Urethral Reconstruction Using the Radial Forearm Free Flap: Experience in Oncologic Cases and Gender Reassignment

Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice

Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.

Penile reconstruction: An up-to-date review of the literature

Objective

: To review the literature on adult penile reconstruction due to Peyronie’s disease, trauma and cosmesis, while emphasising specific surgical techniques and procedures such as phalloplasty, radial forearm free flap reconstruction, and penile transplant.

Methods

: A comprehensive review of the literature for the years 1992–2020 of the PubMed and SpringerLink databases was performed to identify articles on penile reconstruction. Search terms included ‘penile reconstruction’, ‘penile trauma’, ‘phalloplasty’, ‘penile transplant’, and ‘treatment of Peyronie’s’. Relevant articles were selected. All included studies were performed on adults and written in English.

Results

: We were able to identify 46 papers from PubMed and SpringerLink that included the research terms. From these, we included technical details of procedures and gleaned photographs of their works. Additionally, we included photographs from our institution’s own plication surgery cases.

Conclusions

: The field of adult penile reconstruction is performed for a plethora of reasons. From cosmetic to urgent and from routine to complex, it is most certainly a growing subset of Urology that plays a vital role for the men who need it. To our knowledge, this is the most up-to-date review of adult penile reconstruction.

Treatment of Urethral Strictures in Transmasculine Patients

Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.

A review of gender affirmation surgery: What we know, and what we need to know

BACKGROUND

Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature.

METHODS

PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized.

RESULTS

Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery.

CONCLUSION

Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.

Suprapubic phalloplasty in transmen: surgical results and critical review

This article presents the surgical outcomes of a consecutive series of 71 transmen undergoing pre-expanded suprapubic phalloplasty (SPP) in a specialized center. The median [IQR] duration to finalize this three-stage phalloplasty procedure was 7 months [6-7]. Median [IQR] follow-up was 39.4 months [19.7-81.2]. Among those included, 25 (35.2%) had a urethroplasty, and 40 (56.3%) a penile prosthesis as additional procedures. Complications were the result of disorders of wound healing (dehiscence, infection, partial necrosis) or tissue expander (migration, infection). Sixty patients (84.5%) experienced at least one complication during the phalloplasty procedure, mostly minor complications Clavien < IIIa (81.8%). Among these, 16 (22.5%) underwent at least one reintervention, 2 of whom underwent two reinterventions (18 reinterventions in total for Clavien ≥ IIIa complication). There was no loss of phalloplasty. Among the wide variety of techniques developed for phalloplasty, the suprapubic technique seems to be a valuable option for transmen on the path to genital gender affirming surgery.

The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: single-centre experience and systematic review of the current literature

Radial artery forearm free-flap (RAFFF) phalloplasty is considered by most authors as the gold-standard technique for genital gender-affirming surgery (GGAS). RAFFF surgical complications have rarely been investigated, and the aim of this study and literature review is to analyse and focus on the surgical technique and its postoperative vascular complications. From May 2016 to January 2020, a consecutive series of 25 transgender men who underwent GGAS were enrolled in the present study. Age, BMI and smoking habits were recorded for all patients. Overall, vascular flap complications occurred in 20% of cases. Complete flap loss due to acute arterial thrombosis was recorded in a single case (4%). In 8% of cases, limited ventro-proximal arterial ischaemia was detected, while in the remaining 8% of cases, venous ventral ischaemia was reported. These results were compared with the current literature results. Indeed, from our analysis, the number of flap veins (<2) was the only predictive factor for vascular complications. In conclusion, RAFFF represents a reliable option for total phallic construction, leading to satisfactory results in terms of flap survival. To optimize the surgical outcomes, venous vascular drainage should be recommended.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

INTRODUCTION

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure.

OBJECTIVE

To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia.

MATERIALS AND METHODS

A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors.

RESULTS

We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3 cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR = 1.398, p = 0.015), the decision to not perform cystostomy (OR = 2.963, p = 0.014), and splint size (OR = 1.243, p = 0.023) are significantly associated (p < 0.05) with the development of urethrocutaneous fistula.

CONCLUSION

Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

Staged male genital reconstruction with a local flap and free oral graft: a case report and literature review

Background

Male genital skin loss is a common disease in urology. However, male genital skin loss accompanying a penile urethra defect is rarely reported. Herein, we describe a novel surgical technique using a composite local flap and oral mucosal graft to reconstruct the penis, which may provide a new solution for patients with similar conditions.

