RESUMO
BACKGROUND: Radial forearm free flap phalloplasty (RFFF) is a set of complex reconstructive procedures aimed at creating an aesthetic and functional penis in transgender patients. Sensory recovery in the neophallus and donor site is crucial for optimizing outcomes, but the few prior studies that exist assess neophallus sensation at limited locations and time points. The purpose of this study was to prospectively quantify sensory outcomes in the neophallus and donor site following RFFF phalloplasty. METHODS: Sensation testing occurred prospectively over February 2019-January 2021 on Stage 1 RFFF phalloplasty patients using the Pressure Specified Sensory Device (PSSD). On the neophallus, one-point discrimination (1PS) pressure threshold and lengthwise sensory recovery were measured at six circumferential locations proximally to distally. On the donor site, 1PS was measured at three locations on the donor hand. RESULTS: Nineteen patients were included (average age 34.0 years old, range 18-53 years). Among patients that received neophallus testing (n = 13), eight had at least two follow-up appointments. Six of these patients had sensation as of their most recent measurement (75.0%), with an average of 73 days to regain sensation. There was a significantly greater proportion of patients with sensation at the right ventral (80.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.024) and right lateral (100.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.004) aspects of the neophallus over time. Pressure required to elicit sensation decreased by 18.0% from 1 week-1 month postoperatively to 3-7.7 months postoperatively in the right ventral neophallus (96.2 g/mm2 ± 11.3 g/mm2 to 56.6 ± 39.9 g/mm2, p = 0.037). Among patients that received donor site testing (n = 11), mixed effects regression analysis with random intercepts demonstrated significant changes in the thumb (3.4 g/mm2 ± 1.4 g/mm2, p < 0.05) and webspace (13.5 g/mm2 ± 4.9 g/mm2, p < 0.01) that returned to baseline at 3 months postoperatively (1.7 g/mm2 ± 1.0 g/mm2, p > 0.05, and 2.3 g/mm2 ± 4.0 g/mm2, p > 0.05, respectively). CONCLUSION: This pilot study demonstrates that quantitative sensory testing can be used to monitor post-phalloplasty sensory changes. Recovery was significantly associated with contralateral (i.e, right side in a left forearm RFF) aspects of the neophallus, suggesting a possible pattern of circumferential sensory innervation via RFFF sensory nerves. Future studies with a larger sample size and longer follow-ups are necessary to fully characterize sensory recovery in phalloplasty patients.
Assuntos
Antebraço , Retalhos de Tecido Biológico , Pênis , Sítio Doador de Transplante , Humanos , Masculino , Projetos Piloto , Retalhos de Tecido Biológico/transplante , Estudos Prospectivos , Adulto , Pessoa de Meia-Idade , Antebraço/cirurgia , Pênis/cirurgia , Pênis/inervação , Sítio Doador de Transplante/cirurgia , Adulto Jovem , Adolescente , Procedimentos de Cirurgia Plástica/métodos , Feminino , Cirurgia de Readequação Sexual/métodos , Sensação/fisiologia , Resultado do Tratamento , Recuperação de Função Fisiológica , Transplante Peniano , FaloplastiaRESUMO
BACKGROUND: It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date. METHODS: This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. RESULTS: Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes. CONCLUSION: Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.
Assuntos
Transplante Peniano , Procedimentos de Cirurgia Plástica , Masculino , Humanos , Estudos de Viabilidade , Qualidade de Vida , Pênis/cirurgiaRESUMO
Since 2006, five penis transplants have been performed worldwide. Mixed outcomes have been reported, and two of the five penile transplants have required explantation. However, the long-term outcomes have been encouraging when compliance is implemented, whether standard induction and triple therapy maintenance, or single therapy maintenance. Follow-up monitoring of transplant recipients has enabled a synthesis of technical considerations for surgical success and has shown stable leukocyte counts and renal function after a donor bone-marrow-based immunomodulatory regimen followed by tacrolimus monotherapy as long as 3 years post-transplant, as well as continuous nerve regeneration of penile allografts 3 years post-transplant. Areas of uncertainty include the ethics of donor-recipient colour mismatch, surveillance for sexually transmitted infections and how to optimize patient compliance. Questions also remain with respect to the long-term immunological sequelae of penile tissue, functional outcomes, psychosocial implications and patient selection. Patient counselling should be modified to mention the possibility of long-term improvement in nerve regeneration and sufficient renal function with single-therapy maintenance, and to build a longitudinal dialogue and partnership between the patient and the multidisciplinary care team regarding the risks of sexually transmitted infection instead of surveillance.
