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Secondary buried penis reconstruction with split‑thickness skin grafting after previous partial amputations for penile cancer – report of a case


Rekonštrukcia sekundárneho „pochovaného penisu“ s použitím dermoepidermálneho štepu po predchádzajúcich parciálnych amputáciách pre karcinóm penisu – kazuistika

Weibl P, Ameli G, Krauter J, Hübner W. Rekonštrukcia sekundárneho „pochovaného penisu“ s použitím dermoepidermálneho štepu po predchádzajúcich parciálnych amputáciách pre karcinóm penisu – kazuistika.

Úvod: Chirurgická stratégia liečby tzv. „pochovaného penisu“ závisí od etiológie, kvality postihnutých a okolitých tkanív, ako aj od celkovej anatómie vonkajších genitálií.

Materiál a metódy: Autori popisujú chirurgický princíp rekonštrukcie sekundárneho „pochovaného penisu“ po predchádzajúcich parciálnych amputáciách pre lokalizovaný karcinóm penisu, s použitím autológneho dermoepidermálneho štepu (STSG), lipektómie v prepubickej oblasti a skrotoplastiky. 65 ročný pacient s biopticky verifikovaným skvamóznym karcinómom penisu podstúpil primárne glansektómiu s rekonštrukciou „neo‑glansu“ pomocou STSG. Vzhľadom na lokálnu recidívu ochorenia, bola vykonaná parciálna amputácia s rekonštrukciou neo‑glansu s použitím penilnej časti močovej trubice. V bezprostrednom pooperačnom období, v dôsledku sekundárnej infekcie tkanív penisu, bola u pacienta diagnostikovaná vyššie uvedená klinická entita.

Výsledky: Primárnym cieľom chirurgickej revízie je upraviť mikčné obtiaže/možnosť pohlavného styku ako aj optimalizovať psychicku pacienta. Z pohľadu krátkodobého sledovania, bol dosiahnutý želaný efekt.

Záver: STSG je valídnou alternatívou u pacientov s komplexných postihnutím penisu a kompromitovanou anatómiou mieška.

Klíčová slova:

Pochovaný penis – karcinóm penisu – parciálna penektómia – neo‑glans – dermoepidermálny štep


Authors: Peter Weibl;  Ghazal Ameli;  Johanna Krauter;  Wilhelm Hübner
Authors place of work: Department of Urology, Teaching Hospital, Landesklinikum Korneuburg
Published in the journal: Ces Urol 2021; 25(1): 62-68
Category: Kazuistiky

Summary

Weibl P, Ameli G, Krauter J, Hübner W. Secondary buried penis reconstruction with split‑thickness skin grafting after previous partial amputations for penile cancer – report of a case.

Background: Surgical strategy of buried penis depends on the etiology and quality of affected and surrounding tissues, as well as overall anatomy of the external genitalia.

Patients and methods: The authors describe the surgical principle of aquired buried penis reconstruction after previous partial amputations while using principles of split‑thickness skin grafting (STSG), prepubic lipectomy and scrotoplasty. A 65 yrs old patient after biopsy proven squamous cell carcinoma of the penis, had undergone a glansectomy with neo‑glans reconstruction using STSG. A second procedure with neo‑glans reconstruction and urethral flap reconfiguration was done, because of local recurrence. Shortly thereafter, due to a secondary infection of the penis shaft tissues, the patient developed a buried penis.

Results: The surgical goal should repair voiding/sexual functioning and psychological well being, which have been achieved during short term follow‑up.

Conclusion: STSG is a valid alternative for advanced cases in patients with already compromised scrotum.

Keywords:

Buried penis – penile cancer – partial penectomy – neo‑glans – split thickness skin graft

BACKGROUND

Buried penis covers wide spectrum of amonalies of different origins. Acquired buried penis (ABP) is a serious urologic condition with a detrimental impact on quality of life (QoL) and psychological well being. The disease is characterized by various degree of penis shaft entrapment, accompanied with impaired micturition, sexual dysfunctioning, as well as reduced hygiene of the impacted scrotal skin area and reccurent skin infections (1). The most common causes are secondary penoscrotal lymphodema, persistent infections, lichen sclerosus, surgical interventions such as circumcision, and organ sparing procedures for penile cancer (2).

