TRUNK AND LOWER EXTREMITY
CHAPTER 99 RECONSTRUCTION OF THE PENIS
J. JORIS HAGE
INDICATIONS AND REQUIREMENTS
Reconstruction or de novo construction of the penis may be indicated to treat genital ambiguity or severe micropenis, to relieve gender dysphoria in female-to-male transsexuals, or to treat for accidental or (self-) inflicted traumatic loss, oncological amputation, or infection of the penis.
Although masculinization can be extreme in newborns presenting with ambiguous genitalia, genetic females recognized in the neonatal period should be raised as girls as it is easier to adapt the genitalia toward the female phenotype.1,2 Although feminine assignment is often favored over condemning a male patient to a life with an inadequate phallus, it is no longer necessary to routinely assign the female gender to all male newborns with ambiguous genitalia. Three key issues are to be taken into consideration when deciding on the more appropriate gender for such patients. First, the urologist and reconstructive surgeon assess the urogenital anatomy to define the surgical procedures that would be required to construct functional male external genitalia.1,2 Testosterone may be administered to assess the likelihood of penile growth, thus excluding androgen insensitivity and possibly facilitating genital reconstruction. Second, the pattern of pubertal change that can be expected at the time of adolescence must be considered by an endocrinologist. A male role is especially preferable if a male infant has an enzymatic error preventing synthesis of testosterone, because testicular architecture is usually normal. Third, a behavioral scientist assesses the social and cultural background of the newborn and the views of the parents on the most appropriate sex for their child. Unbiased sexual orientation is enhanced if the parents show no ambivalence concerning the chosen sex.1
The above considerations apply only to the newborn in whom genital ambiguity poses an emergency situation. When the diagnosis is initially established at a later age, all measures should be directed toward restoring the concordance of the phenotype with the sex of rearing.2 Moreover, there are those patients in whom no (complete) surgical correction was undertaken even though a proper diagnosis had been made early in life. Complete endocrinologic and urogenital assessment is routine prior to the initiation of reconstructive surgery for such disorders, whether they appear in pediatric, adolescent, or adult cases. Therefore, treatment of genital ambiguity disorders should be restricted to multidisciplinary teams capable of well-balanced individualized recommendations for each patient.
The same principles apply to the treatment to female-to-male transsexuals. Driven by the persistent and unchangeable need to eliminate the difference between the physical reality of the body and gender of the mind, transsexuals seek to adapt their bodies as optimally as possible to the sex they feel they belong to. The key issue prior to considering gender-confirming surgery is to establish beyond reasonable doubt that the transsexual feeling is genuine. The diagnosis of gender dysphoria and the determination of whether sex reassignment surgery is warranted is primarily the task of a behavioral scientist. In addition, appropriate assessment of medical conditions and the effects of the hormonal treatment on liver and other organ systems should he accomplished preoperatively by an endocrinologist. Hence, all specialists involved to collaborate closely as members of a gender team.3
In male patients with penile loss as a result of amputation or infection, the remaining penile stump may prove of insufficient length causing poor personal hygiene and scrotal excoriation because of urine, as well as an inability to void when standing.4 Consultation with a behavioral scientist prior to any reconstructive procedures may prevent postoperative disappointment and frustration of phalloplasty or penile enhancement. In cases where the testes were also lost, the input of an endocrinologist is required and in oncologic patients the urologist has to be involved for proper timing of surgery. Therefore, again, a multidisciplinary approach is preferred.
Reconstruction or construction of the penis should ideally aim at: (a) a reproducible one-stage procedure; (b) creation of a competent neourethra to allow urination while standing; (c) preservation or restoration of tactile and erogenous sensibility in the phallus; (d) preservation of erectile function or sufficient bulk to tolerate the insertion of a prosthetic stiffener; and (e) a result that is aesthetically acceptable to the patient. Additionally, the ideal procedure also requires (f) minimal scarring or disfigurement and (g) no functional loss in the donor area.5
Correction of Genital Ambiguity
In cases where a decision for male gender assignment has been reached in a child with a small but complete micropenis, several surgical techniques to mobilize the cavernous corpora from the pubic rami, to accentuate the penoscrotal junction, and to reduce the pubic fat may be chosen in order to make the small phallus appear more prominent.1 Gonadal tissue that is inconsistent with the male sex should be removed.
