Staged male genital reconstruction with a local flap and free oral graft: a case report and literature review

Male genital skin loss following severe infections such as Fournier’s gangrene or injuries is a common condition in urology. Reconstruction with local pedicled penile flaps. Scrotal flaps, split-thickness skin grafting (STSG) and/or pedicle flaps is an effective technique when the urethra is completely preserved [1, 2]. The use of several materials such as genital or extragenital skin or mucosa has also been described to repair pure urethral defects [3, 4]. However, reports describing a solution for male genital skin loss accompanying a penile urethra defect are rare.

This paper aimed to report a unique case of complete genital skin loss and a penile urethral defect due to a severe traffic accident. We designed a novel staged procedure and successfully treated this patient.

Genital skin loss is usually caused by Fournier’s gangrene, trauma, lymphedema, tumors and other diseases [2, 7, 8]. Reconstruction of the urethra and penile or scrotal skin defects with good functional and cosmetic results presents challenges for surgeons. The selection of proper techniques depends on the size of the defect, condition of the local tissue and status of the wound [9].

STSG is a viable treatment option for patients without urethral injuries. The free skin graft can be harvested rapidly to cover large defects [10] and provide a resurfacing solution for the genital region and perineum. However, for this patient, STSG was not feasible. The main disadvantages were as follows. First, the free grafts commonly undergo contraction when they survive. According to our preoperative design, the new foreskin was prepared for coverage of the cavernous bodies and neourethra during the urethroplasty stage. This disadvantages would cause the new foreskin to have an insufficient size and lead to a poor expansive ability for wrapping the neourethra in the final stage. Second, the lack of subcutaneous tissue and abundant blood is another disadvantage for the survived free skin grafts that leads to a poor healing capacity and a high probability of fistula or necrosis in the urethroplasty stage.

To overcome the disadvantages of STSG, fasciocutaneous or musculocutaneous flaps, including the scrotal skin flap, gracilis myocutaneous flap [11], pedicle anterolateral thigh flap [12], and anteromedial thigh fasciocutaneous flap [13], were used, which produced excellent cosmetic outcomes. These flaps had reliable circulation and provided sufficient size, good flexibility and subcutaneous tissues for the penile shaft. However, there were two contradictions. One was that our patient needed a rapid resurfacing for his penis, but these flap techniques would require a long time. The other was the need for STSG for skin defects, which required healthy skin for a donor site. Therefore, burying the nude penile shaft beneath the skin of the left anteromedial thigh was adopted. This technique had been mentioned in a classic textbook describing the treatment of pure penile skin loss using scrotal skin [14]. The skin of the left anteromedial thigh was the nearest healthy skin that could provide similar characteristics to other flaps that were transferred from other donor sites. The greatest advantage of our method was the ability to prefabricate chimeric flaps.

Various techniques for urethral reconstruction have been described [4, 15, 16]. Flaps and grafts, and even the appendix and intestinal segments, have been used as alternative techniques [17‐21], and most of these techniques were staged procedures. Yazar [9] and colleagues reported a one-stage technique to repair a complex penile defect with composite anterolateral thigh and vascularized fascia lata flaps. In that case, the vascularized fascia lata flap was utilized to repair the lateral and ventral semicircular wall defect of the urethra. They chose this technique because the patient lacked a well-vascularized recipient bed for the surviving free graft. In this situation, the vascularized fascia lata flap could provide reliable circulation for urethroplasty. In contrast, our patient had a vascularized recipient bed for grafts, and the grafts could be easily harvested. Thus, transforming the penis into a penoscrotal hypospadias for an easier operation was a better choice. Moreover, we had no time to harvest such a composite anterolateral thigh and vascularized fascia lata flap in the first stage. Our method was not as creative as Yazar’s, but it was much safer for the repair of the urethral defect. If the graft developed local contracture and necrosis, an additional operation could be performed to patch the graft. Furthermore, an additional operation could be performed to harvest a vascularized fascia lata flap from the other leg when Yazar’s patient experienced operative failure, but we had no room for failure because our patient had only one leg.

In the second stage, the lingual mucosa was utilized to expand the urethral plate for urethroplasty. Oral mucosal grafts have been demonstrated to be an effective technique for urethroplasty [22, 23]. Buccal mucosa grafting is another choice, and the selection depends on the surgeon’s preference. We did not choose an onlay graft technique or a tubed graft technique because of the high breakdown rates, which may be related to the lack of an adequately vascularized graft bed [24]. The dorsal inlay grafting technique that we selected could provide a large, hairless and well-vascularized neourethral plate for urethroplasty. This was the one of the reasons why we performed three operations.

In a standard hypospadias repair, fistula is a major complication, and meatal stenosis, strictures, infection, and chordee are other common complications [25]. Barrier flap coverage with scrotal dartos flaps or tunica vaginalis flaps is a routine procedure in the treatment of hypospadias and decreases the incidence of fistulas [26, 27]. This patient had lost his genital skin and testicles. Fortunately, the preset flap with reliable circulation and a large amount of subcutaneous tissue provided a good wound healing, and no fistula was observed. Stricture is another major complication of urethroplasty. For this patient, a semi-circular anastomosis was performed to prevent stricture. The satisfactory wound healing and anti-infective ability of the preset flap played an important role in the prevention of stricture. Finally, multiple Z-patterns were designed to reduce the tension of the wounds and the risk of chordee.

In this case, penile erection and subsequent sexual intercourse were preserved postoperatively. Although the final outcomes including the function and cosmetic appearance were satisfactory, the patient still had a binding sensation. This may be associated with a large area of scar tissue on the abdominal, perineal and penile skin. The patient also experienced a mild reduction of penile hardness and sensitivity after the operations, although rigiscan testing indicated that he still had satisfactory erectile function. We suspected that the lack of a penile urethra and foreskin were the contributing factors.

Our result showed that this staged procedure was a simple, effective and safe technique. Furthermore, this approach is also practicable for surgeons who have not mastered complicated flap techniques. Although this procedure was time consuming, we still recommend it for cases with complete genital skin loss and penile urethra defects. Moreover, this staged technique can be improved as a treatment strategy by using proper composite local or pedicle transferred flaps and free grafts for repair of complete genital skin and urethra defects. However, longer follow-up and additional cases are needed to further evaluate the continued use of this technique.