The authors describe the surgical principle of aquired buried penis reconstruction after previous partial penectomy procedures for localised penile cancer.

CASE REPORT

A 67 yrs old, sexually active male patient was introduced to our department (in October 2019) with a suspicious well marginated erythematous lesion on the glans (5x5 mm). The lesion was refractory to the previous topical corticoid/antibiotic treatment. Verbal and written informed consent was obtained from the patient in order to proceed with all the diagnostic and therapeutic interventions, as well as a continuous photographic documentation for further academic purposes. The principles outlined in the Declaration of Helsinki have been followed.

The biopsy confirmed partially exulcerated moderately differentiated squamous cell carcimona (SCC) of the penis (p16 positive). Preoperative CT scan was negative and confirmed clinical‑N0 status. A total glansectomy with neo‑glans reconstruction from the corpora cavernosa and split‑thickness skin grafting (STSG) was performed (Fig. 1). Perioperatively we obtianed a negative resection margin from the glans as well as from the urethra. The final histopathology revealed a SCC with infiltration of the subepithelial tissues (pT1bNxL1V1R0, keratinizing type G2) and basaloid intraepithelial neoplasia (PeIN) of the urethra (p16 positive). The overall size of the specimen was 4x3x2.3 cm. In February 2020 we performed a new biopsy of the neo‑glans/ neo‑meatal region due to a newly formed erythematous lesion 2x4 mm (recurrence of SCC was confirmed) (Fig. 2 A, B). Further diagnostic steps using flexible cystoscopy showed otherwise normal urethra and the CT scan was negative. In the meantime the patient underwent two HPV vaccinations, the last one was planned for June 2020. Because of the covid pandemic the surgery was postponed 7 weeks thereafter (in April 2020). According to the patient’s wishes and careful examination of the penile/ scrotal anatomy, we decided to perfom another organ sparing procedure. A partial penectomy (29x27x10 mm/neo‑glans and; 8×5×3 mm/urethral tissue) with neo‑glans reconstruction and coverage of the corpora cavernosa with urethral flap was achieved (Fig. 2). The neo‑glans was reconstructed while using the same principles as described by Palminteri et al. previously (3) (Fig. 2F, G, H, I, J). In addition the technique of scrotoplasty followed the concept initially described by Miranda‑Sousa et al. (4, 5) (Fig. 2C) The pathology revealed HPV associated PeIN and focal finding of SCC pT1NxL0V1G2R0 in the neo‑glans region and PeIN in the urethra, however R0. 10 days later (3 days after the patient’s discharge from the hospital) after the definitive procedure the patient suffered from asuperficial penile shaft tissues infection. Despite local and targeted antibiotic treatment, the patient developed ABP (Fig. 2K, L).

