Phalloplasty

Last updated

Phalloplasty
Specialty Urology
ICD-10-PCS 0VUS07
CPT 54304

Phalloplasty (also called penoplasty) [1] is the construction or reconstruction of a penis or the artificial modification of the penis by surgery. The term is also occasionally used to refer to penis enlargement. [2]

Contents

History

Russian surgeon Nikolaj Bogoraz performed the first reconstruction of a total penis using rib cartilage in a reconstructed phallus made from a tubed abdominal flap in 1936. [3] [4] [5] The first gender-affirming surgery for a trans man was performed in 1946 by Sir Harold Gillies on fellow physician Michael Dillon, documented in Pagan Kennedy's book The First Man-Made Man.[ citation needed ] Gillies' technique remained the standard one for decades. Later improvements in microsurgery made more techniques available.

Indications

A complete construction or reconstruction of a penis can be performed on patients who:[ citation needed ]

There are different techniques for phalloplasty. Construction of a new penis (sometimes called a neophallus or neopenis) [6] typically involves taking a tissue flap from a donor site (such as the forearm). Extending the urethra through the length of the neophallus is another goal of phalloplasty. [7]

Temporary lengthening can also be gained by a procedure that releases the suspensory ligament where it is attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. However, scar formation can cause the penis to retract. Therefore, the American Urological Association "considers the division of the suspensory ligament of the penis for increasing penile length in adults to be a procedure which has not been shown to be safe or efficacious." [8] [9]

Penile implants

An inflatable penile implant inserted into corpus cavernosum of the penis Inflatable penile implant.jpg
An inflatable penile implant inserted into corpus cavernosum of the penis

Phalloplasty requires an implanted penile prosthesis to achieve an erection. Penile prostheses are implanted devices intended to restore the erectile rigidity in cisgender men and to build a neophallus (new penis) in transgender men. Penile implants have been used in phalloplasty surgeries both in cisgender and transgender patients since 1970s. [10]

There are two main types of penile implants – malleable (also known as non-inflatable or semi-rigid) and inflatable implants. Both types have a pair of cylinders implanted into the penis, replacing the non-erectile tissue in cisgender men and serving as the core for the neophallus in the phalloplasty procedure. The cylinder of the inflatable implant is filled with sterile saline solution. Pumping saline into the chambers of this cylinder produces an erection. The glans of the penis, however, remains unaffected.

In sex reassignment surgeries, a new penis is formed with the use of a penile implant surrounded with a tissue flap. [11]

The pump unit of inflatable penile implants resembles a human testicle and can serve as an artificial testicle for concomitant scrotoplasty. [12]

Initially, standard penile implants were used in phalloplasty procedures. However, since there is no corpus cavernosum in the penis undergoing phalloplasty, and the fact that standard penile implants were designed to be implanted in corpus cavernosum, there were many adverse outcomes. [13] Since 2015, Zephyr Surgical Implants proposes malleable and inflatable penile implants particularly designed for phalloplasty surgeries. [14] Implantation procedures are usually done in a separate surgery to allow time for proper healing.

Explanation of techniques

Hip showing scar from skin graft used for phalloplasty. Sex reassignment scar on hip.jpg
Hip showing scar from skin graft used for phalloplasty.

Flap from the arm

[15] Sensation is retained through the clitoral tissue at the base of the neophallus. [15] Nerves from the flap and the tissue it has been attached to may eventually connect. [16]

Flap from the side of the chest

The disadvantages include:

Flap from the leg

Example of stage 1 female-to-male sex reassignment prior to glansplasty penis with tissue grafting scar on the left hip Phalloplasty-Artificial male genitals on grey background.jpg
Example of stage 1 female-to-male sex reassignment prior to glansplasty penis with tissue grafting scar on the left hip

Pubic area flap

Latissimus dorsi phalloplasty

This phalloplasty method is from latissimus dorsi musculocutaneous flap. [17]

Gillies technique

Abdominal muscle

Subcutaneous soft silicone implant

This phalloplasty procedure involves the insertion of a subcutaneous soft silicone implant under the penile skin. [18] [19] [20] [21]

No-touch surgical technique

The no-touch surgical technique for penile prosthesis implantation is a surgical procedure developed by J. Francois Eid for the implantation of a penile implant. [22] Implantation through the use of the "No-Touch" technique minimizes the risk of infection.

