Technical Refinements of Vulvar Reconstruction in Gender-Affirming Surgery.

Penile inversion vaginoplasty involves creation of vulva and a vaginal canal. Few studies describe techniques for creating aesthetic vulvar components, particularly the clitoral hood and labia minora. The authors present their approach to primary vulvoplasty, aiming to achieve the following: (1) labia minora that are well-defined and three-dimensional; (2) labia minora that frame the introitus; (3) sufficient clitoral hooding; (4) a patent introitus that appears closed at rest; and (5) prominent labia majora. In this technique, the labia majora are created by first pulling the superolateral scrotal skin inferiorly and medially toward the perineum. The labia majora incisions may be made laterally, medially, or both laterally and medially, dependent on the amount of penile and scrotal skin available. Initial approximating sutures are placed to anchor the labia inferiorly, and then excess skin is removed medially. The surgeon should avoid excess defatting of the labia majora, which are subject to initial edema and often atrophy with time. The preputial or distal penile shaft skin is used for the clitoral hood and medial aspect of the labia minora, with proximal penile shaft skin used for the lateral surface. The penile skin used for the lateral aspect of the labia minora must be pulled inferomedially toward the perineum, to create a narrow, tapered appearance and avoid effacement of the labia minora. Interrupted horizontal mattress quilting sutures are used to define the labia minora as distinct subunits. By considering homologous structures and anatomical subunits, we are able to create well-defined, aesthetic vulva in trans women and nonbinary individuals.

Surgical Management of Penile Lesions Secondary to Foreign Body Reaction: A Case Report and Systematic Review.

BACKGROUND: To improve the penile contour, some men choose to undergo implantation or injection of nonbiological materials. Foreign body reactions in penile tissue may produce scarring, deformity, ulceration, necrosis, and even gangrene. Consensus is lacking regarding the most effective surgical procedure for reconstruction of these penile lesions. OBJECTIVES: The authors describe one case study and the first systematic review focusing on reconstructive surgical management for penile lesions secondary to foreign body reaction. METHODS: PubMed, Medline, and Cochrane databases were queried for publications written in English, French, Portuguese, and Spanish from 1951 to May 2017. Multiple search terms were applied. RESULTS: Of the 3304 articles identified, 51 were included in the systematic review. All were retrospective studies, case series, or case reports. A total of 260 patients underwent surgical procedures, and the complication rate was 37.3%. The scrotal flap technique was performed most frequently (43.4%) and resulted in 65.6% of the total complications observed. One Brazilian case study was also described with an extensive and circumferential ulcer after six mineral oil bolls implant in the penile subcutaneous tissue. CONCLUSIONS: Restoration of the penile shape preserving the functionality and maintaining a good physician-patient relationship may be a challenge. The scrotal pouch may be advantageous for patch grafting of penile soft-tissue lesions, owing to its skin laxity and good blood supply. A less aggressive surgical approach has the benefits of shorter healing time and fewer early complications. Penile injuries are best treated by experienced surgeons on a case-by-case basis with care given to identify the most appropriate treatment.

Autologous Buccal Micro-Mucosa Free Graft combined with Posterior Scrotal Flap Transfer for Vaginoplasty in Male-To-Female Transsexuals: A Pilot Study.