Fig. 1. A) Total glansectomy and removal of the glandular
part of the urethra for biopsy proven squamous cell carcinoma,
tips of the corpora cavernosa were left intact (frozen
section confirmed negative margins). B) Neo‑glans
reconstruction
with inverted Vicril 4.0 running suture, creating the
fish‑mouth
shape. C) Reconfiguration of the neo‑sulcus
and
placing everting sutures for the urethra using Caprosin 4.0 and
5.0 sutures respectively. D) Split thickness skin graft implantation.
E) 7th postoperative day, local application of Vaseline/
Baneocin two times daily, permanent catheter was removed.
F) 2 weeks after procedure, the successful graft take and complete
epithelialisation of the graft. Some of the residual guilting
sutures are not completely absorbed. G) 1 month after the
surgery, natural and satisfactory cosmetic result<br>
Obr. 1. A) Kompletná amputácia – glans penis a odstránenie
glandulárnej časti močovej trubice pre biopticky
verifikovaný skvamocelulárny karcinóm. Distálne konce
kavernóznych telies boli ponechané (perioperačná histológia
potvrdila negatívne okraje). B) Rekonštrukcia „neo‑glansu“
s invertovaným pokračovacím stehom Vicril 4,0; ktorý vytvára
tvar rybých úst. C) Rekonfigurácia tzv. „neo‑sulkusu“
a následné naloženie evertovaných stehov na močovú
trubicu s použitím Caprosin 4,0; 5,0 D) Implantácia dermoepidermálneho
kožného štepu. E) 7. pooperačný deň,
lokálna aplikácia vazelíny/baneocínu 2× denne, odstránenie
permanentného močového katétra. F) 2 týždne po zákroku,
úspešné primárne zhojenie a kompletná epitelializácia štepu.
Niektoré z reziduálnych tzv. ukotvovacích stehov nie sú ešte
zrezorbované. G) Mesiac po operácii, bol dosiahnutý prirodzene
pôsobiaci a zároveň uspokojivý kozmetický výsledok
Fig. 1. A) Total glansectomy and removal of the glandular part of the urethra for biopsy proven squamous cell carcinoma, tips of the corpora cavernosa were left intact (frozen section confirmed negative margins). B) Neo‑glans reconstruction with inverted Vicril 4.0 running suture, creating the fish‑mouth shape. C) Reconfiguration of the neo‑sulcus and placing everting sutures for the urethra using Caprosin 4.0 and 5.0 sutures respectively. D) Split thickness skin graft implantation. E) 7th postoperative day, local application of Vaseline/ Baneocin two times daily, permanent catheter was removed. F) 2 weeks after procedure, the successful graft take and complete epithelialisation of the graft. Some of the residual guilting sutures are not completely absorbed. G) 1 month after the surgery, natural and satisfactory cosmetic result
Obr. 1. A) Kompletná amputácia – glans penis a odstránenie glandulárnej časti močovej trubice pre biopticky verifikovaný skvamocelulárny karcinóm. Distálne konce kavernóznych telies boli ponechané (perioperačná histológia potvrdila negatívne okraje). B) Rekonštrukcia „neo‑glansu“ s invertovaným pokračovacím stehom Vicril 4,0; ktorý vytvára tvar rybých úst. C) Rekonfigurácia tzv. „neo‑sulkusu“ a následné naloženie evertovaných stehov na močovú trubicu s použitím Caprosin 4,0; 5,0 D) Implantácia dermoepidermálneho kožného štepu. E) 7. pooperačný deň, lokálna aplikácia vazelíny/baneocínu 2× denne, odstránenie permanentného močového katétra. F) 2 týždne po zákroku, úspešné primárne zhojenie a kompletná epitelializácia štepu. Niektoré z reziduálnych tzv. ukotvovacích stehov nie sú ešte zrezorbované. G) Mesiac po operácii, bol dosiahnutý prirodzene pôsobiaci a zároveň uspokojivý kozmetický výsledok

