Phalloplasty in complete aphallia and ambiguous genitalia

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.

Expanding indications for urogenital transplantation: congenital and oncologic defects, and gender affirmation

PURPOSE OF REVIEW

Penile transplantation has become an emerging option for patients with severe genital defects. Only transplantation restores anatomy, sexual, and reproductive function of the penis. However, penile transplantation comes with important technical, psychosocial, ethical, and surgical challenges that must be considered for successful implementation. Indications for penile transplantation have yet to be clearly elucidated.

RECENT FINDINGS

Since 2006, only five penile transplants have been performed globally. Four of the five transplants have been performed following traumatic defects, and one was performed following a total penectomy from squamous cell carcinoma. Only two of the five penile transplants remain intact. However, long-term outcomes are encouraging with optimal surgical planning, patient selection, and immunologic compliance. Clinical implications and ethical considerations are discussed.

SUMMARY

Penile transplantation is a novel solution for penile defects not amenable to traditional reconstructive approaches. With an evidence-based surgical technique, potential advantages include improved urinary function, sensation, and cosmesis. While patient selection is challenging, there is an ongoing effort to identify potential candidates. Indications are discussed in this article.

30 Years of Experience in Musculocutaneous Latissimus Dorsi Flap Phalloplasty with Reinnervation: Optimal Principles

The technique of urogenital plastic surgery continues to pose difficulties for surgeons due to physical features of the anatomical region, which complicates the correction of various severe male urogenital pathologies. The goal of the surgeon is to create a neophallus that allows for urination and intercourse with minimal damage to the donor site. This special topic provides a historical overview and principles for optimal phalloplasty. To improve results in latissimus dorsi free-flap phalloplasty, we share our approach, its benefits, and the lessons we have learned.

Methods

We performed a retrospective review of patients who underwent shaft-only, two-stage or one-stage latissimus dorsi flap phalloplasty with or without reinnervation at a single institution from 1991 through 2020. Patients with a minimum of 1 year of follow-up were included. Data on the patient's demographics, the procedure, and the results of the operation were maintained.

Results

In total, 592 latissimus dorsi flap phalloplasties were performed during the entire study period. Of the phalloplasties, 494 (83.5%) were performed for gender-affirming surgery, of which 470 were performed for transgender patients and 24 for intersex patients. Twenty-five patients (4.2%) had congenital malformations, 17 (2.9%) had oncologic resections, and 56 had posttraumatic loss (9.5%).

Conclusion

Latissimus dorsi flap total phalloplasty with reinnervation is currently one of the few methods that can solve not only an aesthetic problem, but also a functional one without the use of an endoprosthesis if the level of reinnervation and muscle contraction is sufficient.

Management of Gender Determination of Newborns and Children with Disorders of Sex Development Using a Multidisciplinary Approach: An Exploratory Study of Islamic Perspective in Malaysia

Management of newborns with disorders of sex development (DSD), especially in deciding the need for a sex assignment surgery, is a complex matter. It is associated with many bioethical issues, such as concerns about the rights and welfare of the newborns and the reliability of parents' consent to the paternalistic disposition of physicians in making the best decisions. This paper, containing interviews with six medical experts and three religious' experts, aims to raise awareness of the multidisciplinary approach, which uses a combination of medicine, religion, and ethics in managing children with DSD, particularly in Malaysia, to avoid unnecessary psychological, biological, emotional, and societal ramifications.

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.

Urethral reconstruction in aphallia using transpubic exposure and colonic monti neo-urethra - An addition to the De Castro reconstruction

INTRODUCTION

Fashioning a functioning neo urethra in a boy with aphallia is one of the unsolved problems in this condition.

AIM

We present our technique and outcome of operative exposure and neo urethral construction in four aphallic boys.

MATERIALS AND METHODS

Retrospective study of the records of four aphallic boys operated in the period 2015-2019 was undertaken. The demographics, presentation, operative procedure, current follow up and voiding outcome was noted.