Assuntos
Transplante Peniano , Tacrolimo , Masculino , Humanos , Baltimore , Doadores de Tecidos , Pênis/cirurgiaRESUMO
Vascular composite allografts are at the forefront of medical and surgical innovation. With this new technique and the ability to transplant a face, hands, an abdominal wall, a uterus, or even a penis, patients can undergo operations that may drastically improve their quality of life. Although this process presents significant opportunities it is not always an easy road and requires significant upfront counseling and life-long immunosuppression. Often the recovery course is long, with functionality taking months to years to gain. Immunosuppression must be used to prevent rejection of the allograft although it has serious long-term side-effects. Only five patients have undergone penile allotransplantation but reported outcomes from these small numbers have nonetheless offered significant lessons with each patient. While the operation is still in its infancy, it is certain that shared experiences by surgical teams will yield improved outcomes in the future.
Assuntos
Aloenxertos , Transplante Peniano , Alotransplante de Tecidos Compostos Vascularizados/métodos , Humanos , Terapia de Imunossupressão , Masculino , Qualidade de Vida , Análise de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: To review the current understanding of the ethical and societal difficulties of penile transplantation. RECENT FINDINGS: Penile transplantation, as with other forms of vascularized composite allotransplantation, has increasing acceptance in society but is still not entirely accepted. Guidelines aiming to help guide future penile transplant programs in an ethical and scientific safe manner were created. Controversies regarding the economic impact, patient safety, and the rights of the patients choosing penile transplant remains. SUMMARY: Penile transplantation has excellent functional and cosmetic results in the short-term and medium-term. The penis, similar to the face in facial transplantation, carries emotional gravity that relates to visible body parts of another that live forth in a tangible manner contributing to psychological and ethical challenges for both the individual and society more broadly, healthcare administrators, and healthcare workers. In the context of these challenges, controversies emerge related to issues of judgment about what society can and wants to afford. Effects of toxic immunosuppression in a nonlife saving life-enhancing procedure, as well as costs, become arguments that have to be considered in the context of ethical and societal challenges.
Assuntos
Transplante Peniano , Ética , Humanos , MasculinoAssuntos
Parede Abdominal/cirurgia , Transplante Peniano , Escroto/transplante , Alotransplante de Tecidos Compostos Vascularizados/métodos , Traumatismos Abdominais/cirurgia , Adulto , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Pênis/irrigação sanguínea , Pênis/lesões , Procedimentos de Cirurgia Plástica/métodos , Escroto/lesõesRESUMO
BACKGROUND: Penis transplantation represents an exciting new avenue for restoration of male urogenitalia. However, little is known about the specific immunological features of penile transplants, limiting their application in complex urogenital reconstruction. To properly study this emerging form of transplantation, adequate preclinical models are a necessity. The purpose of this study is to establish a clinical and histological rejection classification of urogenital tissue transplants using a new rat heterotopic penile transplant model that includes preputial skin. METHODS: Syngeneic and allogeneic heterotopic penile transplantations were performed on Lewis and Brown Norway rats using a new model designed by our group. Grafts were clinically and histologically monitored at postoperative days (POD) 3-30. RESULTS: Six syngeneic and 25 allogeneic transplants were performed. All syngeneic and tacrolimus-treated grafts survived until endpoint. Allogeneic graft rejection is shown to follow a 4-stage clinical progression with all untreated allografts developing epidermal sloughing at POD7 and full rejecting between POD14 and POD16. Histological samples were used to develop a specific 4-grade rejection classification analogous to the 2007 Banff Criteria for skin-containing allografts. CONCLUSIONS: Graft skin and urethral lining tissue are first rejection targets followed by tunica albuginea and corpora cavernosa in a distal to proximal pattern. We established a robust and reproducible murine model to study the immunobiology of male genital tissue in the context of transplantation and developed a novel 4-grade clinical and histological rejection scale based on graft skin and urethral lining as the main targets of rejection.
