Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous testicular tunica vaginalis graft
Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous...
Weibl, Peter; Plank, Christina; Hoelzel, Rudolf; Hacker, Stefan; Remzi, Mesut; Huebner, Wilhelm
2018-06-01 00:00:00
Arab Journal of Urology (2018) 16, 218–223 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION POINT OF TECHNIQUE Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous testicular tunica vaginalis graft a, a a b a Peter Weibl , Christina Plank , Rudolf Hoelzel , Stefan Hacker , Mesut Remzi , Wilhelm Huebner Department of Urology, Teaching Hospital, Landesklinikum Korneuburg, Austria Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria Received 4 May 2017, Received in revised form 6 February 2018, Accepted 13 February 2018 Available online 21 March 2018 KEYWORDS Abstract Partial penectomy (glansectomy with/or without distal corporectomy) is an acceptable alternative for smaller distal pT3 penile carcinoma lesions in highly Penile cancer; motivated and compliant patients. The authors describe a novel technique of neo- Glansectomy; glans reconstruction using a tunica vaginalis (TV) testis allograft. However, due to Glans reconstruction; an unclear resection margin on final histology, the patient underwent re-do surgery Neo-glans reconstruc- with a neo-glans revision using the well-established mesh split-thickness skin graft tion; (STSG) technique. The penile length was preserved and the penile and bulbar part Tunica vaginalis testis; of the urethra was additionally mobilised in order to obtain a natural and aesthetic Split-thickness skin result for the meatus. graft Neo-glans reconstruction with TV coverage may be another promising alternative, which certainly requires further evaluation. We believe that the donor-site associated ABBREVIATIONS morbidity is minimal when compared to other harvesting sites. However, this is just BM, buccal mucosa; an assumption, because direct comparison data on grafting techniques and neo-glans CC, corpora caver- reconstruction are not available. Nevertheless, we think that for re-do procedures a nosa; Corresponding author. E-mail address: pweibl@yahoo.com (P. Weibl). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier https://doi.org/10.1016/j.aju.2018.02.002 2090-598X 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Neo-glans reconstruction using autologous tunica vaginalis testis 219 NVB, neurovascular standardised approach using a STSG technique should be the treatment method of bundle; choice. STSG, split-thickness 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http:// skin graft; creativecommons.org/licenses/by-nc-nd/4.0/). TV, tunica vaginalis; TVTG, tunica vagina- lis testis graft Introduction frozen-section analysis. The resection margin of the CC, tunica albuginea, as well as the proximal margin of the urethra was negative. Traditional total/partial penectomy is the ‘gold stan- The neo-glans was recreated from CC using an dard’ for the treatment of invasive penile carcinoma. inverted 3–0 polyglactin 910 running suture ‘fish- However, poor aesthetic, functional, and psychological mouth’ closure. The urethra was slightly spatulated outcomes have been reported in patients who undergo from the ventral aspect. About 1 cm distal from the this procedure [1]. The reconstruction of penile anatomy tip of the CC, the penis shaft skin was sutured to the and formation of the neo-glans, in an attempt to restore Buck’s fascia with 4–0 polyglactin 910 to create the the primary appearance and functional improvement neo-sulcus coronarius (Fig. 1). At this stage the tourni- after this mutilating surgery has been the matter of quet was released. intensive investigation over the last decade. The primary A 3-cm transverse incision was made at the anterior goal is to optimise postoperative voiding and potentially wall of the right hemiscrotum. The parietal wall of the sexual functioning. The early results of organ-sparing TV was exposed (Fig. 1). To obtain an optimally sized techniques without glans reconstruction have demon- graft, a rectangle-shaped TV was harvested along the strated mixed and unsatisfactory results, as expected [2]. epididymal area, after precise measuring of the newly More recently, enhanced penile-sparing techniques, formed neo-glans area to be grafted. Following careful such as reconstructive glanduloplasty using split- adaption, the graft was approximated with absorbable thickness skin grafts (STSGs), buccal mucosa (BM) or 5–0 polyglactin sutures at the external meatus and 4–0 scrotal flaps exhibit more favourable outcomes, because polyglactin 910 sutures at the newly formed neo- they have the ability to restore the anatomy and aes- sulcus. We did