RESULTS

The neo phallus was constructed by the De Castro technique in four aphallic boys aged 1-8 years. Pre operative assessment revealed bladder outflow obstruction in two and urinary incontinence in one boy. The operative exposure afforded after reflection of the De Castro flap was utilized in doing a limited pubic symphysiectomy. This exposed the bladder neck, urethra and the urethral termination into the ano rectum. The healthy native urethra was isolated by disconnecting it from its ano rectal termination and a neo urethra constructed from a segment of proximal sigmoid colon by its reconfiguration into a Monti type tube. The neo urethra was then anastomosed to the native urethra and laid within the bed of the De Castro flap so as to reach the neo phallic termination. The De Castro flap was then tabularized over the neo urethra to form the new phallus. Appendicular or ileal Monti Mitrofanoff was also added to the reconstruction. Three boys are voiding well. One boy had a partial bladder outflow obstruction resulting from operative correction of incontinence and is dry on intermittent catheterization. Follow up was for 1-4 years and upper tracts are stable or improved.

CONCLUSION

We describe the transpubic approach to the construction of a reliable neo urethra in the form of a Monti tube from the sigmoid colon in four boys with aphallia. We believe this to be a useful addition to the De Castro procedure for neo phallic construction.

Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications and Outcomes

BACKGROUND

Males born with bladder exstrophy-epispadias complex generally have a shorter phallus, split corpora with dorsal curvature, and a scarred and flattened glans, so substitution phalloplasty is often required.

AIM

The aim of this study was to review the techniques, complications, and outcomes of substitution phalloplasty in bladder exstrophy-epispadias complex patients to determine the ideal surgical procedure and gauge the risks and benefits for the patient.

METHODS

A systematic review of the literature was performed using PubMed/MEDLINE and the Cochrane Library with the following terms: ("phalloplasty"); (("epispadias") OR ("bladder exstrophy") OR ("cloacal exstrophy")). We included only full-text articles reporting data about techniques and outcomes of substitution phalloplasty in patients with bladder exstrophy-epispadias complex.

OUTCOMES

To determine whether patients with bladder exstrophy-epispadias complex might benefit from substitution phalloplasty.

RESULTS

We selected 7 studies involving 47 patients. All the studies were characterized by a low level of evidence and a heterogeneous approach during treatment and outcome assessment. The free radial forearm flap was the most commonly performed technique (89%) with an overall complication rate of 15%. Urethroplasty was performed in 22 of 47 (47%) patients, and in most cases (20/22) a "tube-within-the-tube" technique was performed simultaneously with the phalloplasty (20/47). Urethroplasty complications were recorded in 12 of 22 (54%) patients with 6 fistulae and 6 stenoses. A penile prosthesis was implanted in 32 of 47 (68%) patients and complications occurred in 8 of 32 (25%) patients with 6 erosion. Aesthetic, sexual, and psychological outcomes were satisfactory, but none of the studies used validated instruments for the final assessment.

CLINICAL IMPLICATIONS

It was not possible to formulate any recommendations based on a high level of evidence regarding substitution phalloplasty in patients with bladder exstrophy-epispadias complex.

STRENGTH & LIMITATION

To our knowledge, this is the first review to address bladder exstrophy-epispadias complex patients only. The limitations are mainly represented by the small number of cases because of the rarity of this disease and by the fact that no studies used validated instruments.

CONCLUSION

Substitution phalloplasty in patients with bladder exstrophy-epispadias complex can achieve good functional, aesthetic, psychological, and sexual outcomes. It requires multiple procedures and carries a high complication rate. Multicentric studies including the assessment of patients by means of a validated questionnaire which investigates both sexual function and psychosexual satisfaction are required. Berrettini A, Sampogna G, Gnech M, et al. Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications, and Outcomes. J Sex Med 2021;18:400-409.

Latissimus dorsi free flap phalloplasty: a systematic review

A phalloplasty is a complex genital reconstruction procedure of creating a neophallus. Several techniques to create a neophallus are described, based on different vascularized flaps, and each of them has its advantages and drawbacks. The aim of this study is to present musculocutaneous latissimus dorsi (MLD) flap as a viable option for total phalloplasty, with an interest in clinical outcomes and complications. A comprehensive literature review of all available reports about MLD flap phalloplasty was made. The following keywords were used on PubMed: latissimus dorsi musculocutaneous/myocutaneous free flap and phalloplasty. Research criteria revealed five articles and the results of 182 patients were analyzed. A total number of the patients, indications, operative technique, follow-up period, postoperative results, and complications were presented. In conclusion, MLD free flap presents a good choice for phalloplasty providing sufficient amount of tissue for safe implantation of penile prosthesis and successful penetrative sexual intercourse. The erogenous sensitivity is preserved with clitoris or glans penis incorporated into the base of the neophallus, and voiding in a standing position is achievable after urethral reconstruction. The main drawback is the lack of tactile sensation of the neophallus and the significant advantage is a well-concealed donor site.

