Exploring the possibilities and limits of male genital reconstruction

A bigger team equals a better outcome.

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Phalloplasty, male genital reconstructive surgery, may be the most demanding specialty in urology. Repairing and replacing the penis is an exacting microsurgical procedure that requires multiple specialties and specialists.Eduardo Ruiz Castañé, MDEduardo Ruiz Castañé, MD

“We never work alone on this kind of surgery,” said Eduardo Ruiz Castañé, MD, director of the European Academy of Urology at Fundació Puigvert and professor of urology and andrology at the University of Barcelona in Spain. “You need a specialist in urethral repairs and a specialist in genital reconstruction. I work with a plastic surgeon specializing in breast cancer reconstruction because we use the same flap techniques to rebuild the penis as to rebuild the breast after mastectomy. If the patient is transgender female-to-male, you need an endocrinologist and a psychologist on the team. If the patient has penile cancer, you must have an oncologist, and for very young patients, you need a pediatric urologist. Each of these patients has very different needs, and you need the right team for the patient for a successful reconstruction.”

Dr. Castañé will discuss the expanding potential of genital reconstructive surgery in males during the Confederación Americana de Urología (CAU) Lecture, “Limit Cases in Reconstructive Surgery,” on Monday, May 1, from 7:50 to 8:05 a.m. Not surprisingly, experience is a key element in reducing complications and improving outcomes.

“It is not possible for a urologist to be a good robotic surgeon for radical prostatectomy, to do radical cystectomy and to do genital reconstruction equally well,” Dr. Castañé said. “If you want to be an expert in genital reconstruction, you must do a minimum of one per month. And in the United States, fewer than 10% of urologists are doing this kind of surgery every month.”

Complications are common in phalloplasty, he continued, most often a thrombosis or ischemic event as a result of inadequate blood supply. Graft failure is more common in transgender patients because hormone therapy can increase the risk of thrombosis.

“Graft failure can happen in all kinds of phalloplasty if the anastomosis is not perfect,” Dr. Castañé added. “The most common secondary problems are a fistula in the urethra and stenosis of the urethra. Plus, the graft donor site must be absolutely free of hair. The inside of the forearm is usually a good donor site but you must talk very clearly with your patient about scarring.”

Transgender patients, in particular, can be very sensitive about visible scars, he explained. The abdomen or inner leg may be useful donor sites. Patients with widespread body hair may need a dermatologist for laser depilation of the donor site before surgery.

Urinary and sexual function are also common issues. Depending on the patient, the urethra may be routed through the new phallus or via the perineum. Depending on the reason for reconstruction, patients may or may not be concerned about erectile function after surgery, which may require additional surgery to implant a penile prosthesis.

“Genital reconstruction involves much more than just surgery,” Dr. Castañé said. “Whether your patient had a motorcycle accident, a knife wound, penile cancer, gender reassignment, ambiguous genitalia as an infant or some other need, he needs a specialist.”

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