Phalloplasty for Penile cancer Specific considerations following penectomy
Table 1: Summary of papers reporting phalloplasty following penile cancer treatment
flap using microsurgical techniques, or as a pedicled flap while maintaining its own blood supply. The most common flap used by far is the radial artery forearm free (RFF) flap. Other alternatives include the anterolateral thigh (ALT) flap, musculocutaneous latissimus dorsi (MLD) flap and local abdominal flap [3]. Surgical technique Briefly, penile reconstruction is generally performed over 2 to 3 stages depending on local practices. The first stage involves the creation of a neophallus with or without an integrated urethra, followed by microvascular transfer or rotation to the recipient site. There are several alternatives to an integrated (or tube-in-tube) urethra. A glans is also fashioned either at the same time or at a later stage (glansplasty). An erectile device can be inserted after an interval of at least 3 months. "In recent years, many technical innovations for phalloplasty have been driven by the increasing numbers of individuals requesting transmasculine gender affirmation surgery." Two surgical teams are usually required for a phalloplasty – one team raises the flap while the other prepares the recipient site. The RFF flap is supplied by the radial artery while venous outflow is via the cephalic and basilic veins [4]. If possible, the radial artery is anastomosed to the inferior epigastric artery via a groin incision while the veins are anastomosed to branches of the ipsilateral saphenous vein. A “tube within a tube” urethra is integrated in the flap design and an anastomotic urethroplasty to the native urethra is typically performed with a covering suprapubic catheter and urethral stent. In almost 90% of patients, tactile and erogenous sensation is achieved by neurorrhaphy between the lateral and medial branches of the lateral cutaneous nerve of the forearm with the dorsal penile nerves, if present [4]. Alternatively, an ALT flap may be preferred given the more easily hidden donor site. The flap is supplied by perforations originating from the lateral circumflex femoral artery, with sensation from the lateral femoral cutaneous nerve [5]. The MLD flap has limited sensation (~20%) because it is supplied by the thoracodorsal neurovascular bundle.
Author
n
Age
Primary surgery
Inguinal lymph node dissection
Flap used
Integrated urethra
Mr. Wai Gin (Don) Lee Department of Urology University College London Hospitals NHS Foundation Trust London (GB)
Garaffa (4)
15
43.6 (39-54)*
Total penectomy Total penectomy Total penectomy Total penectomy Partial penectomy Total penectomy
n = 12
RFF
Yes
Akino (7)
1
16
No
RFF
Yes
Hoebeke (8) 1
16
No
RFF
Yes
Lee (5)
1
63
No
ALT
Yes
Sasaki (9)
1
51
No
RFF
Yes
Penile reconstruction, or phalloplasty, refers to the construction of a neophallus through the use of local or distant tissue flaps. Phalloplasty is typically offered when all other options for reconstruction have failed or are inappropriate due to the complex techniques required. In penile cancer, these conditions would arise following a total penectomy or organ-sparing surgery resulting in a functional penile length too short for sexual intercourse or to void while standing. Phalloplasty was first pioneered by N. Bogoraz in 1936 using a tube pedicled abdominal graft and transplanted cartilage as a phallic stiffener [1]. The first patient had suffered traumatic penile amputation, but several men following penectomy for penile cancer were reported in a subsequent case series of 16 men published in 1939. In recent years, many technical innovations for phalloplasty have been driven by the increasing numbers of individuals requesting transmasculine gender affirmation surgery. Reconstruction post-penectomy is more complex, and in this case men should be referred to a tertiary centre with the necessary expertise. Even then, experience can be limited. Only one out of 316 men in a large study reporting the outcomes of phalloplasty had penile cancer [2]. This article will briefly summarise the technical concepts and surgical considerations for phalloplasty in this cohort of patients. Goals of surgery The ideal goal of reconstruction is to create a neophallus that is aesthetically pleasing and sensate (to both erogenous and tactile stimulus) while allowing voiding while standing and sexual intercourse. Ideally, this should be achieved in a single operation with minimal donor site morbidity. Disappointingly, no current technique satisfies all of the above requirements [3[.
Di Summa (10)
1
48
Yes
ALT
No
Abbreviations: RFF, radial free forearm; ALT, anterolateral thigh.
