International Journal of Impotence Research (2003) 15, Suppl 5, S129–S131 & 2003 Nature Publishing Group All rights reserved 0955-9930/03 $25.00 www.nature.com/ijir Use of penile implants in the constructed neophallus

JJ Mulcahy1*

1Urology Department, Indiana University Medical Center, Indianapolis, Indiana, USA

Creation of a neophallus in cases of loss of the penis or female to male trans-sexual is a challenge. The forearm flap is the most popular method used. A may be placed at the original procedure or at a later date to provide support for intercourse. The hydraulic nondistally expanding types provide the best support with less chance of distal erosion. Covering the device with cadaver pericardium or porcine small intestinal submucosa has been helpful in creating a neocorpus cavernosum. International Journal of Impotence Research (2003) 15, Suppl 5, S129–S131. doi:10.1038/ sj.ijir.3901087

Keywords: neophallus; penile implant; penile construction

For an urologist to encounter a reconstructed mosis of the radial artery and vein to the inferior phallus is certainly an unusual circumstance. Loss epigastric artery and vein were used to transfer of the penis is a rare occurrence and reconstruction forearm skin to the groin (Figure 1).6 A smaller following such a loss is a challenge. Phallic segment of the forearm was tubed to form the construction in the 1930s and 1940s consisted of (Figure 2). This was separated by a 1 cm abdominal tube flaps. These methods were pio- segment of fat and around this a larger piece of the neered by Bogoras1 and later by Gilles and Harri- forearm was tubed with the skin on the exterior to son.2 The technique involved creating tabularized cover the neourethra (Figure 3). This technique abdominal skin and subcutaneous tissue flaps sometimes called a tube within a tube has become which were brought down to the prepubic area of popular and is now probably the most commonly the pelvis in multiple stages, first detaching one end used method of neophallic reconstruction.7 as neovascularity occurs through the opposite end of The rectus muscle has also been employed the tubercularized flap. Anastomosis of the new successfully to create a new phallus which has been urethra to the stump of the pre-existing urethra may very functional for sexual activity. Using this be performed at the end of the procedure. technique, penile cylinders are moored Goodwin and Scott3 use as the sole source either in native crural bodies or gortex or Dacron of the neophallus in a two-stage procedure. In the first sleeves attached to an ischiopubic ramus. The rectus stage, scrotal skin is tubed over a catheter to form the muscle is disarticulated at the costal margin and the new urethra, which is then covered by advancing superior epigastric vessels sacrificed. The muscle lateral scrotal flaps. In the second stage, the new maintains its attachment to the pubic arch with the urethra and the surrounding scrotal skin are separated inferior epigastric vessels as its blood supply. This from the remainder of the scrotum and tube to create rectangle is then tabularized around the prosthesis the new penis and a somewhat smaller scrotum. The cylinders and covered with split thickness skin draw back of this technique is that the external penile grafts. Voiding is accomplished through a perineal shaft and the urethral tube contain hair. urethrostomy or an opening at the penoscrotal In the 1970s, Orticochea4 used a gracilis myocu- junction. taneous flap and Puckett and Monte5 employed During these neophallic construction procedures, modifications of a groin flap in constructing a new a stiffener may be used to give support to the penis, phallus. In 1984, Chang and his associates described so intercourse may later be possible. Earlier materi- the radial forearm flap in which the microanasto- als used included costal cartilage, silicone rods, or crudely fashioned acrylic cylinders. Later penile implants were introduced to the marketplace and *Correspondence: JJ Mulcahy, MD, Indiana University provided readily available supports for this purpose. Medical Center, Urology Department, 535 N. Barnhill Dr. Hydraulic, nondistally expanding devices provide #420, Indianapolis, IN 46202, USA. safer support than semirigid rods, as they create less E-mail: [email protected] distal pressure which would decrease the chance of Penile implants in constructed neophallus JJ Mulcahy S130