Assuntos
Rejeição de Enxerto/imunologia , Sobrevivência de Enxerto/imunologia , Microcirurgia/métodos , Transplante de Órgãos/métodos , Transplante Peniano , Animais , Inflamação , Masculino , Modelos Animais , Período Pós-Operatório , Ratos , Ratos Endogâmicos BN , Ratos Endogâmicos Lew , Transplante Heterotópico , Transplante Homólogo , Transplante IsogênicoRESUMO
PURPOSE OF REVIEW: Vascularized composite allotransplantation (VCA) has developed over the past 20 years, resulting in promising new reconstructive prospects for extensive soft tissue defects. More than 200 VCAs have been performed worldwide, including five genitourinary (GU)VCAs and here we review the most recent literature in this field. RECENT FINDINGS: Developments in GUVCA are continuously evolving to improve patient outcomes and suggest ethical equivalency to solid organ transplant. Recent treatment options have focused on preventing GUVCA complications by acknowledging the immunogenic tissue composition of the penis to treat rejection episodes and implementing stem cell transplant to recognized the GUVCA as self. Utilizing modern, postoperative, treatments can minimize complications and although the ethical dilemma remains, the morality of performing a GUVCA has diminished. The ethical focus relic's on standardization of patient safety. SUMMARY: GUVCA has become an established reconstructive surgical option. The prospect of VCA's future insinuates systemization between multidisciplinary VCA programs and the United Network for Organ Sharing in efforts to endorse ethical standardization. Over the last five years, the unprecedented outcomes have shown purpose to GUVCA that initiates an obligation to help those with severe genitourinary tissue defects. Progress in immunobiology continues to evolve optimal immunosuppression drug regimens and tolerance induction protocols, highlighting potential new immunologic pathways for graft acceptance.
Assuntos
Terapia de Imunossupressão/métodos , Transplante de Órgãos/métodos , Transplante Peniano , Sistema Urogenital/cirurgia , Alotransplante de Tecidos Compostos Vascularizados/métodos , Humanos , MasculinoRESUMO
The current techniques for organ transplantation are being pushed to new limits. Thanks to the well-established concepts of vascularized composite allotransplantation, the idea of penile transplantation has come to the forefront of genitourinary reconstruction. The recent successful penile transplantation surgeries present a revolutionary option for a challenging penile disfigurement.
Assuntos
Transplante Peniano , Pênis/cirurgia , Alotransplante de Tecidos Compostos Vascularizados , Humanos , Masculino , Procedimentos Cirúrgicos Urológicos Masculinos/métodosRESUMO
INTRODUCTION: Glans resurfacing has been suggested as a treatment option for the surgical management of superficial penile cancer (Tis, Ta, T1aG1, T1aG2). In this article we describe in detail the glans resurfacing technique with skin graft for penile cancer in a video presentation and we review the current knowledge of the literature. MATERIAL AND METHODS: The procedure is described in a stepwise fashion. Initially the patient is circumcised. The glans is marked in quadrants and completely stripped by dissecting and removing the epithelium and subepithelium layer of the glans. Deep spongiosal biopsies are taken to exclude invasion. Each quadrant is sent separately for biopsy. The surface of the graft size needed is estimated. A partial thickness skin graft is harvested from the thigh with a dermatome. The skin graft is then fenestrated. The graft is rolled over the glans and quilted with multiple sutures. A silicone 16F Foley catheter and a suprapubic catheter are placed. The penis is dressed with multiple gauzes and compressed with an elastic band. RESULTS: The patient is discharged the next day. The dressing and Foley catheter are removed in 7 days. The patient continues to use the suprapubic catheter for 7 more days. The patient refrains from any sexual activity for 6 weeks and is closely followed. CONCLUSIONS: Glans resurfacing is an emerging new appealing surgical technique that is already a recommendation in the EAU guidelines for the treatment of premalignant and superficial penile lesions. The overall satisfaction rate and recovery of the sexual function are acceptable, and it can be considered an ideal procedure to treat superficial penile cancer.
