitive forearm flap phalloplasty is generally not recommended before puberty, we performed a preliminary penile reconstruction during childhood in 4 patients. MATERIALS AND METHODS: Four patients with aphallia who had no sex reassignment at birth were treated at age 9, 17 and 36 months, and 12 years in a single operation. The urethral channel was dissected through an anterior-sagittal-transanorectal approach, and then phalloplasty and urethroplasty were carried out using an abdominal skin flap and a bladder/buccal mucosa free graft. RESULTS: Immediate postoperative outcome was excellent in all the patients. One patient had excellent functional and cosmetic results at 5 years, while 2 had a partial dorsal urethral dehiscence resulting in an epispadiac urethra at 2 years, and 1 had necrosis of the distal urethra and was voiding through a scrotal urethrostomy at 9 months postoperatively. Phalloplasty survived and provided an adequate male appearance in all patients. CONCLUSIONS: Opposite gender should not be assigned in patients affected by penile agenesis, who are better raised according to their karyotype and hormonal production. Definitive phalloplasty in adults may achieve good results. Nevertheless, this procedure is generally performed in postpubertal boys and it is not easily available everywhere. Therefore, we believe that social and psychological concerns justified this type of phalloplasty as a palliative preliminary procedure in 3 of our patients. In those countries where definitive forearm phalloplasty is not available our method may also be justified in older children (as in 1 of our patients) as an attempt at a definitive procedure.     

Penile reconstruction by the free scapular flap and malleable penis prosthesis

BACKGROUND:: Penile reconstruction has always been a challenging problem for plastic surgeons while facing patients with severe congenital deformities and gender dysphoria and those who have suffered penile loss because of trauma, self-amputation, malignancy, and so on. Since 1936, when Bogoras first constructed a total penis, attempts have been made by different techniques, including skin flaps or myocutaneous flaps. And with development of free tissue transfer and microsurgical techniques, various free skin flaps, such as the radial free forearm flap, the superficial inferior epigastric artery flap, the superficial circumflex iliac artery flap, have been attempted for phallic construction, with the goal of functional (including a competent neourethra that allows voiding while standing and sexual intercourse) and cosmetic result. The purpose of our study was to evaluate the scapular free flap and implantation of malleable penile prosthesis for penile reconstruction. PATIENTS AND METHODS:: Since March 2000, 20 patients with penile loss were reconstructed in a 1-stage procedure by transferring scapular flap and implantation of a malleable penile prosthesis. The age of the patients ranged between 21 and 36 years old. Of these patients, 12 had penile amputation resulting from an electric accident; the other 8 were self-amputated. RESULTS:: All the flaps remained 100% viable postoperatively. Follow-up ranged from 1 to 5 years. There were no cases of urethral fistula, urethral stenosis, prosthesis extrusion, or infection. The reconstructed penis yielded satisfactory function and esthetic appearance. CONCLUSION:: The scapular free flap is an ideal flap that achieves satisfactory function and esthetic appearance for penile reconstruction because of its adequate amount of tissue, reliable vascularity, acceptable donor-site morbidity, and reliable blood supply.     

The penis transposed to the perineum with penile-prostatic anastomotic urethroplasty for the treatment of a long segment complex urethral strictures

BackgroundTo present our experience of transposing the penis to the perineum, with penile-prostatic anastomotic urethroplasty, for the treatment of complex bulbo-membranous urethral strictures.MethodsBetween January 2002 and December 2018, 20 patients with long segment urethral strictures (mean 8.6 cm, range 7.5 to 11 cm) and scarred perineoscrotal skin underwent a procedure of transposition of the penis to the perineum and the penile urethra was anastomosed to the prostatic urethra. Before admission 20 patients had unsuccessful repairs (mean 4.5, range 2 to 12); five patients were associated urethrorectal fistula; 16 patients reported severe penile erectile dysfunction (PED) or no penile erectile at any time and four reported partial erections.ResultsThe mean follow-up period was 45.9 (range 12 to 131) months. Nineteen patients could void normally with a mean Qmax of 22.48 (range 15.6 to 31.4) mL/s. One patient developed postoperative urethral stenosis. After 1 to 10 years of the procedure, nine patients underwent the second procedure. Of the nine patients, four underwent straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap, and five underwent straightening the penis and staged Johanson urethroplasty. Seven patients could void normally, one developed urethrocutaneous fistula and one developed urethral stenosis.ConclusionsTransposition of the penis to the perineum with pendulous-prostatic anastomotic urethroplasty may be considered as a salvage option for patients with complex long segment posterior urethral strictures.     

