Penis total penile reconstruction

Penis total penile reconstruction

1. Total Penile Reconstruction
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. History
•It was developed original for trauma patients
•Bogaraz described phallic construction – War
injured persons
•Gillies and Harrison has accomplished penile
reconstruction during 2
nd
World war.

3 Dept of Urology, GRH and KMC, Chennai.

4. •All procedures for phallic construction involed
delayed formation and transfer of tubed
abdominal flaps.
•Tubes were produced from random flaps of
skin and based on blood supply.
•The “tube-within-a-tube” design , the inner
tube allowed the placement of baculum
during intercourse and the outer tube
provided skin coverage.
•Patients voided through a proximal
urethrostomy.
4 Dept of Urology, GRH and KMC, Chennai.

5. •Orticochea constructed the penis using the
gracilis musculocutaneous flap.
•In 1978, Puckeet and Montie constructed
tubed groin flap.
•In 1984, Chang and Hwang used the forearm
flap based on the radial artery , for phallic
reconstruction.
•In 1990, Farrow and associates modified the
radial forearm flap to “cricket Bat” like flap.
5 Dept of Urology, GRH and KMC, Chennai.

6. •Forearm flap is a fasiocutaneous flap based on
radial artery.
•The Ulnar artery also vascularizes the forearm
fascia and most of the forearm skin.
•The forearm flap is elevated and transferred
on the superficial fascia.
•The lateral and medial antebrachial cutaneous
nerves appear proximally beneath the fascia.
•The cephalic, basilic, and medial antebrachial
veins are also included in the flap-for Venous
drainage.

6 Dept of Urology, GRH and KMC, Chennai.

7. •In Chang and Hwang forearm flap the shaft is
covered with the radial aspect of the skin
paddle.
•The deepithelialized strip is made and second
skin island, on theulnar aspect of the skin
paddle, is tubed to form the urethra.
•The urethral tube is then rolled within the
tube of the skin to form a tube-within-a-tube
design.

7 Dept of Urology, GRH and KMC, Chennai.

8. 8 Dept of Urology, GRH and KMC, Chennai.

9. •In the cricket bat modification , the urethral tube
extends distally, overlying either the radial or the
ulnar artery.
•Proximal to urethral strip a border portion of the
skin paddle provides the coverage of the shaft.
•The urethral portion is tubed and transposed by
inverting it to the centre of the shaft portion of
the skin paddle.
•The advantage is urethral portion over the
respective artery is in contrast to the chinese
design in which the ulnar aspect is for distal from
the radial artery.
9 Dept of Urology, GRH and KMC, Chennai.

10. 10 Dept of Urology, GRH and KMC, Chennai.

11. •The modification of the Biemer in which the
flap is elevated on the radial artery and
includes the vascularized piece for the radial
bone to provide rigidity to the new penis.
•Rigidity is obtainable by use of external
applied or internally implanted prosthesis.

11 Dept of Urology, GRH and KMC, Chennai.

12. 12 Dept of Urology, GRH and KMC, Chennai.

13. •The Biemer design is modified to construct a
glans originally described by Puckett and
Montie.
•In this modification the large island is left
distally and flared back over the tip of the
tubed flaps, creating the illusion of a glans
penis.

13 Dept of Urology, GRH and KMC, Chennai.

14. •The disadvantage of forearm flap.
–Unsightly scar, is obvious donor site deformity
–Development of cold intolerance in the hand of
the donor side
–Hairy forearm flap is problematic if it is included in
urethral construction

14 Dept of Urology, GRH and KMC, Chennai.

15. •Sadove and McRoberts proposed the use of
the fibular osteocutaneous flap for phallic
construction.
•The fibula is elevated on the periosteal vessel
along with the overlying skin paddle.
•Urethral reconstruction is by tubed graft
techniques.
•Urethral constructin is merely an application
of the staged graft reconstruction.
•Graft could be split thickness skin.
15 Dept of Urology, GRH and KMC, Chennai.

16. •For only to cover the shaft of the penis the
upper lateral of flap is used.
•This is a faciocutaneous flap, and it cutaneous
vascular territory is centered on the radial
collateral artery.
•The flap is also used for total phallic
constructions.
•The flap is expanded by tissue expander and
elevated across the elbow.
16 Dept of Urology, GRH and KMC, Chennai.

17. •All the flaps described allow micro neuro
surgical coaptation of the flap cutaneous
nerves with recipient nerves
•Cutaneous nerves are usually attached to
dorsal nerves of penis
17 Dept of Urology, GRH and KMC, Chennai.

18. •For the flap transfer the recipient vasculature
is commonly deep inferior epigastric vessel.
•When the deep inferior epigastric vessel used
is often necessary to include saphenous vein
for further venous runoff.

18 Dept of Urology, GRH and KMC, Chennai.

19. •We commonly use gracilis muscle to cover the
urethral anastomosis, increase the vascularity
of the area and lowers the incidence of fistula
and striture formation.
•We can also elevate a bipedicled flap from the
area of the penile shaft based, which is
transposed beneath the phallic flap.
19 Dept of Urology, GRH and KMC, Chennai.

20. •During the phallic construction, urine is
diverted by means of SPC tube, and the
urethra is stened with a No. 14 soft silicone.
•A voiding study is performed between third
and fourth post-operative week.
•Rigidity is obtained by an externally applied or
permanently implanted prostesis

20 Dept of Urology, GRH and KMC, Chennai.

21. •We implant both hydraulic and articulated
prosthesis.
•These devices are anchored to the ischial
tuberosity and the pubis by ancoring the
neocorpora to these bone structures.
•We use commonly two cylinders or rods for
the implantation.

21 Dept of Urology, GRH and KMC, Chennai.

22. Reconstruction after Trauma
•The prime is preserve the penile structures
and function.
•Urine must be diverted, necrotic tissue must
be debrided and any foreign bodies implanted
must be removed.
•After 3 to 6 weeks after trauma, primary
reconstruction can be undertaken.
22 Dept of Urology, GRH and KMC, Chennai.

23. •For groin reconstruction- tensor fascia lata
flap can be used.
•The rectus femoris flap can be transposed to
the area of the lower abdomen and useful for
inguinal reconstruction.
•The gracilis muscle flap is excellent for
perineum and the groin.
23 Dept of Urology, GRH and KMC, Chennai.

24. •Variation of flap designs described for complete
phallic construction have been successfully
applied in select patients for penile
reconstruction
•In Blast penile injury the right corpus cavernosum
, and majority of the penile skin is destroyed or
used for urethral reconstruction.
•In this patient, a flap based on the chinese design
was elevated.
•We used Biemer design flap to construct glans.

24 Dept of Urology, GRH and KMC, Chennai.

25. Thanks
25 Dept of Urology, GRH and KMC, Chennai.