# Reconstructive Surgery for Severe Penile Inadequacy: Phalloplasty with a Free

Authors: N. Lumen; S. Monstrey; P. Ceulemans; E. van Laecke; P. Hoebeke
Journal: Advances in Urology
 (2008)

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## Abstract

Objectives. Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy. Methods. Eleven males (age 15 to 42 years) were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4–49 months). Aesthetic and functional results were evaluated. Results. There were no complications related to the flap. Aesthetic results were judged as “good” in 9 patients and “moderate” in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications  (stricture and/or fistula). Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion. Conclusion. In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.


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## Body

## 1. Introduction

The biological male without penis or with severe penile inadequacy
remains a major challenge to the reconstructive urological surgeon. A clear
definition of severe penile inadequacy has not yet been established but we
consider it as an insufficient penile length and function to obtain successful
sexual intercourse. This implies that puberty must be finished and that the
patient must be sexually active.Next to congenital conditions, which resulted in inadequate penile
development, traumatic events and medically indicated penile amputations, as
well as failed reconstructions of congenital anomalies are also the main reasons
for severe penile inadequacy.An absent or inadequate penis is a devastating condition with
significant psychological and physical impact. Although uncommon, it is a
challenging condition to treat.The different cosmetic and functional requirements for penile
reconstruction are well known as follows. (i) The aesthetic appearance of the
neophallus must be as normal as possible. (ii) The penile shaft must contain a
urethra to allow voiding in a standing position and with a normal stream. (iii)
The penile shaft must allow the implantation of a penile stiffener in order to allow
intercourse. (iv) Morbidity of the donor area must be minimal with an easily
concealed scar. Although phallic reconstruction is a complex surgical procedure,
it is nowadays possible to fulfil most of the above-mentioned requirements
using the new techniques developed in plastic and reconstructive surgery.A large experience has been obtained at our centre with more than 350
female-to-male transsexuals who underwent a penile reconstruction. In this
paper, our experience in phalloplasty using the free radial forearm free flap
(RFF) or the pedicled anterolateral thigh flap (ALTF) is described for patients
with severe penile inadequacy.


## 2. Material and Methods

A cohort of 11 patients (age: 15–42 years) who underwent
phalloplasty at our institution was retrospectively analyzed. Median followup was
25 months (range: 4–49 months). All of them lost most of their functional penile tissues due to different conditions
(Table1). Emptying of the bladder was done through a urethral opening in 6
patients and by catheterisation through an appendico-vesicostomy in 5 patients.
Two of these patients requested a urethral reconstruction for ejaculation, the
other 3 preferred to keep their ejaculatory opening at the ventral aspect of
the scrotum. All of the patients received psychological support and were given
the opportunity to talk with previously operated transsexuals. Our method of
choice for penile reconstruction is the RFF. One patient  refused an RFF because he wanted to avoid a
scar on the forearm and, therefore, chose in favour an ALTF. Three patients
were not a good candidate for a free flap: two patients had a micropenis due to
cloacal exstrophy in which previous corrective and reconstructive surgeries had
altered the pelvic anatomy and vasculature. One patient underwent penile
amputation because of penile necrosis after persistent priapism. This patient
was treated first with an unsuccessful cavernosal-femoral shunt and later embolisation
of the pudendal artery.  In this case,
vascular anatomy was uncertain as well and a free flap was contraindicated. Thus,
seven patients were treated with the RFF and 4 patients with an ALTF.Table 1
Patients' characteristics.
Patientindicationstype of phalloplastyage (years)1shrivelled penis—infected penile stiffeneranterlateral thigh flap422shrivelled penis—bladder exstrophyradial forearm free flap233shrivelled penis—bladder exstrophyradial forearm free flap164penile amputation—epitheloid sarcomaradial forearm free flap155crippled penis—hypospadiasradial forearm free flap206shrivelled penis—bladder exstrophyradial forearm free flap157penile necrosis—traffic accidentradial forearm free flap328shrivelled penis—cloacal exstrophyanterlateral thigh flap169shrivelled penis—cloacal exstrophyanterlateral thigh flap1610micropenis—partial androgen insensitivity syndromeradial forearm free flap3011penile necrosis—embolisation for priapismanterlateral thigh flap38


