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SYMPOSIUM
Year : 2006  |  Volume : 22  |  Issue : 3  |  Page : 255-259
 

Functional penile reconstruction: What do we have as on today?


Department of Andrology, Sexology and STDs, Cairo University, Cairo, Egypt

Correspondence Address:
Hussein Ghanem
139 (A) El Tahrir Street, Dokki, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.27635

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   Abstract 

Penile reconstructive surgeries are performed mainly as radical treatment for conditions associated with congenital abnormalities of the urethra or penis, after penile trauma, penile cancer, short penis, corporal fibrosis and in cases of gender reassignment. In this article, we review the controversial penile augmentation topic, clarifying how most workers disagree with its scientific basis. We also highlight recent advances in surgical techniques in treatment of penile injuries and those employed for female-to-male sex reassignment procedures. We also propose a practical approach for evaluating and counseling patients complaining of a small sized penis.


Keywords: Penile augmentation, penile lengthening, penile reconstruction


How to cite this article:
Ghanem H, Shamloul R. Functional penile reconstruction: What do we have as on today?. Indian J Urol 2006;22:255-9

How to cite this URL:
Ghanem H, Shamloul R. Functional penile reconstruction: What do we have as on today?. Indian J Urol [serial online] 2006 [cited 2017 Jul 22];22:255-9. Available from: http://www.indianjurol.com/text.asp?2006/22/3/255/27635



   Introduction Top


Penile reconstructive surgery is becoming a frequently discussed topic because of the widespread media attention and internet ads. Reconstruction of the lower urinary tract and genitals in males and females is a demanding task with many techniques described in recent years. In males, penile reconstructive surgeries are performed mainly for congenital abnormalities of the urethra or penis, penile trauma or fracture, penile cancer, short penis, corporal fibrosis and in cases of gender reassignment. This review addresses the controversial penile augmentation procedures, penile surgeries following injury and those applied for female to male gender reassignment in patients with gender identity disorders.

Penile augmentation

Man's obsession with his penile size and its relation to sexual potency appears to be present in various cultures. Nowadays, with the era of internet-dominated communication, more men get to express their "concerns" over their penile size publicly and receive all types of information from credible and non-credible sources. Subsequently, various remedies -mostly with no scientific basis- are advertised to treat this "problem".

Penile augmentation is a surgical procedure aiming to lengthen and/or broaden an apparent short or undersized penis. While this type of penile surgeries has now become increasingly common, however, deep-seated issues regarding its principle and patient selection are still questionable. In a recent review, Vardi and Lowenstein noted that surgery to augment penile length or girth suffers serious lack of standardization. This has led to a wide variety of poorly documented surgical techniques, with unconvincing results.[1]

Normal penile size

The average size of the erect penis in the normal adult male is 12.1-12.4 cm according to several studies.[2],[3],[4] On the other hand, a true micropenis is defined as a normally formed but small penis whose length is 2.5 standard deviations below the normal median for age.[5]

Several studies suggest that most men complaining of a small sized penis have in fact normal sized genitals. Some men are simply misinformed but others suffer from what is known as penile dysmorphophobia.[6],[7] Penile dysmorphophobia is a part of the body dysmorphic disorder which is defined by the DSM-IV-TR[8] (a handbook for mental health professionals) as a condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body, which differentiates it from anorexia nervosa and bulimia nervosa, where the patients are preoccupied with their overall weight and body shape. The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient's social, occupational or educational functioning. The most common cause of this decline is the time lost in obsessing about the "imagined defect."

Mondaini et al ,[9] followed by Shamloul[6] studied cohorts of patients complaining of a small penis. Both studies reached similar conclusions. All men complaining of short penis were misinformed regarding the actual normal penile size. Of the 92 patients included in Shamloul's study, 66 (71.7%) complained of a short penis only in the flaccid state and 26 (28.3%) complained of a short penis in both the flaccid and the erect state. None of the patients had erectile dysfunction. None of the patients had a short penis. In another study, Spyropoulosa et al[7] found that all 28 men presenting with a complaint of a small penis in his study suffered from penile dysmorphophobia. Mentioning all these valid conclusions on men complaining of short penis, we should not overlook a fact that in few cases, some men may suffer from a concealed or buried penis, a condition which might need surgical intervention. A concealed penis is a normally developed penis that is partially covered by the suprapubic fat.[10] A penis may also be buried by overzealous circumcision removing excess skin in addition to the prepuce.