As advancements in the design and manufacturing process of the IPP improved its mechanical survival, infection has emerged as the leading cause of implant failure. Although relatively infrequent (varying from .06% to 8.9%) infection of a penile prosthesis results in serious medical consequences for patients, requiring complete removal of the device and permanent loss of penile size and anatomy. [23] [24] Bacterial contamination of the device can occur during the surgery, and is caused by allowing direct or indirect contact of the prosthesis with the patient's skin. Over 70% of infections occur due to the skin microbiome's microorganisms including Staphylococcus epidermidis , Staphylococcus aureus , Streptococcus and Candida albicans . [25]

Traditional strategies to combat infections aim at decreasing skin colony count such as scrubbing skin preparation with alcohol and chlorhexidine or kill bacteria once the implant is contaminated by skin flora such as intravenous antibiotics, antibiotic irrigation and antibiotic-coated implants. The "No-Touch" technique is unique in that it aims to prevent bacterial contamination of the prosthesis by completely eliminating contact of the device with the skin. [26]

Paired with the antibiotic-coated implant, the "No Touch" technique decreases infection to a rate of 0.46%, opposing the traditional method which has an infection rate of 5%. The use of an antibiotic-coated implant and a no-touch surgical technique with skin preparation measures and peri-operative antibiotic use has been found to be of high importance in the prevention of infection among penile implants. [27] Eid developed the technique in 2006 on the hypothesis that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection. [25] [28]

Procedure

Three days prior to the procedure, a patient is placed on oral fluoroquinolones, a grouping of antibacterial drugs. During this time, the patient scrubs the lower abdomen and genitals daily with chlorhexidine soap. On the day of the surgery, vancomycin and gentamicin are administered intravenously one to two hours prior to the procedure. The lower abdomen and genitals are shaved, scrubbed for five minutes with a chlorhexidine sponge and prepped with chorhexidine/alcohol applicator. The area is then draped with a surgical drape and a Vi Drape over the genitalia. Before the incision is made, a Foley catheter is inserted in the bladder through the urethra.

A 3 cm (1.2 in) scrotal incision is made on the penoscrotal raphe and carried down through the subcutaneous tissue to the Buck's fascia. A Scott retractor, a flexible device that holds open the skin of the surgical site, is applied to the area.

Up until this stage of the surgery, the process has been consistent with the sanitary practices associated with standard surgical sterility. [29] At this stage of the "No-Touch" technique, after the incision has been made, all instruments, including surgical gloves, that have touched skin are discarded. A loose drape is then deployed over the entire surgical field and secured at the periphery with adhesive strips. A small opening in the drape is then made overlying the incision and yellow hooks utilized to secure the edges of the opening to the edges of the incision, completely covering and isolating the patient's skin. At this point, new instruments and equipment are replaced and the entire prosthesis is inserted through the small opening of the loose drape. The loose drape allows for manipulation of the penis and scrotum required for this procedure without touching the skin.

Implantation of the device continues with an incision and dilation of corpora, sizing and placing the penile cylinders, and placement of the pump in the scrotum and the reservoir in the retropubic space. Saline is used throughout the implantation for irrigation. Once the corporotomies are closed and all of the tubing and components of the prosthesis covered with a layer of Buck's fascia, subcutaneous tissues are closed and the "No-Touch" drape is removed and the skin closed. [22]

Future

Penis transplantation could also become a standardized method. [30]

See also

Related Research Articles

Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, though many such treatments are also pursued by cisgender and non-intersex persons. It is also known as sex reassignment surgery (SRS), gender confirmation surgery (GCS), and several other names.

<span class="mw-page-title-main">Penis enlargement</span> Technique aimed to increase the size of a human penis

Penis enlargement, or male enhancement, is any technique aimed to increase the size of a human penis. Some methods aim to increase total length, others the shaft's girth, and yet others the glans and foreskin size. Techniques include surgery, supplements, ointments, patches, and physical methods like pumping, jelqing, and traction.

<span class="mw-page-title-main">Metoidioplasty</span> Surgical procedure used to create a penis from the clitoris

Metoidioplasty, metaoidioplasty, or metaidoioplasty is a female-to-male gender-affirming surgery.

Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

Feminizing Gender-affirming surgery for transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.