not apply quilting sutures. thetic appearance of the penis [3–5]. The authors present Finally, a gentle compressive bandage was applied to a novel technique for neo-glans reconstruction using an the penis shaft and neo-glans (the graft was covered with autologous tunica vaginalis (TV) testis free graft baneocin [neomycin and bacitracin] and a paraffin- (TVTG) in the context of penile-preserving surgery for gauze tie-over dressing). At the end of the procedure, penile carcinoma. we placed a 14-F catheter, no drainage was necessary. A penile local anaesthetic block was used to enhance Patient’s presentation and surgical technique postoperative analgesia. The patient was advised to restrain from any physical activity for 48 h. The catheter The authors report a case of a 56-year-old patient with was removed on the postoperative day 7. The patient biopsy confirmed high-grade penile squamous cell carci- was instructed on how to wash the graft site with saline noma (20 mm), arising from the glans penis with inva- solution. A successful complete graft take was consid- sion of the glandular urethra. The patient was ered when the graft did not show any signs of necrosis managed with an intention-to-treat and spare the organ, or desquamation (Fig. 2). followed by neo-glans reconstruction (from corpora cav- ernosa [CC]) using TVTG. Results and revision surgery After general anaesthesia induction, the patient was placed supine and a tourniquet secured at the base of The graft take was acceptable (on the 20th postoperative the penis. A circumferential skin incision was made day); however, because of the Rx margin, we had to per- 5 mm proximal to the coronary sulcus, followed by form additional resection of the urethra in case of high- penis degloving to its base. The deep dorsal vein was iso- grade pT3 penile carcinoma. After careful preparation, lated and secured with 3–0 polyglactin 910 suture an additional 10-mm length of the urethra was excised. (Vicryl; Ethicon Inc., Somerville, NJ, USA) at the The frozen-section analysis of the urethral margins level of the primary incision. Then the meticulous dissec- and tunica albuginea area of the neo-glans close to the tion of the neurovascular bundle (NVB) was performed urethral meatus were negative. Therefore, we decided with full exposure of the tunica albuginea. After sutur- to reconstruct the neo-glans again. We did not compro- ing the NVB, the transverse incision separated the mise the overall length of the penis (Fig. 2). Although, NVB from the distal tips of the CC and the glans. Par- this time we had to mobilise the penile and the distal tial penectomy was completed and the specimen sent for 220 Weibl et al. Fig. 1 Partial penectomy–glansectomy with excision of the tips of the CC (A); neo-glans reconstruction – ‘fish-mouth’ shape (B); harvesting of the TV parietalis testis (C); free-TV graft (D); and subsequent grafting (D). part of the bulbar urethra in order to gain sufficient Discussion length. To regain the new aesthetic appearance of the former neo-glans, we performed debridement of the Glans reconstruction after glansectomy or partial remaining TV tissue. A redo-surgery was performed penectomy with distal corporectomy for penile cancer according to the well-established standardised technique lesions remains a challenging procedure. Firstly, due of meshed STSG [3]. A week after we observed good to the rarity of the disease and secondly, as this type graft take, and 7 days thereafter the neo-glans was of surgery is potentially associated with significant almost completely epithelialized (Fig. 3). At 4 weeks postoperative morbidity. The goal of treatment is to after re-do surgery (Fig. 3), the patient was much more achieve comparable oncological outcomes with satisfied with the final cosmesis when compared to the traditional partial/total penectomy and guarantee ade- TVTG. We have to note, that this direct comparison quate cosmesis and functional results. In general, was subjective and based on patient’s perception only. patients who are willing to undergo such a procedure Final histology of the specimen confirmed malignancy should be compliant and adherent to the follow-up only on the distal resection margin in terms of lympho- protocols. vascular invasion, the remaining tissue (8 mm of the ure- Several techniques for the glans reconstruction with thral length) was negative. The patient underwent different grafting materials have been described in the laparoscopic modified inguinal lymphadenectomy 7 literature. Today, STSG is the most commonly used weeks later, without any signs of malignant spread. and established approach with satisfactory results and Neo-glans reconstruction using autologous tunica vaginalis testis 221 