Surgery: Indications, outcomes, complications and satisfaction

Currently there is no consensus over the indications for penile augmentation surgery. The only available guidelines were suggested by Wessells et al .[4] The authors advise that only men with a flaccid length of less than 4 cm or a stretched or erect length of less than 7.5 cm should be considered candidates for penile lengthening.

Surgery is generally aimed at increasing the perceived penile length or the actual girth. Techniques employed to increase penile length include severing the suspensory ligament with or without V-Y plasty of the lower abdominal skin, possibly with fat, dermis or synthetic material graft to prevent reattachment of the suspensory ligament. Liposuction or lipectomy has been used for overweight patients with a large infrapubic pad of fat. Surgery to enhance the penile girth mainly includes lipoinjection, dermal free or pedicle grafts and venous grafting for the corpora cavernosa.[7],[11],[12],[13] Success following these procedures is minimal. Usually one to two cm extra length is considered to be a success and patients are informed that there is a possibility of no actual gain at all.[7],[14] A "pseudo-longer" penis is perceived due to penile descent and increased convexity of the penile base from advanced skin. The lack of standardized measurement methods makes any claims of extraordinary length highly questionable. Further, the unavailability of any measurements of post-augmentation erect penis together with denial of most patients in noticing any change in their erect penis size adds more uncertainty towards the whole procedure. Because no standard method of measurement exists, claims of extraordinary length gains remain unfounded.

Complications related to penile lengthening procedures include 'scrotalization' where the penis is unsightly being covered by scrotal corrugated skin rather than by its natural smooth skin, 'Dog-ears' may be seen at the ends of the operation scars and skin sloughing. Girth augmentation procedures may be complicated by loss of girth due to fat resorption, nodule formation due to uneven fat reabsorbtion. A deformed appearance may be related to irregular fatty lumps over the penis.[11],[15]

Alter[11] described complications resulting from augmentation procedures in more than 30 patients presenting for reconstruction of penile deformities resulting from penile enlargement surgery performed by other physicians. Specific complaints related to the lengthening procedure included: hypertrophic and/or wide scars, a proximal penile hump from a thick hair-bearing V-Y flap and a low hanging penis. Complications related to girth enhancement included disappearance of fat, penile lumps and nodules and shaft deformities. Wessells et al[15] reviewed the complications of penile augmentation techniques in 12 men. While only 1 patient reported a subjective increase in penile length, all other patients suffered poor cosmetic appearance. Four patients complained of sexual dysfunction and six patients needed a re-do. The latter may be due to penile shortening after releasing the ligaments. This might result from scarring and retraction in the area of the suspensory ligament. The use of stretching devices has been suggested to minimize penile retraction and entrapment in the infrapubic scar.[11],[16]

Besides physical complications, psychological complications are also a concern. A patient with penile dysmorphophobia is already sensitized towards his penile size and any iatrogenic interference would result in self-assurance of his "problem".

Reports on patient's satisfaction following penile augmentation are not encouraging. Li et al[14] reported that only 27% of men with dysmorphophobia were satisfied with the results and an overall satisfaction rate of 35% percent. On the other hand, Spyropoulosa et al ,[7] evaluated responses from eleven patients who underwent penile augmentation, using a questionnaire. Increased sexual self-esteem scores following augmentation surgery were reported among these patients. However, the main limitations of the study included the use of a non-validated questionnaire and employing a sample with a much shorter penis than the mean already reported previously.[13]

In a recent discussion on the email ring of the International Society of Sexual Medicine (posted on ISSM website) most members advised against surgical intervention due to frequent complications and lack of significant results with surgery.[17] Members generally advised patient education and counseling. However, it is to be noted that currently there are no comparative studies that compare the psychological outcome of patients suffering from penile dysmorphophobia treated surgically to those managed by education and psychotherapy.

