Reconstructive urology

UROLOGICAL SURVEY

Reconstructive urology

New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female–to–male transsexuals

Vesely J, Hyza P, Ranno R, Cigna E, Monni N, Stupka I, Justan I, Dvorak Z, Novak P, Ranno S

Clinic of Plastic and Aesthetic Surgery, St. Anna University Hospital, Masaryk University in Brno, Brno, Czech Republic

Ann Plast Surg. 2007; 58: 544–50

From December 2001 to September 2005, the technique of total penile reconstruction with a reinnervated free latissimus dorsi myocutaneous flap was used in 22 patients (24–38 years old) with gender dysphoria. These patients were followed up for at least 11 months (range, 11–44 months). All flaps survived. Complications include hematoma (7 cases), vascular thrombosis (2 cases), partial necrosis (1 case), excessive swelling of the neophallus (3 cases), and skin graft loss at the donor site (1 case). Of the 19 patients included in the final evaluation, the transplanted muscle was able to obtain contraction in 18 (95%) cases and 8 patients (42%) had sexual intercourse by contracting the muscle to stiffen and move the neopenis. The described technique of neophalloplasty proved to be a reliable technique and the muscle movement in the neophallus can be expected in almost all cases. The muscle contraction in the neophallus leads to "paradox" erection–stiffening, widening, and shortening of the neopenis, which allows for sexual intercourse in some patients. Subsequent reconstruction of the urethra is possible.

Editorial Comment

Functioning free muscle flaps have recently been shown to successfully restore volitional voiding in patients with acontractile bladders (1). Apart from the anastomosis of the flap, vasculature to suitable vessels at the recipient site function is achieved by microsurgical coaptation of the motor nerve supplying the flap muscle to a recipient motor nerve supplying an abdominal muscle. The transferred muscle starts acting as a "piggyback" muscle to the same muscle with which it shares its new innervation.

The authors of this paper have applied the same principle for phalloplasty in female–to–male transsexuals. In addition to obtaining a neophallus, the majority of patients were able to contract the muscle after a mean of 4 months. Almost half of the patients used the muscle contraction to stiffen the penis and were thus able to have intercourse.

Contrary to the sole use of latissimus dorsi muscle in detrusor, myoplasty phalloplasty needs a large portion of the overlying skin similar to musculocutaneous flaps used for breast reconstruction. Therefore, the rate of donor site morbidity was larger than previously reported (2), but according to the authors, 83 % considered donor site morbidity as acceptable.

The fact that no urethral reconstruction was done in these patients may be seen as a downfall. However, the possibility of actively stiffening the neophallus may be appealing for some patients. The mean follow–up of almost two years with some patients just followed for a year is too short. Some patients apparently had considerable shrinkage of the graft and this number might get larger with a longer follow–up. However, the concept of using a functioning muscle transfer for phalloplasty is worth to be considered and shows furthermore the possible versatility of this technique applicable in various fields of urology.

References

1. Stenzl A, Ninkovic M, Kölle D, Knapp R, Anderl H, Bartsch G: Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle. Lancet. 1998; 351: 1483–5.

2. Ninkovic M, Stenzl A, Schwabegger A, Bartsch G, Prosser R, Ninkovic M: Free neurovascular transfer of latisstmus dorsi muscle for the treatment of bladder acontractility: II. Clinical results. J Urol. 2003; 169: 1379–83.

Dr. Arnulf Stenzl &

Dr. Karl–Dietrich Sievert

Department of Urology

Eberhard–Karls–University Tuebingen

Tuebingen, Germany

E–mail: [e-mail]

Porcine small intestinal submucosa graft for repair of anterior urethral strictures

Fiala R, Vidlar A, Vrtal R, Belej K, Student V

Department of Urology, University Hospital, Olomouc, Czech Republic

Eur Urol. 2007; 51: 1702–8

OBJECTIVES: We evaluated porcine small intestinal submucosa (SIS) used in the treatment of inflammatory, iatrogenic, posttraumatic, and idiopathic strictures of bulbar and penile urethra. Midterm maintenance of urethral patency was assessed.