Minimising the donor area morbidity of radial forearm phalloplasty using prefabricated thigh flap: A new technique

Phalloplasty is indicated in various conditions of penile loss or absence. There are numerous techniques for phalloplasty including the pedicle and free flaps with the ultimate goal of micturition in standing position, attaining adequate size, aesthesis and sensations for sexual intercourse. Radial forearm phalloplasty is the gold standard flap to achieve above results but gives a very bad scar on the forearm. We present a technique of using prefabricated thigh flap to reduce the morbidity of donor area. The descending branch of lateral circumflex femoral pedicle was placed in a subcutaneous plane over tissue expander. After attaining an adequate size of flap with tissue expansion, it was delayed 3 weeks before phalloplasty. Prefabricated flap was thin and of large size replicating the radial forearm flap used for phalloplasty. Whole forearm defect was covered with the thigh flap, and the thigh could be closed primarily. This new technique of using prefabricated thigh flap has significantly reduced the donor site morbidity both aesthetically and functionally without the use of skin grafting in the whole procedure.

Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male

For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.

The Urogenital Epithelium and Corporal Tissues Are the Primary Targets of Rejection in Penile Vascularized Composite Allotransplantation: A New Real-Time Tissue-Based Monitoring System

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.

Controversies of Sex Re-assignment in Genetic Males with Congenital Inadequacy of the Penis

Sex assignment in 46XY genetic male children with congenital inadequacy of the penis (CIP) is controversial. Traditionally, children with penile length less than 2 cm at birth are considered unsuitable to be raised as males. They are typically re-assigned to female-sex and feminizing genitoplasty is usually done in infancy. However, the concept of cerebral androgen imprinting has caused paradigm shift in the philosophy of sex re-assignment. Masculinization of the brain, rather than length of the penis, is the modern criterion of sex re-assignment in CIP. This review summarizes the current understanding of the complex issue. In 46XY children with CIP, male-sex assignment appears appropriate in non-hormonal conditions such as idiopathic micropenis, aphallia and exstrophy. Female-sex re-assignment appears acceptable in complete androgen insensitivity (CAIS), while partial androgen insensitivity syndrome (PAIS) patients are highly dissatisfied with the assignment of either sex. Children with 5-alpha reductase deficiency are likely to have spontaneous penile lengthening at puberty. Hence, they are better raised as males. Although female assignment is common in pure gonadal dysgenesis, long-term results are not known to justify the decision.

Mystery and realities of phalloplasty: a systematic review

The neophallus creation is still a mystery and it remains challenging even today. In this article, we performed a comprehensive review of the literature regarding phalloplasty and penile reconstructive surgery between January 2008 and May 2016. In this review, we have included 15 research articles and the results of 276 patients were examined. Studies revealed several indications and when indications were reviewed, 191 patients were female-to-male transgender, 9 patients had disorder of sex development/micropenis, 16 had penile amputation/trauma, 9 had ambiguus genitalia, 40 had exstrophy and/or epispadias, 11 had other problems. As a result of this review, phalloplasty is a reliable and useful operation with good functional and aesthetical results.

Male and female aphallia associated with severe urinary tract dysplasia

INTRODUCTION

Aphallia is exceedingly rare (1/30 million births). Previous reports have provided limited detail on associated urinary tract findings.

OBJECTIVE

We reviewed urinary tract anomalies in two boys with aphallia (patients 1 and 2) and a girl with urinary tract dysplasia, a similar external appearance and lack of corporal tissue (patient 3), also consistent with aphallia.

