GLANULOPLASTY WITH SCROTAL FLAP FOR PARTIAL PENECTOMY

0022-5347/01/1663-0887/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 166, 887– 889, September 2001 Printed in U.S.A.

GLANULOPLASTY WITH SCROTAL FLAP FOR PARTIAL PENECTOMY OSVALDO N. MAZZA

AND

´ N M. J. CHELIZ GERMA

From the Ca´tedra de Urologı´a at Universidad de Buenos Aires, Hospital Alema´n and Hospital Durand, Buenos Aires, Argentina

ABSTRACT

Purpose: Reconstructing a penile stump secondary to trauma or cancer should result in satisfactory penile function and appearance. The lack of penile skin, stump retraction in the scrotum and stenosis of the neomeatus must be resolved in these cases. Materials and Methods: A 2-stage surgical technique with a scrotal flap was used in 34 patients with a mean age of 43.2 years to reconstruct the glans. Mean followup was 73.2 months. After penectomy a scrotal flap was designed and its distal extreme was transferred to the penile stump. The urethral end was sutured to a hole in the scrotal flap and the flap borders were sutured to the adjacent albuginea. The flap pedicle was resected 4 to 6 weeks later. Results: Patient recovery was characterized by a normal-appearing penis and unobstructed urinary flow. Definite depilation of the neoglans was required in 17.6% of cases. Partial necrosis of 2 flaps (5.8%) required grafts. Sexual potency was preserved in 7 men (20.5%). In 1 case (2.9%) urethral meatal stenosis resolved with minor surgical procedures. Conclusions: This technique enables us to design a neoglans with acceptable function and appearance, no penile retraction, satisfactory voiding and in certain cases possible intercourse with vaginal penetration. KEY WORDS: penis, surgical flaps, reconstructive surgical procedures

The final appearance of the penis should be a major concern after partial amputation secondary to trauma or cancer. The classic technique described by Pack and Ariel often causes partial penile retraction in the flaccid or erect state, involves urethral meatal stenosis and does not include glanuloplasty.1 Puckett and Montie described a groin flap without sensation that was used to tailor a glans.2 In 1984 Chang and Hwang described a radial forearm flap for phallic reconstruction.3 Farrow et al4 and Biemer5 reported modifications of these flaps in which the glans was formed by a splitthickness skin graft, plicating sutures or tattooing. Almost all glanuloplasties were originally developed for neophalloplasty and not for cases of partial penectomy. Skin grafts and preputial flaps have been placed in certain traumatic situations.6 We report the reconstruction of partially amputated penes by 2-stage development of a neoglans with a tubularized delayed scrotal flap.7 This procedure does not require microsurgery it is seldom compromised by flap life threatening ischemia and it has a low incidence of stenosis and fistula.

tients who had a vital penile stump remaining after surgery or trauma that was long enough for voiding while standing or satisfactory intercourse. Preoperative potency was reported by 31 patients. Stage 1 of the surgical technique involved preparation of the stump. Penectomy was completed and the penile skin borders were sutured to the albuginea at the site of the new balanopreputial sulcus (fig. 1, A and B). For preparation and fixation of the scrotal flap a wide based trapezoidal flap was incised on the anterior side of the scrotum, following penile stump features (fig. 1, C). A 15 mm. scrotal buttonhole was formed and sutured to the urethral end on a 14Fr catheter. The flap periphery was sutured to the albuginea, completing the balanopreputial sulcus. The pedicle was then tubularized (figs. 1, D and E, and 2, A). The flap was elevated onto the tunica dartos. At stage 2 the pedicle was divided and discarded 6 to 12 weeks later (fig. 1, F). Most scrotal flap hair follicles disappeared when stage 1 was completed. When they persisted, definitive depilation was performed at pedicle resection. RESULTS

MATERIALS AND METHODS

Between April 1981 and February 1999, 34 patients 6 to 62 years old (mean age 43.2) underwent 2-stage plastic surgery. Mean followup was 73.2 months (range 5 to 214). Patients were randomized according to surgeon preference. In 32 cases plastic surgery was performed with partial penectomy using oncological safety parameters due to TNM stages T1 and T2 squamous cell carcinoma. Tumor invaded the distal corpus cavernosum in 19 cases, was confined to the glans in 11 and extended to the glans and penile shaft in 2. Resection was performed with a 3 cm. margin proximal to the tumor. Lesion diameter was less than 4 cm. in all cases. Reconstruction was done after partial penectomy due to cancer in 1 patient and after partial amputation due to dog bite in a 6-year-old child. Neither patient had any glans remnant. Partial penile concealment and neomeatal developed stenosis in each case preoperatively. This technique was used in paAccepted for publication April 6, 2001.