Case presentation

A 36-year-old male with a penile urethra defect and a large area of genital skin loss required urethral reconstruction. The meatus had descended to the penoscrotal junction. This procedure was divided into three stages. The first stage of the surgery involved burying the nude penile shaft beneath the skin of the left anteromedial thigh for coverage of the skin defect. The second stage consisted of releasing the penis and expanding the size of the urethral plate for further urethroplasty. The third stage consisted of reconstruction of the anterior urethra 6 months later. Postoperatively, the patient reported satisfactory voiding. The maximal flow rate (MFR) was 22.2 ml/s with no postvoiding residual urine at the 24-month follow-up visit. No edema, infection, hemorrhage, or cicatricial retraction were observed. The patient’s erectile function was satisfactory, and his international index of erectile function-5 score (IIEF-5 score) was 23 at the 24-month follow-up visit. Additionally, the presence of nocturnal penile tumescence demonstrated that he had normal erectile function.

Conclusions

This procedure is an effective surgical option for men with complete foreskin and penile urethra defects. It could also be extended as a treatment strategy when composite local or pedicle transposition flaps and free grafts are needed for specific patients.

Current Concepts in Masculinizing Gender Surgery

LEARNING OBJECTIVES

After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital masculinization. 3. Recognize key steps and anatomy during chest-wall contouring and phalloplasty reconstruction. 4. Discuss major risks and complications of chest-wall contouring and phalloplasty reconstruction.

SUMMARY

Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various masculinizing gender-affirming surgical procedures.

MODERN METHODS OF TREATING DISEASES OF THE BULBO-MEMBRANOUS PART OF URETHRA

Strictures of the bulbous-membranous urethra are a common cause of obstructive urination disorder. Modern trends in the development of medicine lead to a wider application of endoscopic method, a more frequent cause of iatrogenic injury of the urethra. At present, conservative, endourologic and reconstructive methods of care are used to treat urethral strictures. There are several conservative, endourological and reconstructive methods for treating patients with urethral stricture. Conservative methods include interventions that do not involve the destruction of urethral stricture or its reconstruction, such as stenting, blind dilatation, and recanalization of the urethra. Performing blind dilatation strictures of the bulbo-membranous urethra is not recommended because of the high risk of false path formation and low efficiency. Endourological operations refer to surgical methods of care and suggest the natural restoration of urethral tissues after the destruction of stricture. Because of the low effectiveness of correction of strictures of the posterior urethra (more than 90 % of relapses in five years), this method is a variant of temporary or palliative care. Currently, two approaches to the reconstruction of the bulbo-membranous urethra are used: anastomotic and replacement operations. Anastomotic surgery involves excision of the affected area and juxtaposition of healthy urethral tissues without tension. Replacement plastic allows to restore patency of the urethra by increasing the diameter of the lumen due to the implantation of various grafts. The article shows that, based on international clinical studies, the most effective method of reconstructing the bulbomembranous urethra is reconstructive surgical methods.

Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?

BACKGROUND

Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty.

METHODS

A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed.

RESULTS

A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty.

CONCLUSIONS

Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.

Refractory Urethral Stricture Management: Indications for Alternative Grafts and Flaps

PURPOSE OF REVIEW

Urethral strictures that are refractory to initial management present unique challenges to the reconstructive surgeon. Treatment trends have shifted as new tissue resources are becoming available. There is renewed interest in old methods as skill and technique have improved. We describe the scope of the surgical armamentarium available to develop creative approaches and successful outcomes.

RECENT FINDINGS

We discuss techniques to maximize the availability of oral mucosa, harvest and use of rectal mucosa, and developments in tissue engineering. Evolving methods to assess success of repair are also described. Urethral reconstruction for refractory urethral strictures requires proficiency with multiple methods as these strictures often require combining techniques for successful treatment.

Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction

Introduction

Radial forearm free flap (RFFF) tube‐in‐tube phalloplasty is the most performed phalloplasty technique worldwide. The conspicuous donor‐site scar is a drawback for some transgender men. In search for techniques with less conspicuous donor‐sites, we performed a series of one‐stage pedicled anterolateral thigh flap (ALT) phalloplasties combined with RFFF urethral reconstruction. In this study, we aim to describe this technique and assess its surgical outcome in a series of transgender men.

Patients and Methods

Between January 2008 and December 2015, nineteen transgender men (median age 37, range 21–57) underwent pedicled ALT phalloplasty combined with RFFF urethral reconstruction in one stage. The surgical procedure was described. Patient demographics, surgical characteristics, intra‐ and postoperative complications, hospitalization length, and reoperations were recorded.

Results

The size of the ALT flaps ranged from 12 × 12 to 15 × 13 cm, the size of the RFFFs from 14 × 3 to 17 × 3 cm. Median clinical follow‐up was 35 months (range 3–95). Total RFFF failure occurred in two patients, total ALT flap failure in one patient, and partial necrosis of the ALT flap in one patient. Long‐term urinary complications occurred in 10 (53%) patients, of which 9 concerned urethral strictures.

