Total scrotal reconstruction with vertical rectus abdominis musculocutaneous (VRAM) flap in the treatment of penoscrotal lymphedema

Summary A 37-year-old man with scrotal and penile lymphedema was treated by total excision of the scrotal and penile skin and subcutaneous tissue. Split thickness skin grafts were used to cover the penis and the pubic area. An inferiorly based left rectus abdominis muscle with a 12 x 16 cm skin island from the epigastric region was used to reconstruct the scrotum. The VRAM flap is a simple, reliable flap and it provides sufficient coverage of the exposed testicles after total excision of diseased scrotal skin. It also gives a satisfactory esthetic result. The VRAM flap may be another source for reconstruction of the total scrotum. Correspondence to: S.N. Kesim     

Thirty-year experience of utility of island groin flap for scrotal defect single-stage reconstruction

For the last 32years, we have been using island groin flap successfully to cover the scrotal defects in a single stage with good results. This flap utility for single-stage urethral fistula repair was first reported by the senior author in 1987 and was published in Br J Urol.¹We have performed single-stage repair of scrotal defects of medium and moderate size with this flap in 25 cases of Fournier's gangrene and in 4 cases of scrotal avulsion injuries due to road traffic accidents. All had good aesthetic results. More than 50% scrotal size defects were treated by a single groin flap alone. In cases with total loss of the scrotum, the groin flap was used along with two superior medial pedicle thigh flaps. Here, we have included cases of single-stage reconstruction of scrotal reconstruction by island groin flap alone. All our patients were operated under spinal anaesthesia. The results were satisfactory for the patients. We conclude from our 30 years of experience of utilizing this vascular island groin flap for a single-stage repair of scrotal defects of moderate size to be a procedure of better choice.     

Scrotal septocutaneous island flap for the reconstruction of the urethral fistula

We report the reconstruction of the urethral fistula using a scrotal septocutaneous island flap. A scrotal septocutaneous island flap is supplied by vascular networks in the scrotal septum area from both perineal arteries and posterior scrotal arteries. This flap is divided into two flaps, one for urethral lining and the other for the skin defect. We found it to be a simple, useful, and reliable alternative to other local flaps. However, hairless skin of the scrotum must be used for the urethral lining. The musculocutaneous flap is also reliable. However, use of the scrotal septocutaneous island flap can save the musculocutaneous flap for secondary procedures.     

重建阴囊对睾丸生精功能影响的临床观察及实验研究

目的　探讨重建阴囊对睾丸生精功能的影响。方法　对 2例阴囊皮肤撕脱伤后采用髂腹股沟皮瓣重建阴囊进行长达 4年的随访 ,并分别作了精液常规检查、睾丸活检、性功能及性激素水平测定。为排除临床上可能存在的睾丸及精索挫伤造成的生精功能障碍 ,以育龄家兔为实验动物 ,手术剥脱其阴囊 ,采用下腹部皮瓣重建 ,观察其睾丸的生精功能情况。结果　临床病例随访显示 ,在重建阴囊早期 ,对睾丸的生精功能影响不大 ,但随着时间延长 ,精子数及活动率明显降低。皮瓣重建家兔阴囊 2个月后 ,其睾丸的生精功能明显下降 ,与育龄雌兔交配 ,无生育能力。结论　对阴囊皮肤撕脱伤采用较厚的皮瓣重建应慎重。     

Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget's disease

Wide excision of extramammary Paget's disease of the penoscrotal region may leave large defects that cannot be closed easily. The authors describe their experience with a series of 6 patients in whom reconstruction of the scrotal defect was undertaken using the scrotal remnant raised as a stretchable musculocutaneous flap. It was observed that as little as a third of the residual scrotum could be expanded to resurface the entire scrotum. All flaps survived completely. Severe scrotal edema and ecchymosis were observed in 1 patient but the symptoms resolved completely with Trendelenburg positioning. The penile defects were resurfaced individually with thick skin grafts. Good-quality take with no chordee was observed in all patients after initial reconstruction. One patient developed penile contracture after reexcision of recurrent disease. Mean follow-up was 22 months (range, 3-60 months). Large defects of as much as two thirds of the scrotum may be reconstructed successfully using the tissue-expanding scrotal musculocutaneous flap.     