Fig. 2. A) Biopsy proven local recurrence of the squamous
cell carcinoma in neo‑meatal
and the neo‑glans
area. B)
Final result 2 months after the primary procedure. C) Marking
of the incision lines for the scrotoplasty in order to gain
optical lenght of the penis, as well as lines in the neo‑glans
area (> 10 mm proximally from the site of the recurrence). D)
Excision of the neo‑glans
with the accompanying urethra,
frozen section were negative. E, F) Complete mobilization of
the remnant penile and distal part of the bulbal urethra, in
order to gain suficient lenght of the urethra in order to construct
the urethral flap. G) Reconstruction of the neo‑glans
with corpora cavernosa and neo‑sulcus.
H) Ventral spatulation
of the urethra. I) Neo‑glans
is covered with urethral flap
and sutured with resorbable Caprosin 4.0 single interrupted
sutures. J) Final appearance after the procedure. K) 14 days
postoperartively onset of the skin infection of the penis shaft
with complete retraction of the penis shaft. L) 2 weeks after
topical and antibiotic treatment<br>
Obr. 2 . A) Biopsiou potvrdená lokálna recidíva skvamocelulárneho
karcinómu v oblasti neo‑meatu
a neo‑glansu.
B) Konečný vzhľad – 2 mesiace po primárnom zákroku.
C) Označenie plánovaných incízných línií pred skrotoplastikou
za účelom získania dĺžky penisu (avšak jedná sa o optickú
komponentu), demarkácia línií pre nový neo‑glans
(> 10 mm proximálne od miesta recidívy). D) Excízia neo‑glansu
so sprievodnou časťou penilnej močovej trubice,
perioperačná histológia resekčných okrajov bola negatívna.
E, F) Kompletná mobilizácia zvyšku amputovaného penisu
a distálnej časti bulbárnej uretry, za účelom získania dostatočnej
dĺžky uretry potrebnej na prekrytie neo‑glansu
vo forme
laloka. G) Rekonštrukcia neo‑glansu
z corpora cavernosa
a adaptácia kože penisu do úrovne novovytvoreného neo‑sulcusu.
H) Ventrálna incízia močovej trubice. I ) Neo‑glans
je prekrytý distálnou časťou incidovanej uretry. Následná
sutúra vstrebateľným materiálom – Caprosin 4,0 vo forme
jednotlivých stehov. J) Konečný vzhľad po ukončení zákroku.
K) 14. deň po operácii dochádza k infekcii kože a podkožia
v oblasti tela penisu s následným kompletným zanorením.
L) 2 týždne po topickej dezinfekčnej a antibiotickej liečbe
Fig. 2. A) Biopsy proven local recurrence of the squamous cell carcinoma in neo‑meatal and the neo‑glans area. B) Final result 2 months after the primary procedure. C) Marking of the incision lines for the scrotoplasty in order to gain optical lenght of the penis, as well as lines in the neo‑glans area (> 10 mm proximally from the site of the recurrence). D) Excision of the neo‑glans with the accompanying urethra, frozen section were negative. E, F) Complete mobilization of the remnant penile and distal part of the bulbal urethra, in order to gain suficient lenght of the urethra in order to construct the urethral flap. G) Reconstruction of the neo‑glans with corpora cavernosa and neo‑sulcus. H) Ventral spatulation of the urethra. I) Neo‑glans is covered with urethral flap and sutured with resorbable Caprosin 4.0 single interrupted sutures. J) Final appearance after the procedure. K) 14 days postoperartively onset of the skin infection of the penis shaft with complete retraction of the penis shaft. L) 2 weeks after topical and antibiotic treatment
Obr. 2 . A) Biopsiou potvrdená lokálna recidíva skvamocelulárneho karcinómu v oblasti neo‑meatu a neo‑glansu. B) Konečný vzhľad – 2 mesiace po primárnom zákroku. C) Označenie plánovaných incízných línií pred skrotoplastikou za účelom získania dĺžky penisu (avšak jedná sa o optickú komponentu), demarkácia línií pre nový neo‑glans (> 10 mm proximálne od miesta recidívy). D) Excízia neo‑glansu so sprievodnou časťou penilnej močovej trubice, perioperačná histológia resekčných okrajov bola negatívna. E, F) Kompletná mobilizácia zvyšku amputovaného penisu a distálnej časti bulbárnej uretry, za účelom získania dostatočnej dĺžky uretry potrebnej na prekrytie neo‑glansu vo forme laloka. G) Rekonštrukcia neo‑glansu z corpora cavernosa a adaptácia kože penisu do úrovne novovytvoreného neo‑sulcusu. H) Ventrálna incízia močovej trubice. I ) Neo‑glans je prekrytý distálnou časťou incidovanej uretry. Následná sutúra vstrebateľným materiálom – Caprosin 4,0 vo forme jednotlivých stehov. J) Konečný vzhľad po ukončení zákroku. K) 14. deň po operácii dochádza k infekcii kože a podkožia v oblasti tela penisu s následným kompletným zanorením. L) 2 týždne po topickej dezinfekčnej a antibiotickej liečbe

DESCRIPTION OF TECHNIQUE

After initial careful examination of the impacted tissues, viability of the surrounding skin, circumferential extramarginal scar excision of the unhealthy skin around the penis shaft was initiated to get normal tissue at the wound margins. The penis was delivered after adequate release and multiple sharp excisions of postinflammatory subcutaneous tissues (Fig. 3A, B). In order to gain sufficient lenght, we decided to perform a suprapubic lipectomy and complete suspensory ligament division. The body mass index of out patient was 35, with the typical fat tissue deposit in the prepubic region. At this point, a testicular prosthesis (Polytech Health and Aesthetics/Germany 2x2.2 cm) was implanted in the prepubic space, to prevent adhesion of disconnected suspensory ligaments (Fig. 3C).

