Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique

BackgroundPhalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique.AimTo evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients.MethodsBetween 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients’ demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other.ResultsPatients’ demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision.Clinical ImplicationOptimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty.Strengths & LimitationThis retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far.ConclusionThe Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty.Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661–668.     

Long‐Term Evaluation of Donor‐Site Morbidity after Radial Forearm Flap Phalloplasty for Transsexual Men

IntroductionPhalloplasty using the radial forearm flap is currently the most frequently used technique to create the neophallus in transsexual men (formerly described as female‐to‐male transsexual persons). Although it is considered the gold standard, its main disadvantage is the eventual donor‐site morbidity in a young, healthy patient population.AimThe study aims to examine the long‐term effects of radial forearm flap phalloplasty in transsexual men and to evaluate aesthetic outcome, scar acceptance, bone health, and daily functioning.Main Outcome MeasuresScars were evaluated with the patient and observer scar assessment scale, the Vancouver Scar Scale, and self‐reported satisfaction. Bone health was assessed using dual X‐ray absorptiometry and peripheral quantitative computed tomography, and daily functioning using a physical activity questionnaire (Baecke). These measurements were compared with 44 age‐matched control women.MethodsThis is a cross‐sectional study of 44 transsexual, a median of 7 years after radial forearm flap phalloplasty, recruited from the Center for Sexology and Gender Problems at the Ghent University Hospital, Belgium.ResultsWe observed no functional limitations on daily life activities, a pain‐free and rather aesthetic scar, and unaffected bone health a median of 7 years after radial foreram flap phalloplasty. Over 75% of transsexual men were either satisfied or neutral with the appearance of the scar.ConclusionsTranssexual men, despite scarring the forearm, consider the radial forearm flap phalloplasty as worthwhile.     

Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap

BackgroundConstructing a sensitive phallus is a key objective in sex affirmation surgery, but still there is a major lack of evidence in outcome analysis of postoperative sensibility of the newly constructed body part.AimTo evaluate the innervation and sensibility of a forearm free-flap neophallus with nerve coaptation by a broad-spectrum follow-up.MethodsThe phallic sensibility of 20 transgender individuals who underwent phalloplasty with a free radial forearm flap was evaluated by a standardized multimodal approach, examining 5 main sensory modalities. Measurements were performed in defined areas at the phallus and at the unoperated forearm as a control area. Additionally, all patients were asked to complete a questionnaire about their subjective quality of life and ability to orgasm.OutcomeThis study evaluated the following parameters: perception of pressure (Semmes-Weinstein monofilaments) and vibration (C64 Hz tuning fork), static two-point discrimination, sharp-blunt and hot-cold discrimination at the phallus and the forearm, sum score of calculated life satisfaction, and ability to orgasm.ResultsMost of the patients (n = 14) were able to perceive 2 or more sensory modalities tested at the newly constructed phallus. 2 patients did not develop any sensibility. Interestingly, the median values for vibration perception were similar for the phallus and the unoperated forearm. Pressure sensibility was present at the phallus, but less than at the forearm. Moreover, sharp-blunt sensibility was present in 11 patients. In contrast, clear cold-warm discrimination could not be achieved, although the majority of patients detected the cold stimulus. A two-point discrimination of up to 23 mm could not be detected in either body part. 15 patients experienced orgasms without difficulty after 23 months (n = 20 after 54 months).Clinical ImplicationsWe observed successful recovery of sensibility at the phalli for the majority of patients, including the preservation of orgasm.Strengths & LimitationsOur institution is one of the few centers regularly performing phalloplasties in transgender patients, especially preferring the technique of Gottlieb and Levine. This study contributes to the few studies that perform sensory testing at the phallus and is unique in its kind in that it uses a multimodal approach. A limitation of this study is the limited number of cases and the limited validity of vibratory testing.ConclusionConfirming a promising tactile sensibility after phalloplasty with a neurovascular radial forearm flap, the next step would be to identify whether this reinnervation effectively develops due to nerve coaptation or spontaneous sprouting.Küenzlen L, Nasim S, van Neerven S, et al. Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap. J Sex Med 2020;17:1012–1024.     

Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty

IntroductionAfter free or pedicled flap phalloplasty, many transgender men need penile prosthesis implantation to successfully engage in penetrative sexual intercourse. Postoperative complications occur frequently. There is a choice between inflatable and malleable penile prostheses. Until recently, no prostheses were designed specifically for this population.AimThe aim of this study was to describe our preliminary experience with, and surgical outcomes of, implantation of the ZSI 100 FtM Malleable Penile Implant after phalloplasty in transgender men.MethodsA retrospective chart study was conducted on surgical characteristics and postoperative complications after implantation of the ZSI Malleable Penile Implant in transgender men in 3 European centers for genital transgender surgery in Amsterdam, Stockholm, and Reykjavik.Main Outcome MeasureThe main outcomes measures were surgical outcome, complications, and reason of implant failure.Results25 patients were retrospectively identified, with a mean age of 36 ± 9 years at implantation. The mean time between prosthesis implantation and phalloplasty was 3.6 ± 2.5 years. 10 patients previously underwent free radial forearm flap phalloplasty, 6 patients had anterolateral thigh flap phalloplasty, 2 patients had superficial circumflex iliac artery perforator phalloplasty, 1 patient had groin flap phalloplasty, and 6 patients underwent combination flap phalloplasty. With a mean follow-up of 6.3 months, prosthesis explantation because of complications was performed in 8 patients (32%), because of infection (n = 3), protrusion (n = 4), or pubic pain (n = 1). In an additional 3 patients, the prosthesis was explanted due to difficulty living with the malleable prosthesis. Of those with the prosthesis in place, 13 of 14 patients (93%) were able to engage in penetrative sexual intercourse.Clinical ImplicationsThe current article provides advantages and disadvantages of this medical device.Strength & LimitationsThis is the first study on the ZSI Malleable Penile Implant prostheses in this patient group. It also provides information on the use of malleable prostheses; whereas current literature predominantly focusses on inflatable devices. Limitations comprise the small patient population, short follow-up time, and retrospective nature of the study.ConclusionComplication rates of the ZSI Malleable Penile Implant prosthesis seem high at the start of the learning curve. Although designed specifically for the transgender community, not all transgender patients will be eligible for this type of prosthesis. Patients need to be well counseled on specific (dis)advantages of the prosthesis.Pigot GLS, Sigurjónsson H, Ronkes B, et al. Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty. J Sex Med 2020;17:152–158.     

Flap Combination Phalloplasty in Female-to-Male Transsexuals

BackgroundAlthough phalloplasty with a free radial forearm (RF) flap is the gold standard for sex reassignment surgery in female-to-male transsexuals, it can result in unsightly scars, lymphedema, and numbness of the hand.AimTo introduce the concept of flap combination phalloplasty and its clinical application.MethodsThis is a retrospective chart review study of patients undergoing phalloplasty using various multiple flaps. Demographic data, surgical data, and outcomes were recorded.OutcomesOf the 15 cases, 5 were urethral fistulas; 4 were venous thrombosis; 2 were urethral calculus; and 1 was a partial flap loss.Results15 patients were included (age range 25–43 years, median 34 years). An RF flap and a deep inferior epigastric artery perforator flap combination were most frequently used. The median operative time for flap combination phalloplasty was 10.5 hours (range 6.5–12.5 hours). There was no total flap necrosis, but there was 1 case of partial flap loss. There were urethral fistulas in 5, venous thrombosis in 4, and urethral calculus in 2 cases.Clinical ImplicationsFlap combination phalloplasty will become the third option when both the RF flap and the anterolateral thigh pedicle flap are not useful.Strength & limitationsFlap combination phalloplasty is a complex operative procedure with a prolonged operative time, but it can provide more flap selection and reduce the morbidity at each donor site. Choosing from many different options can be beneficial to patients.ConclusionFlap combination phalloplasty has a similar complication rate to other procedures and has advantages in terms of flexibility and less donor site morbidity; it may thus be an option when either the RF flap or the anterolateral thigh pedicle flap cannot be used.Namba Y, Watanabe T, Kimata Y. Flap Combination Phalloplasty in Female-to-Male Transsexuals. J Sex Med 2019;16:934–941.     

Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients

IntroductionThe “traditional” method to perform vaginoplasty in male-to-female transgender surgery consists in inverting the penoscrotal skin into a surgically created cavity in the perineum between the rectum and the bladder creating a neovagina. To overcome the noteworthy disadvantage of lack of depth, the use of a rectosigmoid graft can be preferred over the penile skin inversion.AimThe aim of this study was to compare 2 methods for vaginoplasty in male-to-female transgender surgery in regard of the functional and cosmetic long-term result. Additionally this study aims to understand key factors leading to secondary sigmoid vaginoplasty in patients with previous penile skin inversion.MethodsThis is a retrospective survey of outcomes and complications of 43 patients who underwent neovaginoplasty by the same senior surgeon, between 2007 and 2017. 13 patients underwent a secondary rectosigmoid neovagina later (30.2%). Moreover, we performed an aesthetic and functional evaluation on 28 patients (65%) at long-term follow-up. Mean follow-up was 32.6 ± 3.5 months (average ± SEM). Patients were also evaluated by a questionnaire to assess both aesthetic and functional (penetration, orgasm, and pain) outcomes. Statistical analysis was used to compare results between groups.Main Outcome MeasurePatient satisfaction was assessed by a questionnaire sent to all 43 patients and was made of 5 questions (Q1 to Q5) designed in a way to evaluate patient outcomes in terms of both functionality and cosmesis of the neovagina.ResultsOur findings showed that the use of a rectosigmoid graft in secondary cases significantly decreased sexual pain during intercourse. Both techniques had similar aesthetic and functional outcomes with mostly satisfied patients (no statistical significance).Clinical ImplicationsThe use of sigmoid vaginoplasty could improve functional outcomes when compared to penile skin inversion vaginoplasty.Strength & LimitationsThis study strength is its retrospective nature conducted on a prospectively-maintained database limiting biases with 43 consecutive vaginoplasties, performed by the same surgeon. Relative limitation was that not all patients returned our questionnaire and, thus, only 65% of our patients were evaluated for satisfaction.ConclusionThis study reports long-term outcomes in transgender surgery using 2 different techniques for neovagina creation. The use of sigmoid vaginoplasty showed better functional outcomes than penile skin inversion, whereas cosmetic results were similar.di Summa PG, Watfa W, Krähenbühl S, et al. Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients. J Sex Med 2019;16:2030?2037.     

外阴癌广泛切除术后患者外阴重建术的临床分析

目的探讨外阴癌广泛切除术后创面修复、外阴重建的手术治疗方法。方法回顾性分析2003年3月—2005年10月北京协和医院收治的14例外阴癌患者的临床资料,14例患者均行外阴广泛性局部扩大切除术,采用带蒂股前外侧皮瓣或下蒂腹直肌肌皮瓣修复外阴缺损创面,并行外阴重建术。结果14例行外阴重建术的患者中,有13例患者的皮瓣全部成活,于术后12～14 d切口拆线,切口Ⅰ期愈合,其中1例行股前外侧皮瓣转移修复术的患者腹股沟区手术切口发生感染,但其皮瓣及供区植皮Ⅰ期愈合;1例行股前外侧皮瓣转移修复术的患者皮瓣发生部分坏死,面积约4 cm×6 cm,经局部换药、创面植皮治疗,术后36 d完全愈合。14例患者接受了2～20个月的术后随访,重建后的外阴形态丰满,富有弹性,阴道口无狭窄,疤痕无明显挛缩。结论应用股前外侧皮瓣或腹直肌肌皮瓣转移修复外阴癌广泛切除术后的皮肤软组织缺损,进行外阴重建,可使患者在手术切除肿瘤后获得外阴解剖外观及部分功能的恢复,具有临床应用价值。     

Surgical Outcomes and Patients' Satisfaction with Suprapubic Phalloplasty

IntroductionMany techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, which leads many patients to explore alternatives.AimThe aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty.MethodsMedical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being.Main Outcome MeasuresMedical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables.ResultsDuration of surgery and of hospital stay was relatively short in the first (1 hour 30 minutes; 3 days) and last (1 hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2 hour 15 minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Mean = 12.83 cm), and 71% with the circumference (Mean = 10.83 cm) of their neophallus. Satisfactory appearance was significantly correlated (P < 0.01) with penile length (r = 0.69) and diameter (r = 0.77). Sexual satisfaction was significantly correlated with penile diameter (r = 0.758), frequency of orgasm (r = 0.71), perceived importance of voiding while standing (r = 0.56), presurgery satisfaction with sexuality (r = 0.58), current masculine–feminine scale (r = 0.58), attractive–unattractive scale (r = 0.69), and happy–depressed scale (r = 0.63).ConclusionSuprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site. Terrier J-É, Courtois F, Ruffion A, and Morel Journel N. Surgical outcomes and patients satisfaction with suprapubic phalloplasty. J Sex Med 2014;11:288–298.     