Gangrena de Fournier: de urgencia urológica hasta el departamento de cirugía plástica

Fournier's gangrene (FG) is a rare and potentially fatal infectious disease characterised by necrotic fasciitis of the perineum and abdominal wall in addition to the scrotum and penis in men and the vulva in women. Skin loss can be very damaging and difficult to repair. This condition must be treated aggressively. Several techniques are used to reconstruct lost tissue: skin grafts, transposition of the testicles and spermatic cords to a subcutaneous pocket in the upper thigh, scrotal musculocutaneous flaps, fasciocutaneous flaps and several other types of pediculated myocutaneous flaps are all employed.The supero-medial thigh skin flap is a likely arterial flap and has been shown to be an effective method for reconstructing large scrotal defects.     

Single-stage muscle flap reconstruction of major scrotal defects: report of two cases.

Major scrotal defect with exposed testes and/or spermatic cords are a challenge for the reconstructive surgeon. The bacterial flora of the perineum, difficulty of immobilisation and the contour of the testes make testicular cover a difficult task [Br. J. Plast. Surg. 41 (1988) 190].Traditional approaches have used simple skin grafts or if not feasible, multi-staged procedures with initial burying of the testes under delayed medial thigh flaps. Better techniques then evolved to permit early single-staged coverage using flaps rather than skin grafts in these usually contaminated and unsuitable wounds to improve the cosmetic outcome of the reconstruction and reduce patient discomfort and hospital stay.Muscle flaps represent an excellent reconstruction option in the contaminated perineum especially in patients with impaired ability to deal with infection such as diabetic or toxic patients.We present two cases of reconstruction of the scrotum using simple, reliable single-stage muscle flap techniques with good aesthetic results and review the literature.     

Low grade sarcoma of scrotal wall

We report a rare case of low grade sarcoma of scrotal wall. A male child aged 2 1/2 years presented with history of scrotal lymphoedema involving the left side of scrotum, slowly progressive since birth. We planned scrotectomy but the patient was lost to follow-up. During intervening period, left inguinal omentopexy was done elsewhere. The patient again presented 3 years later with multiple swellings in scrotum. We performed almost complete scrotectomy with reconstruction of the scrotal defect using scrotal remnant as a stretchable musculocutaneous flap. A third of the residual scrotum could be expanded to resurface the entire scrotum. On histopathology, low grade malignant peripheral nerve sheath tumor of grade-I was confirmed. Post-operative follow-up showed no residual disease.     

阴囊皮肤多源性血供系统应用解剖学研究

目的探讨阴囊皮肤血供模式,明确可能的阴囊皮瓣供区。方法对10具(20侧)成年男尸阴囊皮肤进行解剖学研究。结果阴囊前动脉来自阴部外浅动脉,于阴茎根部侧方分成内、外侧支,分布于阴囊前外侧皮肤,内侧支口径为(0.54±0.34)mm和(0.69±0.09)mm;来自闭孔动脉前皮支的阴囊外侧动脉[出现率为85％,外径(0.62±0.19)mm]分布于阴囊外侧中1/3区皮肤;阴囊后动脉于阴囊后极处,分成阴囊后动脉外侧支与阴囊中隔动脉,前者[外径(0.8±0.1)mm]分布于阴囊后外侧区皮肤,后者[外径(0.9±0.2)mm]分布于阴囊中隔及阴囊中缝侧方皮肤。结论上述4组血管均在阴囊肉膜层内走行,其终末支血管相互吻合,在每一侧阴囊形成一个较为完整的动脉网络,由此提出4种类型的阴囊皮瓣切取方式,其他类型的阴囊皮瓣是上述阴囊皮瓣切取方式的变化形式。     

Anteriorly based pudendal thigh flap for scrotal reconstruction based on the deep external pudendal artery (DEPA) flap

Background

Major scrotal skin loss represents a significant challenge for reconstructive surgeons. Although many therapeutic methods have been established for the treatment of such defects, each technique has its own advantages and disadvantages. A posteriorly based pudendal thigh fasciocutaneous flap at the perianal region has been described for reconstruction of genital organs, but an anteriorly based pudendal thigh fasciocutaneous flap has not been described for scrotal reconstruction.

Aim

The aim of this study was to introduce and evaluate the use of an anteriorly based pudendal thigh flap for scrotal reconstruction.

Methods

Twenty flaps in 15 patients with major scrotal defects were subjected to reconstruction using this flap. The etiology of scrotal loss was Fournier gangrene in all cases. Five patients each underwent bilateral and ten patient unilateral reconstructions, by the anteriorly based pudendal thigh flap, based on the deep external pudendal artery (DEPA).

Results

All 20 flaps survived completely. Additionally, the donor site was closed directly, and the scar was hidden in the perineal crease. The donor site healed uneventfully, as one patient required a secondary procedure for healing.