Next stage of our reconstruction included penile fixation with so called „tacking sutures“ (Vicril 4.0) between the tunica albuginea of the penile shaft base and edges of subdermal dartos of abdominal skin to prevent retraction of the penis. This manoeuvre allows formation of the penoscrotal and penopubic angle. The urethral flap was inspected and left intact, the margins served as the neo‑sulcus border. The final step was aimed to correct the total penis shaft skin defect, which was substituted with STSG. The graft was typically harvested from the upper left lateral thigh using a pneumatic dermatome (at a thickness 0.4 mm, size of the graft was 9×7 cm). The skin graft was meshed at the ratio of 1:1.5 (Fig. 3D, E). The graft was sutured at the critical areas around the penis base, neo‑sulcus with a running Saphilquick 4.0 suture. Consequently, quilting sutures were used to enhance the overall adherence and optimal graft take. Saphilquick 4.0 interrupted sutures were placed between the graft and superficial part of the tunica albuginea to improve the stabilization. The graft was covered with 1 layer of nonadhering dressing (JENONET‑Paraffin gauze), followed by the „tie‑over dressing“ bolster placement. Penis shaft was wrapped within, and two bolsters were sutured together in order to maintain compression. (Fig. 3F). We routinely tend to leave the dressing for 5 days (Fig. 3K, L) in situ either for scrotal, penile shaft grafting or glans resurfacing cases.