*Median (range)
Table 1: Summary of papers reporting phalloplasty following penile cancer treatment
Inserting an erectile device requires special consideration, given the lack or loss of typical anatomical landmarks. A rear tip extender or malleable penile prosthesis can be placed in the crus of the penis (if preserved) at the time of phalloplasty to help identify the structures for subsequent penile prosthesis insertion. A penoscrotal incision is typically used, and dilatation of the cylinder space within the neophallus is performed to size 18 Hegar [6]. The device is prepared as routine, but a polyethylene terephthalate (Dacron) cap is sutured to the cylinder tip to prevent migration within the neophallus (Fig. 1). The device is kept partially inflated for a week to allow a capsule to form. Specific considerations following penectomy Penile reconstruction in men following either partial or total penectomy can be complicated by surgical scarring and the loss of structures that would normally be present at the recipient site. Thorough and precise surgical planning is therefore required when considering penile reconstruction in this population. Ideally, the urologist who performed the penectomy should be consulted or their operation report reviewed. This is not always possible, so it is essential that the reconstructive urologist has the experience to manage unexpected intraoperative findings. Anastomotic variations may be required when structures like the long saphenous vein and dorsal penile nerves are sacrificed in the primary surgery. Alternative venous anastomoses can be performed to the femoral vein, the venae comitantes of the inferior epigastric artery or the dorsal penile vein, if present. Similarly, neurorrhaphy to the ilioinguinal nerves or genital branch of the genitofemoral nerve may be required instead. When present, a perineal urethrostomy will need to be reversed and re-routed to the orthotopic position while maximising native urethral length. Our experience suggests that it is rare for a man to decline reversal of his perineal urethrostomy, although this would minimise the risk of future urethral complications. Timing of surgery The timing of the surgery is essential. Our centre recommends a minimum of one year of recurrence- free survival before we consider penile reconstruction. Phalloplasty involves complex reconstruction and it is not advisable to offer the surgery without an adequate period of follow-up. A single stage total penectomy followed by immediate RFF phalloplasty has been described, but the patient subsequently developed nodules suspicious of distant tumour recurrence in the lungs at the time the manuscript was published [8]. Delaying reconstruction by a year was successful in another 16-year-old male with no tumour recurrence after 7 years of follow-up [7]. This patient did not suffer any persistent adverse psychological impact due to the delayed approach. Surgical and functional outcomes There is little published data on phalloplasty following surgical treatment for penile cancer, given the rarity of the condition and complexity of reconstruction. Only one cross-sectional retrospective study reported the outcomes of penile reconstruction following penile cancer (n=15) [4] in addition to a handful of case reports (Table 1).
Functional and cosmetic outcomes following RFF phalloplasty were excellent after a median (range) follow-up of 20 (1-68) months [4]. All were satisfied with the cosmesis and size of the neophallus (Fig 2 and 3), and 90% of men reported sensation. Five out of seven men with an erectile device could engage in sexual intercourse. Urethral complications (strictures and fistulae) were the most common complication, occurring in 47% of men, and one man required explant of his erectile device due to infection (14%). Conclusion Phalloplasty following penectomy for penile cancer is a challenging endeavour that requires several surgical stages. Both microsurgical free flaps or pedicled flaps should be offered for penile reconstruction, but it is important to individualise the choice depending on the requirements of the patient. An erectile device is usually required for sexual intercourse. Men report good satisfaction and quality of life following phalloplasty despite the significant risk of complications. References 1. Schulteiss D, Gabouev AI, Jonas U. Nikolaj A. Bogoraz (1874- 1952): Pioneer of phallosplasty and penile implant surgery. J Sex Med . 2005;2(1):139-146. 2. Doornaert M, Hoebeke P, Ceulemans P, Tsjoen G, Heylens G, Monstrey S. Penile reconstruction with the radial forearm flap: An update. Handchirurgie Mikrochirurgie Plastische Chirurgie . 2011;43(4):208- 214. 3. Lee WG, Christopher N, Ralph DJ. Penile Reconstruction and the Role of Surgery in Gender Dysphoria. Eur Urol Focus . 2019;5(3):337-339. 4. Garaffa G, Raheem AA, Christopher NA, Ralph DJ. Total phallic reconstruction after penile amputation for carcinoma. BJU Int . 2009;104(6):852-856. 5. Lee GK, Lim AF, Bird ET. A novel single-flap technique
Contemporary phalloplasty techniques usually employ a distant flap that is transferred as a free
for total penile reconstruction: the pedicled anterolateral thigh flap. Plast Reconstr Surg . 2009;124(1):163-166.
6. Lee WG, Christopher AN, Ralph DJ (2020). IPP in Neophallus. In Mulcahy J, Moncada I, Garcia E and Salamanca J (editors) T extbook of Urogenital Prosthetic Surgery . Editorial Medica Panamericana SA. 213-31. 7. Akino T, Shinohara N, Hatanaka K, Kobayashi N, Yamamoto Y, Nonomura K. Successful penile reconstruction after multimodal therapy in patients with primitive neuroectodermal tumor originating from the penis. Int J Urol. 2014;21:619-21. 8. Hoebeke PB, Rottey S, Van Heddeghem N, Villeirs G, Pauwels P, Schrauwen W, et al. One-stage penectomy and phalloplasty for epithelioid sarcoma of the penis in an adolescent. Eur Urol 2007;51:1429-32. 9. Sasaki K, Nozaki M, Morioka K, Huang TT. Penile reconstruction: combined use of an innervated forearm osteocutaneous flap and big toe pulp. Plast Reconstr Surg. 1999;104:1054-8. 10. di Summa P, Sapino G, Bauquis O. Total urethra and penile shaft reconstruction with combined pedicled anterolateral thigh flap and radial forearm free flap after total penectomy. Arch Plast Surg 2022;49:448- 52.
Figure 1. Single cylinder device prepared with Dacron cap in place
Saturday 11 March 15:42 - 15:52 ESGURS Meeting: Complex genitourethral reconstruction in benign and malignant disease Pink Area, Coral 4
Figure 2: The neophallus deflated
Figure 3: The neophallus inflated
European Urology Today
February/March 2023
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