BACKGROUND: The inverted peno-scrotal flap method is considered the standard method of vaginoplasty in male-to-female genital reassignment surgery. Though with numerous advantages, the method has its limitations regarding skin texture, lack of inherent lubrication, and that the tissues for creating the labia depend on the amount of tissues remaining after vaginoplasty. Our purpose was to describe the procedure and outcome of vaginoplasty applying a new technique: autologous buccal micro-mucosa free graft combined with posterior scrotal flap transfer, which could solve some of the problems the previous methods had. METHODS: Nine male-to-female transsexual patients received our new method of vaginoplasty from July 2010-October 2015. We described the details of the surgical procedure and evaluated the long-term anatomical and functional outcomes. RESULTS: In a mean clinical follow-up period of 25.3 months and phone interview follow-up of 50.3 months, we observed that the neovaginas in the nine cases were all of sufficient volume, lined with mucosa, with natural mucosal discharge. The oral donor sites resulted in no visible scars or malfunction. Eight patients experienced uneventful postoperative periods, while one patient suffered from scrotal flap prolapse. All the patients were sexually active and reported sexual satisfaction, with no need of lubrication. CONCLUSION: The reported technique achieves the outcomes of creating a neovagina of sufficient volume, without serious stenosis in long-term follow-up. The neovagina is lined with mucosa and has appropriate lubrication as well as good sexual sensation. The reported method is easy and economical to perform and retains enough tissues for vulvoplasty to achieve a superior cosmetic appearance, with rare risk of complications and donor area malfunction. Additionally, this technique is feasible and advantageous to the patients who have insufficient peno-scrotal skin for neovaginal lining as well as those with unfavorable previous vaginoplasty. All of these indicate that this technique is a promising option for vaginoplasty in male-to-female transsexual surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of Penile Shaft Defects Following Silicone Injection by Bipedicled Anterior Scrotal Flap.

PURPOSE: Numerous causalities, including attempts at penile augmentation with silicone or paraffin, can lead to extensive circular penile shaft defects. Reconstruction is challenging and skin grafting is a suboptimal option despite its widespread use. We present a surgical technique for penile shaft reconstruction with a bipedicled anterior scrotal flap. MATERIALS AND METHODS: A retrospective data analysis was performed of patients treated for symptomatic penile siliconomas who underwent subsequent penile reconstruction with a bipedicled anterior scrotal flap between 2010 and 2015. The surgical technique is described and depicted in detail. RESULTS: A total of 43 men were treated with radical circular excision of penile siliconomas and extensive shaft defects were reconstructed with a bipedicled anterior scrotal flap. Mean ± SD age was 36.95 ± 11.27 years, mean followup duration was 10.69 ± 9.54 months and mean operative time was 2.53 ± 0.46 hours. The operation proved uneventful in all cases. Only minor complications were observed, such as partial necrosis in 9% of patients, hematoma of the donor site in 12% and partial wound disruption in 19%. The mean patient satisfaction score was 4.37 on a scale of 1 to 5. All patients reported postoperative erection ability and the ability to achieve sexual intercourse. CONCLUSIONS: We present a surgical technique to reconstruct extensive penile shaft defects with an axial scrotal flap, which provides well vascularized coverage with comparable donor skin quality and thickness. The results are associated with minor donor site morbidity, good functional and aesthetic outcomes, and high patient satisfaction.

A new surgical technique for concealed penis using an advanced musculocutaneous scrotal flap.

BACKGROUND: Until recently, no single, universally accepted surgical method has existed for all types of concealed penis repairs. We describe a new surgical technique for repairing concealed penis by using an advanced musculocutaneous scrotal flap. METHODS: From January 2010 to June 2014, we evaluated 12 patients (12-40 years old) with concealed penises who were surgically treated with an advanced musculocutaneous scrotal flap technique after degloving through a ventral approach. All the patients were scheduled for regular follow-up at 6, 12, and 24 weeks postoperatively. The satisfaction grade for penile size, morphology, and voiding status were evaluated using a questionnaire preoperatively and at all of the follow-ups. Information regarding complications was obtained during the postoperative hospital stay and at all follow-ups. RESULTS: The patients' satisfaction grades, which included the penile size, morphology, and voiding status, improved postoperatively compared to those preoperatively. All patients had penile lymphedema postoperatively; however, this disappeared within 6 weeks. There were no complications such as skin necrosis and contracture, voiding difficulty, or erectile dysfunction. CONCLUSIONS: Our advanced musculocutaneous scrotal flap technique for concealed penis repair is technically easy and safe. In addition, it provides a good cosmetic appearance, functional outcomes and excellent postoperative satisfaction grades. Lastly, it seems applicable in any type of concealed penis, including cases in which the ventral skin defect is difficult to cover.

Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome.

INTRODUCTION: We present a novel technique using ventral slit with scrotal skin flaps (VSSF) for the reconstruction of adult buried penis without skin grafting. TECHNICAL CONSIDERATIONS: An initial ventral slit is made in the phimotic ring, and the penis is exposed. To cover the defect in the ventral shaft skin, local flaps are created by making a ventral midline scrotal incision with horizontal relaxing incisions. The scrotal flaps are rotated to resurface the ventral shaft. Clinical data analyzed included preoperative diagnoses, length of stay, blood loss, and operative outcomes. Complications were also recorded. Fifteen consecutive patients with a penis trapped due to lichen sclerosus (LS) or phimosis underwent repair with VSSF. Each was treated in the outpatient setting with no perioperative complications. Mean age was 51 years (range, 26-75 years), and mean body mass index was 42.6 kg/m(2) (range, 29.8-53.9 kg/m(2)). The majority of patients (13 of 15, 87%) had a pathologic diagnosis of LS. Mean estimated blood loss was 57 cc (range, 25-200 cc), mean operative time was 83 minutes (range, 35-145 minutes), and all patients were discharged on the day of surgery. The majority of patients (11 of 15, 73.3%) remain satisfied with their results and have required no further intervention. Recurrences in 3 of 15 (20.0%) were due to LS, panniculus migration, and concealment by edematous groin tissue; 2 of these patients underwent subsequent successful skin grafting. CONCLUSION: VSSF is a versatile, safe, and effective reconstructive option in appropriately selected patients with buried penis, which enables reconstruction of penile shaft skin defects without requiring complex skin grafting.

A new use of scrotal septal skin flap in repairing hypospadias.

In our study, we introduce the use of a scrotal septal skin flaps in repair of hypospadias. Between June 2006 and October 2008, 30 patients were treated by using a penile local flap to reconstruct the urethra, and a scrotal septal skin flap to cover the wound located on the ventral side of the penis. Of 30 patients, 4 presented with urine leakage, but this condition healed spontaneously after 2 to 4 weeks. Urine leakage healed without problem in the remaining patients, and they had unobstructed urinary flow. Additionally, they all were satisfied with genital appearance after the reconstruction. We conclude that our method is a convenient means to cover the wound at the ventral side of the reconstructed urethra by using a scrotal septal skin flap during hypospadias repair. This procedure provides good urinary function and satisfactory appearance to the patients. In addition, this method solves the problem of very limited local tissue for urethral reconstruction in the hypospadias patient.

[Restoration of partial penile defect by scrotal skin flap in combination with penile lengthening].

OBJECTIVE: To evaluate the feasibility and clinical efficacy of a scrotal skin flap in combination with penile lengthening for repairing penile defects. METHODS: From 1999 to 2008, 7 cases (19 to 42 years old) of penile defects were treated by scrotal skin flap in combination with penile lengthening. The average preoperative length of stubbed penis was 2.1 cm in flaccid (range: 1.0 to 3.0 cm) and 4.8 cm in erection (range: 3.0 to 5.5 cm). All cases were treated with penile elongation. And a bilateral scrotal skin flap supplied by anterior scrotal artery (n = 3) or whole anterior scrotum flap (n = 4) was used to cover the exposed penile shaft. The scrotal incision was sutured directly. RESULTS: There was no need for urethra reconstruction. It was simple to obtain the scrotal skin flap. And the operation might be quickly performed with a lesser hemorrhage as compared with penile reconstruction. The scrotal flaps survived without any necrosis and all wounds healed primarily with an excellent contour and erectile function. When followed up for 1 - 5 years, the average preoperative penile length was 6.4 cm in flaccid (range: 5.0 to 7.5 cm) and 9.5 cm in erection (range: 8.0 to 10.5 cm). All cases had normal functions of urination, erection and gonobolia. Five cases had satisfied sexual life and one experienced a sexual life. CONCLUSIONS: The method of restoring partial penile defect with scrotal skin flaps is both simple and efficacious. Reasonable appearance and penile length are restored in most cases with better sensory and erectile functions.