Following masculine assignment in a truly intersex patient, genital correction is similar to that of severe hypospadias. Complete cordectomy is performed to mobilize the cavernous corpora and the urethra is lengthened to bring the perineal urethral orifice to the tip of the glans. Moreover, the ventral aspect of the glans is reconstructed to give it a normal appearance. This can often be accomplished in a single stage with the neourethra being constructed proximally from the midportion of a bifid scrotum meeting a distal rotated vascularized skin flap from the hooded foreskin. If necessary, a thick non-hirsute skin graft can be used to bridge a gap of any length. The prepenile, or “shawl,” scrotum that drapes around the base of the penis can be transposed caudally at a later stage and testicular implants may be inserted.1,2
The techniques mentioned above compare with metaidoioplasty, in which a penile substitution with clitoral enlargement and urethral lengthening is performed in female-to-male transsexuals.6–8 The term metaidoioplasty is derived from the Greek with “meta” as the prefix denoting the concept of “after” or “subsequent to.” Aidoio is an archaic combining form relating to the genitals and -plasty is the suffix derived from plastos (formed, shaped) meaning shaping. Indeed, androgen intake may stimulate the growth of the clitoris to the point where this organ can suffice as a phallus. Although metaidoioplasty is performed according to the principles of hypospadias surgery, the female external genitalia actually provide more tissue for surgical construction of a male phallus than a severe hypospadias patient has available. An overdeveloped clitoris may be distinguished from an underdeveloped penis by the frenulum on the ventral surface of the phallus. In normal males there is only a single midline frenulum, whereas in normal females there are two frenula, each lateral to the midline. Furthermore, the so-called chordae holding down the female clitoris represent the conjoined continuation of both labial spongiosus corpora toward the glans clitoris rather than solely fibrous strands present in severe hypospadias. The major labia are anterior in position to the scrotum and are “transposed” in relation to the penis. The minor labia correspond to the nonfused pendulous urethra and central penis covering, whereas the female urethral orifice is comparable to the perineal hypospadias situation.
During the single-stage metaidoioplasty, the clitoris is partially released and stretched by resection of the ventral chordae and the urethra is lengthened to the tip of the glans using a pedicled musculomucosal flap raised from the anterior vaginal wall and minor labial skin (Figure 99.1). In most patients the metaidoioplasty is combined with the construction of a bifid scrotum in which testicular prostheses are implanted, hence effecting the dorsal transposition of the major labia by bilateral V–Y advancement. Metaidoioplasty allows the base of the clitoris to be advanced approximately 3 cm anteriorly.6–8 If provided with a sufficiently lengthened urethra this clitoris-penoid will act as a normal and complete penis, albeit a small one hardly capable of sexual penetration. In female-to-male transsexuals where the clitoris seems to be large enough to provide a phallus that will satisfy the patient, this one-stage procedure is the method of choice.
Alternatively, efforts may also be made to construct a phallus de novo. The relevant differences between the female and male urogenital anatomy represent the surgical goals for phalloplasty in female-to-male transsexuals (Figure 99.2). The internal genitalia are superfluous but the urethra requires lengthening, and some sort of phallus has to be added. Because the male scrotum has abundant skin as compared with the female major labia, the labial skin requires augmentation and the insertion of testicular prostheses. Female erectile tissues are much less developed than their male counterparts and they are ideally replaced by an implant in female-to-male transsexuals.