Urethra reconstruction following resection of penile leiomyosarcoma

Leiomyosarcoma is a rare tumor, particularly in genital area. We present a case of penile lyomyosarcoma. Surgical treatment involved subcutaneous penectomy, preserving a sensate skin envelope, bilateral groin dissection and perineal urethrostomy. Reconstruction of the urethra and soft tissue was carried out using a free radial forearm flap. We believe that subcutaneous penectomy should be considered as a treatment option in selected cases of penile tumor as this facilitates urethral reconstruction.     

Phalloplasty: The dream and the reality

Phalloplasty has come a long way as Plastic Surgery has evolved over the years. The complication ridden multistage tube pedicles popularized by Gillis were, with the advent of microsurgery, replaced by radial forearm flaps. The composite osteo-cutaneous version of this flap promised ‘All for one and one for all’ assuring both a reliable urinary conduit and a phallus stiffener. Prelamination and prefabrication to make the neo-urethra came with the promise of reducing both fistula and strictures but that did not happen and flap failure rates increased. Penile stiffeners of various types have been introduced; the artificial ones were associated with high infection and failure rates and are best inserted after the neo-penis regains some sensitivity. With the introduction of perforator flaps the Anterolateral thigh flap in its sensate pedicled form has started replacing the Radial forearm free flap as the first choice flap because of a hidden donor area and lack of microsurgical expertise requirement. Being sensate it tolerates a stiffener better. It is now possible to reconstruct an aesthetically pleasing glans as well, thus meeting both the aesthetic and functional desires of the patient. Complications encountered in this reconstructive effort include flap failure, urethral fistula, urethral stricture and stiffener related problems.KEY WORDS: Gender reassignment, penile reconstruction, phalloplasty     

Avulsion injuries of the male external genitalia: classification and reconstruction with the customised radial forearm free flap.

Between 1995 and 2003, 36 men underwent penile reconstruction for avulsion injuries with radial forearm free flap. Classification was according to location of the native urethra at presentation. In type I injury the meatus was at the corporal stump. In type II injury there was loss of corpora with preservation of the crura leaving the meatus near the pubic symphysis. In type III injuries there was a perineal urethrostomy. In type IV injuries urinary diversion via a supra-pubic catheter was required. In some instances, the flap was designed obliquely over the forearm rather than vertically to gain length. Secondly, we fashioned additional 8-11 cm length of the urethral portion of the flap (with separate draining vein) to tap into the perineal urethrostomy. Seven patients had type I injuries, 15 patients had type II injuries, 10 patients had type III injuries and four patients had type IV injuries. All 22 patients with type I/II injuries and 7/10 patients with type III injuries underwent phalloplasty in a single stage. Three patients with type III injuries had two-stage reconstructions while all four patients with type IV injuries underwent reconstruction in three stages. There was one flap loss, eight developed fistula and six patients developed late stricture. Overall patient satisfaction with the reconstruction was very high.     

Pedicled superficial inferior epigastric artery perforator flap for salvage of failed metoidioplasty in female‐to‐male transsexuals

Metoidioplasty represents a viable option for female‐to‐male transsexual patients seeking gender reassignment surgery. The aim of this procedure is to create a microphallus with lengthening of the urethra to the tip of the hypertrophied and released clitoris. However, fistula formation and urethral obstruction might occur in the long term and reconstruction represents a challenging problem in this setting. In this report, we present the tubed superficial inferior epigastric artery perforator island flap as an option for urethral reconstruction after failed metoidioplasty in a female‐to‐male transsexual patient. In a 26‐year‐old transsexual patient a combination of urethral fistula, urethral stenosis, and disintegrated distal neourethra had developed as a consequence of postoperative hematoma formation. Metoidioplasty was reconstructed by means of a tubed, pedicled superficial inferior epigastric artery perforator flap from the left lower abdomen. The long‐term result was stable with pleasing genital appearance, adequate functional outcome, and satisfactory donor site morbidity. In our opinion, this procedure may represent a viable alternative for urethral reconstruction in thin patients. © 2014 Wiley Periodicals, Inc. Microsurgery 35:403–406, 2015.     