Fig. 2 Final status 3 weeks after primary procedure (A); secondary resection of the urethra and prepucium (B); mobilisation of the urethra proximal to the bulbar urethra (C); reconstruction of the neo-glans and neo-sulcus (D,D ); mesh STSG implantation (E); application of the tie-over dressing (F). comparable oncological outcomes to total/partial penec- and may theoretically be susceptible to shrinkage or tomy without glans/neo-glans reconstruction. desquamation [3]. Harvesting of BM is more complex For cases with an adequate amount and length of than TV, and can be associated with significant bother- urethral tissue, an inverted flap procedure has accept- some postoperative morbidity [7]. Last but not least, we able cosmetic and functional outcomes [6]. In our pre- are not advocates of full-skin grafting (foreskin/scro- sent scenario, our patient required a substantial length tum) for neo-glans reconstruction. of the urethra, thus an inverted flap procedure was not TV testis despite its anatomical location is relatively possible. That was one of the reasons why we decided superficial and quite easy to harvest. Additionally, it to harvest TV. Other alternatives are oral BM graft has uniform thickness, elasticity, and therefore ideal and full-skin grafts from the scrotum or lower abdomen properties to guarantee graft safety during erection. [4,5]. One may argue that BM is commonly used in ure- When compared to synthetic grafts, the procedural costs thral reconstruction due to its robust microvascular net- are reduced. Furthermore, TV is much easier to harvest work and enhanced microcirculation. On the other than other autologous grafts, such as STSG/full- hand, BM is adapted to a wet environment like TV, thickness skin graft or BM. 222 Weibl et al. Fig. 3 Final appearance at 1, 2 and 4 weeks after the secondary procedure. Patient obtained full morning erections 14 days postoperatively. Because of the location of the TV, there are no visible safety of free TV vs vascularised TV flap for penile scars and postoperative morbidity is not significant, as reconstructive surgery. The use of skin grafting is now with other donor-harvesting sites. But direct compara- common and well established in penile surgery for vari- tive data on this topic are lacking from the literature. ous pathologies and should be the method of choice for TVTG application is faster, and has a potential to revision-surgery cases. decrease operative time, whilst specific graft preparation Conclusion is not needed. However, it is unclear which form of TV exhibits better graft-take properties –meshed or stan- TVTG should be considered as another alternative in the dard TVTG, or TVTG transplanted as a vascularised spectrum of reconstructive surgery options for glans flap. The use of the TV as a graft material has been restoration, e.g. in those institutions where other options described in urethral reconstruction and Peyronie’s dis- like expertise or specific surgical armamentarium are ease with acceptable short-term results [8,9]. On the con- lacking. The surgical approach to neo-glans reconstruc- trary, the role of TV in penile enhancement surgery in tion is still controversial owing to a lack of direct compar- animal models showed unsatisfactory results, because isons of different operative techniques with regard to of insufficient vascularisation [10]. functional and cosmetic-related outcomes, as well as a Glans resurfacing or neo-glans reconstruction partner appearance assessment. In the meantime, the requires high expertise in the field of reconstructive STSG seems to be the most studied and established tech- and plastic surgery. In general, the use of grafts is asso- nique for glans reconstruction, which is why it should be ciated with donor-site morbidity and the risks of poor considered as the strategy of choice for revision graft take. Many modifications with regard to the graft procedures. material have been published; however, none of them are as well established as the STSG [11]. For that reason, Conflict of interests we chose a standardised STSG for the second procedure in order to minimise risk of graft take failure and unsat- The authors declare that they have no competing isfactory cosmetic appearance. interests. STSG may require lower metabolic demand when compared to the free TVTG, which is more suitable Source of Funding for the revision surgery. Potential risk of lymphoedema and haematoma is reduced as opposed to the full- None. thickness skin graft, due to the meshed features of the STSG. References The described surgical neo-glans reconstruction using autologous testicular TV may be a promising alterna- [1] Opjordsmoen S, Fossa˚ SD. Quality of life in patients treated for tive. It is