Figure 1 Forearm flap divided into two segments. (a) For tubularization into the urethra and (b) to be wrapped around the outside of the neourethra. (c) A length of 1 cm deepithelia- lized segment is located between the two flaps (adapted from Chang and Huang6). Figure 2 Segment (a) is tublarized to form the new urethra (adapted from Chang and Huang6). the foreign material wearing through the skin to the exterior. With the rectus muscle technique, the quisite sexual sensitivity has been lacking in all of inflatable implant is placed at the time of the phallic these constructed penises. creation to minimize shortening of the penis as Situations where phallic construction would be muscle atrophy occurs with time. If one returns at a warranted would be following for penile later date to place a prosthesis, a period of 6 months , traumatic , penile necrosis, and should elapse to allow inflammation to subside in changing of sex from the female to male. completely. Materials such as cadaver pericardium This surgery is certainly challenging. No native (Tutoplast-Mentor Corporation, Santa Barbara, CA, corpora cavernosa exist and placing a support in the USA) and porcine small intestinal submucosa (SIS- neophallus which would render intercourse possi- Stratosis Cook, Spencer, IN, USA) can be placed ble is fraught with many problems. The implant is around the penile implant cylinders before inser- tunneled through fibro, fatty, or muscular tissue and tion. These materials with time will form a lattice for care must be taken to provide adequate protection scar formation by the body adding a tough protective on the lateral surfaces and distally to prevent covering to further minimize the chance of cylinder extrusion of the foreign material to the exterior. erosion. Placing one cylinder will usually suffice for Also, the type of skin used to reconstruct the penis adequate ridigity and less chance of complications certainly does not at all resemble the glans or the of erosion. natural foreskin of the native penis. If penile With construction of the neophallus, innervation amputation is necessary, it is certainly prudent to has been a problem. Although a phallic appearing save all native tissue possible for further reconstruc- organ has been constructed, sensitivity is minimal at tion of the phallus. In performing these procedures, best. Use of a sural nerve graft has given some one should be prepared for multiple operations improvement in the sensitivity, but certainly ex- including salvage to preserve the penis from

International Journal of Impotence Research Penile implants in constructed neophallus JJ Mulcahy S131 with time has been the rule. If an arterial anasto- mosis has been used to reconstruct the new phallus, one should use a Doppler on the operating field to identify the location of this artery when placing a prosthesis. Damage to the artery is certainly a possible occurrence and may result in loss of the phallus. The base of the phallus may also need additional support with a structure such as a gracilis myocutaneous flap to prevent erosion of parts in this area and also to support the rigidity of the phallus. The rectus muscle has given the best support for a phallus for which erectile function is the desired modality. The excessive bulk of tissue provides adequate protection for an inflatable prostheses cylinder and minimizes the chance of erosion of parts to the exterior. The radial forearm flap gives the best result if voiding through the end of the neophallus is the desired outcome. Many trans- sexual patients would prefer this modality rather than be sexually active with the neophallus. If a prosthesis is used, it should be partially inflated for 2 months following the placement to allow an adequate capsule to develop around the inflated cylinder. The patient should be advised also to inflate the device frequently thereafter to prevent contracture of the tissue surrounding the prostheses cylinder which will occur with time.

References

1 Bogoras NA. Plastic restoration of the penis. Sovet Khir 1936; 8: 303 – 307. 2 Gillies HD, Harrison HR. Congenital absence of the penis. Br J Plast Surg 1948; 1: 8 – 28. 3 Goodwin WE, Scott WW. . J Urol 1952; 68: 903 – 908. 4 Orticochea M. A new method of total reconstruction of the Figure 3 Segment (b) is tubularized around the outside of the penis. Br J Plast Surg 1972; 25: 347 – 366. whole structure. Cartilage or a penile implant may be inserted as a 5 Puckett CL, Monte JE. Construction of male genitalia in the stiffener or added at a later date (adapted from Chang and transsexual using a tubed groin flap for the penis and a Huang6). hydraulic inflation device. Plast Reconstr Surg 1978; 61: 523 – 530. 6 Chang TS, Huang WY. Forearm flap in one-stage reconstruc- tion of the penis. Plast Reconstr Surg 1984; 74: 251 – 258. deterioration. If a stiffener is not used to maintain 7 Gilbert DA, Winslow BH. Penis construction. Semin Urol adequate length of the penis, shrinkage of the penis 1987; 5: 262 – 269.

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