Assuntos
Neoplasias Penianas/cirurgia , Transplante Peniano , Lesões Pré-Cancerosas/cirurgia , Transplante de Pele , Humanos , Masculino , Neoplasias Penianas/fisiopatologia , Pênis/fisiopatologia , Lesões Pré-Cancerosas/fisiopatologia , Procedimentos de Cirurgia Plástica , Pele/fisiopatologia , Transplantes , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos MasculinosRESUMO
BACKGROUND: Although significant surgical advances have been made in the form of microvascular surgery and autologous free tissue transfer, penile reconstruction still poses several difficult challenges. Although interest in penile vascularized composite allotransplantation has grown since the first attempted transplant in 2006, little is known regarding the kinetics of rejection and subsequent function of penile allografts. The penis contains multiple tissue types that are not qualified by the Banff 2007 vascularized composite allotransplantation classification system, including urogenital mucosal epithelium and erectile tissues. In this study, the authors investigate the propagation of rejection and the resultant function following rejection in rat and human penile tissues. METHODS: Rejected human and rat penile tissues were examined using an ex vivo real-time tissue-based derivative of the classic mixed lymphocyte reaction assay to determine the interactions occurring between en bloc penile tissues and peripheral blood mononuclear cells (autologous and allogeneic). Correlative in vivo heterotopic rat penile vascularized composite allotransplantation was used to correlate ex vivo findings. RESULTS: In both human and rat ex vivo systems and in vivo rat vascularized composite allotransplantation, the urethral mucosa was the first to undergo rejection-associated apoptosis. The urethral mucosa was the most immunogenic and led to the highest level of peripheral blood mononuclear cell proliferative generations in all systems, whereas the neural tissues of the penis remained immune privileged. CONCLUSION: These findings are the first to describe the kinetics of rejection in both human and rat penile vascularized composite allotransplantation and that the urethral mucosa is the most antigenic, suffering the highest level of rejection-associated apoptosis and peripheral blood mononuclear cell proliferative aggregation.
Assuntos
Rejeição de Enxerto/imunologia , Transplante Peniano , Procedimentos de Cirurgia Plástica/efeitos adversos , Alotransplante de Tecidos Compostos Vascularizados/efeitos adversos , Animais , Apoptose/imunologia , Técnicas de Cultura de Células , Células Cultivadas , Aloenxertos Compostos/imunologia , Aloenxertos Compostos/transplante , Sobrevivência de Enxerto/imunologia , Humanos , Leucócitos Mononucleares/imunologia , Masculino , Mucosa/imunologia , Miografia , Ereção Peniana , Pênis/imunologia , Ratos , Procedimentos de Cirurgia Plástica/métodos , Técnicas de Cultura de Tecidos , Urotélio/imunologia , Alotransplante de Tecidos Compostos Vascularizados/métodosRESUMO
Technical success has been achieved in several forms of vascularized composite allotransplantation, including hand, face, penis, and lower extremity. However, the risks of lifelong immunosuppression have limited these procedures to a select group of patients for whom nontransplant alternatives have resulted in unsatisfactory outcomes. Recent reports of facial allograft failure, and subsequent reconstruction using autologous tissues, have reinforced the idea that a surgical contingency plan must be in place in case this devastating complication occurs. Interestingly, backup plans in the setting of vascularized composite allotransplantation consist of the nontransplant alternatives that were deemed suboptimal in the first place. Moreover, these options may have been exhausted before transplantation, and may therefore be limited in the case of allograft loss or reamputation. In this article, the authors describe the surgical and nonsurgical alternatives to hand, face, penis, and lower extremity transplantation. In addition, the authors explore the ethical implications of approaching vascularized composite allotransplantation as a "last resort" or as a "high-risk, improved-outcome" procedure, focusing on whether nontransplant options eventually preclude vascularized composite allotransplantation, or whether vascularized composite allotransplantation limits future nontransplant reconstruction.
Assuntos
Transplante de Face/métodos , Transplante de Mão/métodos , Perna (Membro)/transplante , Transplante Peniano , Alotransplante de Tecidos Compostos Vascularizados/métodos , Amputação Cirúrgica/estatística & dados numéricos , Rejeição de Enxerto/etiologia , Humanos , Terapia de Imunossupressão/efeitos adversos , Masculino , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: The surgical techniques currently available for penile reconstruction for trans-men with gender dysphoria present with multiple drawbacks and often fail to meet patients' expectations. Literature reports three cases where penile transplantation has been performed for cis-men, with the last two cases being considered successful. AIM: To determine whether an en bloc surgical dissection can be performed in a male cadaver, in order to include structures necessary for penile transplantation (from a deceased donor male) to a recipient with female genitalia in gender affirmation surgery. METHOD: The study was conducted in the form of explorative dissections of the genital and pelvic regions of three male cadavers preserved in phenol-ethanol solution. RESULTS: The first two dissections failed to explant adequately all the relevant structures. The third dissection, which was performed along the pubic arch and through the perineum, succeeded in explanting the relevant structures: it, in fact, allowed for identification and adequate transection of urethra, vessels, dorsal nerves, crura of corpora cavernosa, and bulb of corpus spongiosum, in en bloc explantation of male genitalia. CONCLUSIONS: It is possible to explant the penis and associated vessels, nerves, and urethra en bloc from a cadaver. This study suggests a surgical technique for en bloc explantation aiming for transplantation of the penis from a cadaveric donor male to a recipient with female genitalia.