Salvage of a complicated penis replantation using bipedicled scrotal flap following a prolonged ischaemia time.

Microsurgical replantation is the standard method to treat penile amputation. The loss of variable area of skin is a common complication following penile replantation due to prolonged ischaemia time, postoperative venous congestion, oedema and wound infection. There is limited literature available on the management of complications following replantation. A skin graft is commonly used to resurface the denuded areas after skin necrosis. However, this simple and rapid approach has some inherent disadvantages, including paresthesia, contracture, mismatched skin colour and disfiguring donor site. In this report, we present the salvage of a replanted penis by a bipedicled scrotal flap in which the skin fragment was necrosed due to prolonged ischaemia time. Cosmetic and functional outcomes in the 1-year follow-up period were satisfactory.

Functional restoration of penis with partial defect by scrotal skin flap.

PURPOSE: We investigated a reconstructive method with better sensory and erectile function for partial penile defects and report our long-term results of surgical correction using scrotal skin flaps. MATERIALS AND METHODS: We retrospectively analyzed the records of 18 patients with penile defects referred to us between 1992 and 2007. All cases were treated with a scrotal skin flap initially to repair the secondary defect after penile elongation. RESULTS: Of the 18 cases treated during the 15-year period the mechanism of primary injury was circumcision in 3, animal bite in 9 and penile tumor dissection in 6. Penile elongation, division of the suspensory ligament and scrotal skin flaps achieved penile augmentation and enhancement. Six cases were treated with a bilateral scrotal skin flap supplied by the anterior scrotal artery and 12 were repaired with a total anterior scrotal skin flap supplied by the anterior and posterior scrotal arteries. Penile length in the flaccid and erectile states was obviously increased postoperatively (p <0.05). All patients were followed 1 to 9 years (mean 2.3) postoperatively. Deep and superficial sensation recovered and erectile function was retained. Of the 18 patients 15 reported satisfied sexual intercourse during the 0.5 to 5-year followup. CONCLUSIONS: The method of correcting partial penile defect using scrotal skin flaps is effective and simple according to our long-term experience. This method achieves reasonable cosmesis and penile length in most cases with better sensory and erectile function.

[Clinical effect of pedicled scrotal septal flap urethroplasty on long-segment posterior urethral stricture].

OBJECTIVE: To investigate the therapeutic effect of pedicled scrotal septal flap urethroplasty on long-segment posterior urethral stricture and to assess its application value. METHODS: From January 2003 to December 2007, 24 patients (age range, 6-54 years old) with long-segment urethral stricture underwent pedicled scrotal septal flap urethroplasty. The duration of the disease was 1-5 years. The stricture was caused by traumatic urethral injury or disruption in 22 cases, postoperative complication of suprapubic transvesical prostatectomy in 1 case, and recurrent urethral infection due to long-term indwelling urinary catheter in 1 case. Urethroscopy or cystourethrography examination confirmed that all cases had urethral stricture 2.0-5.5 cm in length. Eleven cases were complicated with urethral false passage, 6 with urethral fistula, 2 with intestinal fistula, and 6 with erectile dysfunction. The result of excretion urography of bilateral upper urinary tracts was negative in all cases. Pedicled scrotal septal flap 2.5 cm x 2.0 cm-6.5 cm x 2.5 cm in size was harvested during operation, and urethroplasty was performed. RESULTS: Volume of blood loss during operation was 100-500 mL (average 270 mL). The operative time was 90-220 minutes (average 135 minutes). All flaps survived. All wounds healed by first intention. All patients had normal urination after operation. Over the follow-up period of 12-36 months (average 18.6 months), 1 of the 24 patients suffered from urinary incontinence, 2 from urethral stricture, 1 from urethral stricture and urethral fistula, and 1 from urethral diverticulum around the distal anastomosis. Those patients got normal urination after symptomatic treatment. No urethral stone, urinary incontinence, and new case of erectile dysfunction occurred. The maximum urinary flow rate 16 months after operation was 14-21 mL/s (average 17.6 mL/s). Voiding cystourethrography 22 months after operation showed unblocked urinary tract and no formation of stricture and fistula. CONCLUSION: Pedicled scrotal septal flap urethroplasty, featured by simple operative method, easy flap harvest, and high survival rate of flap, is one of safe and effective methods for treating long-segment posterior urethral stricture.