Managing a patient complaining of a small sized penis

A physician attending to patients complaining of a small penis should have a strategy for the management of these patients. These patients usually have suffered from this false belief for years and would not be cured just by being told that they are normal. The 'management plan' the authors use is outlined in appendix 1. We propose it for the initial evaluation and counseling of physically normal men with a complaint of a small penis.


   Penile reconstruction following trauma Top


Penetrating penile trauma

Most cases of penile trauma are associated with multiple injuries. The specific management of genital trauma must be placed within the context of the treatment of the patient and his injuries as a whole.[18] A thorough history of the mechanism of injury is invaluable, as is a detailed assessment of the extent of the injuries sustained. The principles of care are debridement of devitalized tissue with the preservation of as much viable tissue as possible, hemostasis, diversion of urine in selected cases and the removal of foreign bodies.[19]

The tissue chosen for reconstruction following trauma needs to provide good coverage and be suitable for reconstruction.[20] Split-thickness skin-grafting provides good coverage and dependable take that is reproducible and durable, but these grafts contract more than full-thickness skin grafts and their use on the shaft should be kept to a minimum.[18] If there has been extensive destruction of deeper tissues or if later prosthetic placement is being considered, then skin flaps, which transfer vascularity, can be used.

The surgical approach will be dependent upon the site and extent of the injury, but a subcoronal incision with penile degloving usually gives good exposure.[18] A defect in the tunica albuginea can be closed primarily, after copious irrigation. With too much tissue loss, the defect can be further repaired with a patch. If associated suspected urethral injury is suspected, a urethrogram, taken either preoperatively or perioperatively, is useful in assessing the level and extent of the injury.[18]

Penile avulsion injuries and amputation

Most of these injuries are self-inflicted in psychotic patients, but some are related to industrial accidents. After acute management of the severed penis, surgery should follow immediately.

Reattachment can be achieved using microsurgical or non-microsurgical techniques,[21] However, non-microsurgical techniques are associated wit a higher postoperative urethral stricture rate and more problems with loss of sensation. The best results are seen with microsurgical re-implantation. First the corpora cavernosa and urethra are aligned and repaired and then the dorsal penile arteries, the dorsal vein and the dorsal nerves are repaired with the use of an operating microscope. The cavernosal arteries are generally technically difficult to anastomose. The fascia and skin are closed in layers and both a urethral and a suprapubic catheter placed. If the severed penis cannot be found or is unsuitable for reattachment, then the end should be closed as after partial penectomy. The penile stump may then subsequently be considered for a lengthening procedure. A major reconstructive procedure such as a radial artery phalloplasty[22] or a pubic phalloplasty[23] is reserved for a short stump or as a salvage procedure if the smaller operations have not been successful.


   PENILE RECONSTRUCTION FOR FEMALE-TO-MALE SEX REASSIGNMENT Top


Bogoras[24] first attempted a total penile reconstruction surgery for sex reversal in 1936. This was followed by several different procedures to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Initially, the procedures used pedicled cutaneous or myocutaneous flaps from the groin,[25] rectus abdominis[26] or gracilis muscles.[27] With improvements in free tissue transfer and microvascular techniques, new procedures based on the use of free flaps such as the radialis,[22] the lateral arm[28] and the deltoid.[29]

The goal of penile reconstruction is to achieve an aesthetically acceptable neophallus that enables urination in the standing position and that allows sexual intercourse. The phallus should be constructed to an adequate size and bulk (possibly in a single stage); should have enough rigidity to allow penetration and enough protective, erogenous sensation to allow enjoyment of intercourse; and should permit the urethra to exit at the glans tip without stricture or fistulas.[30],[31]