There was no penile retraction or urinary obstruction during recovery in 33 patients (97%). Meatal stenosis in 1 case subsequently resolved with ventral meatotomy. Vaginal penetration was subjectively reported by 7 men (20.5%). No further studies were performed of the etiology of postoperative erectal dysfunction. In 33 patients with penile cancer there was no tumor recurrence in the graft region. Definitive depilation of the neoglans was required in 7 cases (20.5%). All patients had a balanopreputial sulcus with partial sliding of penile skin on the neoglans and a nonredundant prepuce (fig 2, B). Partial flap necrosis in 2 cases (5.8%) required the resection of fibrotic tissue and a partial skin graft in 1. Neomeatal stenosis was not evident in these cases. No local recurrence was observed. DISCUSSION

The purpose of penile stump reconstruction is to preserve to the greatest extent possible the morphology of the penis, a

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GLANULOPLASTY WITH SCROTAL FLAP FOR PENECTOMY

FIG. 1. A, penile stump after penectomy. B, suture of penile skin to albuginea and suture of corpora cavernosa. C, scrotal flap harvesting. D and E, suture of flap to urethra and albuginea. F, penile reconstruction after flap pedicle division.

permeable meatus and the facilitation of sexual activity. Fulfilling these principles depends on the nature and characteristics of the cutaneous segment transferred, glans reconstruction and sexual activity. In terms of the characteristics of the cutaneous segment, although scrotal skin is hirsute, it allows us to preserve penile skin, which is usually nonredundant. When the corpus cavernosum is covered with penile skin, as in the classic technique described in 1963 by Pack and Ariel,1 the penis when erect and even when flaccid partially retracts into the scrotum. Extragenital skin used as a partial skin graft6, 8 involves a poorly developed vascular bed, such as the albuginea. For glanuloplasty Benderev described rotational flaps to supplement skin coverage of a portion of the penis.9 Greenberger and Lowe reported sharp incision of the distal suspensory ligament of the penis, stump advancement and the transfer of scrotal flaps based on the superior lateral scrotum for covering the penile stump.10 Advancement and skin coverage avoid the creation of a perineal meatus. These 2 techniques resolve the lack of penile skin but do not involve neoglans formation. The purpose glanuloplasty is usually to reconstruct the glans by neophalloplasty, in which the flap allotted to the neophallus has a cutaneous segment that forms the new glans.2– 6, 11, 12 A recent modification of the forearm flap includes a big toe pulp segment for glans con-

struction.13 Although it has been performed in only 1 case, the authors report good cosmetic and functional results. Notably Jordan used a smaller forearm flap for glans formation via microsurgical technique.14 In neophalloplasty the design of a balanopreputial sulcus depends on partial skin graft coverage of the whole circumference of the penis. When using a scrotal flap, the sulcus is naturally placed at the joint of penile and scrotal skin. when flaccid, penile skin partially slides on the neoglans, resembling a prepuce that partially covers the penile and (fig 3). Due to the pigmentation characteristics of the scrotum, which differs from that of penile skin, the neoglans is much more similar to the natural glans. Although using scrotal flaps to cover the lateral sides of the denuded penis has been described previously,9, 10 to our knowledge their use in glans design has not been reported. Using flaps instead of grafts minimizes the possibility of posterior retraction. Although the flap that we describe is randomized, it does not require microsurgery, may be used when the usual donor sites of a free flap are unsuitable, has satisfactory vitality and is associated with partial necrosis in 5.8% of cases as well as a low incidence of postoperative stenosis. After partial penectomy due to trauma or surgery sexual potency may be preserved, as reported in about 25% of cases.15–17 We did not perform any diagnostic tests of the etiology of erectile dysfunction and have simply described selfreported postoperative potency. A better understanding of the etiology of impotence in 24 patients is mandatory since psychological or social reasons due to cancer diagnosis and a change in penile morphology may be added to traumatic or surgical causes of impotence. No sexual history of the 6-yearold boy was obtained. Nevertheless, since plastic surgery enables the preservation of a sexual appearance and does not result in a buried penis, it may facilitate function. This procedure is not only cosmetic, but also reconstructive and any effort to preserve penile morphology is worthwhile. CONCLUSIONS