METHODS: Fifty patients aged 45–73 yr with anterior urethral stricture underwent urethroplasty using a porcine SIS collagen–based matrix for urethral reconstruction. Stricture was localized in the bulbar urethra in 10 patients, the bulbopenile area in 31 cases, and in the distal penile urethra in nine patients. All patients received a four–layered SIS patch graft in an onlay fashion. A voiding history, retrograde and antegrade urethrography, and cystoscopy were performed preoperatively and postoperatively. Failure was defined as stricture confirmed on urethrogram.

RESULTS: After a mean follow–up of 31.2 mo (range: 24–36 mo), the clinical, radiological, and cosmetic findings were excellent in 40 (80%) patients. Restricture developed in one of 10 bulbar, five of 31 bulbopenile, and four of nine penile strictures. These all occurred in the first 6 mo postoperatively. All patients with recurrences needed further therapy, but there has been no additional recurrence observed to date. No complications such as fistula, wound infection, UTI, or rejection were observed.

CONCLUSIONS: Use of inert porcine SIS matrix appears to be beneficial for patients with bulbar and bulbopenile strictures. Midterm results are comparable to skin flaps and mucosal grafts.

Editorial Comment

Several recent reports have used porcine small intestinal submucosa (SIS) produced either commercially or by individual laboratories as a substitute for autologous flaps in urethral stricture surgery. The initial experimental results were promising (1,2), however, clinical results were mixed (3).

When using porcine acellular matrix, it might be applied either alone functioning as a scaffold for the ingrowths of the neighboring healthy urethra or together with cultivated urothelial cells as urethral wall substitute.

The authors of this contribution used commercially available porcine SIS in an onlay fashion for bulbar, bulbopenile, and distal penile urethral defects after careful excision of strictured urethral segments. The results were acceptable for bulbar strictures but clearly unsatisfactory for penile and bulbopenile strictures. One should be cautious with the interpretation of the results in bulbar strictures: one of ten patients with bulbar stricture surgery recurred after 24 — 36 months. Considering the small number in this subgroup and the possibility of further recurrences with longer follow–up one has to question the use of xenogenic acellular matrices over autologous free flaps such as buccal mucosa. Recent experimental studies have shown that at least in commercial products there are nuclear remnants identifiable within the matrix of the presumably acellular small intestinal submucosa suggesting possible remnant donor DNA (4). Under in vitro conditions, it was also seen that human urothelial cell growths was grossly impaired. Furthermore, SIS so far did not yield any other obvious benefit for patients nor does it help to reduce any surgical costs. We therefore have to continue our search for suitable biomaterials in urethral reconstructive surgery. Until we succeed to find something current standard techniques such as buccal mucosa are the best and safest choice.

References

1. Kropp BP, Ludlow JK, Spicer D, Rippy MK, Badylak SF, Adams MC, et al.: Rabbit urethral regeneration using small intestinal submucosa onlay grafts. Urology. 1998; 52: 138–142.

2. Sievert KD, Bakircioglu ME, Nunes L, Tu R, Dahiya R, Tanagho EA: Homologous acellular matrix graft for urethral reconstruction in the rabbit: histological and functional evaluation. J Urol. 2000; 163: 1958–1965.

3. Santucci RA, Barber TD: Resorbable extracellular matrix grafts in urologic reconstruction. Int Braz J Urol. 2005; 31: 192–203.

4. Feil G, Christ–Adler M, Maurer S, Corvin S, Rennekampff HO, Krug J, et al.: Investigations of urothelial cells seeded on commercially available small intestine submucosa. Eur Urol. 2006; 50: 1330–7.

Dr. Karl–Dietrich Sievert &

Dr. Arnulf Stenzl

Department of Urology

Eberhard–Karls–University Tuebingen

Tuebingen, Germany

E–mail: [e-mail]–tuebingen.de

Publication Dates

• Publication in this collection
  29 Aug 2007
• Date of issue
  June 2007