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Truong MH, Ngo TQ, Vu TD. Penile Glans Necrosis Associated With Antiphospholipid Syndrome: A Rare Complication. Cureus 2023; 15:e39999. [PMID: 37416028 PMCID: PMC10322111 DOI: 10.7759/cureus.39999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Penile glans necrosis is a rare clinical condition caused by trauma, diabetes mellitus, adverse effect of vasoconstrictive solutions, and circumcision. Antiphospholipid syndrome (APS) is categorized as an autoimmune disease with the presence of antiphospholipid antibodies that results in an increased risk of vascular thrombosis and obstetrical complications. In this article, we report a rare case of a 20-year-old boy with penile glans necrosis due to penile vascular thrombosis following catastrophic antiphospholipid syndrome (CAPS) which we successfully treated at People's Hospital 115.
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Affiliation(s)
- Minh H Truong
- Department of Urology and Renal Transplantation, People's Hospital 115, Ho Chi Minh, VNM
| | - Trung Q Ngo
- Department of Urology and Renal Transplantation, People's Hospital 115, Ho Chi Minh, VNM
| | - Thang D Vu
- Department of Intensive Care Unit and Poison Control, People's Hospital 115, Ho Chi Minh, VNM
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Scarcella S, Law YXT, Bravi CA, Piazza P, Heldwein FL, Ronchi P, Lacetera V, Beatrici V, Gauhar V, Castellani D. Does using a laser improve outcomes of conventional circumcision in adult and children populations? Results from a systematic review and meta-analysis. Andrology 2023; 11:54-64. [PMID: 36251782 DOI: 10.1111/andr.13321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Male circumcision is a well-known old surgery, and several recently developed techniques have been scaled up, including the introduction of laser technology, as alternative approaches to overcome morbidity of conventional surgery scalpel/suture method OBJECTIVES: We aimed to perform a systematic review and meta-analysis of studies comparing laser circumcision versus conventional circumcision technique in terms of perioperative outcomes and efficacy (complications, unacceptable appearance, reoperation rate) both in children and adults. MATERIALS AND METHODS This review was performed following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were analyzed using the inverse variance of the mean difference with a random effect, 95% confidence interval (CI), and p-value. The incidence of complications, unacceptable appearance, and reoperation rate were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as odds ratio (OR), 95% CI, and p-value. Significance was set at p-value ≤0.05 and 95%CI. RESULTS Seven studies were included. In comparison to the conventional circumcision, laser circumcision shoved lower visual analogue score at 24-h, and 7 days after surgery, a lower rate of overall complication rate (OR 0.33, 95% CI 0.24-0.47, p < 0.001), scarring (OR 0.09, 95% CI 0.02, 0.41, p = 0.002), and unacceptable appearance (OR 0.09, 95% CI 0.05, 0.15, p < 0.001). We found no statistically significant difference in surgical time, and incidence of bleeding, infection, wound dehiscence, and reoperation rate. DISCUSSION AND CONCLUSION Our review infers that laser-assisted circumcision is certainly a safe and strong contender as the procedure of choice in both children and adult populations.
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Affiliation(s)
- Simone Scarcella
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro-Fano, Italy
| | - Yu Xi Terence Law
- Department of Urology, National University Hospital, Singapore, Singapore
| | - Carlo Andrea Bravi
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium.,ORSI Academy, Melle, Belgium
| | - Pietro Piazza
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Flavio L Heldwein
- Department of Urology, Federal University of Santa Catarina, Florianopolis, Brazil
| | - Piero Ronchi
- Department of Urology, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona, Polytechnic University of the Marche Region, Ancona, Italy
| | - Vito Lacetera
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro-Fano, Italy
| | - Valerio Beatrici
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro-Fano, Italy
| | - Vineet Gauhar
- Department of Urology Ng Teng Fong General Hospital (NUHS), Singapore, Singapore
| | - Daniele Castellani
- Department of Urology, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona, Polytechnic University of the Marche Region, Ancona, Italy.,Faculty of Medicine, School of Urology, Polytechnic University of Le Marche, Ancona, Italy
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A Retrospective Case Series in Fournier’s Disease: And Its Emergency Management et Grafting Technique for Penis Coverage. Emerg Med Int 2022; 2022:6710777. [PMID: 36200075 PMCID: PMC9527405 DOI: 10.1155/2022/6710777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 12/01/2022] Open
Abstract
Fournier's gangrene is a necrotizing soft tissue infection of the genital, perineal, and perirectal areas. A primary isolated involvement of the penis is rare, but it can be affected in some circumstances. The purpose of this case series is to present the findings of our thirteen years' experience in the reconstruction of the penis in Fournier's gangrene and our full-thickness grafting technique to cover the penis rod. We retrospectively reviewed patient data who underwent a penis reconstruction following Fournier's gangrene in 2018. The data was analyzed to report the estimated percentage of complications, of patients with primary or secondary gangrene of the penis, the number of reinterventions, and finally the percentage of deaths or recovery. 23 patients underwent reconstruction with our technique of full-thickness skin graft. In all cases, the skin graft was harvested from the upper arm with an arrow shape mark. No further penile revision surgery was required, and neither patient complained about retraction, nor traction, or pain during erection. The donor site healed without any complications. We believe that the coverage of the penis using our grafting technique is safe, easily reproducible, and demonstrates excellent esthetic and functional results.