important to note, further studies are war- penile cancer. A follow-up study. Br J Urol 1994;74:652–7. ranted to confirm the utility of this surgical principle. [2] Jordan GH. Penile reconstruction, phallic construction and urethral reconstruction. Urol Clin North Am 1999;26:1–13. Certainly more patients are needed, to compare the Neo-glans reconstruction using autologous tunica vaginalis testis 223 [3] Palminteri E, Berdondini E, Lazzeri M, Mirri F, Barbagli G. [8] Liu B, Li Q, Cheng G, Song N, Gu M, Wang Z. Surgical Resurfacing and reconstruction of the glans penis. Eur Urol treatment of Peyronie’s disease with autologous tunica vaginalis 2007;52:893–8. of testis. BMC Urol 2016;16:1. https://doi.org/10.1186/s12894- [4] Cook A, Khoury AE, Bagli DJ, Farhat WA, Pippi Salle JL. Use 016-0120-3. of buccal mucosa to simulate the coronal sulcus after traumatic [9] Foinquinos RC, Calado AA, Janio R, Griz A, Macedo Jr A, Ortiz penile amputation. Urology 2005;66:1109. V. The tunica vaginalis dorsal graft urethroplasty: initial experi- [5] Mazza ON, Cheliz GM. Glanuloplasty with scrotal flap for ence. Int Braz J Urol 2007;33:523–31. partial penectomy. J Urol 2001;166:887–9. [10] Bagbanci S, Dadali M, Emir L, Aydogmus Y, Ozer E. Penile [6] Sansalone S, Garaffa G, Vespasiani G, Zucchi A, Kuehhas FE, enhancement with rectus muscle fascia and testicular tunica Herwig R, et al. Glans reconstruction with the use of an inverted vaginalis grafts: an experimental animal study. Int Urol Nephrol urethral flap after distal penile amputation for carcinoma. Arch 2015;47:915–20. Ital Urol Androl 2013;85:24–7. [11] Kamel MH, Bissada N, Warford R, Farias J, Davis R. Organ [7] Wood DN, Allen SE, Andrich DE, Greenwell TJ, Mundy AR. sparing surgery in penile cancer: a systematic review. J Urol The morbidity of buccal mucosal graft harvest for urethroplasty 2017;198:770–9. https://doi.org/10.1016/j.juro. 2017.01.088. and the effect of nonclosure of the graft harvest site on postoperative pain. J Urol 2004;172:580–3.
http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.pngArab Journal of UrologyTaylor & Francishttp://www.deepdyve.com/lp/taylor-francis/neo-glans-reconstruction-for-penile-cancer-description-of-the-primary-rcyRPFG2WZ
Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous testicular tunica vaginalis graft
Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous testicular tunica vaginalis graft
Abstract
AbstractPartial penectomy (glansectomy with/or without distal corporectomy) is an acceptable alternative for smaller distal pT3 penile carcinoma lesions in highly motivated and compliant patients. The authors describe a novel technique of neo-glans reconstruction using a tunica vaginalis (TV) testis allograft. However, due to an unclear resection margin on final histology, the patient underwent re-do surgery with a neo-glans revision using the well-established mesh split-thickness skin graft...
Arab Journal of Urology (2018) 16, 218–223 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ONCOLOGY/RECONSTRUCTION POINT OF TECHNIQUE Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous testicular tunica vaginalis graft a, a a b a Peter Weibl , Christina Plank , Rudolf Hoelzel , Stefan Hacker , Mesut Remzi , Wilhelm Huebner Department of Urology, Teaching Hospital, Landesklinikum Korneuburg, Austria Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria Received 4 May 2017, Received in revised form 6 February 2018, Accepted 13 February 2018 Available online 21 March 2018 KEYWORDS Abstract Partial penectomy (glansectomy with/or without distal corporectomy) is an acceptable alternative for smaller distal pT3 penile carcinoma lesions in highly Penile cancer; motivated and compliant patients. The authors describe a novel technique of neo- Glansectomy; glans reconstruction using a tunica vaginalis (TV) testis allograft. However, due to Glans reconstruction; an unclear resection margin on final histology, the patient underwent re-do surgery Neo-glans reconstruc- with a neo-glans revision using the well-established mesh split-thickness skin graft tion; (STSG) technique. The penile length was preserved and the penile and bulbar part Tunica vaginalis testis; of the urethra was additionally mobilised in order to obtain a natural and aesthetic Split-thickness skin result for the meatus. graft Neo-glans reconstruction with TV coverage may be another promising alternative, which certainly requires further evaluation. We believe that the donor-site associated ABBREVIATIONS morbidity is minimal when compared to other harvesting sites. However, this is just BM, buccal mucosa; an assumption, because direct comparison data on grafting techniques and neo-glans CC, corpora caver- reconstruction are not available. Nevertheless, we think that for re-do procedures a nosa; Corresponding author. E-mail address: pweibl@yahoo.com (P. Weibl). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier https://doi.org/10.1016/j.aju.2018.02.002 2090-598X 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Neo-glans reconstruction using autologous tunica vaginalis testis 219 NVB, neurovascular standardised approach using a STSG technique should be the treatment method of bundle; choice. STSG, split-thickness 2018 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http:// skin graft; creativecommons.org/licenses/by-nc-nd/4.0/). TV, tunica vaginalis; TVTG, tunica vagina- lis testis graft Introduction frozen-section analysis. The resection margin of the CC, tunica albuginea, as well as the proximal margin of the urethra was negative. Traditional total/partial penectomy is the ‘gold stan- The neo-glans was recreated from CC using an dard’ for the treatment of invasive penile carcinoma. inverted 3–0 polyglactin 910 running suture ‘fish- However, poor aesthetic, functional, and psychological mouth’ closure. The urethra was slightly spatulated outcomes have been reported in patients who undergo from the ventral aspect. About 1 cm distal from the this procedure [1]. The reconstruction of penile anatomy tip of the CC, the penis shaft skin was sutured to the and formation of the neo-glans, in an attempt to restore Buck’s fascia with 4–0 polyglactin 910 to create the the primary appearance and functional improvement neo-sulcus coronarius (Fig. 1). At this stage the tourni- after this mutilating surgery has been the matter of quet was released. intensive investigation over the last decade. The primary A 3-cm transverse incision was made at the anterior goal is to optimise postoperative voiding and potentially wall of the right hemiscrotum. The parietal wall of the sexual functioning. The early results of organ-sparing TV was exposed (Fig. 1). To obtain an optimally sized techniques without glans reconstruction have demon- graft, a rectangle-shaped TV was harvested along the strated mixed and unsatisfactory results, as expected [2]. epididymal area, after precise measuring of the newly More recently, enhanced penile-sparing techniques, formed neo-glans area to be grafted. Following careful such as reconstructive glanduloplasty using split- adaption, the graft was approximated with absorbable thickness skin grafts (STSGs), buccal mucosa (BM) or 5–0 polyglactin sutures at the external meatus and 4–0 scrotal flaps exhibit more favourable outcomes, because polyglactin 910 sutures at the newly formed neo- they have the ability to restore the anatomy and aes- sulcus. We did not apply quilting sutures. thetic appearance of the penis [3–5]. The authors present Finally, a gentle compressive bandage was applied to a novel technique for neo-glans reconstruction using an the penis shaft and neo-glans (the graft was covered with autologous tunica vaginalis (TV) testis free graft baneocin [neomycin and bacitracin] and a paraffin- (TVTG) in the context of penile-preserving surgery for gauze tie-over dressing). At the end of the procedure, penile carcinoma. we placed a 14-F catheter, no drainage was necessary. A penile local anaesthetic block was used to enhance Patient’s presentation and surgical technique postoperative analgesia. The patient was advised to restrain from any physical activity for 48 h. The catheter The authors report a case of a 56-year-old patient with was removed on the postoperative day 7. The patient biopsy confirmed high-grade penile squamous cell carci- was instructed on how to wash the graft site with saline noma (20 mm), arising from the glans penis with inva- solution. A successful complete graft take was consid- sion of the glandular urethra. The patient was ered when the graft did not show any signs of necrosis managed with an intention-to-treat and spare the organ, or desquamation (Fig. 2). followed by neo-glans reconstruction (from corpora cav- ernosa [CC]) using TVTG. Results and revision surgery After general anaesthesia induction, the patient was placed supine and a tourniquet secured at the base of The graft take was acceptable (on the 20th postoperative the penis. A circumferential skin incision was made day); however, because of the Rx margin, we had to per- 5 mm proximal to the coronary sulcus, followed by form additional resection of the urethra in case of high- penis degloving to its base. The deep dorsal vein was iso- grade pT3 penile carcinoma. After careful preparation, lated and secured with 3–0 polyglactin 910 suture an additional 10-mm length of the urethra was excised. (Vicryl; Ethicon Inc., Somerville, NJ, USA) at the The frozen-section analysis of the urethral