<span class="mw-page-title-main">Breast augmentation</span> Surgical procedure

Breast augmentation and augmentation mammoplasty is a cosmetic surgery procedure, which uses breast-implants and/ or fat-graft mammoplasty technique to increase the size, change the shape, and alter the texture of the breasts. Although in some cases augmentation mammoplasty is applied to correct congenital defects of the breasts and the chest wall in other cases it is performed purely for cosmetic reasons.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

Genital reconstructive surgery may refer to:

<span class="mw-page-title-main">Scrotoplasty</span> Type of surgery to create or repair the scrotum

Scrotoplasty, also known as oscheoplasty, is a type of surgery to create or repair the scrotum. Scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s. The development of testicular implants began in 1940 made from materials outside of what is used today. Today, testicular implants are created from saline or gel filled silicone rubber. There are a variety of reasons why scrotoplasty is done. Some transgender men and intersex or non-binary people who were assigned female at birth may choose to have this surgery to create a scrotum, as part of their transition. Other reasons for this procedure include addressing issues with the scrotum due to birth defects, aging, or medical conditions such as infection. For newborn males with penoscrotal defects such as webbed penis, a condition in which the penile shaft is attached to the scrotum, scrotoplasty can be performed to restore normal appearance and function. For older male adults, the scrotum may extend with age. Scrotoplasty or scrotal lift can be performed to remove the loose, excess skin. Scrotoplasty can also be performed for males who undergo infection, necrosis, traumatic injury of the scrotum.

<span class="mw-page-title-main">Vaginectomy</span> Surgical removal of the vagina

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.

Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.

Penis transplantation is a surgical transplant procedure in which a penis is transplanted to a patient. The penis may be an allograft from a human donor, or it may be grown artificially, though the latter has not yet been transplanted onto a human.

<span class="mw-page-title-main">Penile implant</span> Medical device

A penile implant is an implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size which leads to seek surgical and non-surgical solutions for penis alteration. Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants.

Urethroplasty is the surgical repair of an injury or defect within the walls of the urethra. Trauma, iatrogenic injury and infections are the most common causes of urethral injury/defect requiring repair. Urethroplasty is regarded as the gold standard treatment for urethral strictures and offers better outcomes in terms of recurrence rates than dilatations and urethrotomies. It is probably the only useful modality of treatment for long and complex strictures though recurrence rates are higher for this difficult treatment group.

<span class="mw-page-title-main">Gary Alter</span> American surgeon

Gary J. Alter is an American plastic surgeon. His specialties include sex reassignment surgery, genital reconstruction surgery and facial feminization surgery. He appeared in two episodes of the reality television series, Dr. 90210. PRNewswire reported on June 5, 2015 that Dr. Gary J. Alter performed the body work plastic surgery on Caitlyn Jenner. He has a practice in Beverly Hills, CA.

<span class="mw-page-title-main">Buried penis</span> Male congenital condition

Buried penis, also called hidden penis or retractile penis, is a congenital or acquired condition in which the penis is partially or completely hidden below the surface of the skin. A buried penis can lead to urinary difficulties, poor hygiene, infection, and inhibition of normal sexual function.

<span class="mw-page-title-main">Webbed penis</span> Medical condition

Webbed penis also known as buried or concealed penis is an acquired or congenital condition in which the scrotal skin extends onto the ventral penile shaft. The penile shaft is buried in the scrotum or tethered to the scrotal midline by a fold or web of skin. The urethra and erectile bodies are usually normal. Webbed penis is usually asymptomatic, but the cosmetic appearance is often unacceptable. This condition may be corrected by surgical techniques.

<span class="mw-page-title-main">Miroslav Djordjevic</span> Serbian genital surgeon

Miroslav L Djordjevic is a Serbian surgeon specializing in sex reassignment surgery, and an assistant professor of urology at the School of Medicine, University of Belgrade, Serbia.

<span class="mw-page-title-main">Zephyr Surgical Implants</span> Swiss-based penile surgical implant manufacturer

Zephyr Surgical Implants (ZSI) is a Swiss-based medical device manufacturer that produces and distributes artificial urinary sphincters and penile implants worldwide. ZSI products are used in the management of moderate-to-severe urinary incontinence in men, erectile dysfunction, Peyronie's disease, penis enlargement, and female-to-male gender reassignment surgery.

Penile implants may be employed to treat erectile dysfunction or urinary troubles after a spinal cord injury.

