Microsurgical Reconstruction of Penis

Introduction: The absence or loss of the penis has serious psychological and social implications. History of reconstruction and construction of the penis has run parallel to the history of plastic surgery, creating higher expectations as techniques are improved. The reconstruction was first described in 1936 by the Russian surgeon Borgoras, although it was phalloplasty with tubular abdominal flap Gillies a very popular procedure and established the benchmark for decades. The era of microsurgery allowed the use of well-vascularized tissue with minimal defects at the donor sites. In 1984, Hwang and Chang described the use of the radial forearm free flap for reconstruction of the penis, giving a semieréctil function with autologous cartilage. The reconstruction include both aesthetic and functional objectives: Normal or near -normal appearance, presence of urethra at the distal end of the penis and allows urination in a standing position, protective and erogenous sensitivity, sufficient length and diameter to perform sexual penetration, internal stiffness to provide similar feel to the erection, procedure performed in a single surgical time and low donor site morbidity.

Methodology and Material: Between December 1998 and July 2012, 16 microsurgical procedures for penile reconstruction were performed in in three Hospitals: Clínica San Pedro Claver, (6 patients), Hospital San José (5 patients) and the Misericordia Hospital Foundation, (5 patients). The average age was 30.5 years, range between 15 and 58 years. The etiologies of the lesions were: Trauma (traumatic amputations, gunshot wounds, traffic accidents) in 5 patients, Cancer Penis in 2 patients, Adrenal Hyperplasia in two patients, Sequelae of Iatrogenics in 2 patients, sexual ambiguity in 2 patients, necrosis by infection in 2 patients and thrombosis of Cavernous Bodies in 1 patient. All reconstructions were performed after trauma, on average 5 years after amputation (except for 2 patients with sexual ambiguity). No specific type of preoperative examinations were performed. Monitoring of patients was between 18 and 50 months with an average time of 35 months.

Results: In most patients (94%) reconstruction was performed using the radial forearm free flap or “Chinese flap,” in one patient (6%) free osteocutaneous fibula flap was used. Of the 16 patients reconstructed, presented early complications in 3 patients (12%), Total flap necrosis in 1 patient (6%) and partial necrosis 1 patients (6%). As late complications were reported: urethral fistula in 4 patients (25%), fracture of the rib graft 1 patients (6%), resorption of costal graft in 2 patients (12%), extrusion of silicone prosthesis in 1 patient (6%) and neourethra stenosis in 1 patient (6%).Among the most frequent late complications found urological complications such as fistulas and urethral stenosis, which occurred in 31% of our patients. Our case series of 16 patients with penile microsurgical reconstruction radial forearm flap is the largest series published in our country, becoming an important reference point for the treatment of this disease, since really the absence of penis, either congenital or acquired, is not a common condition.

Conclusions: The penile reconstruction is a surgical procedure that involves significant aesthetic and functional considerations for both the patient and the surgeon. The ingenious techniques that have been developed throughout history prove it. Local flaps imply the need for multiple surgical times and the aesthetic and functional results are not always the best. The advent of microsurgery represented significant progress for penile reconstruction. The radial forearm free flap (Chinese flap), is the technique of choice because the procedure can be performed in a single surgical time, a functional urethra is obtained, a sensitive and good aesthetic results is provided. Improve technical persist, such as maintenance of erection, the presence of urethral fistulas and psychological adaptation of patients to their new condition.