Complications of Penile Augmentation by Use of Nonmedical Industrial Silicone

IntroductionPenile augmentation has been reported in the literature by injecting various materials by nonmedical persons.AimThis study aims to present our experience in management of penile augmentation complications associated with injection or implantation of industrial silicone by lay persons.Main Outcome MeasuresEarly surgical intervention can lead to faster recovery and better cosmetic and functional outcome.MethodsTwo patients had injection of industrial silicone paste, and the other two had industrial silicone ring implantation. All the patients except one were presented after 13 months of the procedure. Patients with industrial silicone ring presented with multiple sinuses of penile skin in one, and abscess discharge pus from the site of implanted ring in the other. Both patients with injected silicone paste presented with swelling and deformity of the penis that interfered with their intercourse. Silicone ring patients underwent skin incision and drainage of the infected materials and extraction of the implants with delayed skin closure. The two patients with silicone paste injection underwent two‐stage penile reconstructions using scrotal flap.ResultsPatients with extracted rings had smooth recovery with acceptable cosmetic outcome. One of them was not initially satisfied with the length of his penis that was overcome by short‐term use of vacuum device. One of the patients with silicone paste injection had wound infection that was successfully treated with local wound care. Both had satisfactory penile length and acceptable cosmetic outcome. All patients had normal erectile function postoperatively.ConclusionComplications of using industrial silicone injection can be drastic, and awareness of the public can avoid using of this material for penile augmentation. Shamsodini A, Al‐Ansari AA, Talib RA, Alkhafaji HM, Shokeir AA, and Toth C. Complications of penile augmentation by use of nonmedical industrial silicone. J Sex Med 2012;9:3279–3283.     

Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty

IntroductionThe free radial forearm (FRFA) flap is universally still considered as the gold standard technique in penile reconstruction. Typically, a considerably large flap is required, often involving almost the entire circumference of the forearm. Partial necrosis may occur at the distal-most (dorsoradial) part of the flap as a result of insufficient perfusion.AimTo describe a new technique using the posterior interosseous artery (PIOA) to supercharge FRFA phalloplasty.MethodsIn a 12-month period, all patients having FRFA flap phalloplasty were enrolled. Perioperative, after complete flap dissection, an indocyanine green perfusion scan was performed. In case of insufficient perfusion at the distalmost part of the flap, a supramicrosurgical anastomosis was performed between the FRFA pedicle and the PIOA (artery only).Main Outcome MeasuresStudied outcomes included the rate of marginal necrosis, surgical time, postoperative posterior interosseous nerve damage and urethral complications (fistula, stenosis or necrosis).ResultsA total of 27 FRFA flap phalloplasties was performed. Anastomosis of the PIOA was needed in 15 cases. No marginal necrosis was observed in these cases. There were no cases of postoperative posterior interosseous nerve damage. There were no significant differences in urethral complications (fistula, stenosis or necrosis) between the 2 groups.Clinical ImplicationsIn selected cases where insufficient perfusion of the dorsoradial part of the flap is present, patients may benefit from arterial supercharging to prevent postoperative marginal necrosis.Strength & LimitationsStrengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include single institution series and a limited number of patients.ConclusionArterial supercharging is effective in improving perfusion of large FRFA flaps used in phalloplasty when dorsoradial hypoperfusion is detected on an indocyanine green perfusion scan. It is a technically challenging addition to the standard technique because of the small size of the vessels, the close relationship between the PIOA and the posterior interosseous nerve, and the vulnerability of the newly constructed intra-flap anastomosis.De Wolf E, Claes K, Sommeling CE, et al. Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty. J Sex Med 2019;16:1111–1117.     