Fig. 3. A) Dissection and excision of fibrotic tethering tissues of
the penis shaft and tunica dartos, and consequent penoscrotal
angle repair. B) Complete penis degloving, removal of the
scar and postinflamatory tissues. C) Total suspensory ligament
release to increase the overall penis length and placement of
the testicular prosthesis 2 × 2.5 cm, after complete lipectomy
of Mons pubis. D) The harvesting area (lateral left thigh was
used as the harvest area. A pneumatic dermatome is used with
slow and steady pressure to harvest the skin graft at a thickness
(0.4 mm). Moderately expanded STSG (1 : 1.5 expansion) was
harvested to cover the entire penis shaft. E) Placing of tacking
sutures from the firm subdermal penis shaft tissues to the penis
base and rectus fascia. Consequent STSG coverage. F) The graft
was covered with 1 layer of nonadhering dressing (JENONET‑Paraffin
gauze), followed by the tie‑over
dressing bolster placement.
Penis shaft is wrapped within, and two bolsters are
sutured together in order to maintain compresion and graft
take. Several sutures are placed at the critical sites around the
penis base. The bolster was left intact in situ for 5 days. G,H)
A continuous negative‑pressure
dressing (on the harvested area)
of 51 mmHg was maintained for 5 days with the patient on the
bed rest (VAC‑Vacuum
Assisted Closure, KCI; Kinetic Concept;
Austria). I) 3rd postoperative day – donor site. J) 7th postoperative
day – donor site, wound bed is completely granulated, after
two VAC cycles for 3 days and one day without VAC. K,L) One
week after the procedure the graft is viable, without any signs of
inflamation or ischemic changes. M) Two weeks postoperatively
the mesh graft was completely taken and epithelialized. N) Final
cosmetic result after 2 months<br>
Obr. 3. A ) Preparácia a excízia fibrotických tkanív penisu
a tunica dartos, následná korekcia penoskrotálneho uhla.
B) Tzv. kompletný „degloving“ penisu, odstránenie nežiadúcich
pozápalových jaziev a tkanív. C) Po lipektómii v oblasti mons
pubis, vykonané kompletné uvoľnenie ligamenta suspensoria
penis za účelom získania dĺžky penisu, a umiestnenie testikulárnej
protézy 2 × 2,5 cm. D) Miesto odberu dermoepidermálneho
štepu (ľavá bočná časť stehennej oblasti). Na odber bol použitý
„pneumatický dermatóm“. S pomalým a rovnomerným
tlakom bol odobratý kožný štep v hrúbke (0,4 mm). Stredne
expandovaný štep (expanzia v pomere 1 : 1,5) bol použitý
na prekrytie tela penisu. E) Naloženie ukotvovacích stehov
v oblasti podkožných vrstiev pri báze penisu a fascie musculi
recti abdominis. Implantácia štepu na telo penisu. F) Na miesto
štepu bol naložený nepriľnavý obväz (JENONET–
parafínová
gáza), na ktorý bol aplikovaný tzv. „tie‑over
dressing“. Telo
penisu bolo zabalené do dvoch penových vankúšov, ktoré
boli nazvájom fixované sutúrami, aby vytvárali dostatočnú kompresiu za účelom ideálnej adherencie štepu. V oblasti
kritických miest boli naložené dodatočné fixačné stehy. Dressing bol ponechaný intaktný po dobu 5 dní. G, H) Kontinuálny
podtlakový dressing na mieste odberu štepu bol udržiavaný na tlakových hodnotách 51 mmHg (VAC – Vacuum Assisted
Closure, KCI; Kinetic Concept; Rakúsko) po dobu 5 dní. Pacient mal indikovaný kľud na lôžku. I) 3. pooperačný deň – miesto
odberu. J) 7. pooperačný deň – miesto odberu, pozorovať takmer kompletnú granuláciu spodiny, po dvoch cykloch VAC
počas 3 dní a jeden deň bez VAC systému. K, L) Týždeň po zákroku pozorovať vitálny transplantát, bez akýchkoľvek príznakov
zápalu alebo ischemických zmien. M) Dva týždne po operácii pozorovať ideálne ujatie štepu a známky konečnej fázy
epitelializácie. N) Objektívny nález po 2 mesiacoch
Fig. 3. A) Dissection and excision of fibrotic tethering tissues of the penis shaft and tunica dartos, and consequent penoscrotal angle repair. B) Complete penis degloving, removal of the scar and postinflamatory tissues. C) Total suspensory ligament release to increase the overall penis length and placement of the testicular prosthesis 2 × 2.5 cm, after complete lipectomy of Mons pubis. D) The harvesting area (lateral left thigh was used as the harvest area. A pneumatic dermatome is used with slow and steady pressure to harvest the skin graft at a thickness (0.4 mm). Moderately expanded STSG (1 : 1.5 expansion) was harvested to cover the entire penis shaft. E) Placing of tacking sutures from the firm subdermal penis shaft tissues to the penis base and rectus fascia. Consequent STSG coverage. F) The graft was covered with 1 layer of nonadhering dressing (JENONET‑Paraffin gauze), followed by the tie‑over dressing bolster placement. Penis shaft is wrapped within, and two bolsters are sutured together in order to maintain compresion and graft take. Several sutures are placed at the critical sites around the penis base. The bolster was left intact in situ for 5 days. G,H) A continuous negative‑pressure dressing (on the harvested area) of 51 mmHg was maintained for 5 days with the patient on the bed rest (VAC‑Vacuum Assisted Closure, KCI; Kinetic Concept; Austria). I) 3rd postoperative day – donor site. J) 7th postoperative day – donor site, wound bed is completely granulated, after two VAC cycles for 3 days and one day without VAC. K,L) One week after the procedure the graft is viable, without any signs of inflamation or ischemic changes. M) Two weeks postoperatively the mesh graft was completely taken and epithelialized. N) Final cosmetic result after 2 months
Obr. 3. A ) Preparácia a excízia fibrotických tkanív penisu a tunica dartos, následná korekcia penoskrotálneho uhla. B) Tzv. kompletný „degloving“ penisu, odstránenie nežiadúcich pozápalových jaziev a tkanív. C) Po lipektómii v oblasti mons pubis, vykonané kompletné uvoľnenie ligamenta suspensoria penis za účelom získania dĺžky penisu, a umiestnenie testikulárnej protézy 2 × 2,5 cm. D) Miesto odberu dermoepidermálneho štepu (ľavá bočná časť stehennej oblasti). Na odber bol použitý „pneumatický dermatóm“. S pomalým a rovnomerným tlakom bol odobratý kožný štep v hrúbke (0,4 mm). Stredne expandovaný štep (expanzia v pomere 1 : 1,5) bol použitý na prekrytie tela penisu. E) Naloženie ukotvovacích stehov v oblasti podkožných vrstiev pri báze penisu a fascie musculi recti abdominis. Implantácia štepu na telo penisu. F) Na miesto štepu bol naložený nepriľnavý obväz (JENONET– parafínová gáza), na ktorý bol aplikovaný tzv. „tie‑over dressing“. Telo penisu bolo zabalené do dvoch penových vankúšov, ktoré boli nazvájom fixované sutúrami, aby vytvárali dostatočnú kompresiu za účelom ideálnej adherencie štepu. V oblasti kritických miest boli naložené dodatočné fixačné stehy. Dressing bol ponechaný intaktný po dobu 5 dní. G, H) Kontinuálny podtlakový dressing na mieste odberu štepu bol udržiavaný na tlakových hodnotách 51 mmHg (VAC – Vacuum Assisted Closure, KCI; Kinetic Concept; Rakúsko) po dobu 5 dní. Pacient mal indikovaný kľud na lôžku. I) 3. pooperačný deň – miesto odberu. J) 7. pooperačný deň – miesto odberu, pozorovať takmer kompletnú granuláciu spodiny, po dvoch cykloch VAC počas 3 dní a jeden deň bez VAC systému. K, L) Týždeň po zákroku pozorovať vitálny transplantát, bez akýchkoľvek príznakov zápalu alebo ischemických zmien. M) Dva týždne po operácii pozorovať ideálne ujatie štepu a známky konečnej fázy epitelializácie. N) Objektívny nález po 2 mesiacoch

