Neo-phalloplasty in children and adolescents for acquired penile loss.

Summary Introduction From 2000 to 2019, the De Castro's neo-phalloplasty was used in 47 patients with congenital and acquired penile loss. Purpose Herein, the technical aspects of penile reconstruction and the outcomes in 17 children and adolescents treated for total or sub-total acquired penile loss are reported. Material and methods The median age at the time of injury was 3 months (range: 2 days–15 years). Twelve patients were born with normal penis but suffered injuries (11) or underwent surgical resection of the penis (1). The remaining 5, affected by bladder exstrophy (2) or cloacal exstrophy (3), had penile loss due to surgical complications. Results The median age at the time of surgery was 5 years (range: 2–20 years). The median length of the procedure was 5 h (range 4–8 h). Skin expander were inserted in preparation of phalloplasty in 9 patients. Corpora-cavernosa remnants were found and incorporated in the neophallus in 12 patients. In 7 patients, urethral remnants were also incorporated into the repair, placing the meatus at the tip of the neophallus. In the remaining patients the urethra was left in the acquired position after penile loss creating a perineal (2), scrotal (3), peno-scrotal (3), or posterior penile (1) urethrostomy. The first patient of this series was the only patient to receive simultaneously phalloplasty and total urethroplasty, with failure of urethral reconstruction. The median follow-up was 2 years (range 1–11 years). The overall complication rate was about 47%. All of the complications were late and required surgical revision. The results were assessed regarding overall functionality (voiding, erection/erogenous areas, masturbation/sexual intercourse) and aesthetic outcome using subjective and objective parameters. Psychological evaluation for both patient and parents was performed in 4 cases. Discussion There are no specific guidelines for treating significant penile injuries in the pediatric population. We do not think secondary severe penile impairments should wait until adult age for repair. In this specific subgroup of patients technical aspects differ from phalloplasty done for congenital aphallia, due to the possible presence of corpora-cavernosa/urethral remnants and the feasibility to perform a “functional phalloplasty” with very encouraging results. Conclusion The De Castro's neo-phalloplasty remains one of the few techniques available for total penile reconstruction in pediatric age group. Data demonstrate that this technique for acquired aphallia is feasible and reproducible, however, it is a challenging procedure with a high complication rate and likelihood of revisions. Download : Download high-res image (336KB) Download : Download full-size image Summary Figure . A composite rectangular skin flap is designed (A) and developed (B) in the lower abdomen. The most cranial part of the flap is used to reproduce a spherical glans penis and the urethral meatus. The lateral margins are elongated with multiple triangular extensions which will result in a longer dorsal penile dimension. Summary Table . Functional and aesthetic outcome. Patient Aesthetic judgment Tanner stage Urinary continence Good voiding Erogenous area Erection Sexual intercourse 1 Good Right grade Yes Yes Excluded (no CC) Excluded (no CC) Excluded (no CC) 2 ( Fig. 4 ) Good Right grade Yes Yes Yes Yes Yes 3 ( Fig. 5 ) Good Right grade Yes Yes Excluded (no CC) Excluded (no CC) Excluded (no CC) 4 Good Right grade Yes Yes Excluded (young) Excluded (young) Excluded (young) 5 ( Fig. 6 ) Good Right grade Yes Yes Excluded (young) Excluded (young) Excluded (young) 6 Good Right grade Yes Yes Yes Yes Excluded (young) 7 Poor Right grade Partial Yes Excluded (no CC) Excluded (no CC) Excluded (no CC) 8 ( Fig. 7 ) Acceptable Right grade Mitrofanoff continent urinary diversion Yes Excluded (no CC) Excluded (no CC) Excluded (no CC) 9 Acceptable Right grade Mitrofanoff continent urinary diversion Yes Excluded (no CC) Excluded (no CC) Excluded (no CC) 10 Acceptable Right grade Mitrofanoff continent urinary diversion Yes Excluded (young) Excluded (young) Excluded (young) 11 Good Right grade Yes Yes Yes No No 12 Poor Excluded Yes Yes Yes No No 13 Good One lower grade Yes Yes Yes No No 14 Poor One lower grade Yes Yes Yes No No 15 Acceptable Right grade Yes Yes Excluded (young) Excluded (young) Excluded (young) 16 ( Fig. 8 ) Good Right grade Yes Yes Yes Yes Yes 17 Good Right grade Yes Yes Excluded (young) Excluded (young) Excluded (young)