Aesthetic and Functional Outcomes of Neovaginoplasty Using Penile Skin in Male to Female Transsexuals

IntroductionIn the treatment of transgender women, the surgical construction of a neo vagina, or vaginoplasty, is the final stage in the transition to the desired gender. Surgeons aim to create a neovagina that is in function and appearance as close to a biological vagina as possible. However, to date, it is insufficiently clear whether transgender women are satisfied with the functional and cosmetic outcomes of vaginoplasty.AimsOur aim was to assess if penile skin inversion neovaginoplasty performed in transgender women meet the objectives strived for, by determining functional and aesthetic outcomes, as well as the physical and sexual well being and satisfaction.MethodsWe performed a retrospective survey study on 49 transgender women who underwent vaginoplasty using the penile skin inversion technique. Participants were asked to fill out the Female Sexual Function Index (FSFI), a combination of the Amsterdam Hyperactive Pelvic Floor Scale—Women (AHPFS W) and the Female Genital Self Imaging Scale, and a short questionnaire for self evaluation of vaginoplasty. Photographs of the genitalia were taken for objective assessment by an independent panel.Main Outcome MeasuresPrimary outcomes were the functional and aesthetic evaluation as perceived by the trangender women themselves. Secondary outcomes were the aesthetic evaluation of the vaginoplasty by an independent panel.ResultsFunctionality and appearance were both given an average score of 8 out of 10. Despite this high score, 56% is sexually dysfunctional according to the FSFI, mainly because of not being sexually active, or due to problems with lubrication and discomfort. In 75%, the result met the expectation and 70% thinks their genital is feminine enough.ConclusionThis study demonstrates that, despite relatively low FSFI scores, this group of transgender women is very satisfied with both the functional and aesthetic results of neovaginoplasty using penile skin inversion. Buncamper ME, Honselaar JS, Bouman M B, Özer M, Kreukels BPC, and Mullender MG. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male to female transsexuals. J Sex Med 2015;12:1626–1634.     

Spontaneous occurrence of synergistic bacterial gangrene following external pelvic irradiation

A case of spontaneous synergistic bacterial gangrene occurring after external pelvic irradiation is presented in a 25-year-old woman with invasive cervical cancer. Treatment consisted of aggressive antibiotic therapy and extensive excision and debridement followed by split-thickness skin grafting. Both recovery and cosmetic results were satisfactory. The pathophysiology, predisposing factors, and treatment modalities are presented.     

Surgical Solutions for the Complications of the Vaseline Self‐Injection of the Penis

IntroductionPenile girth enhancement by the injection of Vaseline is an existing practice. Many cases develop severe complications that need surgery.AimTo report on the reconstructive surgical solutions of the complications of Vaseline self‐injection and the outcomes. To develop a modification of a one‐step reconstruction method involving the use of pedicled scrotal flaps.Main Outcome MeasuresThe complications and their surgical solutions were classified as regards severity and difficulty. The outcomes were observed and a newly introduced one‐step surgical method was investigated.MethodsSeventy‐eight consecutive patients (87.2% of them with a history of imprisonment) were divided into three groups. In group A, aesthetic penile defects or phimosis caused by the Vaseline necessitated circumcision or local excision. In group B, the whole penile skin was involved, and total skin removal and two‐ or (a newly modified) one‐step reconstructive surgery were performed. In group C, both the whole penile skin and the scrotum were involved: complete skin removal and skin grafting or skin pedicled flap transplantation were carried out.ResultsIn five cases in group B, postoperative skin necrosis made a second operation necessary. There was one intraoperative urethral injury, where a urethral fistula developed and a second urethral reconstruction was performed. There was no major complication with the newly developed one‐stage pedicled flap procedure. At the end of the therapy, all the cases were healed. All of the patients reported successful sexual intercourse after the operations and 91% were satisfied with the result.ConclusionsThe complications depend mainly on the amount of Vaseline injected, the hygienic circumstances, and the personal tolerability. In the worst cases, only radical skin removal and skin transplantation can solve the problem. The newly developed one‐step arterial branch‐preserving scrotal skin flap reconstruction appears to be a suitable and cost‐effective solution for these patients.     