Porcine small intestinal submucosa graft for repair of anterior urethral strictures

OBJECTIVES: We evaluated porcine small intestinal submucosa (SIS) used in the treatment of inflammatory, iatrogenic, posttraumatic, and idiopathic strictures of bulbar and penile urethra. Midterm maintenance of urethral patency was assessed. METHODS: Fifty patients aged 45-73 yr with anterior urethral stricture underwent urethroplasty using a porcine SIS collagen-based matrix for urethral reconstruction. Stricture was localized in the bulbar urethra in 10 patients, the bulbopenile area in 31 cases, and in the distal penile urethra in nine patients. All patients received a four-layered SIS patch graft in an onlay fashion. A voiding history, retrograde and antegrade urethrography, and cystoscopy were performed preoperatively and postoperatively. Failure was defined as stricture confirmed on urethrogram. RESULTS: After a mean follow-up of 31.2 mo (range: 24-36 mo), the clinical, radiological, and cosmetic findings were excellent in 40 (80%) patients. Restricture developed in one of 10 bulbar, five of 31 bulbopenile, and four of nine penile strictures. These all occurred in the first 6 mo postoperatively. All patients with recurrences needed further therapy, but there has been no additional recurrence observed to date. No complications such as fistula, wound infection, UTI, or rejection were observed. CONCLUSIONS: Use of inert porcine SIS matrix appears to be beneficial for patients with bulbar and bulbopenile strictures. Midterm results are comparable to skin flaps and mucosal grafts.     

Burned ear reconstruction using a prefabricated free radial forearm flap

Postauricular skin, postauricular fascia, temporoparietal fascia (pedicle or free), the free radial forearm flap (fascial or fasciocutaneous), and free lateral arm fascial flap, have been used for burned ear reconstruction reported in the literature. Patients who did not have normal tissue around the ear region, because of severe thermal injuries to the external ear, are not available for draping the costal cartilage framework; these patients require free flaps. The author reports a burned ear reconstruction, using a prefabricated free radial forearm fasciocutaneous flap, included an autogenous costal cartilage framework. In this case, the front and back of the cartilage framework were covered with the skin of the forearm flap. This is the main difference from other techniques in the literature. This flap is valuable for burned ear reconstruction, when local tissue and other free flaps are not available.     

Two modifications of the radial forearm flap for reconstruction of complex facial defects

The free radial forearm flap has been one of the most common free flaps of recent decades. This flap is employed predominantly in head and neck reconstruction. The possibility of combining bone, muscle, and nerves with the fasciocutaneous flap greatly enhanced reconstructive options. However, the frequently unsightly donor site and the development of other readily available free flaps have led to a decline in the use of the radial forearm flap. Nevertheless, for reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, the radial forearm flap still remains a prime choice. Two modifications of the standard forearm flap are presented. The first patient had two large defects at the nose and mental area after radical resection of a basal-cell carcinoma. Soft-tissue reconstruction was achieved with a conventional forearm flap and a second additional skin island based on a perforator vessel originating proximally from the pedicle. Both skin islands were independently mobile and could be sutured tension-free into the defects after tunneling through the cheek, with vascular anastomosis to the facial vessels. The second patient required additional volume to fill the orbital cavity after enucleation of the eye due to an ulcerating basal-cell carcinoma. In this case, the body of the flexor carpi radialis muscle was included in the skin flap to fill the defect. The skin island was used to reconstruct the major soft-tissue defect.     

Second free radial forearm flap for urethral reconstruction after partial flap necrosis of tube‐in‐tube phalloplasty with radial forearm flap: A report of two cases

We present a salvage procedure to reconstruct the neo‐urethra after partial flap necrosis occurring in free radial forearm flap (RFF) phalloplasty for sex reassignment surgery. Two cases of tube‐in‐tube phalloplasty using a free sensate RFF are described in which partial flap necrosis occurred involving the complete length of the neo‐urethra and a strip of the outer lining of the neo‐phallus. Neo‐urethra‐reconstruction was performed with a second RFF from the contralateral side providing well‐vascularized tissue. No flap‐related complications were observed. Twelve months postoperatively, both patients were able to void while standing. A satisfactory aesthetic appearance of the neo‐phallus could be preserved with an excellent tactile and erogenous sensitivity. Using this technique, we successfully salvaged the neo‐urethra and reconstructed the outer lining of the neo‐phallus © 2013 Wiley Periodicals, Inc. Microsurgery 34:58–63, 2013.     