References

  1. ↑ Ferri, Fred F. (2020). Ferri's Clinical Advisor 2021 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 594. ISBN   978-0-32371-334-4.
  2. ↑ "Penis Enlargement". The Aesthetic Society. 28 April 2020. Retrieved 11 March 2023.
  3. ↑ Rashid M, Tamimy MS (2013). "Phalloplasty: The dream and the reality". Indian J Plast Surg. 46 (2): 283–93. doi: 10.4103/0970-0358.118606 . PMC   3901910 . PMID   24501465.
  4. ↑ Segal RL, Camper SB, Burnett AL (2014). "Modern utilization of penile prosthesis surgery: a national claim registry analysis". Int J Impot Res. 26 (5): 167–71. doi:10.1038/ijir.2014.11. PMID   24830674. S2CID   205152894.
  5. ↑ Schultheiss D, Gabouev AI, Jonas U (2005). "Nikolaj A. Bogoraz (1874-1952): pioneer of phalloplasty and penile implant surgery". J Sex Med. 2 (1): 139–46. doi:10.1111/j.1743-6109.2005.20114.x. PMID   16422917.
  6. ↑ Vaughan, Jeanette; Villegas, Whitney (2023). Evidence-Based Trauma Pearls, An Issue of Critical Care Nursing Clinics of North America, E-Book. Elsevier Health Sciences. p. 182. ISBN   978-0-32393-934-8.
  7. ↑ Morrison, Shane D.; Shakir, Afaaf; Vyas, Krishna S.; Kirby, Johanna; Crane, Curtis N.; Lee, Gordon K. (September 2016). "Phalloplasty: A Review of Techniques and Outcomes". Plastic and Reconstructive Surgery. 138 (3): 594–615. doi:10.1097/PRS.0000000000002518. ISSN   0032-1052. PMID   27556603. S2CID   40941956.
  8. ↑ "American Urological Association – Penile Augmentation Surgery". www.auanet.org. Archived from the original on 26 July 2019. Retrieved 14 March 2018.
  9. ↑ Chen, Kuo-Liang; Eberli, Daniel; Yoo, James J.; Atala, Anthony (23 February 2010). "Bioengineered corporal tissue for structural and functional restoration of the penis". Proceedings of the National Academy of Sciences. 107 (8): 3346–3350. Bibcode:2010PNAS..107.3346C. doi: 10.1073/pnas.0909367106 . PMC   2840474 . PMID   19915140.
  10. ↑ Carrion, Hernan; Martinez, Daniel; Parker, Justin; Hakky, Tariq; Bickell, Michael; Boyle, Alexander; Weigand, Luke; Carrion, Rafael (July 2016). "A History of the Penile Implant to 1974". Sexual Medicine Reviews. 4 (3): 285–293. doi:10.1016/j.sxmr.2016.05.003. PMID   27871961.
  11. ↑ Kang, Audry; Aizen, Joshua M.; Cohen, Andrew J.; Bales, Gregory T.; Pariser, Joseph J. (June 2019). "Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male". Translational Andrology and Urology. 8 (3): 273–282. doi: 10.21037/tau.2019.06.02 . PMC   6626310 . PMID   31380234.
  12. ↑ Chung, Eric (February 2017). "Penile prosthesis implant: scientific advances and technological innovations over the last four decades". Translational Andrology and Urology. 6 (1): 37–45. doi: 10.21037/tau.2016.12.06 . PMC   5313299 . PMID   28217449.
  13. ↑ van der Sluis, Wouter B.; Pigot, Garry L.S.; Al-Tamimi, Muhammed; Ronkes, Brechje L.; de Haseth, Kristin B.; Özer, Müjde; Smit, Jan Maerten; Buncamper, Marlon E.; Bouman, Mark-Bram (October 2019). "A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty". Urology. 132: 195–201. doi:10.1016/j.urology.2019.06.010. PMID   31229517. S2CID   195328117.
  14. ↑ Pigot, Garry L.S.; Sigurjónsson, Hannes; Ronkes, Brechje; Al-Tamimi, Muhammed; van der Sluis, Wouter B. (January 2020). "Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty". The Journal of Sexual Medicine. 17 (1): 152–158. doi:10.1016/j.jsxm.2019.09.019. PMID   31680006. S2CID   207890601.