Most authors currently agree that the free forearm flap is the gold standard for phalloplasty. A complete urethra can be reconstructed using a tube-into-tube technique. Sensitive innervation can be achieved by coaptation of the anterolateral and the anteromedial forearm nerves. Penile rigidity can be obtained by including in the flap a stick of the radial bone or by using a prosthesis, but donor-site morbidity remains a challenge, even using skin expansion.[31]

In a recent study, the tensor fasciae latae was used to develop a neophallus,[32] by creating a neurovascular flap that is able to create a sensate neophallus of adequate size with very little donor- site disfigurement. The authors report that in four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. They concluded that island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.[32]

Felici and Felici, very recently, reported a new technique for phalloplasty in female-to-male sex reassignment operations.[33] They used the anterolateral thigh (ALT) flap, which they reported to be ideal for phalloplasty: "safe, sensate, hairless, with a long pedicle and large amount of soft tissues, which can be harvested in a single procedure and with a low donor site morbidity".[33] In their experience with 6 phalloplasties using the ALT flap, the authors report that the shape and the consistency of the neo-phallus are suitable, the flap can be sensate and an erectile prosthesis can easily be implanted. No significant complications were observed and patient's satisfaction was high.


   Conclusions Top


Penile reconstructive surgeries encompass a wide variety of invasive procedures established to treat several penile abnormalities. The highly controversial penile augmentation needs thorough investigations and procedural standardization before being considered an option to treat short penis. There has been a significant increase in the techniques employed to approach different penile injuries and female-to-male sex assignment. It is expected that with the advancement of successful surgical and anatomical research, higher success rate of penile reconstructive surgeries may be possible.