Conclusions

In experienced hands, one‐stage pedicled ALT phalloplasty combined with RFFF urethral reconstruction is a feasible alternative surgical option in eligible transgender men, who desire a less conspicuous forearm scar. Possible drawbacks comprise flap‐related complications, difficult inner flap monitoring and urethral complications.

Phalloplasty: A Review of Techniques and Outcomes

BACKGROUND

Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes.

METHODS

A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.

CONCLUSIONS

Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

Retrospective analysis of individual risk factors for urethrocutaneous fistula after onlay hypospadias repair in pediatric patients

BACKGROUND

To retrospectively identify the individual risk factors for the urethrocutaneous fistula (UCF) in pediatric patients after hypospadias repair (HR) with onlay island flap urethroplasty.

METHODS

A total of 167 patients who underwent primary HR at Nanjing Medical University Affiliated Children Hospital from January 2009 to December 2012 were enrolled. Clinical data including the patient' age at HR, hypospadias type and urethral defect length were documented.

RESULTS

Among 167 patients, 12.6% patients (n = 21) developed UCF after HR. Postoperative UCF occurred in 3.9% (3/76) cases at age of 0-2 years, 14.3% (9/63) at 2-4 years, 20.0% (2/10) at 4-6 years and 38.9% (7/18) at 6-12 years. The incidences of UCF were 12.0% (3/25), 11.4% (5/132) and 30.0% (3/10) for distal, middle and proximal types of hypospadias. As to the urethral defect length, the incidences of UCF were 8.2% (5/61) in patients with a length of ≤ 2 cm, 12.8% (9/70) in 2-3 cm, 22.6% (7/31) in 3-4 cm and 0% (0/5) in above 4 cm. Older age at HR was significantly associated with the high incidence of UCF formation (P = 0.004), while the hypospadias type and urethral defect length did not affect it (P = 0.264 and P = 0.312, respectively).

CONCLUSIONS

The patient' age at HR was a risk factor for the UCF formation after HR, and treatment of HR within two years old might be with the least incidence of UCF.

Phalloplasty: The dream and the reality

Phalloplasty has come a long way as Plastic Surgery has evolved over the years. The complication ridden multistage tube pedicles popularized by Gillis were, with the advent of microsurgery, replaced by radial forearm flaps. The composite osteo-cutaneous version of this flap promised ‘All for one and one for all’ assuring both a reliable urinary conduit and a phallus stiffener. Prelamination and prefabrication to make the neo-urethra came with the promise of reducing both fistula and strictures but that did not happen and flap failure rates increased. Penile stiffeners of various types have been introduced; the artificial ones were associated with high infection and failure rates and are best inserted after the neo-penis regains some sensitivity. With the introduction of perforator flaps the Anterolateral thigh flap in its sensate pedicled form has started replacing the Radial forearm free flap as the first choice flap because of a hidden donor area and lack of microsurgical expertise requirement. Being sensate it tolerates a stiffener better. It is now possible to reconstruct an aesthetically pleasing glans as well, thus meeting both the aesthetic and functional desires of the patient. Complications encountered in this reconstructive effort include flap failure, urethral fistula, urethral stricture and stiffener related problems.

Sex reassignment surgery for transsexuals

PURPOSE OF REVIEW

The purpose of this article is to report on the most recent findings on the current surgical treatments for sex reassignment surgery for both male-to-female and female-to-male transsexuals.

RECENT FINDINGS

For male-to-female sex reassignment surgery, researches aim to refine the inverted peno-scrotal flap surgical technique in order to increase the neovaginal length and width, prevent complications and ameliorate the cosmetic outcome.Bowel segment vaginoplasty, used mainly for secondary cases, is becoming more and more common.For female-to-male sex reassignment surgery, the radial forearm flap is the only procedure that has proved to fulfil most of the patient expectations; however, because of a high complications rate, long recovery time and a large number of the required operations, and the absence of guarantee that patients will be satisfied, the free radial forearm flap is not the best option for every patient. Alternatives such as abdominal/groin flap, thigh flap and metaidoioplasty are very much used.

SUMMARY

In order to provide the best care for transsexual patients, centres performing sex reassignment surgery should co-operate and implement both the refinements and the new techniques offered and/or requested.