### 2.1. Surgical Technique

Two operative teams are working simultaneously: the urological team (P. Hoebeke and N. Lumen)
is preparing the acceptor area, while the flap is harvested by the plastic
surgeons (S. Monstrey and  P. Ceulemans). Depending on the underlying
condition, any useful penile and cavernosal tissue is preserved in order to be incorporated
at the basis of the phallus (Figure1). The urethral stump, if available, is
prepared for connection with the phallic urethra and, if available, a dorsal
penile nerve is identified.Figure 1
Incorporation of residual penile tissue at the base of the phallus.


#### 2.1.1. Free Radial Forearm Flap (Figure2)

This flap is harvested
from the forearm and shaped to a phallus using a tube-in-a-tube technique while
being attached to the forearm by its vascular pedicle. A small skin flap and
skin graft are used to create a corona and a sulcus to imitate a circumcised glans
of the penis. The free flap is then transferred to the pubic area and after performing
the urethral anastomosis, the radial artery is microsurgically connected
end-to-side to the common femoral artery. The venous anastomosis is performed
under microscopic magnification between the cephalic vein and the greater
saphenous vein. One forearm nerve (N.cutaneus antebraci) is connected to the
ilioinguinal nerve for protective sensation and the other nerve is anastomosed
to the dorsal penile nerve for erogenous sensation.Figure 2
The radial forearm free flap using the tube-in-a-tube principle for creation of the neourethra.


#### 2.1.2. Anterolateral Thigh Flap (Figure3)

This flap is a pedicled
perforator flap supplied by the descending branch of lateral femoral circumflex
artery. The perforator vessels are identified using Doppler-ultrasound just
prior to incision. The lateral femoral cutaneous nerve is transsected after
harvesting the flap. The flap is tunneled underneath the adductor muscles and
then transferred to the pubic area. At this moment, the flap is shaped into a
phallus using the tube-in-tube technique. Once at the pubic area, the urethral
anastomosis is finished. Any tension on the pedicle must be avoided. The nerve
is reattached to its stump using a subcutaneous tunnel above the adductor
muscles.The anterolateral thigh flap. (a) Preoperative: the vascular pedicle is marked
at the middle using Doppler-ultrasound. (b) Postoperative.
(a)(b)The defect on the donor area is covered with split-thickness skin grafts harvested from the
medial and anterior thigh. All patients receive a suprapubic urinary diversion
postoperatively. The patients remain in bed during a one-week period after
which the transurethral catheter is removed. One week later, the suprapubic
catheter is clamped and voiding is started. It sometimes takes several days
before good voiding is observed. The average admission period for the
phalloplasty procedure is about 2,5 weeks. Tattooing of the glans can be
performed after a 3 to 6 month period, before sensation is returned to the
penis. For the implantation of a penile prosthesis, return of sensation to the
top of the neophallus is required. This usually takes about one year. An AMS
Ambico prosthesis using one cylinder is implanted. A median scrotal incision is
used and the tract through the phallus is bluntly dilated. If possible, the
base of the cylinder is fixed in the remnants of the corpora cavernosa. If not,
the cylinder is attached to the ramus inferior ossis pubis with a nonresorbable
suture. Evaluation of sensation and aesthetic appearance was done by
questionnaire. Voiding was evaluated by uroflowmetrie and measurement of
residual urine by echography. In case a stricture was suspected, urethrography
was performed


## 2.1. Surgical Technique

Two operative teams are working simultaneously: the urological team (P. Hoebeke and N. Lumen)
is preparing the acceptor area, while the flap is harvested by the plastic
surgeons (S. Monstrey and  P. Ceulemans). Depending on the underlying
condition, any useful penile and cavernosal tissue is preserved in order to be incorporated
at the basis of the phallus (Figure1). The urethral stump, if available, is
prepared for connection with the phallic urethra and, if available, a dorsal
penile nerve is identified.Figure 1
Incorporation of residual penile tissue at the base of the phallus.