CASE REPORTS (FIGURE)

Patients 1 and 2 both had a 46XY karyotype, bilateral descended testes in well-formed scrotums, and posterior skin tags containing rudimentary urethras. Patient 1 had a focal area of urethral narrowing; a posterior bladder diverticulum, which drained a ureter; bilateral grade 5 vesicoureteral reflux, with a right partial renal duplication; and hydronephrosis of all moieties. Patient 2 had posterior urethral valves and a bladder diverticulum. Right ureterovesical junction obstruction required a tapered reimplant and later conversion to right-to-left transureteroureterostomy. Patient 3 had a 46XX karyotype and fused, well-formed labia majora. A posterior skin tag was associated with a stenotic urogenital sinus, beyond which were a vagina posteriorly and a right refluxing ureter anteriorly. The left ureter was absent, and a miniscule pouch represented a maldeveloped or absent bladder. Laparoscopy revealed ovaries and normal Müllerian structures. Bilateral renal dysplasia necessitated renal transplant and the creation of an ileocecal neobladder and Mitrofanoff channel. Corporal tissue was diminutive or absent in all.

DISCUSSION

We see from these three patients that corporal tissue absence can occur in both male and female patients. We propose that the term aphallia can apply to both sexes, as it is the absence of corporal tissue that defines this condition. This is the only report to include and characterize findings in both male and female aphallia patients. Labioscrotal folds develop with a smooth appearance, and, posteriorly, a urethral orifice or Urogenital (UG) sinus with skin tag may be seen. Obstruction at the level of the urethra was common. Severe urinary tract dysplasia was seen in all, a finding not consistently seen or characterized in previous reports.

CONCLUSION

In girls with severe urinary tract dysplasia and characteristic genital ambiguity, aphallia should be considered. Co-occurrence of aphallia and severe urinary tract dysplasia warrants further urinary tract imaging in all aphallia patients, including voiding cystourethrography, renal bladder ultrasound, and serum creatinine level. Urinary tract reconstruction may be performed without hampering future penile reconstruction, due to modern phallic reconstructive techniques.

Neophalloplasty in boys with aphallia: A systematic review

OBJECTIVE

Aphallia is a rare penile congenital abnormality. The aim of this systematic review was to assess all available literature on neophalloplasty in infancy with an interest in technical alternatives and clinical outcome.

MATERIALS AND METHODS

We performed a Pubmed search using the terms: neophalloplasty, neophallus, and phalloplasty, and selected articles that presented technical alternatives for penile construction in cases of penile dysgenesis, especially aphallia in children and/or adolescents.

RESULTS

A total of 319 articles were identified in the initial search. Among the different techniques presented in 19 papers collected, we categorized reconstructive procedures into two groups: microsurgical and non-microsurgical techniques. Among the microsurgical techniques, procedures such as the osteocutaneous fibular flap (n = 18), the myocutaneous latissimus dorsi flap (n = 24), and the radial forearm free flap (n = 293) were reported. Among the non-microsurgical techniques, we found a wider range of technical options (6 in total). Most were based on groin, abdominal, and scrotal flaps. Long-term reports on the functionability of the neophallus and psychological aspects of the patients are lacking.

CONCLUSION

In assessing recent literature, it seems rational that neophalloplasty should be regarded as the preferred strategy for boys born with aphallia, in opposition to female gender assignment.

"Bird-Wing" abdominal phalloplasty: A novel surgical technique for penile reconstruction

Aim:

To describe a technique of phalloplasty that is devoid of donor site scarring and suitable for urethral inlay and penile prosthesis in subsequent stages in cases of aphallia.

Materials and Methods:

Four patients with various disorders of sex development with 46 XY and severe penile deficiency, including one with complete androgen insensitivity syndrome who was initially raised as female, have been operated using a “Bird Wing” lower abdominal skin crease incision.

Results:

The patients’ age ranged from 6 to 17 years with preoperative stretched penile lengths between 1 and 2.5 cm. Phallic sizes between 7.5 and 12.5 cm was achieved leaving the donor site unremarkable with lower abdominal skin crease linear scar and excellent postoperative recovery.

Conclusions:

This phalloplasty technique can be utilized as a definitive procedure in many situations of penile insufficiency. Subsequent stages of urethral repair and insertion of penile prosthesis can be easily added.

Pelvic, Perineal and Genital Reconstructions

Perineogenital and pelvic surgery is challenging due to the complex anatomy and physiology, multi-organ involvement and microbial environment of this region. In reconstructive surgery local and pedicled flaps are usually applicable. Microvascular flaps are rarely needed. Positioning of the scars, tension in the wound edges and pressure conditions must be taken into account, because failed correction may create more functional and aesthetic problems as the defect itself. This brief review focuses on the reconstructive methods of perineum, genitals and pelvic floor, site by site, with special emphasis on functional details.