Penile Reconstruction

In terms of blast injuries or GSWs to the phallus or testicles and scrotum that are on the rise from the recent wars in the middle east, technology still has a lot of catching up to do in order for surgeons to be able to adequately preserve urinary and sexual function for the male veteran. In a six month period at a major US Army Combat Support Hospital located in Iraq in 2008, almost 3600 casualties were seen; of those, 172 patients presented with one or more urogenital injury, 119 veterans had injuries to the external genitalia, and penetrating trauma to the penis and scrotum accounted for another 59 of the veterans (Waxman, 2008). This study conducted was the first to ever look at the rise of genital trauma occurring to our veterans. When approximately 5% of returning veterans come home with not only the psychological scars of war, but have to face the cold reality that they may never be able to have children again (or at all) and that their penis may never be sexually functional, the need for new technologies to keep up with the ever-evolving injuries of war is greater than ever.

Severe trauma to external genitalia from an IED (Waxman, 2009)

Severe trauma to external genitalia from an IED (Waxman, 2009)

In combat, 50% of all external genital injuries from penetrating trauma are either from bullets or shrapnel; Improvised Explosive Devices or IED blasts accounted for the other 50%. Of those veterans who suffered testicular or scrotal damage, treatment was fairly straightforward with salvage of testicular tissue occurring where possible and orchiectomies being preformed the remainder of the time. Statistics on veterans as they left country reported that approximately 52% of all patients with testicular or scrotal injuries lost one or both testicles by orchiectomy (Hudak, 2009), but that number was expected to rise as further evaluation of “testis initially repaired in theater underwent later removal because of suspicion of mass” (Waxman, 2008).

Preservation of penile tissue and function in theater falls into the hands of a urologist (if

Vacuum assisted closure device (Hudak,2009)

available) and a general surgeon. Initial treatment includes “exploration, debridement and repair of isolated soft tissue injuries to the penis” followed by “staged reconstruction using vacuum assisted wound closure devices and/or split-thickness skin grafts” (Hudak, 2009). In severe cases mainly involving high velocity GSWs to the penis without urethra involvement, partial penectomies had to be preformed due to progressive necrosis of penile tissue (Hudak, 2009).

Neophallus prior to release from vascular supply (Horton, 1990)

Once a partial or full penectomy occurs, reconstruction becomes the next main focus for care providers. A number of operations are available with varying levels of success for penile reconstruction including using a lower abdominal pedicled fascia flap, a paraumbilical island flap or a free forearm flap (also known as a Istanbul flap) (Hu, 2005). Each procedure has similar basis in the theory of harvesting a skin flap from the abdomen, thigh or forearm for use in constructing new external penile tissue as well as the urethra and corpus penis. In case studies done with each procedure, excellent results were obtained for patients with the free forearm flap with higher degrees of satisfactory or partially satisfactory sex lives following the operation, but a number of patients who’d received either the paraumbilical or lower abdominal flaps elected to have the surgery repeated using the free forearm flap (Hu, 2005).

In order to efficiently use the free forearm fasciocitaneous flap, a surgeon well skilled in

Outline of the Free Forearm Istanbul Flap (Mutaf, 1999)

microsurgery must be included on the procedure. The procedure itself utilizes a “tube-in-a-tube” procedure for the formation of both the urethra and the external penile tissue. In the surgery, any remaining corpora and urethra are mobilized to be used as a good base to build onto. Horton (1990) describes the procedure as utilizing a flap large enough to match the patient’s penile needs from the forearm, which is then vascularly based on the radial artery, its vena comitans, and the cephalic vein. Sensation is provided by use of the lateral and medial antebrachial cutaneous nerves (Horton, 1990). The “tube-in-a-tube” portion is formed when the “ulnar portion of the flap is tubed over a stent to form the neourethra” while the radial portion of the flap “is used to form the phallus” (Horton, 1990). Secondary to the success of the “tube-in-a-tube” procedure, a patient must have an osteocutaneous flap harvested from a split bone segment of the radius (Mutaf, 1999). This bone segment provides the penile rigidity necessary for sexual intercourse. Once the forearm flap has been wrapped around both the neourethra and the bone segment, the new member is ready for transplantation onto the recipient site (Mutaf, 1999). Innervation for the newly formed phallus comes from the medial and lateral antebrachial cutaneous nerves when the are then paired with the pudendal nerves or their dorsal penile branches in the pelvis (Mutaf, 1999).

Immediate postoperative result of neopenis reattachment (Horton, 1990)

The free forearm Istanbul Flap has had a very high success rate with 100% of patients in Dr. Mutaf’s study reporting the return of orgasm through sexual intercourse and having the return of tactile sensitivity throughout the neopenis (Mutaf, 1999). In addition to the functional success of the procedure, the Istanbul Flap has relatively few complications that occur. The main complications of a procedure like this are the occurrences of urethral fistula formation arising at the junction of the native urethra and neourethra and the growth of hair in the neuurethra due to the tissue that was used to produce the neopenis coming from the forearm where hair growth occurs. This hair growth can cause partial obstructions and even urinary stones. Despite the complication risks and the extensive scaring that occurs at the donor site, the free forearm Istanbul Flap is the most successful procedure in use to battle the growing number of penile injuries that veterans are coming home with.

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