A challenging case of total phalloplasty.

Plastic surgery continues to maintain a prominent presence in the evolution of male genital reconstruction. In this case report, we are presenting a case of post-electric burn with a total loss of penis. Sustaining other major injuries following an electric burn with loss of right upper limb and extensive tissue damage to left upper limb, abdomen and both thighs, this young male patient was initially managed from life-threatening problems. With many options closed following a major electric burn and its acute management, penile and urethral reconstruction was a unique and a great challenge in this patient. Heeding to the patient's wish of male pattern micturition, we had performed a successful reconstruction of urethra and entire phallus with groin flap.

INTRODUCTION

The development of techniques for phalloplasty has paralleled the evolution of flap development in reconstructive surgery itself. Gillies and Harrison,[1] in 1948, were amongst the first to take up the challenge. They used two abdominal tubes in a multi-staged procedure. Tubed pedicled skin flaps[2] were followed by local myocutaneous flaps.[34] In the mid-1980s microsurgical free flaps were introduced. The aims of penile reconstruction are to enable urination in the standing position, to enable sexual intercourse and to reconstruct an aesthetically acceptable penis with adequate tactile, protective and ideally erogenous sensation.[5]

Construction of a phallus with the above criteria has always been a formidable surgical challenge and many problems have not been solved satisfactorily, even with the introduction of free flap transfer.[6]

CASE REPORT

A 21-year-old male sustained severe electrical burns on lower abdomen, genitalia, lower and upper limbs following accidental exposure to high tension electricity (12,000 V). The lesions covered 25% of his total body surface area with 20% third degree burns and 5% second degree burns. He presented with gangrene of right upper limb in its entirety, carbonization of external genitalia with subsequent complete loss of penis and left hemi scrotum and testis [Figure 1]. The evolution of his general condition was very difficult as a result of haemodynamic and infection problems, which required intensive care. Locally, debridements of necrotic tissue were immediately performed, followed by a tensor fascia lata flap to protect the left femoral vessels and a local transposition flap to protect the brachial vessels in the left forearm.

Figure 1

(a) Acute electrical burns. (b) Penile gangrene

Disarticulation of right upper limb at the shoulder level done with primary closure of the defect. Non-viable penis and left hemi scrotum with testis was debrided. The right hemiscrotum with testis was mobilized to cover the defect in the genital region with a perineal urethrostomy. Approximately 20% of the body surface area was skin grafted within 2 months. Nineteen months after the accident, reconstructive surgery of the external genitalia was performed.

SURGICAL TECHNIQUE

Penis was planned to be reconstructed in stages. In the first stage, the right paragenital non-hairy skin was tubularized to create a neourethra from the perineal urethrostomy site to pubic region [Figure 2].

Figure 2

Flap pattern

Six weeks later staged penile reconstruction proceeded using a right-side groin flap. With non-availability of other adjacent tissues and with the loss of right upper limb and entire left forearm being grafted with a transposition flap to protect brachial vessels, groin flap remained the option for reconstruction. A tube within a tube was created from a single folded, 17 cm wide and 16 cm long groin flap [Figure 3]. A 4 cm wide area along the midline of flap, without the presence of hair was tubed inward around a 16 French Foley catheter to form the neourethra. The adjacent skin of about 1 cm on either side was deepithelialized to allow the flap to be rolled onto itself. The remaining 11 cm width of skin was wrapped around the inner tube portion to provide external cover. With the catheter introduced onto the pubic urethra, urethral repair and skin closure with a tumble of the groin flap done [Figure 4]. About 3 weeks later, an axial delay of the flap done followed by flap division in another week's time.

Figure 3

Neourethroplasty

Figure 4

Phalloplasty

RESULTS

The healing of the donor site was complete in 15 days. The flap provided a satisfactory aesthetic result and enabled urination in standing position after catheter removal at 15th day after flap division [Figure 5]. The patient was extremely satisfied with his reconstructed penis and reported tactile sensation. Glans sculpturing is planned for the patient in future.[7] Implantation of prosthesis could provide penile erection and penetration during sexual intercourse.

Figure 5

Neophallus with catheter in neourethra

DISCUSSION

Advancements in microsurgical techniques[89] have expanded the number of potential penile reconstructive procedures, and there is general agreement that they represent the method of choice for penile reconstruction. In phalloplasty, in female-to-male transsexuals and penile reconstruction in male patients following loss in trauma or malignancy, microsurgery is routinely performed with the radial forearm flap being the mainstay.[10] Its main disadvantages of too hairy skin for urethral reconstruction and donor site morbidity cannot be ignored. In this very complex surgical case, with loss of entire right upper limb and left forearm being grafted in its entirety and with the loss of majority of adjacent tissues, groin flap is probably the choice. However, the major difficulty was the staged nature of procedure. The patient had a small fistula at the penoscrotal junction in the dorsal aspect which healed by conservative management. After an 18 month follow-up, the patient was very pleased with the appearance of penis and his wish of male pattern urination being fulfilled [Figure 6].

Figure 6

18 months postop with male pattern micturition with neophallus

DISCLOSURE

Neither author has any financial conflict of interest with any of the content discussed in this article.