### 2.1.1. Free Radial Forearm Flap (Figure2)

This flap is harvested
from the forearm and shaped to a phallus using a tube-in-a-tube technique while
being attached to the forearm by its vascular pedicle. A small skin flap and
skin graft are used to create a corona and a sulcus to imitate a circumcised glans
of the penis. The free flap is then transferred to the pubic area and after performing
the urethral anastomosis, the radial artery is microsurgically connected
end-to-side to the common femoral artery. The venous anastomosis is performed
under microscopic magnification between the cephalic vein and the greater
saphenous vein. One forearm nerve (N.cutaneus antebraci) is connected to the
ilioinguinal nerve for protective sensation and the other nerve is anastomosed
to the dorsal penile nerve for erogenous sensation.Figure 2
The radial forearm free flap using the tube-in-a-tube principle for creation of the neourethra.


### 2.1.2. Anterolateral Thigh Flap (Figure3)

This flap is a pedicled
perforator flap supplied by the descending branch of lateral femoral circumflex
artery. The perforator vessels are identified using Doppler-ultrasound just
prior to incision. The lateral femoral cutaneous nerve is transsected after
harvesting the flap. The flap is tunneled underneath the adductor muscles and
then transferred to the pubic area. At this moment, the flap is shaped into a
phallus using the tube-in-tube technique. Once at the pubic area, the urethral
anastomosis is finished. Any tension on the pedicle must be avoided. The nerve
is reattached to its stump using a subcutaneous tunnel above the adductor
muscles.The anterolateral thigh flap. (a) Preoperative: the vascular pedicle is marked
at the middle using Doppler-ultrasound. (b) Postoperative.
(a)(b)The defect on the donor area is covered with split-thickness skin grafts harvested from the
medial and anterior thigh. All patients receive a suprapubic urinary diversion
postoperatively. The patients remain in bed during a one-week period after
which the transurethral catheter is removed. One week later, the suprapubic
catheter is clamped and voiding is started. It sometimes takes several days
before good voiding is observed. The average admission period for the
phalloplasty procedure is about 2,5 weeks. Tattooing of the glans can be
performed after a 3 to 6 month period, before sensation is returned to the
penis. For the implantation of a penile prosthesis, return of sensation to the
top of the neophallus is required. This usually takes about one year. An AMS
Ambico prosthesis using one cylinder is implanted. A median scrotal incision is
used and the tract through the phallus is bluntly dilated. If possible, the
base of the cylinder is fixed in the remnants of the corpora cavernosa. If not,
the cylinder is attached to the ramus inferior ossis pubis with a nonresorbable
suture. Evaluation of sensation and aesthetic appearance was done by
questionnaire. Voiding was evaluated by uroflowmetrie and measurement of
residual urine by echography. In case a stricture was suspected, urethrography
was performed


## 2.1.1. Free Radial Forearm Flap (Figure2)

This flap is harvested
from the forearm and shaped to a phallus using a tube-in-a-tube technique while
being attached to the forearm by its vascular pedicle. A small skin flap and
skin graft are used to create a corona and a sulcus to imitate a circumcised glans
of the penis. The free flap is then transferred to the pubic area and after performing
the urethral anastomosis, the radial artery is microsurgically connected
end-to-side to the common femoral artery. The venous anastomosis is performed
under microscopic magnification between the cephalic vein and the greater
saphenous vein. One forearm nerve (N.cutaneus antebraci) is connected to the
ilioinguinal nerve for protective sensation and the other nerve is anastomosed
to the dorsal penile nerve for erogenous sensation.Figure 2
The radial forearm free flap using the tube-in-a-tube principle for creation of the neourethra.