[Combined buccal mucosal graft and scrotal flap for reconstruction of urethra in primary hypospadias repair].

OBJECTIVE: To investigate a method of repairing hypospadias by combining buccal mucosal graft with scrotal flap and its therapeutic effect. METHODS: From March 2002 to December 2007, 42 patients with hypospadias underwent primary urethral reconstruction using buccal mucosal graft and scrotal flap. The patients ranged in age from 18 months to 18 years. There were 21 cases of penoscrotal type, 12 cases of scrotal type and 9 cases of perineal type. Among them, 8 cases were at initial operation, and 34 cases suffered from'the failure of hypospadias repair 6-19 months (average 10 months) after initial operation. During operation, the defect of urethra was 3-7 cm (average 4.2 cm) when the penis was straightened; the buccal mucosa (3.0 cm x 1.2 cm-7.0 cm x 1.5 cm) was transplanted to the tunica albuginea in the ventral aspect of the penis, and was paired with the scrotal flap (3.0 cm x 1.5 cm-7.0 cm x 1.5 cm) to repair urethra. RESULTS: The incision of 38 cases healed by first intention, and no complication occurred. At 7 days after operation, 4 cases had urinary fistula at either coronary sulcus or anastomotic stoma, one of which spontaneously closed 2 months after operation and the rest 3 recovered by repairing urinary fistula 6 months after operation. All patients were followed for 3-48 months (average 18 months). Urination was smooth, the reconstructed urethral opening was at the tip of glans peins without retraction and with appearance similar to the normal urethral opening. The appearance of penis and scrotum was satisfying, and the penis was straightened completely. CONCLUSION: Combined buccal mucosal graft and scrotal flap, with considerable tissue for urethra tract reconstruction and low incidence rate of urethral stricture, is one of the effective methods to repair hypospadias.

[Staged treatment of the severe hypospadias in adult].

OBJECTIVE: To report the treatment of serious hypospadias in adults with free graft of tubed mouth mucosa and scrotal fascia flaps. METHODS: The tubed mouth mucosa was free grafted to fabricate the distal segment of urethra. It was anastomosed to the urethra at the second stage. The scrotal fascia flap was used to cover the penile wound. The biggest flap was 3 cm in width and 6.5 cm in length. RESULTS: From Jan. 2002 to Dec. 2007, 76 adults with severe hypospadias were treated. Infection happened in 4 cases. 2 cases had urethral fistula due to the partial flap necrosis which was healed automatically within 2-4 weeks. All the other patients healed primarily. CONCLUSIONS: It is a good method for the treatment of serious hypospadias in adults with scrotal fascia flaps and free graft of tubed mouth mucosa which is anastomosed to the urethra at the second stage.

[Repair of hypospadias using scrotal septum vascular pedicle flap with two wing-like split-thickness skin graft].