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Elrouby A, Saad I, Kotb M. Two levels vs. one level of phallopexy in the treatment of concealed penis in patients in pediatric age group. Front Pediatr 2022; 10:1001825. [PMID: 36741097 PMCID: PMC9895086 DOI: 10.3389/fped.2022.1001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 12/28/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Concealed penis, which is the congenital type of buried penis, is a condition in which a normal-sized penis is totally or partially hidden by pubic, scrotal, or thigh skin. Several procedures had been described for its correction including phallopexy, that is, fixation of penile Buck's fascia to the sub-dermis. AIM OF THE WORK Our work aims to study the difference in outcome between performing phallopexy at one level and at two levels. MATERIAL AND METHODS Our study included 180 uncircumcised patients who had a concealed penis while having an average length of an outstretched penis. These patients were divided into two groups: the first one was treated with one level of phallopexy at the 3 and 9 o'clock points, while the second group was treated with the same procedure in addition to another level of stitches at the mid-penile level. The follow-up was carried out for one post-operative year regarding penile skin edema, infection, congestion, necrosis, and/or re-retraction. RESULTS The overall success rate was 96.1% for a normally-looking penis without post-operative re-retraction. Re-retraction developed in two patients (2.2%) of those who had one-level phallopexy and in five patients (5.6%) of those who had two-level phallopexy without statistical significance (FE p = .444). Penile skin edema developed in 76 patients (42.2%) being significantly lower in patients with lower body weight (p = .030*). CONCLUSION Phallopexy could be performed safely in the case of the concealed penis with satisfactory results. Two levels of phallopexy did not add any advantage to the post-operative results besides the fact that this may be demanding, time-consuming, and may require higher resources, so we recommend the easier one-level phallopexy in the treatment of such conditions with satisfactory results.
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Affiliation(s)
- Ahmed Elrouby
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Israa Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mostafa Kotb
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Tripodi D, Amabile MI, Gagliardi F, Frusone F, Varanese M, De Luca A, Pironi D, D’ Andrea V, Sorrenti S, Cannistrà C. Algorithm of rational approach to reconstruction in Fournier's disease. Open Med (Wars) 2021; 16:1028-1037. [PMID: 34286099 PMCID: PMC8272539 DOI: 10.1515/med-2021-0294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/02/2021] [Accepted: 04/10/2021] [Indexed: 01/01/2023] Open
Abstract
Background Fournier's gangrene is a rare form of necrotizing fasciitis that affects the genital area up to the perineal region and sometimes the abdominal wall. Objectives Our article aims to show that in the treatment of extensive forms of Fournier's gangrene, correct use of flap and skin grafts and a quick reconstruction of the exposed tissues avoid scarring retraction of the testicles and deformation of the penis. Materials and methods We retrospectively reviewed the clinical and photographic data of Fournier's gangrene cases treated at our Institute. The data were evaluated to obtain an estimate of the results of the reconstructive technique used, in terms of percentage of occurred healings and eventual complications. Results A total of 34 patients underwent surgery for Fournier's gangrene. In nine cases (26.5%), we had minor complications: in four patients, suffering from diabetes and obesity, a retard in attachment of graft occurred, while in five patients with perianal problems there was a delay in healing due to the onset of local infection. Conclusion The reconstruction approach described here may reduce surgical times. In Fournier's gangrene, the exposed tissues must be reconstructed as quickly as possible.
