Penile reconstructive surgeries are performed mainly as radical treatment for conditions associated with congenital abnormalities of the urethra or penis and other conditions such as penile trauma, penile cancer, short penis, corporal fibrosis, in cases of gender reassignment and also in patients having undergone penile enlargement operations by other physicians resulting in cosmetic and functional deformities.
Penetrating Penile Trauma
Most cases of penile trauma are associated with multiple injuries. The specific management of genital trauma must be placed within the context of the treatment of the patient and his injuries as a whole. A thorough history of the mechanism of injury is invaluable, as is a detailed assessment of the extent of the injuries sustained. The principles of care are debridement of devitalized tissue with the preservation of as much viable tissue as possible.
The tissue chosen for reconstruction following trauma needs to provide good coverage and be suitable for reconstruction. Split-thickness skin-grafting provides good coverage and dependable take that is reproducible and durable, but these grafts contract more than full-thickness skin grafts and their use on the shaft should be kept to a minimum. If there has been extensive destruction of deeper tissues or if later prosthetic placement is being considered, then skin flaps, which transfer vascularity, can be used.
Penile avulsion injuries and amputation
Most of these injuries are self-inflicted in psychotic patients, but some are related to industrial accidents. After acute management of the severed penis, surgery should follow immediately.
Reattachment can be achieved using microsurgical or non-microsurgical techniques. The best results are seen with microsurgical re-implantation.
PENILE RECONSTRUCTION FOR FEMALE-TO-MALE SEX REASSIGNMENT
Bogoras first attempted a total penile reconstruction surgery for sex reversal in 1936. This was followed by several different procedures to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Initially, the procedures used pedicled cutaneous flaps from the groin, rectus abdominis or gracilis muscles. With improvements in free tissue transfer and microvascular techniques, new procedures based on the use of free flaps such as the radialis, the lateral arm and the deltoid were used.
The goal of penile reconstruction is to achieve an aesthetically acceptable neophallus that enables urination in the standing position and that allows sexual intercourse. The phallus should be constructed to an adequate size and bulk (possibly in a single stage); should have enough rigidity to allow penetration and enough protective, erogenous sensation to allow enjoyment of intercourse; and should permit the urethra to exit at the glans tip.
Most authors currently agree that the free forearm flap is the gold standard for phalloplasty. A complete urethra can be reconstructed using a tube-into-tube technique. Sensitive innervation can be achieved by coaptation of the anterolateral and the anteromedial forearm nerves. Penile rigidity can be obtained by including in the flap a stick of the radial bone or by using a prosthesis.
Felici and Felici, very recently, reported a new technique for phalloplasty in female-to-male sex reassignment operations. They used the anterolateral thigh (ALT) flap, which they reported to be ideal for phalloplasty: "safe, sensate, hairless, with a long pedicle and large amount of soft tissues, which can be harvested in a single procedure and with a low donor site morbidity". In their experience with 6 phalloplasties using the ALT flap, the authors report that the shape and the consistency of the neo-phallus are suitable, the flap can be sensate and an erectile prosthesis can easily be implanted. No significant complications were observed and patient's satisfaction was high.