Second free radial forearm flap for urethral reconstruction after partial flap necrosis of tube-in-tube phalloplasty with radial forearm flap: a report of two cases

We present a salvage procedure to reconstruct the neo-urethra after partial flap necrosis occurring in free radial forearm flap (RFF) phalloplasty for sex reassignment surgery. Two cases of tube-in-tube phalloplasty using a free sensate RFF are described in which partial flap necrosis occurred involving the complete length of the neo-urethra and a strip of the outer lining of the neo-phallus. Neo-urethra-reconstruction was performed with a second RFF from the contralateral side providing well-vascularized tissue. No flap-related complications were observed. Twelve months postoperatively, both patients were able to void while standing. A satisfactory aesthetic appearance of the neo-phallus could be preserved with an excellent tactile and erogenous sensitivity. Using this technique, we successfully salvaged the neo-urethra and reconstructed the outer lining of the neo-phallus

Total urethral construction with the radial artery-based forearm free flap in the transsexual

OBJECTIVE

to report our experience of using a radial artery-based forearm free flap urethroplasty (RAFFFU) inside a pre-fashioned pedicled pubic phalloplasty for female-to-male gender reassignment.

PATIENTS AND METHODS

a neourethra based on the RAFFF was incorporated into a previously constructed phalloplasty in 27 patients. Surgical outcome, patients' satisfaction and voiding sensation of the neourethra were subjectively and prospectively assessed by direct questioning during the follow-up.

RESULTS

after a median follow-up of 9.2 months, all patients who completed the two stages of the procedure were able to void from the tip of the phallus while standing. Donor-site morbidity was minimal, with all patients reporting a complete recovery of forearm sensation and mobility. The overall satisfaction rate was 92%.

CONCLUSIONS

the RAFFFU is the best technique of total urethral construction in female-to-male transsexuals who opt not to undergo a RAFFF phalloplasty.

Human urine-derived stem cells seeded in a modified 3D porous small intestinal submucosa scaffold for urethral tissue engineering

The goal of this study was to determine whether urothelial cells (UC) and smooth muscle cells (SMC) derived from the differentiation of urine-derived stem cells (USC) could be used to form engineered urethral tissue when seeded on a modified 3-D porous small intestinal submucosa (SIS) scaffold. Cells were obtained from 12 voided urine samples from 4 healthy individuals. USC were isolated, characterized and induced to differentiate into UC and SMC. Fresh SIS derived from pigs was decellularized with 5% peracetic acid (PAA). Differentiated UC and SMC derived from USC were seeded onto SIS scaffolds with highly porous microstructure in a layered co-culture fashion and cultured under dynamic conditions for one week. The seeded cells formed multiple uniform layers on the SIS and penetrated deeper into the porous matrix during dynamic culture. USC that were induced to differentiate also expressed UC markers (Uroplakin-III and AE1/AE3) or SMC markers (α-SM actin, desmin, and myosin) after implantation into athymic mice for one month, and the resulting tissues were similar to those formed when UC and SMC derived from native ureter were used. In conclusion, UC and SMC derived from USC could be maintained on 3-D porous SIS scaffold. The dynamic culture system promoted 3-D cell-matrix ingrowth and development of a multilayer mucosal structure similar to that of native urinary tract tissue. USC may serve as an alternative cell source in cell-based tissue engineering for urethral reconstruction or other urological tissue repair.

Total phallic reconstruction in female-to-male transsexuals

BACKGROUND

The goal of total phallic construction is the creation of a sensate and cosmetically acceptable phallus. An incorporated neourethra allows the patient to void while standing, and the insertion of a penile implant allows the patient to resume sexual activities, thus improving quality of life.

OBJECTIVE

To report our experience of total phallic construction with the use of the radial artery free flap in female-to-male transsexuals.

DESIGN, SETTINGS, AND PARTICIPANTS

The notes of the 115 patients who underwent total phallic construction with the use of the radial artery-based forearm free flap between January 1998 and December 2008 were reviewed retrospectively.

MEASUREMENTS

The surgical outcome, cosmesis of the phallus, complications, eventual need for revision surgery, and patient satisfaction were recorded during the follow-up.

RESULTS AND LIMITATIONS

This technique allowed the reconstruction of a cosmetically acceptable phallus in 112 patients; 3 patients lost the phallus due to venous thrombosis in the immediate postoperative period. After a median follow-up of 26 mo (range: 1-270 mo), 97% of patients are fully satisfied with cosmesis and size of the phallus. Sensation of the phallus was reported by 86% of patients. Urethral strictures and fistulae in the phallus and join-up site were the most common complications, occurring respectively in 9 and 20 patients; however, after revision surgery, 99% of patients were able to void from the tip of the phallus while standing.

CONCLUSIONS

The radial artery-based forearm free flap technique is excellent for total phallic construction, providing excellent cosmetic and functional results.

Thrombotic cutaneous gangrene with autoamputation of the penis: a rare extracolonic manifestation of ulcerative colitis in a child

We present a pediatric patient with ulcerative colitis who developed thrombotic cutaneous gangrene involving skin of the lower chest, abdomen, back, bilateral buttocks, bilateral thighs, perineum, and genitalia, ultimately resulting in autoamputation of the glans penis. After an extensive review of the literature, we describe the diagnosis and management of this devastating condition.