Phalloplasty in cis-men with penile insufficiency: evaluation of outcomes and surgical complications : Good ability to achieve orgasm, high urinary complication rate

Individualized care for patients with intersex (differences of sex development): Diagnosis and treatment of aphallia

This review discusses issues and concerns in the management of aphallia, updating status of a post-pubertal individual who required further surgery after having initial surgery for aphallia as an infant. Through this case, which discusses an 18-year-old young adult who had penile agenesis, who desired further phalloplasty involving glanuloplasty and implantation of an erectile device, we highlight the importance of periodic evaluation and close follow up. Surgery during infancy or early childhood to create a penis is important for gender development in a boy, especially if there were functional testes during fetal life, even if this surgery would only be the first stage. There is a strong probability of subsequent surgery after initial phalloplasty before puberty, even with the use of currently refined techniques. Here we discuss the changing techniques that document the ongoing, continued refinement of these procedures, highlighting that further outcome data are needed to identify ways to further optimize current techniques.

Sexual health outcomes after penile reconstruction in the exstrophy-epispadias complex

INTRODUCTION

The penis in exstrophy-epispadias complex (EEC) males is diminutive and patients are often dissatisfied with appearance and length. Due to an increased risk of psychosexual dysfunction, patients desire penile reconstruction. Surgical options include penile lengthening with a full thickness skin graft (SG) or tissue expansion (TE) used for cutaneous coverage or neophalloplasty using a radial forearm free flap or pedicled antero-lateral thigh flap.

OBJECTIVE

The aim of this study was to assess sexual health outcomes before and after SG or TE assisted lengthening and neophalloplasty.

STUDY DESIGN

Patients aged 18 years or older, who underwent penile reconstruction were identified using an institutionally approved database of EEC patients. Patient perception of penile appearance, sexual function, their frequency of sexual intercourse and overall satisfaction with reconstruction were assessed using a survey consisting of validated and non-validated questions.

RESULTS

Eighty-three patients underwent penile reconstruction, 57 met the inclusion criteria and 28 responded to the survey (49.1%). Fourteen were reconstructed using a SG, 6 with TE and 8 underwent neophalloplasty. Median time from reconstruction to survey completion was 4.4 years (range 1.2-13.2) Four patients had a diagnosis of epispadias, 1 cloacal exstrophy, 23 classic bladder exstrophy (CBE). Before reconstruction patients were dissatisfied with their penile appearance with a median penile perception score of 4.5 compared to 7.5 after surgery (p = 0.0034, Fig. 1). Twenty-three patients were dissatisfied with penile length, with 18 reporting an improvement following reconstruction (p = 0.0002). There was no correlation in time after reconstruction with PPS or satisfaction with penile length (p = 0.86 and p = 0.55, respectively). Overall, the median Sexual Health Inventory for Men (SHIM) score was 19, with no difference between the surgical groups (p = 0.33). Nine patients engaged in sexual intercourse before reconstruction which increased to 17 afterwards.

CONCLUSION

All three surgical methods improved patient perception of penile appearance and length. Patients who previously never engaged in intercourse were able to and those who had were doing so more frequently, of which a greater proportion were in a relationship. The results are encouraging though must be interpreted with caution due to the small number of responders and possible risk of bias. These findings provide vital information for future patients and routine psychological assessment will help manage patient expectations to improve satisfaction.

Functional and surgical outcomes after phalloplasty in cis men

PURPOSE

Evaluate the surgical outcomes along with a comprehensive assessment of functional outcomes in cis men (non-trans) who underwent phalloplasty.

METHODS

All consecutive cis men who underwent phalloplasty from 2008 to 2018 for penile insufficiency due to various causes were included. These underwent phalloplasty by either a radial forearm free flap (RFFF) or suprapubic phalloplasty (SPP). Data were collected from medical files. A questionnaire was sent a minimum of 1 year after surgery to each patient to evaluate sexual function and self-esteem, satisfaction with genitals, and urinary function.

RESULTS

Among the 19 patients included, 12 underwent RFFF and 7 SPP; 25% of those who had RFF and 14.3% of those with SPP had a Clavien-Dindo ≥ 2 complication. A total of 16 patients had a urethroplasty procedure, 50.0% of whom had a Clavien-Dindo ≥ 2 complication. Penile prostheses were implanted in 14 patients; 64.3% of whom had a complication. Seven patients answered the questionnaire (36.8%); the relationship satisfaction score was 89.5/100 and the confidence score was 100/100. Among the 5 patients who had a sexual relationship, all reported having a lot of pleasure during sexual intercourse and reached orgasm at least "regularly". At least 66.7% of the patients were "satisfied" or "very satisfied" about the size and the appearance of genitals. Among the 5 patients who answered questions regarding urinary function, 60.0% had standing micturition, and 80.0% reported being comfortable in public toilets.

CONCLUSION

Despite the high frequency of complications and the need for revision surgery, phalloplasty seems to allow a satisfying psychosexual and urinary functions for cis men suffering from penile insufficiency.

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.

Long-term outcome of urethral and genital reconstruction in hypospadias and exstrophy-epispadias complex

PURPOSE OF REVIEW

Although immediate surgical outcomes of genitourinary reconstruction used to be the main focus in hypospadias and exstrophy-epispadias complex (EEC), recent research demonstrates rising concerns about long-term functional and psychosexual outcomes. Recent results about long-term outcomes of complex genitourinary reconstruction in those children transitioning into adulthood are summarized and discussed in this comprehensive review.

RECENT FINDINGS

Long-term outcomes in hypospadias focus on psychosexual satisfaction and decisional regret. Interestingly, uncomplicated hypospadias repair results in equal satisfaction rates to those found in controls. Most adult patients are happy with their parents' decision to have them undergo surgery during childhood. No decisional regret was found in parents. Reinterventions were associated with a decline in satisfaction, as was a decrease in perceived penile length. Long-term, males with EEC are more dissatisfied with penile length than with continence problems. In cases of severe penile insufficiency, phalloplasty shows promising psychosexual outcomes at the price of a high complication rate. Female EEC patients show higher rates of pregnancy complications, portending a higher risk of miscarriage.

SUMMARY

Psychosexual satisfaction of patients with repaired hypospadias transitioning into adulthood demonstrates equal satisfaction rates to those found in controls, without decisional regret associated with surgery during childhood. In EEC, more complications are seen when transitioning into a sexually active adult life.

An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know

Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.