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Affiliation(s)
- Domenico Tripodi
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Maria Ida Amabile
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Federica Gagliardi
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Federico Frusone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Marzia Varanese
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Alessandro De Luca
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Daniele Pironi
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Vito D’ Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, CAP 00161, Italy
| | - Claudio Cannistrà
- Plastic and Reconstructive Surgery Unit, Centre Hospitalier Universitaire Bichat Claude-Bernard, Paris, France
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Abstract
Buried penis is a condition where the penis is hidden by abdominal or suprapubic skin or fat. In adult men, buried penis occurs as an acquired condition most commonly caused by morbid obesity. The clinical characteristics of three obese men with adult acquired buried penis are described and the associated features of the buried penis are reviewed. In addition to morbid obesity, a buried penis can result from other etiologies, such as hidradenitis suppurativa, iatrogenic causes such as elective surgeries, infections, lichen sclerosus, penoscrotal lymphedema, and traumatic events. Lower urinary tract symptoms, such as voiding, and post-voiding problems are the most common presenting complaints; however, bacterial and fungal infections, phimosis, psychological issues, and sexual dysfunction, are also buried penis-related symptoms. The evaluation of a man with adult acquired buried penis begins with a detailed history for condition-related symptoms. Examination of the patient, both standing and supine with an attempt to demonstrate the penis using digital compression of the surrounding skin and fat, should be performed to determine the extent of the problem and whether comorbid conditions-such as infection and lichen sclerosus-are present. Both buried penis and lichen sclerosus can predispose to the development of penile squamous cell carcinoma; the diagnosis of this tumor can be delayed in men with adult acquired buried penis since an adequate penile examination is difficult or impossible. A multidisciplinary approach-including surgeons, primary care physician, registered dietitian nutritionist, and psychiatrist-should be considered for a patient with a buried penis. The surgical management is individualized and based on not only the extent of the problem but also whether an associated condition, such as urethral stricture, is present. Most patients are pleased with the functional and aesthetic outcome following surgery.
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Affiliation(s)
- Philip R Cohen
- Dermatology, San Diego Family Dermatology, National City, USA
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Jing P, Zou J, Zhao D, Yang J, Feng S, Wang C. [Clinical study of concealed penis correction surgery based on principle of midline symmetry]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:505-508. [PMID: 32291990 DOI: 10.7507/1002-1892.201909106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective To investigate the effectiveness of concealed penis correction surgery based on the principle of midline symmetry. Methods Between January 2016 and September 2018, 18 children with concealed penis were treated with correction surgery based on the principle of midline symmetry. All children were 3-12 years old, with an average age of 8.3 years. Physical examination showed that the penis was short; the penis body could not be exposed or be exposed too limited; the corpus cavernosum developed well. The pressure dressing was removed at 3 days after operation and the urethral tube was removed. The color of the glans, the swelling and congestion of penis and scrotum, and the blood supple of the prepuce flap were observed. Results The operation time ranged from 47 to 54 minutes, with an average of 50 minutes. All children were followed up 3 months after operation. There was no hemorrhage and necrosis of the glans and no infection or ischemic necrosis of the flap. All patients had different degree of prepuce edema at 3 days after operation, 5 patients still had prepuce edema at 2 weeks, and the prepuce edema in all patients subsided at 3 months. All penises were exposed well after midline symmetric anastomosis with no bulky prepuce and scrotum. Conclusion The correction surgery based on the principle of midline symmetry can be used to correct the appearance of the concealed penis effectively.
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Affiliation(s)
- Peng Jing
- Department of Pediatric Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Jiaqiong Zou
- Department of Clinical Laboratory, the First Affiliated Hospital of Chengdu Medical College, Chengdu Sichuan, 610500, P.R.China
| | - Dan Zhao
- Department of Pediatric Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Jinfeng Yang
- Department of Pediatric Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Songlin Feng
- Department of Pediatric Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
| | - Cheng Wang
- Department of Pediatric Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong Sichuan, 637000, P.R.China
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Aubé M, Chua M, DeLong J, McCammon K, Tonkin J, Gilbert D, Virasoro R. Predictors of surgical complications and evaluation of outcomes after surgical correction of adult-acquired buried penis. Int Urol Nephrol 2019; 52:687-692. [PMID: 31797250 DOI: 10.1007/s11255-019-02347-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine predictors for surgical complications and assess patient satisfaction after surgical treatment of Adult-Acquired Buried Penis (AABP). METHODS A retrospective review was performed on all patients diagnosed with AABP who underwent surgical treatment at a single institution from January 2013-December 2017. Patient demographics and peri-operative data were extracted. Univariate and multivariate regression analyses were performed to identify predictors for surgical complications. Patients' post-operative satisfaction was likewise assessed for factors such as successful outcome, post-operative erection quality, and complications related to the surgery. RESULT Twenty-four patients of median age 61.5 years (IQR 54-67) with median follow-up of 12 months (IQR 3.25-29) were included. Overall success was 87.5% (21/24). Complications occurred in 15 (62.5%) patients with 7 (29%) Clavien-Dindo category ≥ 3. Based on regression analyses, body mass index (BMI) ≥ 40 (HR 25; 95% CI 1.45-431.81) and tobacco smoking (HR 14.6; 95% CI 1.15-199.98) were identified as independent predictors of overall complications. Concomitant performance of abdominal panniculectomy was associated with Clavien-Dindo category ≥ 3 (HR 28; 95% CI 2.4-326.74) complications. Patient satisfaction was associated with surgical success (p < 0.0001), post-operative erection (p < 0.027), and absence of surgical morbidity that needed further surgical intervention (p = 0.032). CONCLUSION Surgical management of AABP following an individualized algorithm results in a high success rate but also in relatively high procedure-related morbidity. Peri-operative BMI ≥ 40 and tobacco smoking have higher odds for overall complication occurrence, while concomitant abdominal panniculectomy results in more occurrence of Clavien-Dindo category ≥ 3 morbidities. Patient's eventual satisfaction correlates well with surgical success, post-procedural erection condition, and lack of Clavien-Dindo ≥ 3 morbidity.