Glanuloplasty with a tubularized delayed scrotal flap, which is generally done as a complement to partial penectomy for stages T1 and T2 penile carcinoma, improves the function and appearance of the remainder of the penis. Although this technique has the disadvantage of requiring 2 surgical stages, stage 2 causes minimal morbidity and makes possible outpatient treatment and local anesthesia. The facts that penile skin is not required for reconstruction and the neoglans highly resembles the natural glans are of the utmost importance. REFERENCES

FIG. 2. A, at stage 1 scrotal flap is sutured to penile stump. B, at stage 2 glans is reconstructed.

1. Pack, G. T. and Ariel, I. M.: Treatment of tumors of the penis. In: Treatment of Cancer and Allied Diseases: Tumors of the Male Genitalia and the Urinary System, 2nd ed. New York: Harper and Row, p. 15, 1963 2. Puckett, C. L. and Montie, J. E.: Construction of male genitalia in the transsexual, using tube groin flaps for the penis and hydraulic inflation device. Plast Reconstr Surg, 61: 523, 1978 3. Chang, T. S. and Hwang, W. Y.: Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg, 74: 251, 1984 4. Semple, J. L., Boyd, J. B., Farrow, G. A. et al: The “cricket bat” flap: a one-stage free forearm flap phalloplasty. Plast Reconstr Surg, 88: 514, 1991 5. Biemer, E.: Penile construction by the radial arm flap. Clin Plast Surg, 15: 425, 1988 6. Horton, C. E. and Dean, J. A.: Reconstruction of traumatically acquired defects of the phallus. World J Surg, 14: 757, 1990 7. Mazza, O. N.: Reconstructio´ n del mun˜ o´ n peneano. Te´ cnica original. Rev Argentina Urol Nefrol, 53: 5, 1987 8. De Souza, L. J.: Subtotal amputation for carcinoma of the penis with reconstruction of penile stump. Ann R Coll Surg Engl, 58: 398, 1976

GLANULOPLASTY WITH SCROTAL FLAP FOR PENECTOMY 9. Benderev, T. V.: Preservation of penile length in penile cancer and trauma by use of a pedicled flap. J Urol, 140: 145, 1988 10. Greenberger, M. L. and Lowe, B. A.: Penile stump advancement as an alternative to perineal urethrostomy after penile amputation. J Urol, 161: 893, 1999 11. Fang, R. H., Kao, Y. S. and Lin, J. T.: Glans sculpting in phalloplasty: experiences in female-to-male transsexuals. Br J of Plast Surg, 51: 376, 1998 12. Munawar, A.: Surgical treatment of the male genitalia. J Int Coll Surg, 27: 352, 1957 13. Sasaki, D., Nozaki, M., Morioka, K. et al: Penile reconstruction: combined use of an innervated forearm osteocutaneous flap

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and big toe pulp. Plast Reconstr Surg, 104: 1054, 1999 14. Jordan, G. H.: Penile reconstruction, phallic construction, and urethral reconstruction. Urol Clin North Am, 26: 1, 1999 15. Stoudemire, A., Techman, T. and Graham, S. D., Jr.: Sexual assessment of the urologic oncology patient. Psychosomatics, 26: 405, 1985 ´ ncona, C. A., Botega, N. J., De Moraes, C. et al: Quality of life 16. D’A after partial penectomy for penile carcinoma. Urology, 50: 593, 1997 17. Opjordsmoen, S., Waehre, H., Aass, N. et al: Sexuality in patients treated for penile cancer: patients’ experience and doctors’ judgement. Br J Urol, 73: 554, 1994