margins level of the primary incision. Then the meticulous dissec- and tunica albuginea area of the neo-glans close to the tion of the neurovascular bundle (NVB) was performed urethral meatus were negative. Therefore, we decided with full exposure of the tunica albuginea. After sutur- to reconstruct the neo-glans again. We did not compro- ing the NVB, the transverse incision separated the mise the overall length of the penis (Fig. 2). Although, NVB from the distal tips of the CC and the glans. Par- this time we had to mobilise the penile and the distal tial penectomy was completed and the specimen sent for 220 Weibl et al. Fig. 1 Partial penectomy–glansectomy with excision of the tips of the CC (A); neo-glans reconstruction – ‘fish-mouth’ shape (B); harvesting of the TV parietalis testis (C); free-TV graft (D); and subsequent grafting (D). part of the bulbar urethra in order to gain sufficient Discussion length. To regain the new aesthetic appearance of the former neo-glans, we performed debridement of the Glans reconstruction after glansectomy or partial remaining TV tissue. A redo-surgery was performed penectomy with distal corporectomy for penile cancer according to the well-established standardised technique lesions remains a challenging procedure. Firstly, due of meshed STSG [3]. A week after we observed good to the rarity of the disease and secondly, as this type graft take, and 7 days thereafter the neo-glans was of surgery is potentially associated with significant almost completely epithelialized (Fig. 3). At 4 weeks postoperative morbidity. The goal of treatment is to after re-do surgery (Fig. 3), the patient was much more achieve comparable oncological outcomes with satisfied with the final cosmesis when compared to the traditional partial/total penectomy and guarantee ade- TVTG. We have to note, that this direct comparison quate cosmesis and functional results. In general, was subjective and based on patient’s perception only. patients who are willing to undergo such a procedure Final histology of the specimen confirmed malignancy should be compliant and adherent to the follow-up only on the distal resection margin in terms of lympho- protocols. vascular invasion, the remaining tissue (8 mm of the ure- Several techniques for the glans reconstruction with thral length) was negative. The patient underwent different grafting materials have been described in the laparoscopic modified inguinal lymphadenectomy 7 literature. Today, STSG is the most commonly used weeks later, without any signs of malignant spread. and established approach with satisfactory results and Neo-glans reconstruction using autologous tunica vaginalis testis 221 Fig. 2 Final status 3 weeks after primary procedure (A); secondary resection of the urethra and prepucium (B); mobilisation of the urethra proximal to the bulbar urethra (C); reconstruction of the neo-glans and neo-sulcus (D,D ); mesh STSG implantation (E); application of the tie-over dressing (F). comparable oncological outcomes to total/partial penec- and may theoretically be susceptible to shrinkage or tomy without glans/neo-glans reconstruction. desquamation [3]. Harvesting of BM is more complex For cases with an adequate amount and length of than TV, and can be associated with significant bother- urethral tissue, an inverted flap procedure has accept- some postoperative morbidity [7]. Last but not least, we able cosmetic and functional outcomes [6]. In our pre- are not advocates of full-skin grafting (foreskin/scro- sent scenario, our patient required a substantial length tum) for neo-glans reconstruction. of the urethra, thus an inverted flap procedure was not TV testis despite its anatomical location is relatively possible. That was one of the reasons why we decided superficial and quite easy to harvest. Additionally, it to harvest TV. Other alternatives are oral BM graft has uniform thickness, elasticity, and therefore ideal and full-skin grafts from the scrotum or lower abdomen properties to guarantee graft safety during erection. [4,5]. One may argue that BM is commonly used in ure- When compared to synthetic grafts, the procedural costs thral reconstruction due to its robust microvascular net- are reduced. Furthermore, TV is much easier to harvest work and enhanced microcirculation. On the other than other autologous grafts, such as STSG/full- hand, BM is adapted to a wet environment like TV, thickness skin graft or BM. 222 Weibl et al. Fig. 3 Final appearance at 1, 2 and 4 weeks after the secondary procedure. Patient obtained full morning erections 14 days postoperatively. Because of the location of the TV, there are no visible safety of free TV vs vascularised TV flap for penile scars and postoperative morbidity is not