The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International,Multi-Center Case Series

IntroductionSome transgender men express the wish to undergo genital gender-affirming surgery. Metoidioplasty and phalloplasty are procedures that are performed to construct a neophallus. Genital gender-affirming surgery contributes to physical well-being, but dissatisfaction with the surgical results may occur. Disadvantages of metoidioplasty are the relatively small neophallus, the inability to have penetrative sex, and often difficulty with voiding while standing. Therefore, some transgender men opt to undergo a secondary phalloplasty after metoidioplasty. Literature on secondary phalloplasty is scarce.AimExplore the reasons for secondary phalloplasty, describe the surgical techniques, and report on the clinical outcomes.MethodsTransgender men who underwent secondary phalloplasty after metoidioplasty were retrospectively identified in 8 gender surgery clinics (Amsterdam, Belgrade, Bordeaux, Austin, Ghent, Helsinki, Miami, and Montreal). Preoperative consultation, patient motivation for secondary phalloplasty, surgical technique, perioperative characteristics, complications, and clinical outcomes were recorded.Main Outcome MeasureThe main outcome measures were surgical techniques, patient motivation, and outcomes of secondary phalloplasty after metoidioplasty in transgender men.ResultsEighty-three patients were identified. The median follow-up was 7.5 years (range 0.8–39). Indicated reasons to undergo secondary phalloplasty were to have a larger phallus (n = 32; 38.6%), to be able to have penetrative sexual intercourse (n = 25; 30.1%), have had metoidioplasty performed as a first step toward phalloplasty (n = 17; 20.5%), and to void while standing (n = 15; 18.1%). Each center had preferential techniques for phalloplasty. A wide variety of surgical techniques were used to perform secondary phalloplasty. Intraoperative complications (revision of microvascular anastomosis) occurred in 3 patients (5.5%) undergoing free flap phalloplasty. Total flap failure occurred in 1 patient (1.2%). Urethral fistulas occurred in 23 patients (30.3%) and strictures in 27 patients (35.6%).Clinical ImplicationsA secondary phalloplasty is a suitable option for patients who previously underwent metoidioplasty.Strengths & LimitationsThis is the first study to report on secondary phalloplasty in collaboration with 8 specialized gender clinics. The main limitation was the retrospective design.ConclusionIn high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty.Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019;16:1849–1859.     

Speech and swallowing function after reconstruction with a radial forearm free flap or a pectoralis major flap for tongue cancer.

BACKGROUND AND PURPOSE: The tongue plays a more significant role in English than in Mandarin, both in apical-palatal consonant production and tense-lax distinction. Theoretically, the same surgical intervention may produce a less significant impact on postoperative Mandarin production. The impact of tongue reconstruction on Mandarin articulation has not been reported. This study compared the tongue function outcome obtained using two methods of tongue reconstruction, radial forearm free flap transfer and pectoralis major flap transfer. METHODS: Twenty-five patients with carcinoma of the tongue underwent tumor resection. The surgical defects were reconstructed using a pectoralis major flap in six patients and a radial forearm flap in 19 patients. Swallowing and speech function were evaluated 6 months to 5 years after the reconstruction. Speech intelligibility and a Mandarin articulation test were used to evaluate the articulation proficiency before and after surgery. Clinical evaluation of deglutition included a questionnaire on dietary habits and a swallowing rating of 1 to 7. RESULTS: Clinical evaluation showed that patients with free flap reconstruction had more intelligible speech (p = 0.014) even after total glossectomy. Assessment of data obtained by clinical questionnaire showed no significant difference between the two groups in swallowing function. Motility due to flap pliability increased speech intelligibility but had little effect on swallowing function. CONCLUSION: Our results suggest that radial forearm flap transfer is better than pectoralis major flap transfer in preserving speech function and that there is no significant difference between the two methods of reconstruction in their impact on swallowing function.     

The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature

IntroductionLichen sclerosus (LS) of the glans penis is a chronic, progressive, scleroatrophic inflammatory process of unknown etiology affecting the glans penis, prepuce, and urethra and may lead to severe impairment of sexual and urinary function.AimsTo report our experience of surgical management of LS of the glans penis.Main Outcome MeasuresComplications, patients’ satisfaction, cosmesis, resolution of pain and puritus, and postoperative sexual function and were recorded retrospectively.MethodsThe surgical outcome of the 31 patients who have undergone resurfacing of the glans penis with the use of skin grafting for the management of genital LS in our institute is reported.ResultsAfter a median follow‐up of 12.8 months, 26 patients (84%) were fully satisfied with cosmetic and functional results, and 71% of them have resumed sexual activity.ConclusionsResurfacing of the glans penis represents a simple and reproducible technique for the management of LS and yields excellent functional and cosmetic results. Garaffa G, Shabbir M, Christopher N, Minhas S, and Ralph DJ. The surgical management of Lichen Sclerosus of the glans penis: Our experience and review of the literature. J Sex Med 2011;8:1246–1253.     