FIGURE 99.1. Metaidoioplasty. A–F. In metaidoioplasty, the clitoris is stretched to become a phallus and the urethra is lengthened to the tip of the phallus using an anterior vaginal musculomucosal flap and labial skin flaps. A. Pre-op. B. Post-op. C. To allow for the release of the clitoral shaft and to secure neourethral lining and cover, the vestibular skin between meatus and glans clitoris is incised in a W-like fashion. D. The midline vestibular skin is undermined toward the glans thereby exposing the spongiosus tissue and chordae. These structures are resected to bare the ventral aspect of both cavernous corpora. E. After the phallus is stretched, the vaginal mucosa and vestibular skin flaps are rolled onto a catheter and sutured in a watertight fashion. Both flaps are anastomosed in a beveled fashion to prevent strictures. F. To strengthen the neourethra thus created, the medial aspect of the left minor labium is de-epithelialized and sutured to cover the pendular part of the neourethra. The lateral surface of the right minor labium is used to cover the perineal fixed part of the neourethra. (From Hage JJ. Metaidoioplasty—an alternative phalloplasty technique in transsexuals. Plast Reconstr Surg. 1996;97:161, with permission.)
FIGURE 99.2. A, B. Male vs. female anatomy. The relevant differences between female and male representing the surgical goals for phalloplasty in transsexual patients involve the superfluous female internal genitalia like the vagina (V) and uterus and ovaries (U). Conversely, the female body is short of erectile tissues (C), testes, and sufficient scrotal skin. Furthermore, in female-to-male surgery, the urethra should be lengthened (B, bladder and urethra; R, rectum). A. Male. B. Female.
Phalloplasty in female-to-male transsexuals can seldom be achieved in one stage because of the need to create a competent neourethra allowing a urine stream to break cleanly from the tip of the newly constructed phallus.5 Urethral construction in a properly situated phallus involves fitting the phallus with the pendular part of the urinary conduit, and also advancing the original female urinary orifice to a more anterior position. Advancement up to the base of the clitoris may be accomplished by construction of the perineal part of the neourethra using a flap raised from the anterior vaginal wall.5,9Construction of this fixed part is often performed separately from phalloplasty but may be combined with the hysterectomy. Other surgeons construct this pars fixa using an extra-long urethral part of the flap used for phalloplasty or, even, free grafts.
A variety of techniques have been used for the reconstruction of the actual phallus, and the development of techniques for phalloplasty has paralleled the evolution of plastic surgery. Randomly vascularized or axial pattern pedicled skin flaps and regional myocutaneous flaps, however, do not provide adequate sensibility to the phallus. Because such sensibility is a condition sine qua non for use of an incorporated stiffener prosthesis, I regard these to be techniques with few indications for phalloplasty. Although the ideal requirements of phalloplasty have not all been met by any single technique, microsurgical free flap techniques lead to superior functional and aesthetic results.5,10 Using free flaps, it is possible to provide the phallus with protective sensibility by coapting one of the dorsal clitoral or inguinal nerves to a cutaneous nerve in the flap. Because no erogenous phallic sensibility is to be expected in the neophallus, the second dorsal clitoral nerve should be left unharmed. To construct the pendular phallic part of the neourethra, the technique of a roll-in-a-roll is frequently used (Figure 99.3). Alternatively, the neourethra may be preconstructed by burial of a full-thickness skin graft in the flap to be used for the phalloplasty at a later stage.11
Rigidity techniques should only be performed secondarily, after sensibility has recurred in the free flap used for the phalloplasty. A constant rigid phallus may serve as a source of embarrassment to the patient and, therefore, inflatable hydraulic prostheses are to be preferred.5,12 Because such prostheses demonstrate mechanical failure, however, some authorities have their patients use external devices for erection, whereas others fully rely on edema, scar fibrosis, or congestion to give sufficient rigidity.
Apart from the need to give the perineum a scrotum-like appearance, aesthetic considerations require the construction of a glans-like tip of the neophallus. The Norfolk technique of coronal ridge and sulcus construction leads to superior results when a circumcised appearance is desired.5,10 Triangular flaps at the distal end of the flap give the phallus a conic glans and a sagittally slitted aspect of the urethral orifice and prevent meatal stricture (Figure 99.3).