## 2.1.2. Anterolateral Thigh Flap (Figure3)

This flap is a pedicled
perforator flap supplied by the descending branch of lateral femoral circumflex
artery. The perforator vessels are identified using Doppler-ultrasound just
prior to incision. The lateral femoral cutaneous nerve is transsected after
harvesting the flap. The flap is tunneled underneath the adductor muscles and
then transferred to the pubic area. At this moment, the flap is shaped into a
phallus using the tube-in-tube technique. Once at the pubic area, the urethral
anastomosis is finished. Any tension on the pedicle must be avoided. The nerve
is reattached to its stump using a subcutaneous tunnel above the adductor
muscles.The anterolateral thigh flap. (a) Preoperative: the vascular pedicle is marked
at the middle using Doppler-ultrasound. (b) Postoperative.
(a)(b)The defect on the donor area is covered with split-thickness skin grafts harvested from the
medial and anterior thigh. All patients receive a suprapubic urinary diversion
postoperatively. The patients remain in bed during a one-week period after
which the transurethral catheter is removed. One week later, the suprapubic
catheter is clamped and voiding is started. It sometimes takes several days
before good voiding is observed. The average admission period for the
phalloplasty procedure is about 2,5 weeks. Tattooing of the glans can be
performed after a 3 to 6 month period, before sensation is returned to the
penis. For the implantation of a penile prosthesis, return of sensation to the
top of the neophallus is required. This usually takes about one year. An AMS
Ambico prosthesis using one cylinder is implanted. A median scrotal incision is
used and the tract through the phallus is bluntly dilated. If possible, the
base of the cylinder is fixed in the remnants of the corpora cavernosa. If not,
the cylinder is attached to the ramus inferior ossis pubis with a nonresorbable
suture. Evaluation of sensation and aesthetic appearance was done by
questionnaire. Voiding was evaluated by uroflowmetrie and measurement of
residual urine by echography. In case a stricture was suspected, urethrography
was performed


## 3. Results

Mean dimensions of the flap (including urethra) were 15 by 14 cm.A total flap survival was noticed in all patients, and there were no complications
concerning the donor area. Eight of the eleven patients underwent urethral
reconstruction. In 2 patients, this was only done for ejaculation through the
phallus. In 8 patients, there was sufficient penile and/or cavernosal tissue to
be incorporated at the base of the newly reconstructed phallus.Of 8 patients in which a urethra was reconstructed, 4 patients developed urethral complications.
A persistent fistula at the anastomosis of the neourethra to the native urethra
developed in 3 patients (all treated by RFF), of which a concomitant urethral
stricture was present in 2 patients. One ALTF-patient developed an isolated
urethral stricture, also at the anastomosis site. In case of a fistula, surgical
closure was needed and successful in all 3 patients. The urethral strictures
were managed by end-to-end urethroplasty in one patient and by a two-stage
urethroplasty in the other patient. After these secondary procedures, all
patients (without appendico-vesicostomy) could void in a standing position.Aesthetic appearance was excellent in 9 patients (Figure4), which all expressed their
extreme happiness with the result. In 2 patients, the aesthetic results were
moderate. One patient was treated by an RFF and developed a hypertrofic scar
causing a clear deformity of the phallus. A Z-plasty was used to solve this
problem. The other patient was treated by an ALTF and suffered from a skin rash
of unknown origin at the phallus but also at other places of his body.Excellent aesthetic appearence after RFF (a)-(b) and ALTF (c) phalloplasty.
(a)(b)(c)All of the patients treated by RFFF report protective and erotic sensitivity in their
phallus. The patients treated by ALTF have some sensation in the phallus
supplied by the lateral femoral cutaneous nerve but markedly inferior compared
to the RFF due to the fact that only protective sensation has been provided.A penile prosthesis was implanted in 6 patients. Unfortunately, in 2 patients the
erectile implant had to be removed because of infection. The other 4 patients
report satisfactory sexual intercourse.