Assuntos
Transplante Peniano , Pênis/cirurgia , Cadáver , Dissecação/métodos , Feminino , Disforia de Gênero/terapia , Humanos , Masculino , Períneo/cirurgia , Transplante/métodosRESUMO
Vascularized composite allotransplantation has enabled the performance of five reported penile transplantations across the world with additional transplantations planned. Penile transplantation raises ethical questions concerning aesthetics, morbidity, function, and cost-burden given the more readily available and less morbid alternative of phalloplasty.
Assuntos
Tomada de Decisão Clínica/ética , Transplante Peniano , Pênis/irrigação sanguínea , Procedimentos Desnecessários/ética , Alotransplante de Tecidos Compostos Vascularizados/ética , Coito , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Masculino , Segurança do Paciente , Ereção Peniana , Qualidade de Vida , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Procedimentos Desnecessários/efeitos adversos , Procedimentos Desnecessários/economia , Alotransplante de Tecidos Compostos Vascularizados/efeitos adversos , Alotransplante de Tecidos Compostos Vascularizados/economiaRESUMO
BACKGROUND: In male-to-female genital sex reassignment surgery, the clitoris, its prepuce, and the labia minora remain among the most difficult structures to construct. We describe the authors' clitoroplasty and vulvoplasty technique. METHODS: All patients who underwent male-to-female sex reassignment surgery at a single center, between June 2012 and June 2016, were prospectively included. The standard pedicled island neurovascular flap of the glans penis was harvested in a letter M fashion with attached preputial skin. The central triangle of the M was used for the neoclitoris formation. Labia minora and the clitoral prepuce were created with both legs of the M and the preputial skin attached to it. Tactile and erogenous sensitivity was evaluated. RESULTS: Ninety-seven patients were included (mean age, 32 years; range, 17-54 years). All clitoroplasties and vulvoplasties were completed in the same surgical stage as the vaginoplasty. There were no cases of deep or total flap necrosis. Eight patients developed partial and superficial skin necrosis of the flap; one presented an abscess in labia majora, and another patient had urethral hematoma; both required drainage. None of the complications left any sequelae. At 6 months' follow-up all patients maintained tactile and erogenous sensitivity. CONCLUSIONS: The proposed technique represents an aesthetic refinement of the previously described pedicled glans penis flap by allowing the creation of a sensate neoclitoris, its preputial hood, and labia minora with excellent outcomes in the same surgical stage as the sex reassignment.
Assuntos
Estética , Transplante Peniano , Cirurgia de Readequação Sexual/métodos , Transexualidade , Vulva/cirurgia , Adolescente , Adulto , Clitóris/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Prospectivos , Retalhos CirúrgicosRESUMO
The International Society of Vascularized Composite Allotransplantation held its 13th congress "Defining Success" in October 2017 in Salzburg, Austria. A total of 122 delegates from 22 countries representing 5 continents attended the conference. The theme strived to provide pathways to accomplish best possible outcomes in this unique and multifaceted field of transplantation. "Ignite talks," a new feature introduced for the first time at the Salzburg meeting served as key elements for productive discussions on both congress days. The "ignitors" had been selected as experts from Europe, the Americas and Asia in vascularized composite allotransplantation and neighboring disciplines and provided a global perspective of their topic. Posttransplant treatment regimens, including the most burdensome side effects of immunosuppressants in addition to novel and future therapeutic options were discussed in depth. An additional ethics symposium summarized and advanced topics that had been discussed during the first international workshop on bioethical challenges in reconstructive transplantation held earlier in 2017.