Versatile lotus petal flap for vulvoperineal reconstruction after gynecological ablative surgery

OBJECTIVE: The objective of the present work was to assess the efficacy and complications of the use of the lotus petal flap in the vulvoperineal reconstruction among female patients treated for vulvar malignancies. METHODS: Between December 2000 and April 2003, five patients underwent vulvoperineal reconstructions with the fasciocutaneous skin flaps elevated from gluteal folds immediately after vulvoperineal ablative surgeries at National Cancer Center Hospital, Tokyo, Japan. RESULTS: The mean surface area of vulvoperineal tissue defects was 157.9 cm(2) (64.0-195.0 cm(2)), which could be filled completely by bilateral lotus petal flaps. The mean length of follow-up was 18 months (7-32 months). All flaps successfully survived without fatal necrosis. In postoperative follow-up, all patients had no complaint of pain and no abnormal sensation at the site of flap or at the donor site, and the lotus petal flap caused no severe damage to excretion, mobility of the hip, or the sensation in the vulvoperineal area. The gluteal fold could make the donor-site scar stand out in all patients. CONCLUSION: The lotus petal flap is thought to be one of the most ideal reconstructive procedures for vulvoperineal region from various viewpoints of oncology, function, wound healing, and cosmetic surgery.     

Single Center Outcomes after Reconstructive Surgical Correction of Adult Acquired Buried Penis: Measurements of Erectile Function,Depression, and Quality of Life

IntroductionManagement of adult acquired buried penis is a troublesome situation for both patient and surgeon. The buried penis has been associated with significant erectile and voiding dysfunction, depression, and overall poor quality of life (QOL).AimTo identify outcomes following reconstructive surgery with release of buried penis, escutcheonectomy, and circumcision with or without skin grafting.MethodsWe retrospectively identified 11 patients treated by a single surgeon between 2007 and 2011, patient ages were 44–69; complete data review was available on all 11.Outcome MeasuresValidated European Organisation for Research and Treatment of Cancer 15 QOL, Center for Epidemiologic Studies Depression Scale (CES‐D), and International Index of Erectile Function (IIEF) surveys assessed patient QOL, depression, and erectile function pre‐ and postoperatively.ResultsMean body mass index (BMI) was 48.8 (42.4–64.6). Mean operative time was 191 minutes (139–272). Mean length of stay was 2.1 days. Ten of 11 patients required phallic skin grafting. There was one perioperative complication resulting in respiratory failure and overnight stay in the intensive care unit. Wound complications were seen in 2/11 patients, and 1 needed surgical debridement for superficial wound infection. Skin graft take was seen in 100% of the patients. Ninety‐one percent of patients noted significant improvement in voiding postoperatively. Ninety‐one percent of patients reported significant erectile dysfunction preoperatively. Subsequently, IIEF scores improved post surgery by an average of 7.7 points. Clinical depression was noted to be present in 7/11 patients preoperatively and 2/11 postoperatively based on CES‐D surveys. QOL improved significantly in 10/11 compared with preoperative baseline; however, many patients noted significant difficulties based on their weight and other comorbidities.ConclusionsManagement of adult acquired buried penis is a challenging, yet correctable problem. In our series it appears that by using established surgical techniques we were able to achieve significant improvements in erectile function, QOL, and measures of depression. Rybak J, Larsen S, Yu M, and Levine LA. Single center outcomes after reconstructive surgical correction of adult acquired buried penis: measurements of erectile function, depression, and quality of life. J Sex Med 2014;11:1086–1091.     

A Case Series of Robot-assisted Rectus Abdominis Flap Harvest for Pelvic Reconstruction: A Single Institution Experience

Study ObjectiveTo analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction.DesignCase series.SettingAcademic setting.PatientsPelvic reconstruction surgery patients.InterventionsThe rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall.Measurements and Main ResultsA retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57–79 years) and median follow-up time of 9.2 months (range = 5–12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset.ConclusionRobot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.