Phalloplasty with free (septocutaneous) fibular flap sine fibula

PURPOSE: The free prefabricated fibular flap has been used as a good alternative to the free radial forearm flap in female-to-male sex reassignment surgery. We describe a new technique of harvesting the flap without sacrificing the fibula. The neophallus is thinner, more elegant, less rigid and able to contain a hydraulic penile prosthesis. MATERIALS AND METHODS: Five biologically female patients underwent reassignment surgery using this technique. Average patient age was 30 years (range 24 to 37) and average followup was 25 months. All patients underwent total hysterectomy, salpingo-oophorectomies, vaginectomy and urethral prelamination 6 months before flap surgery. The lateral calf cutaneous island was raised on the peroneal artery septocutaneous perforators without disrupting the continuity of the fibula. Urethro-urethral anastomosis was done 3 months later. RESULTS: All patients sustained good results with no flap loss. Voiding from a standing position was achieved and the neophallus was esthetically acceptable. Donor morbidity was minimal with no disturbance to ambulation compared to the conventional method, in which the fibula is sacrificed. CONCLUSIONS: The free fibular flap without the fibula is a challenging refinement of neophallus construction that confers benefits to recipient and donor sites. It is a welcomed addition to the armamentarium for neophalloplasty.     

Infection-induced urethral defect treated by urethral reconstruction with a radial forearm flap

Abstract A 47-year-old man was admitted with the chief complaint of a urethral defect. An approximately 17-cm defect of the urethra seemed to have been occurred by the infection of implanted foreign bodies in the penile skin. Reconstruction of the urethra and the ventral skin was performed with a free radial forearm flap. A fistula formed at the proximal anastomosis after the operation, but was controlled conservatively. Urethral stricture at the proximal anastomosis subsequently developed. A urethral stent made of shape memory alloy was placed with the preservation of voiding function.     

A comparison of the donor-site morbidity after using the prelaminated fasciomucosal flap and the fasciocutaneous radial forearm flap for intraoral reconstruction.

Since 1996 we have performed mucosal prelamination of the distal radial forearm flap for functional reconstruction of defects of the intraoral lining. This study was undertaken to demonstrate that the prelaminated fasciomucosal radial forearm flap can provide physiological oropharyngeal reconstruction with mucus-producing tissue, while avoiding the donor-site complications of the fasciocutaneous radial forearm flap. We examined the donor hand at least 6 months postoperatively in 20 patients after using a prelaminated fasciomucosal radial forearm flap and in 15 patients after harvesting a classical fasciocutaneous radial forearm flap. The evaluation of hand function included range of motion, grip power, pinch power, sensibility and vascular analysis in both hands. The patients were asked about cold intolerance, pain and any restrictions in daily life, and the cosmetic appearance of the donor hand was noted. In the prelaminated-flap group (n 20), two patients had decreased wrist extension, and one of these patients also had reduced strength and mild hypaesthesia in the donor hand. In the classical-fasciocutaneous-flap group (n 15), six patients had decreased wrist extension, five patients had reduced strength and four patients had diminished sensibility in the donor hand. Painful neuromas were found only after fasciocutaneous flaps (three cases). Subjective assessment revealed restricted hand function in one patient in the prelaminated-flap group, and in five patients who had undergone fasciocutaneous flap transfer. The results of this study show that using the prelaminated fasciomucosal radial forearm flap minimises the donor-site morbidity. Furthermore, we were able to improve the cosmetic appearance of this very exposed region.     

Creating two independent fasciocutaneous free flaps from a single radial forearm donor site

The authors describe the creation of two independent fasciocutaneous free flap units from a single radial forearm donor site. After the radial forearm flap is elevated in the standard manner, based on the entire length of the radial artery, the individual flap units are developed as island flaps based on the proximal and the distal radial artery respectively by transecting the radial artery, its accompanying veins, and the cephalic vein. Thus, two independent radial forearm free flaps are created from a single donor site: The proximal one has antegrade flow and the distal one has retrograde flow. The individual free flap units were transferred, and microvascular anastomoses were performed simultaneously by two surgical teams. This technique was used in 2 patients presenting with bilateral foot defects that required reconstruction with a thin, reliable flap such as the radial forearm flap.     

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction

BACKGROUND: Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. METHODS: A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. RESULTS: The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. CONCLUSIONS: The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.