The harvested area was managed with the application of Biatain silicone bolster (10×20 cm, Coloplast/ Austria) and the negative pressure V.A.C therapy (KCI Medical, Austria). The pressure was set to -50mmHg for 72 hours in the first phase (Fig. 3G, H). Thereafter the wound was evaluated for secretion, initial granulation, oedema, and degree of erythema around the margins (Fig. 3I). When the wound secretion was limited, we applied OpSite‑Post‑OP‑VISIBLE (10x20 cm, Smith & Nephew‑Austria) waterproof adhesive transparent dressing on the 4th postoperative day, which allowed us continuous inspection of the area. Two days later, we left the wound open. Topical administration of Vaseline mixted with Baneocin cream (Bacitracin/Neomycin) was recommended for the next 7–10 days for the harvested and grafting area. Strict bed rest was advised for 3 days. As a thromboprophylactic measure Enoxaparin‑Natrium (Sanofi‑Aventis‑Austria; 40 mg subcutaneously) was started the evening after the operation. Broad spectrum second generation cephalosporin (Cefuroxim 1.5 g) twice daily was administered for next 5 days. Urethral catheter CH 14 was left in situ for 10 days. The next abdominal CT scan was performed 3 and 6 months postoperatively with negative result. the patient was also advised to further check the neo‑glans as well as inguinal region.

DISCUSSION

Short term follow‑up (6 months) revealed, that we were able to achieve acceptable voiding as well as sexual functioning (self stimulation and oral intercourse). However due to the relative short penis, vaginal coitus was not satisfactory. During the first 4 weeks the patient was advised to perform clean intermittent catheterization (2× per week) with Ch12 catheter in order to prevent onset of meatal stenosis. The final cosmetic appearance was considered very adequate (Fig. 3M).