 
   References Top

1.Vardi Y, Lowenstein L. Penile enlargement surgery: Fact or illusion? Nat Clin Pract Urol 1995;2;114-5.  Back to cited text no. 1    
2.Ponchetti R, Mondaini N, Bonafe M, Di Loro F, Bisconi S, Masieri L. Penile length and circumference: A study on 3.300 young Italian males. Eur Urol 2001;39:183-6.   Back to cited text no. 2    
3.Spyropoulosa E, Borousas D, Mavrikos S, Dellis A, Bouronis M, Athanasiadis S. Size of external genitalia organs and somatometric parameters among physically normal men younger than 40 years old. Urology 2002;60:485-91.  Back to cited text no. 3    
4.Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: Guidelines for penile augmentation. J Urol 1996;156:995-7.   Back to cited text no. 4    
5.Aaronson IA. Micropenis: Medical and surgical implications. J Urol 1994;152:4-14.  Back to cited text no. 5  [PUBMED]  
6.Shamloul R. Treatment of men complaining of short penis. Urology 2005;65:1183-5.   Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Spyropoulosa E, Christoforidisb C, Borousasa D, Mavrikosa S, Bourounisa M, Athanasiadisa S. Augmentation phalloplasty surgery for penile dysmorphophobia in young adults: Considerations regarding patient selection, outcome evaluation and techniques applied. Eur Urol 2005;48:121-8.   Back to cited text no. 7    
8.American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders (DSM-TV-TR). 4th ed. Text revision. APA: Washington, DC; 2000.  Back to cited text no. 8    
9.Mondaini N, Ponchietti R, Gontero P, Muir GH, Natali A, Caldarera E, et al . Penile length is normal in most men seeking penile lengthening procedures. Int J Impot Res 2002;14:283-6.  Back to cited text no. 9    
10.Elder JS. Congenital anomalies of the genitalia. In : Walsh PC, Retik AB, et al . (editors) Campell's Urology. WB Saunders Co: Philadelphia, London, Torronto; 1998. p. 2120-43.  Back to cited text no. 10    
11.Alter GJ. Penile enlargement surgery. Tech Urol 1998;4:70-6.  Back to cited text no. 11  [PUBMED]  
12.Austoni E, Guarneri A, Cazzaniga A. A new technique for augmentation phalloplasty: Albugineal surgery with bilateral saphenous grafts: Three years of experience. Eur Urol 2002;42:245-53.  Back to cited text no. 12    
13.Shaeer O, Shaeer K. Penile girth augmentation using flaps "Shaeer's augmentation phalloplasty": A case report. J Sex Med 2006;3:164-9.  Back to cited text no. 13    
14.Li CY, Kayes O, Kell PD, Christopher N, Minhas S, Ralph DJ. Penile suspensory ligament division for penile augmentation: Indications and results. Eur Urol 2006;49:729-33.  Back to cited text no. 14    
15.Wessells H, Lue TF, McAninch JW. Complications of penile lengthening and augmentation seen at 1 referral center. J Urol 1996;155:1617-20.  Back to cited text no. 15    
16.Ralph DJ, Palumbo F, Pryor JP. The penile suspensory ligament. AUA 95th Annual Meeting. Atlanta, Georgia; 2000.   Back to cited text no. 16    
17.http://www.issm.info/ accessed March 22, 2006.  Back to cited text no. 17    
18.Summerton DJ, Campbell A, Minhas S, Ralph DJ. Reconstructive surgery in penile trauma and cancer. Nat Clin Pract Urol 2005;2:391-7.  Back to cited text no. 18    
19.Jordan GH, Schlossberg SM. Surgery of thepenis and urethra. In : Campbell's Urology. 8th ed. Walsh P, et al , editors. WB Saunders: Philadelphia; 2002. p. 3886-954.  Back to cited text no. 19    
20.Jordan GH. Penile reconstruction, phallic reconstruction and urethral reconstruction. Urol Clin North Am 1999;26:1-13.  Back to cited text no. 20    
21.Bhanganada K, Chayavatana T, Pongnumkul C, Tonmukayakul A, Sakolsatayadorn P, Komaratat K, et al . Surgical management of an epidemic of penile amputations in Siam. Am J Surg 1983;146:376-82.  Back to cited text no. 21    
22.Chang TS, Hwang HY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg 1984;74:251-8.  Back to cited text no. 22    
23.Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int 2005;95:120-4.  Back to cited text no. 23    
24.Puckett CL, Montie JE. Construction of male genitalia in the transsexual, using a tubed groin flap for the penis and a hydraulic inflation device. Plast Reconstr Surg 1978;61:523-30.  Back to cited text no. 24    
25.Kenney J, Edgerton MT. Phalloplasty: Past, present and future. In : Proceedings of the 10th International Symposium on Gender Dysphoria. Amsterdam: The Netherlands; 1987.  Back to cited text no. 25    
26.Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg 1972;25:347-66.  Back to cited text no. 26    
27.Upton J, Mutimer KL, Loughlin K, Ritchie J. Penile reconstruction using the lateral arm flap. J R Coll Surg Edinb 1987;32:97-101.  Back to cited text no. 27    
28.Hage JJ, de Graaf FH, van den Hoek J, Bloem JJ. Phallic construction in female-to-male transsexuals using a lateral upper arm sensate free flap and a bladder mucosa graft. Ann Plast Surg 1993;31:275-80.  Back to cited text no. 28    
29.Harashina T, Inoue T, Tanaka I, Imai K, Hatoke M. Reconstruction of the penis with a free deltoid flap. Br J Plast Surg 1990;43:217-22.  Back to cited text no. 29    
30.Gilbert DA, Horton CE, Terzis JK, Devine CJ Jr, Winslow BH, Devine PC. New concepts in phallic reconstruction. Ann Plast Surg 1987;18:128-36.  Back to cited text no. 30    
31.Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: Some reflections on refinements of technique. Microsurgery 1993;14:592-8.  Back to cited text no. 31    
32.Santanelli F, Scuderi N. Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap. Plast Reconstr Surg 2000;105:1990-6.   Back to cited text no. 32    
33.Felici N, Felici A. A new phalloplasty technique: The free anterolateral thigh flap phalloplasty. J Plast Reconstr Aesthet Surg 2006;59:153-7.  Back to cited text no. 33    


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