Conclusion

An anteriorly based pudendal thigh flap is highly reliable for coverage of major scrotal defects. This flap allows adequate coverage with excellent aesthetic appearance of the scrotum.Level of Evidence: Level II, therapeutic study.

     

阴囊纵隔皮瓣与阴囊中厚皮片对合移植Ⅰ期修复重型尿道下裂

目的探索一种可行的安全可靠的手术方法修复尿道,矫正重型尿道下裂畸形。方法对于严重型尿道下裂而阴囊发育正常的患者,运用阴囊纵隔岛状皮瓣同时对合取舍自阴囊的中厚皮片移植,Ⅰ期修复尿道治疗尿道下裂畸形。结果共计15例,术后随访1年,包括阴茎近端和阴茎阴囊及阴囊型尿道下裂,Ⅰ期完成治疗,治疗效果良好,没有尿道狭窄和尿瘘等并发症发生,手术后的尿道外口正位于阴茎头中央,阴茎矫直,无偏曲,排尿尿线直,尿道镜检查再造尿道内壁平整光滑。结论利用阴囊纵隔瓣对合阴囊中厚皮片Ⅰ期成形尿道,完成严重型尿道下裂的修复,效果可靠,操作简单,对合技术同时综合了皮片和皮瓣再造尿道的优点,并且能充分保证矫正阴茎下弯畸形,取得再造阴茎外观和功能上的满意疗效,是一种较理想的治疗手段。     

A new use of scrotal septal skin flap in repairing hypospadias

In our study, we introduce the use of a scrotal septal skin flaps in repair of hypospadias. Between June 2006 and October 2008, 30 patients were treated by using a penile local flap to reconstruct the urethra, and a scrotal septal skin flap to cover the wound located on the ventral side of the penis. Of 30 patients, 4 presented with urine leakage, but this condition healed spontaneously after 2 to 4 weeks. Urine leakage healed without problem in the remaining patients, and they had unobstructed urinary flow. Additionally, they all were satisfied with genital appearance after the reconstruction. We conclude that our method is a convenient means to cover the wound at the ventral side of the reconstructed urethra by using a scrotal septal skin flap during hypospadias repair. This procedure provides good urinary function and satisfactory appearance to the patients. In addition, this method solves the problem of very limited local tissue for urethral reconstruction in the hypospadias patient.     

EXTRAMAMMARY PAGET's DISEASE OF THE PENIS AND SCROTUM: EXCISION, RECONSTRUCTION AND EVALUATION OF OCCULT MALIGNANCY

PURPOSE: We describe treatment and reconstruction in patients after surgery for extramammary Paget's disease of the penis and scrotum. We also investigated whether this disease causes an increased risk of undiagnosed visceral malignancy. MATERIALS AND METHODS: We reviewed the databases at our institution from 1996 to 2000 and identified 6 men 67 to 87 years old (mean age 76). In addition, we reviewed the literature on the clinical and pathological features of this disease. RESULTS: In our 6 patients scrotal involvement was present in 83% and penile extramammary Paget's disease was present in 33%. Each man underwent wide local excision and large skin defects were immediately reconstructed with split-thickness skin grafts. In 1 case extramammary Paget's disease had spread to the superficial inguinal nodes. At a mean followup of 29 months there has been no local recurrence and internal malignancy has not been diagnosed. Our literature review revealed 13 patients with penoscrotal extramammary Paget's disease and visceral malignancy, including 12 (92%) with malignancy of the genitourinary system. CONCLUSIONS: Extramammary Paget's disease of the penis and scrotum is a rare disease that can be managed by excision and immediate reconstruction with skin grafting or a local skin flap. Disease may spread to the regional lymph nodes. Although genitourinary cancer may accompany penoscrotal extramammary Paget's disease, an extensive search for cancer of the thorax or abdomen may be unnecessary because only 1 reported case of colon cancer has been associated with penile or scrotal extramammary Paget's disease.     

Surgical reconstruction of the sequelae of penile and scrotal gangrene: a plea for simplicity

Gangrene of the scrotum with or without involvement of the penile skin and occasionally beyond these limits, is not an uncommon problem in some parts of the world. Various workers have used different techniques to provide skin cover including transplantation of testes, free skin grafts, axial groin flaps and myocutaneous flaps. This study brings out our experience with the treatment of 43 cases in the last 11 years. In three cases the gangrene had spread beyond the scrotum and penis and cover had to be supplemented with split-skin grafts. In all the other cases, cover was provided with scrotal skin remnants at the edge of the lesion and on the penis with the inner layer of the prepuce, which had remained intact.     

