Boyd H. Winslow

New concepts in phallic reconstruction.

Over the past four years we have performed total phallic reconstructions in 12 patients. Six patients underwent reconstruction following trauma, 3 were female-to-male transsexuals, and 3 had micropenis deformities. These reconstructions were one-stage microsurgical tissue transfers that included urethral reconstruction and coaptation of erogenous nerves. The surgical indications, techniques, and results are discussed.

Hidden penis release: adjunctive suprapubic lipectomy

We believe the hidden penis may be caused and concealed by a prominent suprapubic fat pad in addition to the restrictive fibrous bands of the dartos fascia fixing the shaft of the penis proximally while loose skin folds prolapse distally over the phallus. A penis of inadequate length or appearance may affect body image. Patients with this problem often require psychological support. Hidden penis may be distinguished from micropenis by palpating adequate corpora and showing a stretched penile length within 2 SD of normal. Excision of suprapubic fat with sectioning of the tethering dartos bands will release and increase the length of the penis. Suprapubic fat pad resection may also be helpful to elongate a short penis in cases of adult microphallus, or after partial penectomy because of trauma or cancer. Circumcision is contraindicated.

Phallic Construction in Prepubertal and Adolescent Boys

During the last 10 years we performed microsurgical phallic reconstruction in 7 prepubertal and 4 adolescent boys. Indications for surgery included post-traumatic amputation, circumcision accident, developmental anomalies and micropenis. In addition, we performed phalloplasty on 5 other patients 18 to 24 years old. Total phallic reconstruction consisted of 1-stage microsurgical tissue transfers that included urethral reconstruction, coaptation of erogenous nerves, aesthetic refinement and, in some cases, scrotal reconstruction. All postpubertal patients recovered erogenous sensibility in the reconstructed phallus and the ability to masturbate. Surgical indications, techniques and results are discussed.

Phallic Reinnervation via the Pudendal Nerve

Total phallic reconstruction presents the genitourinary reconstructive surgeon with one of the most difficult surgical challenges. The development of microsurgical techniques and free tissue transfers have advanced phallic reconstruction by reducing the number of surgical procedures and by allowing more selectivity in choosing the best innervated donor tissue. During the last 5 years 16 patients underwent total phallic reconstruction using free tissue transfers from distant donor sites. The pudendal nerve was coapted routinely to the major sensory nerves of the donor free flap. The most accurate objective baseline parameters of penile sensibility are pressure and vibratory thresholds, and electrically evoked potentials. We examined 30 normal subjects and 7 patients at least 1 year postoperatively for penile (phallic) sensibility. A pressure aesthesiometer, a biothesiometer and electrodiagnostic studies were used for testing. The 7 postoperative patients (in all of whom the pudendal nerve was incorporated into the reconstruction) had an encouraging return of tactile and erogenous sensibility compared to normal subjects. This is a promising advance in phallic reconstruction.

Microsurgical hypospadias repair.

Successful primary hypospadias repair depends on careful execution of surgical principles, particularly during the urethroplasty portion of the procedure. These principles include careful tissue handling, development of well-vascularized flaps, and avoidance of placing sutures in the uroepithelial surface. Despite meticulous repair, the complication rate requiring secondary surgery is 15 to 30 percent. For the past year, the authors have utilized an operating room microscope, microsurgical instruments, a specially designed microsuture, and a Biooclusive dressing to decrease the postoperative morbidity and subsequent complications requiring secondary surgery (6.5 percent). A comparison of 50 hypospadias patients on whom no microsurgical repair had been used was made with 62 patients on whom microsurgical techniques were employed. The nonmicrosurgical group had 17 complications, 12 of which required reoperation (24 percent). The microsurgical group had 8 complications, 4 of which required reoperation (6.5 percent).

Urethroplasty using diverticular tissue.

Diverticula that occur in the neourethra following repair of hypospadias, epispadias or urethral stricture generally are associated with obstruction distal to the dilated segment. This diverticular tissue can be moderately elastic and well vascularized. We have been able to relieve the stenosis by developing and advancing a diverticular flap, simultaneously reducing the size of the diverticulum.

Single-stage phallic reconstruction

SummaryPhallic construction/reconstruction represents one of the most challenging areas of surgery. The multiplicity of aesthetic, functional, and structural problems set this field apart from most other areas of reconstructive surgery. Described herein is a procedure for total phallic construction in a single stage. The procedure utilizes a combination of local muscle or myocutaneous flaps and free microvascular transfer flaps. The procedure results in a cosmetically acceptable phallus which has erogenous sensibility. Erectile function currently is obtained by the implantation, in a separate stage, of an erectile prosthesis.

The use of paraexstrophy flaps for urethral construction in neonatal girls with classical exstrophy

Primary closure of classical exstrophy was performed with paraexstrophy skin flaps for urethral lengthening in 4 female neonates. In all cases more than 2.0 cm. of urethral length were achieved. Efficacy of bladder closure and subsequent bladder neck revision were enhanced by the use of these flaps. The technique of urethral construction is described and our results are discussed.

Scrotal Recurrence of Paratesticular Rhabdomyosarcoma in a Previously Undescended Testicle 5 Years after Orchiectomy

A case of scrotal recurrence of a paratesticular rhabdomyosarcoma 5 years after orchiectomy and chemotherapy is described. To our knowledge local recurrences have been reported previously only in the inguinal region. The patient had a history of orchiopexy, which may have contributed to the scrotal recurrence.

Acute Bilateral Testicular Torsion in the Adolescent

A case of acute bilateral testicular torsion in the adolescent is reported. This case reaffirms the need to perform bilateral scrotal exploration in cases of suspected torsion. Although it represents an extreme rarity, delay in exploration may have resulted in bilateral orchiectomy. The case also appears to be another example of intermittent testicular pain as a harbinger of impending torsion in a patient with the bell clapper deformity. Perhaps a more aggressive approach should be taken to explore patients surgically who present with intermittent scrotal pain.