  15. 1 2 Al-Tamimi, Muhammed; Pigot, Garry L.; van der Sluis, Wouter B.; van de Grift, Tim C.; van Moorselaar, R. Jeroen A.; Mullender, Margriet G.; Weigert, Romain; Buncamper, Marlon E.; Özer, Müjde; de Haseth, Kristin B.; Djordjevic, Miroslav L. (November 2019). "The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series". The Journal of Sexual Medicine. 16 (11): 1849–1859. doi:10.1016/j.jsxm.2019.07.027. ISSN   1743-6095. PMID   31542350. S2CID   202731384.
  16. ↑ Hontscharuk, Rayisa; Siotos, Charalampos; Schechter, Loren S. (13 November 2020). "Strategies for innervation of the neophallus". Plastic and Aesthetic Research. 7: 65. doi: 10.20517/2347-9264.2020.124 . ISSN   2347-9264. S2CID   228915526.
  17. ↑ "Phalloplasty, neophallus, female to male surgery, transgender". Genital Surgery Belgrade. Retrieved 24 May 2022.
  18. ↑ Shirvanian, V.; Lemperle, G.; Araujo Pinto, C.; Elist, J. J. (2014). "Shortened penis post penile prosthesis implantation treated with subcutaneous soft silicone penile implant: case report". International Journal of Impotence Research. 26 (3): 100–104. doi:10.1038/ijir.2013.44. PMID   24305609. S2CID   25075692.
  19. ↑ "Shortened penis post penile prosthesis". MDLinx. Archived from the original on 5 April 2023. Retrieved 16 February 2016.
  20. ↑ "A Retrospective Evaluation of the Safety and Effectiveness of a Silicone Block Implant for Elective Cosmetic Surgery of the Penis". SMSNA.org. Archived from the original on 1 March 2016. Retrieved 18 February 2016.
  21. ↑ Hannah Smothers (27 January 2016). "Penis Implants Exist Now, and They Start at a Size Large". Cosmopolitan.com.
  22. 1 2 Eid, J. Francois (2011). "No-Touch Technique". J Sex Med. 8 (1): 5–8. doi:10.1111/j.1743-6109.2010.02137.x. PMID   21199375.
  23. ↑ Mulcahy, John J. (2010). "Current approach to the treatment of penile implant infections". Therapeutic Advances in Urology. 2 (2): 69–75. doi:10.1177/1756287210370330. PMC   3126071 . PMID   21789084.
  24. ↑ Gomelsky, A.; Dmochowski, RR (2003). "Antibiotic prophylaxis in urologic prosthetic surgery". Current Pharmaceutical Design. 9 (12): 989–96. doi:10.2174/1381612033455198. PMID   12678865.
  25. 1 2 Eid, J. Francois; Wilson, Steven K.; Cleves, Mario; Salem, Emad A. (2012). "Coated Implants and "No Touch" Surgical Technique Decreases Risk of Infection in Inflatable Penile Prosthesis Implantation of 0.46%". Urology. 79 (6): 1310–5. doi:10.1016/j.urology.2011.11.076. PMID   22521187.
  26. ↑ Carson, CC (2004). "Efficacy of antibiotic impregnation of inflatable penile prostheses in decreasing infection in original implants". J Urol. 171 (4): 1611–4. doi:10.1097/01.ju.0000118245.66976.e1. PMID   15017233.
  27. ↑ Elmussareh, Muhammad; Goddard, Jonathan Charles; Summerton, Duncan John; Terry, Timothy Robin (2013). "Minimizing the risk of device infection in penile prosthetic surgery: a UK perspective". Journal of Clinical Urology. 6 (5): 280–288. doi:10.1177/2051415813488367. S2CID   57282051.
  28. ↑ Muench, Peter J. (2013). "Infections Versus Penile Implants: The War on Bugs". Journal of Urology. 189 (5): 1631–1673. doi:10.1016/j.juro.2012.05.080. PMID   23085299.
  29. ↑ Richard Pearcy & Raj Persad, publication date unknown, "Inflatable penile prosthesis," in BJU International Website Atlas of Surgery and Surgical Devices, see , accessed 31 May 2014
  30. ↑ "A Pioneering Approach to Sex Reassignment Surgery from a World Leader in the Field". reports.mountsinai.org. Retrieved 24 May 2022.

Sources

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