Giant penoscrotal elephantiasis

A patient with massive lymphedema of the penis and scrotum is reported. After radical excision of the elephantoid tissues a reconstruction with a posterior scrotal flap and a skin graft was performed. The surgical options and the literature are reviewed. Good cosmetic and functional results were obtained with a one-stage procedure. Received: 16 April 1999 / Accepted: 1 June 1999     

阴囊Paget病（附44例报告）

收治４４例阴囊Ｐａｇｅｔ病患者，分析了Ｐａｇｅｔ病灶的典型表现及治疗方法。对于经久不愈的阴囊皮损，应怀疑Ｐａｇｅｔ病。治疗首选手术切除，对于切除范围大的病灶，可用植皮或转移皮瓣闭合创面。如果病灶边界欠清，切缘皮肤应常规送快速冰冻切片检查。     

Surgical treatment of distal hypospadias

From a total of 1,164 cases of hypospadias operations between 1966 and 1981 we report our experience in the operative treatment of distal hypospadias (n = 208). The best time for hypospadias repair is between 3 and 6 years of life. With correction of chordee it is most important to excise all penile skin of poor quality. The standard operation for the correction of chordee is the procedure described by Erdely and Bosio. If there is insufficient penile skin, scrotal skin is used to cover the skin gap. In the case of a small scrotum, only the proximal defect is covered by scrotal skin and the distal part by the procedure described by Blair, Browne, Ombredanne and Edmunds. The formation of a new urethra is accomplished with the use of Duplay's principle. We prefer subcutaneous running suture under tension with rubber bands. In the case of multiple previous operations and failed reconstruction of the urethra a tube of scrotal skin is formed and brought to the tip of the penis subcutaneously. Many authors have described numerous procedures for the treatment of hypospadias. We have combined the advantages of all techniques and formed our own approach always taking the individual case into consideration. With this approach we have good results in the treatment of hypospadias.     

Scrotal reconstruction using a superficial circumflex iliac artery perforator flap following Fournier's gangrene

Fournier's gangrene is a type of necrotising fasciitis around the scrotum and perineum. Because of its aggressive nature, patients should be treated with broad‐spectrum antibiotics and emergency, radical debridement during the acute phase. After recovering from the acute phase, reconstruction of the scrotal and perineal soft tissue defects is needed and is often challenging. Traditionally, various reconstruction methods have been used, including skin grafts, fasciocutaneous flaps and musculocutaneous flaps, each with its pros and cons. We successfully covered a wide scrotal defect using a superficial circumflex iliac artery perforator flap, which has not been previously reported for this indication. The design and operative technique are introduced in this study.     

Two cases of traumatic denudation of the penile and scrotal skin

Two cases of denudation injuries of the penis and the scrotum are reviewed. In the first case a total skin erosion of the penis and scrotum has happened. In the second injury, the major part of the skin was lost. The reconstructive operations are shown in a series of photographs. Replacement of the total skin deficiency was performed by placing a split-thickness graft on the penis, while reconstruction of the scrotum was carried out by using a thigh pedicle flap. In the second case partial loss of the skin could be replaced by mobilizing the free skin edges.     

Perineoscrotal reconstruction using a medial circumflex femoral artery perforator flap

Major scrotal defects may result from infection due to Fournier's gangrene, excision of scrotal skin diseases, traumatic avulsion of scrotal and penile skin, and genital burns. The wide spectrum of bacterial flora of the perineum, difficulty in providing immobilisation, and obtaining a natural contour of the testes make testicular cover very difficult. Various methods have been reported to cover the penoscrotal area, including skin grafting, transposing them to medial thigh skin, and use of local fasciocutaneous or musculocutaneous flaps. In this report, reconstruction using six local medial circumflex femoral artery perforator (MCFAP) flaps was undertaken in five male patients (mean age, 47 years) with complex penoscrotal or perineal wounds. The cause of the wounds in four patients was Fournier's gangrene, and was a wide papillomateous lesion in the other patient. Flap width was 6-10 cm and flap length was 10-18 cm. The results showed that a MCFAP flap provided the testes with a pliable local flap without being bulky and also protected the testicle without increasing the temperature. The other advantage of the MCFAP flap was that the donor-site scar could be concealed in the gluteal crease. Our results demonstrated that the MCFAP flap is an ideal local flap for covering penoscrotal defects.