Assuntos
Rejeição de Enxerto , Terapia de Imunossupressão/métodos , Imunossupressores/uso terapêutico , Alotransplante de Tecidos Compostos Vascularizados/métodos , Áustria , Congressos como Assunto , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Procedimentos de Cirurgia Plástica , Transplante Homólogo , Útero/transplante , Transplante PenianoRESUMO
BACKGROUND: Phalloplasty poses a unique challenge to the plastic and reconstructive surgeon. The development of advanced microsurgical techniques has greatly augmented the range of surgical approaches available. METHODS: A systematic review of the MEDLINE and Cochrane databases was performed to identify clinical studies of total penile reconstruction published within the last 10 years using the search algorithm: "(phallus or penis or penile) and (reconstruction or phalloplasty or transplant)". RESULTS: The primary literature search retrieved 1400 articles. After applying inclusion and exclusion criteria, 30 studies were selected for review. The radial forearm free flap is the preferred technique for total phalloplasty; however, other techniques including the fibular osteocutaneous flap, anterolateral thigh flap, latissimus dorsi flap, scapular free flap, and abdominal flap are described. Background, indications, and preoperative and postoperative care are also discussed. CONCLUSIONS: Total penile reconstruction can provide functional, aesthetic, and psychosocial benefits to the patient. Use of the radial forearm free flap has been proposed as the gold standard; however, the wide range of potential complications associated with phalloplasty warrants an individualized approach to each patient.
Assuntos
Pênis/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos , Coleta de Tecidos e Órgãos/métodos , Humanos , Masculino , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Próteses e Implantes , Transplante PenianoRESUMO
PURPOSE: Phalloplasty is a critical step in female-to-male (transmale) gender confirming genital surgery. We examined outcomes between transmales who underwent phalloplasty with vaginectomy and full-length urethroplasty using the anterolateral thigh pedicled flap or the radial forearm free flap. MATERIALS AND METHODS: We performed a single center, retrospective study of patients who underwent phalloplasty with vaginectomy and full-length urethroplasty using an anterolateral thigh pedicled flap or a radial forearm free flap from April 2013 to July 2016. All patients had at least 6 months of followup. Urethral and nonurethral complications were recorded. Complication rates were assessed using the OR of the anterolateral thigh pedicled flap and the radial forearm free flap groups. RESULTS: Of the 213 patients 149 and 64 underwent radial forearm free flap and anterolateral thigh pedicled flap phalloplasty, respectively. Patients with a radial forearm free flap had a significantly higher body mass index than those with an anterolateral thigh pedicled flap. The overall urethral complication rate for radial forearm free flap and anterolateral thigh pedicled flap phalloplasty was 31.5% and 32.8%, and the rate of partial or total neophallus loss was 3.4% and 7.8%, respectively. Patients in the pedicled flap cohort experienced significantly greater odds of urethral fistula (OR 2.50, p = 0.024), nonurethral complications (OR 2.38, p = 0.027) and phallus wound dehiscence (OR 5.03, p = 0.026). CONCLUSIONS: Anterolateral thigh pedicled flap phalloplasty was associated with overall greater odds of urethral and other complications at 6 months of followup. Our findings can help guide surgical decision making when selecting a flap for phalloplasty.
Assuntos
Retalhos de Tecido Biológico/transplante , Transplante Peniano , Cirurgia de Readequação Sexual/métodos , Deiscência da Ferida Operatória/epidemiologia , Fístula Urinária/epidemiologia , Adulto , Tomada de Decisão Clínica/métodos , Feminino , Antebraço/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Cirurgia de Readequação Sexual/efeitos adversos , Deiscência da Ferida Operatória/etiologia , Coxa da Perna/cirurgia , Pessoas Transgênero , Uretra/cirurgia , Fístula Urinária/etiologia , Vagina/cirurgiaAssuntos
Transplante Peniano , Procedimentos Cirúrgicos Urológicos Masculinos/tendências , Rejeição de Enxerto/prevenção & controle , Humanos , Imunossupressores/uso terapêutico , Masculino , Seleção de Pacientes , Apoio Social , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/ética , Alotransplante de Tecidos Compostos Vascularizados/éticaRESUMO
OBJECTIVE: We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer. BACKGROUND: Penis transplantation represents a new paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide. METHODS: After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone. RESULTS: Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future. CONCLUSIONS: We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.