Experience with Microsurgical Reconstruction of the Penis

Introduction: The aim of penile construction is the creation of a sensate and cosmetically acceptable penis. An incorporated neourethra allows the patient to void while standing, and the insertion of a penile implant allows the patient to resume sexual activities, thus improving quality of life.

The radial artery flap allows the creation of all components of a penis, including the glans, and the urethra. The medial and lateral cutaneous nerves of the forearm, when co-apted with the clitoral or dorsal penile nerves, provide sensation to the neophallus.

Methodology and Material: Over a 20-year period, 15 patients underwent total or partial phallic reconstruction using the radial artery flap. 3 patients had surgical amputation of the penis for malignancy, 5 patients had post traumatic penile deficiency, and the rest were female to male transsexuals. The radial artery flap was used for reconstruction of the penoscrotal urethra in one patient who had a recurrent stricture of the urethra.

In our early cases (4), the neo -urethra was reconstructed using a skin graft buried under the forearm skin in an initial stage. In the later cases, the entire neo-urethra and phallus were reconstructed using the design described by Jordan et al.

Phallic reconstruction for gender reassignment was done was the last stage in a series of surgeries. A urethral advancement using a flap of anterior vaginal wall was performed at the time of colpocleisis, and phallic reconstruction was performed three months later.

The neo-urethra was joined to the end of the native urethra, the labia majora was closed behind the neophallus to form the scrotum. Medial and lateral cutaneous nerves of the forearm were coapted to the dorsal nerves of the clitoris. The deep inferior epigastric vessels were used to revascularize the radial artery flap in 9 patients, and the femoral vessels in 3 patients, with vein grafts.

A suprapubic cystostomy was done for urinary diversion in all patients, and was removed after all wounds had healed, and a micturating cyst-urethrogram revealed no leaks. In 2 patients, 18 months after the reconstruction, once the neophallus had become sensate, silicone penile implants were inserted in the penis, and testicular implants in the scrotum.

Results: There were two failures of the radial artery flap, necessitating removal of the entire neophallus. Partial flap necrosis was seen in one patient, and the remaining flaps healed uneventfully. Two patients had urine leakage from the junction of the neo-urethra with the native urethra, which healed over a 4 week period. One patient had a few episodes of urethral infection due to hair growth in the neo-urethra. Tactile and erogenous sensations were restored in all the neophalli. Two patients who had penile implants inserted, were able to perform sexual intercourse with their partners.

In one patient whose radial artery flap failed, a pedicled anterolateral flap was performed to reconstruct the neophallus alone. He needed several procedures to debunk the phallus, and the create a urethra, but the result was far from satisfactory.

Conclusions: Neophallic reconstruction is a technically demanding procedure. The radial artery flap gives aesthetically and functionally the best result, with the size and shape of the neophallus closely matching the normal. However problems with the urethral junction are common. Since this is a life changing operation, patient selection must be done carefully. Patients need to be psychiatrically evaluated before the surgery. More importantly, they need to be counselled about the possibility of failure, as the consequences of failure can be physically and emotionally devastating.