OBJECTIVE: To investigate the effect of scrotal septum vascular pedicle flap with two wing-like split-thickness skin graft in reconstructing urethra in patients with hypospadias and in reducing the complications. METHODS: From January 2007 to March 2008, 30 cases of hypospadias were treated, with a median age of 10 years (2-20 years). There were 13 cases of proximal shaft type, 12 cases of penoscrotal type and 5 cases of scrotal type. There were 8 cases with operation history. The flap size ranged from 4.0 cm x 0.8 cm to 9.0 cm x 1.0 cm and 5 mm with two wing-like split-thickness skin graft. When the downward curvature corrected, length of the flap could be determined by the length of the urethra that needed to be reconstructed. RESULTS: All flaps survived. The incision healed by first intention in all patients except one whose incision healed after change dressing because of frequent erection. Incision at donor site healed well. Eighteen patients were followed up for 6-12 months, including 8 with second operation history. The reconstructed urethras were unobstructed and no urethrostenosis or urinary fistula happened. CONCLUSION: This is an improved technique of the scrotal septum flap in urethra reconstruction. It takes advantages of both flap and split-thickness skin graft in reconstructing urethra and avoids the disadvantages of a single tissue. It is a good choice for treating hypospadias whose urinary meatus locates neighborly to penoscrotal junctional zone.

Penis covering and simultaneous urethral replacement by scrotal skin for severe penile and urethral necrosis.

OBJECTIVES: Penile strangulation with severe necrosis and concomitant significant tissue loss is a challenging problem for reconstructive surgery. Final reconstruction and tissue augmentation of the resected penis often require multi-step plastic reconstruction. METHODS: Severe damage of the phallus with gangrene and septic complication caused by a bronze ring were first conservatively treated to achieve dry gangrene. The glans of the penis, the whole penile skin, and distal third of the corpus spongiosum with the urethra were lost to necrosis, resulting in a missing urethral segment on the penis. Surgery was performed 3 months after removing the metal ring; a one-step skin and urethral reconstruction was done. RESULTS: Good functional and esthetic results could be achieved by mid-term follow-up. CONCLUSION: In long-lasting penile strangulation with damaged blood supply, further surgery and treatment are needed in addition to immediate decompression. Most commonly in these situations, amputation seems to be the best and easiest action to be taken. However, our case shows that even in a most severe situation, careful conservative treatment allows preserving the phallus, and subsequently reconstruction enables reaching the best functional and esthetic results.

Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps.

OBJECTIVE: To study scrotal microvascularization and apply the findings to the design of reliable skin flaps for reconstructive surgery of complex urethral or panurethral stenoses. MATERIALS AND METHODS: In 15 cryopreserved male cadavers, scrotal skin vascularization was explored using macro- and microdissections, and the scrotal sac made transparent using the Spalteholtz method. A meticulous descriptive analysis of the arterial network was conducted out in all cases to evaluate the number, distribution and anastomosis of the cutaneous arteries of the scrotum. RESULTS: Scrotal skin is irrigated by two main vascular systems, through the inferior external pudendal arteries and the perineal arteries, which branch into multiple scrotal arteries. These arteries are distributed in three cutaneous territories, two lateral and one central, which are widely inter-anastomosed. Each lateral territory receives an inferior external pudendal artery which accesses at the midpoint of the scrotal root and fans out to cover the entire corresponding hemiscrotum. The central cutaneous territory is vascularized through the branches of two main scrotal arteries which are a continuation of the perineal arteries and which access via the posterior face, running deeply on both sides of the septum. CONCLUSIONS: The special anatomical distribution of scrotal branches stemming from perineal arteries enables the construction of adequate reliable longitudinal median island scrotal flaps for the reconstructive surgery of panurethral stenosis, as profuse axial vascularization is ensured.

Management of urethral calculi associated with hairballs after urethroplasty for severe hypospadias.

Urethral calculus is a late complication of urethroplasty for hypospadias when hair-bearing scrotal skin is included in the neourethra. From 1992 to 2002, we had one adolescent and four adult hypospadiac patients with urethral calculi. All patients had undergone staged repair for severe hypospadias at our institute or another hospital in their childhood. Open ureterolithotomy or endoscopic ureterolithotripsy was conducted except in one patient. Open ureterolithotomy was conducted successfully including retubularization with trimming of the diverticular area of the neourethra in two patients. Endoscopic ureterolithotripsy was conducted via Lithoclast in the other two patients. The calculi were struvite in the four patients.