The missing penile shaft skin can be replaced either with local vascularised scrotal flaps or skin grafting. Skin grafts can be harvested and prepared as full thickness or meshed. Current literature does not provide enough evidence with regard to graft superiority. STSG is currently a well established surgical technique, with good survival rates (6, 7). To date, there is no universal treatment algorithm defined, one of the reasons is the heterogenous patient population and rarity of the disease (8, 9).

In our patient, we were sceptical about scrotal skin grafting, in order not to compromise the overall anatomy after previous scrotoplasty, Although the pedicled scrotal flaps has been widely established in pediatric and adult patient population with favourable outcomes (10, 11, 12). The relative disadvantage of the scrotal graft is the presence of hair follicles, which may require secondary multiple laser treatments.

CONCLUSION

Surgical strategy of buried penis depends on the etiology and quality of affected and surrounding tissues, as well as overall anatomy of the external genitalia. The definitive treatment and surgical goal should repair voiding/sexual functioning and overall psychological well being of these individuals. STSG is a valid alternative for advanced cases in patients with already compromised scrotum.

Došlo: 9. 11. 2020

Přijato: 4. 2. 2021

Kontaktní adresa:

Assoc. Prof. Peter Weibl, MD, PhD.

Department of Urology, Teaching Hospital – Landesklinikum Korneuburg, Wiener Ring 3–5, 2100 Korneuburg, Austria

e‑mail: pweibl@yahoo.com

Conflicts of interest: Authors have no conflicts of interest or any financial competing interests.

Financial support: None.

Contributions: Substantial contributions to the design of the work, or acquisition of the perioperative figures, analysis or interpretation of data for the work: P. Weibl, G. Ameli, J. Krauter.

Drafting of the manuscript and critical revision for important intellectual content: P. Weibl, W. Hübner.


Zdroje

1. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of „buried“ penis in adulthood: an overview. Plast Reconstr Surg 2009; 124(4): 1186–1195.

2. Smith‑Harrison LI, Piotrowski J, Machen GL, Guise A. Acquired Buried Penis in Adults: A Review of Surgical Management. Sex Med Rev 2020; 8(1): 150–157.

3. Palminteri E, Fusco F, Berdondini E, Salonia A. Aesthetic neo‑glans reconstruction after penis‑sparing surgery for benign, premalignant or malignant penile lesions. Arab J Urol 2011; 9(2): 115–120.

4. Miranda‑Sousa A, Keating M, Moreira S, Baker M, Carrion R. Concomitant ventral phalloplasty during penile implant surgery: a novel procedure that optimizes patient satisfaction and their perception of phallic length after penile implant surgery. J Sex Med 2007; 4(5): 1494–1499.

5. Caso J, Keating M, Miranda‑Sousa A, Carrion R. Ventral phalloplasty. Asian J Androl 2008; 10(1): 155–157.

6. Alwaal A, McAninch JW, Harris CR, Breyer BN. Utilities of Split Thickness Skin Grafting for Male Genital Reconstruction. Urology 2015; 86(4): 835–839.

7. Lindsay A, AH Muncey W, Chung PH, et al. Surgical and Functional Outcomes Following Buried Penis Repair With Limited Panniculectomy and Split‑thickness Skin Graft. Urology 2017; 110: 234–238.

8. Donatucci CF, Ritter EF. Management of the buried penis in adults. J Urol 1998; 159(2): 420–424.

9. King IC, Tahir A, Ramanathan C, Siddiqui H. Buried penis: evaluation of outcomes in children and adults, modification of a unified treatment algorithm, and review of the literature. ISRN Urol 2013; 2013: 109349.

10. Manasherova D, Kozyrev G, Gazimiev M. Buried Penis Surgical Correction: Midline Incision Rotation Flaps. Urology 2020; 138: 174–178.

11. Westerman ME, Tausch TJ, Zhao LC, et al. Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome. Urology 2015; 85(6): 1501–1504.

12. Guo L, Zhang M, Zeng J, et al. Utilities of scrotal flap for reconstruction of penile skin defects after severe burn injury. Int Urol Nephrol 2017; 49(9): 1593–1603.

Štítky
Dětská urologie Nefrologie Urologie

Článek vyšel v časopise

Česká urologie

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2021 Číslo 1
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