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Affiliation(s)
- Mélanie Aubé
- Department of Urology, McGill University Health Center, Montreal, QC, Canada
| | - Michael Chua
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jessica DeLong
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kurt McCammon
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jeremy Tonkin
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - David Gilbert
- Department of Plastic Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Ramón Virasoro
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, USA.
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Xin ZC, Yang BC, Li M, Yuan YM, Cui WS, Tang Y, Fang D, Song WD. [Appllication of human acellular dermal matrix in surgical treatment of genitourinary disease]. JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:778-782. [PMID: 31420640 DOI: 10.19723/j.issn.1671-167x.2019.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Humanacellular dermal matrix (HADM) is widely used in the field of burn wound repair and tissue engineering plastic surgery. HADM is manufactored by physical and chemical decellular process to remove the antigenic components that might cause immune rejection in dermis.The extracellular matrix of three-dimensional cell scaffold structure with collagen fibers had been used for wound repair and tissue regeneration, while HADM characterized with low absorption rate after implantation and strong ability to induce angiogenesis in host tissue. Studies reported that after the HADM was implanted into the patient, the host cells, such as fibroblasts and myofibroblasts, as well as lymphocytes, macrophages, granulocytes and mast cells, rapidly infiltrated the graft. The connective tissue and neovascularization were then formed within the HADM three-dimensional cell scaffold, the lymphatic system also appears after vascular reconstruction. Traditional urethral reconstruction using autologous skin flaps has some defects, such as complexity of the technology, risk of necrosis of the skin flaps after transplantation, and failure to achieve functional repair of the urethral epithelium. It has been reported that using HADM to reconstruct the urethra in patients with urethral stricture, hypospadias and bladder-vaginal fistula, showed promising results. Others have reported the experience of using HADM to repair and reconstruct congenital classic bladder exstrophy. HADM has also been used for tissue repair in patients with penile skin defect caused by Fonier's gangrene and hidradenitis suppurativa, and implanted under Bucks' fascia to enlarge the penis. The report of HADM implantation for treating premature ejaculation also deserves attention. Researchers found that HADM implantation can form a tissue barrier between the skin and corpus cavernosum, which can effectively reduce penile sensitivity and treat premature ejaculation. The safety and effectiveness of HADM implantation in the treatment of premature ejaculation need to be further standardized by data from multi-center, large-sample clinical studies. In summary, HADM is the extracellular matrix and three-dimensional cell scaffold of human dermis. As a new type of tissue repair material, new blood vessels are formed actively after implantation, which shows good histocompatibility. HADM has shown increasingly broad application prospects in treatment of genitourinary diseases including penis, urethra and bladder diseases. HADM has also been used in the treatment of premature ejaculation in recent clinical studies, and its long-term safety and efficacy need to be further investigated.
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Affiliation(s)
- Z C Xin
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - B C Yang
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - M Li
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - Y M Yuan
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - W S Cui
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - Y Tang
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - D Fang
- Andrology Center, Peking University First Hospital, Beijing 100034, China
| | - W D Song
- Andrology Center, Peking University First Hospital, Beijing 100034, China
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Patino G, Zheng MY, Breyer BN, Cohen AJ. Skin Grafting Applications in Urology. Rev Urol 2019; 21:8-14. [PMID: 31239824 PMCID: PMC6585185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Skin grafting is a closure technique widely used in plastic surgery. Urologists may encounter patients with diseases that lead to severe tissue loss due to infection, trauma, burns, malignancy, skin maladies, or primary lymphedema. The development and study of skin harvesting techniques to manage tissue coverage of burns has allowed for great advances and the widening application of skin grafting. As such, there is a growing recognition and application of skin grafts within urology. The aim of surgical treatment and skin grafting within urology is to preserve genital function, improve quality of life, and restore cosmetic damage. In addition to basic technique, this article reviews specific surgical methods employed in reconstruction for patients with Fournier gangrene, buried penis, and hidradenitis suppurativa. Urologists must be aware of these techniques in order to provide adequate counseling for patients considering these operations and when encountering complications.
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Affiliation(s)
| | - Micha Yin Zheng
- School of Medicine, University of California, San Francisco San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, Epidemiology and Biostatistics, University of California, San Francisco San Francisco, CA
| | - Andrew J Cohen
- Department of Urology, University of California, San Francisco San Francisco, CA
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