## 4. Discussion

Reconstructive surgery for severe penile insufficiency is necessary
because of the devastating effect on psychological and sexual function. Gender
reassignment, as used in the past, has controversial results and is nowadays
abandoned [1]. Reconstructive surgery with phalloplasty is available and generally
used in female-to-male transsexuals. Phalloplasty procedures have followed
advances made in plastic surgery. The development of microsurgical free-flap techniques
made the first microsurgical phalloplasty possible using a free radial forearm flap
[2]. The radial forearm flap has been widely accepted as the best donor site
for penile reconstruction and is nowadays the golden standard in phalloplasty
for female-to-male transsexuals [3–5]. This same technique can also be applied for
severe penile insufficiency.In this series, the RFF was the method of choice. No complications
concerning flap survival or at the donor site were reported. Of the seven
patients treated with RFF, the aesthetic appearance was good in 6 patients and
moderate in 1 patient.  Other series
using the RFF in penile insufficiency also report encouraging results with a
good aesthetic appearance and low donor site morbidity. The results of
phalloplasty using radial forearm free flap in penile insufficiency are
encouraging, the aesthetic appearance is good and donor morbidity is low [6, 7].
Erotic sensation was reported by all
patients treated with RFF. Althougd subjective (a questionnaire was used), this
finding is consistent with the work of Selvaggi et al. [8]. Coaptation of one
of the cutaneous nerves of the flap with a remnant of the dorsal penile nerve
seems to be essential in obtaining this result.Nevertheless, other types of free flaps have been described: Djordjevic
et al. [9] reported the musculocutaneous latissimus dorsi free flap, Sengezer
et al. [10] suggested the osteocutaneous free-fibula flap, and N. Felici and A. Felici
[11] described the free anterolateral thigh flap. They all report satisfactory
results. The type of free flap that is used mostly depends on the personal
preference and the experience of the plastic surgeon that is involved in
phalloplasty.In case of uncertain pelvic vasculature and anatomy, the use of a pedicled
flap is preferred because it brings its own blood supply to the phallus. In our
series, 2 patients had uncertain pelvic anatomy because of several previous
reconstructive pelvic surgeries for cloacal exstrophy and one patient had
uncertain pelvic vasculature because of previous shunting procedures and
embolisation for persistent priapism. Possible flaps in these situations are
the pedicled island groin flap (insensate) [12] or the pedicled anterolateral
thigh flap [13]. In this series, one patient was a good candidate for RFF but
he refused this technique because of the extensive scar at the forearm. This
scar can be considered as a tell-tale sign of transsexualism. For this reason
he preferred an ALTF. Although the aesthetic appearance was good in 3 patients
and moderate in 1 patient, sensitivity remains a concern in these pediculated
flaps. Although subjective (a questionnaire was used), they all reported less
sensitivity compared to the patients treated with RFF. For this reason, an
additional connection to the clitoris nerve should be considered.The major drawbacks of phalloplasty are the urethral complications and
the problems with the penile stiffeners. Urethral complication rate (stricture
and/or fistula) was high but this is comparable to the large experience with
transsexual phalloplasty [3]. Secondary procedures are needed to treat these
complications in which the treatment of urethral strictures, especially, is
challenging and difficult. Late occurrences of urethral stenosis are always
possible because the skin urethra is prone to retract in the long term. If
urethral reconstruction is not necessary, for example, in case of continent
urinary diversion, it should not be performed unless the patient specifically
asks for it.Obtaining sufficient rigidity to allow penetration is extremely difficult
because there is no good substitute for the unique erectile tissue of the
penis. The RFFF and ALTF are too soft and, thus, implantation of a penile
stiffener is needed for sexual intercourse. The implantation must be withheld
until the urethra is free of strictures or fistulas and until the phallus is
endowed with sufficient protective sensation. This usually takes 12 months.
Sufficient protective sensation is needed in preventing breakdown and erosion
of the stiffener. Despite all, explantations rates are high (20–50%) [3, 14, 15]
and comparable to the 33,3% explantation rate in this series. One of the
possible explanations for this is the less vascularised skin and subcutaneous
tissue in the neophallus which can lead to diminished resistance against infection
and perforation. Another reason can be the much more intensive use of the
penile stiffener in comparison with mostly older and less active impotent men,
with a higher chance of malfunction on the long term.


## 5. Conclusions

Due to the devastating impact on the psychological and sexual function,
penile reconstruction of severe penile inadequacy is needed. Today, penile
reconstruction using phalloplasty is available. A free flap, such as the radial
forearm free flap, is the method of choice because of good aesthetic results,
low donor site morbidity, and excellent erogenous sensitivity. In case a free
flap is contraindicated, a pedicled flap, such as the anterolateral thigh flap,
should be used. This flap has comparable aesthetic results, but sensitivity is
a major concern in this flap.Urinary complications and problems with penile stiffeners are frequent
and patients must be informed about these possible complications. Despite this,
phalloplasty is a valuable treatment option for severe penile insufficiency.



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