As surgical techniques have developed, the combination of pedicled and free flaps, or even of two free flaps, has been applied. Such sophisticated methods do not always lead to better results than the use of a single free flap. Microsurgical techniques allow the surgeon to choose the free-flap donor site. The most frequently used are the radial forearm flap,5,10 the lateral upper arm flap, and the fibula flap.11 The donor site may be chosen in such a way as to prevent obvious scaring. Still, laborious techniques such as pretransfer tissue expansion and posttransfer correction of the donor site may be indicated. Consequently, the quest for other free-flap donor sites to be used for phalloplasty continues and neophalloplasty remains one of the most challenging procedures in reconstructive surgery.
FIGURE 99.3. Free flap penile reconstruction. Design of a free flap allowing the construction of the phallic part of the neourethra by the tube-within-a-tube roll technique. The 2.5 cm narrow skin strip is tubed outside-in to become the neourethra. Next to this strip, the flap is de-epithelialized over a width of 1 cm. This allows for the wider 10 to 11 cm skin part to be tubed and sutured in a watertight fashion around the urethral part to become the outer aspect of the phallic shaft. Proximally, the urethral skin flap is extended 1 cm beyond the outer flap to reinforce the anastomosis between this phallic part of the neourethra and its fixed perineal part. Two triangular flaps at the distal end of the flap give the phallus a conic glans and a sagittally slitted aspect of the urethral orifice and prevent meatal stricture. A distally based circumferential skin flap is dissected to be sutured to its own base in order to form the coronal ridge. The donor site is covered with a split-thickness skin graft to mimic the coronal sulcus. In cases where a radial forearm free flap is used, multiple vessels and nerves may be included (A, artery; N, nerve; V, vein). (Modified from Hage JJ, de Graaf FH. Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery. 1993;14:592, with permission.)
Most of the free flap phalloplasty techniques are also applicable in men who have sustained traumatic loss of their penis. In these patients the loss is often partial, necessitating the reconstruction of the extracorporal, or pendular, part of the penis only. In these patients and oncologic patients alike, combined suprapubic lipectomy and penile enhancement by uncovering its subcutaneous parts may offer a simple and satisfactory alternative.4,13 Penile enhancement aims to increase the external functional length of the penis by uncovering its subcutaneous parts with preservation of erogenous and tactile sensitivity (Figure 99.4). The non-hirsute skin that was previously used to cover the amputated corpora is spared to create the neoglans, and the remaining subcutaneously covered length of the combined corpora cavernosa and corpus spongiosum is dissected. Care is taken not to injure the dorsal penile neurovascular system. Dorsally, this dissection is continued up to the pubic symphysis, leaving only the deepest part of the suspensory ligament intact. To allow the pubic edge of the circumferentially incised skin to be anchored to the suspensory ligament dorsally, all but 1 cm of pubic fat is resected subcutaneously.13 Ventrally, the dissection is extended to bare 1 to 2 cm of the fascia of the bulbospongiosus muscle. Recessing the scrotum skin edge toward this muscle will restore the penoscrotal angle. Subsequent suturing of the lateral skin edges to the bared base of the penile shaft will preserve the entire length of the enhanced penis. A thin partial-thickness skin graft is used to cover the bare surface of the shaft because it is more likely to successfully take on the poorly vascularized tunica albuginea that may even have been irradiated in oncologic patients. By meshing this graft, the risk of postoperative edematous bulkiness is further reduced and the definition of the neoglandular corona is better maintained.4
In cases of severe micropenis or genital ambiguity the main question for the reconstructive surgeon concerns what the fate of the presented organ will be—can it be made any bigger or should gender reassignment be contemplated.1,2 A useful objective criterion for function is the ability to void standing up through an opened fly. It is surprising how short a penis can be used to accomplish this task, especially if a boy is given adequate instruction and trousers with adequate openings. The same applies for male amputees and for female-to-male transsexuals who had a metaidoioplasty: a very small penis is compatible with the normal male role. Thus, the prospect of a very small penis should not, on its own, be an indication for assignment to the female gender or phalloplasty.1
Although a small phallus may perform normal urination, it is more difficult to get away with an abnormal appearance. Little boys are very conscious of their genitalia and only a few men with a micropenis will feel confident to change clothes or shower in public. No operation has yet been devised to predictably make the corpora of the truly small penis longer, but the techniques for phalloplasty used for female-to-male gender confirmation can be applied to male adults. The disadvantage in infants is that the constructed phallus may not grow. Now that neophallic sensibility and possible rigidity may be secured, these techniques may be appropriate for the healthy adult male patient with a small but sexually sensitive penis or penile stump.
