Isolated aphallia: a case report and review of literature

Background

Aphallia is a rarest of rare congenital anomaly the incidence being 1 in 10 to 30 million live births. Seen at birth, it leaves the parents and family disturbed. Immediate counselling though done; it may take time for the parents to come to a decision.

Case presentation

A newborn was brought for genital examination and since the penis was not present and the scrotum with testes were normal, aphallia was suspected. At 1 month after all the necessary investigations, isolated aphallia without any other congenital anomalies was confirmed. The options offered were gender reassignment before the age of 18 months or staged phallo and urethroplasty. Parents are so far undecided.

Conclusions

Aphallia results from failure of the genital tubercle to develop, leading to the absence of all the penile components. Diagnosis of aphallia includes the absence of the phallus, male karyotype and normally developed scrotum with normal testicles. Usually, this anomaly is associated with multiple other anomalies involving the urinary, gastrointestinal and musculoskeletal systems. Management of this condition is challenging and requires a multidisciplinary approach. In addition to managing the associated anomalies, the options to treat aphallia will depend on the type, severity of associated anomalies, family background and socioeconomic status of the family. Psychological counselling along with surgery (in the form of gender reassignment or phalloplasty) are the mainstays of treatment. The literature of this anomaly and the treatment is reviewed.

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.

Tricholithobezoar: An Unusual Late Complication of Neourethral Reconstruction in Aphallia

An 18-year-old man born with aphallia had undergone phallic reconstruction in childhood followed by total urethral reconstruction with a buccal mucosal graft and groin-based pedicle (Singapore) flap urethroplasty at 13 years of age. The patient presented with obstructive voiding symptoms lasting 6 months followed by acute urinary retention. The results of a voiding cystourethrogram showed a filling defect in the distal urethra that had been reconstructed by use of the skin flap. On urethroscopy, a 3 cm×2 cm sized tricholithobezoar was seen in the distal urethra. Pneumatic lithotripsy followed by bulbar urethrolithotomy was performed in the same operation to extract the bezoar. The remaining hairs were mechanically epilated. The patient has been doing well for 6 months of follow-up.

Urethral reconstruction using allogenic frozen-thawed bladder mucosa: an experimental study

OBJECTIVE

To determine the feasibility and effectivity of allogenic frozen-thawed bladder mucosa for urethroplasty.

METHODS

Bladder mucosa was harvested from 6 New Zealand rabbits. Changes in the bladder mucosa as seen by histological and electron microscope examination were compared between the frozen-thawed and fresh groups. Twelve urethral stricture models were established and randomly divided into two groups. In the test group, we performed urethroplasty with allogenic frozen-thawed bladder mucosa, and the same operation was done in the control group, but using fresh bladder mucosa. The result of retrograde urethrography and histological changes of the urethral sample were compared postoperatively.

RESULTS

No obvious changes on histological and electron microscope examination were observed in the frozen-thawed bladder mucosa. Inflammation reaction of the surgical site in the test group was milder than that of the controls 2 weeks after surgery. The urethral epithelial cells grew well 2 weeks after surgery, but lots of epithelia were necrotic in the control group. The urethra of all rabbits in the test group had good continuity and the urethral lumen was large in the test group 2 months after surgery. There was a layer of urethral epithelium in the test group 2 months after surgery, whereas scar tissue was found in the control group.

CONCLUSIONS

The freeze-thaw technique can maintain bladder mucosa structure and biological function. Frozen-thawed allogenic bladder mucosa may be a potential material for urethroplasty.