significant, as reconstructive surgery. The use of skin grafting is now with other donor-harvesting sites. But direct compara- common and well established in penile surgery for vari- tive data on this topic are lacking from the literature. ous pathologies and should be the method of choice for TVTG application is faster, and has a potential to revision-surgery cases. decrease operative time, whilst specific graft preparation Conclusion is not needed. However, it is unclear which form of TV exhibits better graft-take properties –meshed or stan- TVTG should be considered as another alternative in the dard TVTG, or TVTG transplanted as a vascularised spectrum of reconstructive surgery options for glans flap. The use of the TV as a graft material has been restoration, e.g. in those institutions where other options described in urethral reconstruction and Peyronie’s dis- like expertise or specific surgical armamentarium are ease with acceptable short-term results [8,9]. On the con- lacking. The surgical approach to neo-glans reconstruc- trary, the role of TV in penile enhancement surgery in tion is still controversial owing to a lack of direct compar- animal models showed unsatisfactory results, because isons of different operative techniques with regard to of insufficient vascularisation [10]. functional and cosmetic-related outcomes, as well as a Glans resurfacing or neo-glans reconstruction partner appearance assessment. In the meantime, the requires high expertise in the field of reconstructive STSG seems to be the most studied and established tech- and plastic surgery. In general, the use of grafts is asso- nique for glans reconstruction, which is why it should be ciated with donor-site morbidity and the risks of poor considered as the strategy of choice for revision graft take. Many modifications with regard to the graft procedures. material have been published; however, none of them are as well established as the STSG [11]. For that reason, Conflict of interests we chose a standardised STSG for the second procedure in order to minimise risk of graft take failure and unsat- The authors declare that they have no competing isfactory cosmetic appearance. interests. STSG may require lower metabolic demand when compared to the free TVTG, which is more suitable Source of Funding for the revision surgery. Potential risk of lymphoedema and haematoma is reduced as opposed to the full- None. thickness skin graft, due to the meshed features of the STSG. References The described surgical neo-glans reconstruction using autologous testicular TV may be a promising alterna- [1] Opjordsmoen S, Fossa˚ SD. Quality of life in patients treated for tive. It is important to note, further studies are war- penile cancer. A follow-up study. Br J Urol 1994;74:652–7. ranted to confirm the utility of this surgical principle. [2] Jordan GH. Penile reconstruction, phallic construction and urethral reconstruction. Urol Clin North Am 1999;26:1–13. Certainly more patients are needed, to compare the Neo-glans reconstruction using autologous tunica vaginalis testis 223 [3] Palminteri E, Berdondini E, Lazzeri M, Mirri F, Barbagli G. [8] Liu B, Li Q, Cheng G, Song N, Gu M, Wang Z. Surgical Resurfacing and reconstruction of the glans penis. Eur Urol treatment of Peyronie’s disease with autologous tunica vaginalis 2007;52:893–8. of testis. BMC Urol 2016;16:1. https://doi.org/10.1186/s12894- [4] Cook A, Khoury AE, Bagli DJ, Farhat WA, Pippi Salle JL. Use 016-0120-3. of buccal mucosa to simulate the coronal sulcus after traumatic [9] Foinquinos RC, Calado AA, Janio R, Griz A, Macedo Jr A, Ortiz penile amputation. Urology 2005;66:1109. V. The tunica vaginalis dorsal graft urethroplasty: initial experi- [5] Mazza ON, Cheliz GM. Glanuloplasty with scrotal flap for ence. Int Braz J Urol 2007;33:523–31. partial penectomy. J Urol 2001;166:887–9. [10] Bagbanci S, Dadali M, Emir L, Aydogmus Y, Ozer E. Penile [6] Sansalone S, Garaffa G, Vespasiani G, Zucchi A, Kuehhas FE, enhancement with rectus muscle fascia and testicular tunica Herwig R, et al. Glans reconstruction with the use of an inverted vaginalis grafts: an experimental animal study. Int Urol Nephrol urethral flap after distal penile amputation for carcinoma. Arch 2015;47:915–20. Ital Urol Androl 2013;85:24–7. [11] Kamel MH, Bissada N, Warford R, Farias J, Davis R. Organ [7] Wood DN, Allen SE, Andrich DE, Greenwell TJ, Mundy AR. sparing surgery in penile cancer: a systematic review. J Urol The morbidity of buccal mucosal graft harvest for urethroplasty 2017;198:770–9. https://doi.org/10.1016/j.juro. 2017.01.088. and the effect of nonclosure of the graft harvest site on postoperative pain. J Urol 2004;172:580–3.
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