Total sensate phalloplasty including an erectile implant is not considered an option in the oncologic patient who is at risk for neophallic lymphedema resulting from inguinal lymph node dissection or adjuvant radiotherapy.4 Moreover, an increasing number of men present after partial penis amputation as organ-saving therapies are gaining interest among urological oncologists. Still, adhering to a 1.5 to 2 cm surgical cancer-free margin often leads to a phallus width in which voiding in the standing position and sexual intercourse are impossible, particularly in obese patients. These patients may be offered penile enhancement to relieve the psychological sequelae of inadequate penile length.13
Patients presenting for reconstruction or de novo construction of the penis require tailor-made treatment. The plethora of techniques for penile (re)construction stresses that various indications pose different requirements and suggests that not one technique may pass as a fit-for-all.
FIGURE 99.4. Penile enhancement after partial amputation. Left to right: The skin that was used to cover the amputated corpora cavernosa (CC) and corpus spongiosum (CS) is incised in an oblique circumferential fashion to recreate a neoglans (A). The remaining subcutaneously covered length of the penile shaft is subsequently dissected deep to Buck’s fascia (B). Dorsally, this dissection is continued up to the pubic symphysis (S) and partly into the deep suspensory ligament, whereas, ventrally, it is extended to bare 1 to 2 cm of the fascia of the bulbospongiosus muscle (MB). Following resection of pubic subcutaneous fat, the pubic skin is secured to the abdominal wall. The marked difference in circumferential width between the neoglans and the dissected penile corpora is sutured to the tunica albuginea to mimic the coronal ridge (C). The pubic and scrotal skin edges are anchored to the suspensory ligament and bulbospongiosus fascia (D) and the lateral skin edges are anchored to the tunica albuginea. The resulting bare surface of the penile shaft is then covered by a partial-thickness skin graft. (Modified from Hage JJ. Simple, safe, and satisfactory secondary penile enhancement after near-total oncologic amputation. Ann Plast Surg. 2009;62:685, with permission.)
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4. Hage JJ. Simple, safe, and satisfactory secondary penile enhancement after near-total oncologic amputation. Ann Plast Surg. 2009;62:685-689.
5. Hage JJ, de Graaf FH. Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery. 1993;14:592-598.
6. Hage JJ. Metaidoioplasty—An alternative phalloplasty technique in transsexuals. Plast Reconstr Surg. 1996;97:161-167.
7. Hage JJ, van Turnhout AA. Long-term outcome of metaidoioplasty in 70 female-to-male transsexuals. Ann Plast Surg 2006;57:312-316.
8. Djordjevic ML, Stanojevic D, Bizic M, et al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;6:1306-1313.
9. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44:611-614.
10. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124:510-518.
11. Hage JJ, Winters HAH, van Lieshout J. Fibula free flap phalloplasty: modifications and recommendations. Microsurgery. 1996;17:358-365.
12. Hoebeke P, de Cuypere G, Ceulemans P, Monstrey S. Obtaining rigidity in total phalloplasty: experience with 35 patients. J Urol. 2003;169: 221-223.
13. Horton CE, Dean JA. Reconstruction of traumatically acquired defects of the phallus. World J Surg. 1990;14:757-762.