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Scrotal flap phalloplasty as temporary neophallus in infants and children with penile agenesis: Multi-institutional experience and long-term follow-up

  • Author Footnotes
    1 Postal address: Av. Dr. Enéas Carvalho de Aguiar, 255, Cerqueira César - São Paulo, 05403–000, Brazil. Tel.: +55 11 996132914; fax: +55 11 31591921
    Bruno Nicolino Cezarino
    Correspondence
    Correspondence to: Bruno Nicolino Cezarino, Children’s Hospital of San Antonio and Methodist Children’s Hospital. San Antonio, Texas. USA.
    Footnotes
    1 Postal address: Av. Dr. Enéas Carvalho de Aguiar, 255, Cerqueira César - São Paulo, 05403–000, Brazil. Tel.: +55 11 996132914; fax: +55 11 31591921
    Affiliations
    Uropediatric Unit, Division of Urology, Hospital Das Clínicas, Faculdade de Medicina da Universidade de São Paulo São Paulo, Brazil
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  • Ricardo Arceo
    Affiliations
    Hospital Shriners para Niños Mexico City, Mexico
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  • Jeffrey A. Leslie
    Affiliations
    Children’s Hospital of San Antonio and Methodist Children’s Hospital San Antonio, Texas, USA
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  • Martin Koyle
    Affiliations
    Hospital for Sick Children Toronto, Canada
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  • Francisco Tibor Dénes
    Affiliations
    Uropediatric Unit, Division of Urology, Hospital Das Clínicas, Faculdade de Medicina da Universidade de São Paulo São Paulo, Brazil
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  • Juan Carlos Prieto
    Correspondence
    Correspondence to: Juan Carlos Prieto, Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo Medical School, Brazil.
    Affiliations
    Children’s Hospital of San Antonio and Methodist Children’s Hospital San Antonio, Texas, USA
    Search for articles by this author
  • Author Footnotes
    1 Postal address: Av. Dr. Enéas Carvalho de Aguiar, 255, Cerqueira César - São Paulo, 05403–000, Brazil. Tel.: +55 11 996132914; fax: +55 11 31591921
Published:October 06, 2022DOI:https://doi.org/10.1016/j.jpurol.2022.10.001

      Summary

      Introduction

      Aphallia is a rare congenital disorder pertaining to genotypic males. Early surgical creation of a neophallus is recommended to reinforce the child’s male gender-identity, favoring proper psychosexual development. Modern microsurgical techniques used to create a neophallus in adults are not recommended in children due to the invasiveness and complexity of the procedures, along with high complication rates. Scrotal flap phalloplasty is a simple and reproducible technique to create a temporary neophallus in prepubertal boys with aphallia.

      Objective

      We present a multi-institutional experience, ten years after the initial description of the scrotal flap phalloplasty (SFP) technique, in which a flap from the well-developed scrotum is used to build a temporary neophallus, without obvious scars in patients with aphallia.

      Study design

      The records of surgical neophalloplasty for aphallia patients from 4 centers between 2011 and 2021 were reviewed. All patients had at least one year follow-up to assess for short and long-term complications. Age at initial operation, associated anomalies, and other related surgical procedures were analyzed.

      Results

      The post-operative aesthetic result in all patients was satisfactory and has been maintained in the long-term follow-up, with all patients presenting a cylindrical structure resembling an uncircumcised penis, without evidence of significant contraction or loss of length. (Summary Figure)

      Discussion

      Non-microsurgical neophalloplasty techniques in patients with penile agenesis are temporary procedures that help to establish the body image and preserve the psychosexual development of the patient with aphallia. These techniques do not involve tissue transplant from a distant region, and are simpler to perform, with less scarring at the donor sites. Due to significant donor scars and considerable morbidity and complexity associated with the definitive phalloplasty techniques, we created a simple, reproducible and straightforward procedure to serve as a temporary neophallus in young boys with aphallia. As affected patients usually have a well-formed scrotum with normal and orthotopic testicles, it is the ideal donor site for a temporary neo-phallus in childhood. Furthermore, other donor sites are preserved for a definitive phalloplasty. There are limitations to this study, as quality of life could not be assessed and psychological or gender-identity investigations have not been carried out. None of these children have reached puberty, and hence decision and outcomes of definitive neophallus reconstruction has not been considered to date.

      Conclusion

      Summary Figure
      Graphical AbstractLong-term results (patients 1 and 2).

      Keywords

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      References

        • Docimo S.
        No title.
        in: The Kelalis-King-Belman Textbook of Clinical Pediatric Urology. 5th ed. CRC Press, Boca Raton FL2007: 1242
        • Diamond M.
        Pediatric management of ambiguous and traumatized genitalia.
        J Urol. 1999 Sep; : 1021-1028
        • Bogoraz N.A.
        On complete plastic reconstruction of a penis is sufficient for coitus.
        Sov Surg. 1936; 8: 303-309
        • Chang T.S.
        • Hwang W.Y.
        Forearm flap in one-stage reconstruction of the penis.
        Plast Reconstr Surg. 1984; 74: 251-258
        • Nair R.
        • Sriprasad S.
        844 Sir Harold Gillies: Pioneer of phalloplasty and the birth of uroplastic surgery.
        Eur Urol Suppl. 2010 Apr; 9: 269
        • Orticochea M.
        A new method of total reconstruction of the penis.
        Br J Plast Surg. 1972; 25 (C): 347-366
        • Puckett C.L.
        • Reinisch J.F.
        • Montie J.E.
        Free flap phalloplasty.
        J Urol. 1982; 128 ([Internet]) ([cited 2021 Apr 12]): 294-297
        • Hage J.J.
        • Bout C.A.
        • Bloem J.J.A.M.
        • Megens J.A.J.
        Phalloplasty in female-to-male transsexuals: what do our patients ask for?.
        Ann Plast Surg [Internet]. 1993; 30 ([cited 2021 Apr 12]): 323-326
        • Rashid M.
        • Tamimy M.S.
        (Indian J Plast Surg)Phalloplasty: the dream and the reality. 46. 2013: 283-293 ([cited 2021 Apr 12])
        • De Castro R.
        • Merlini E.
        • Rigamonti W.
        • Macedo A.
        Phalloplasty and urethroplasty in children with penile agenesis: Preliminary report.
        J Urol. 2007; 177: 1112-1117
        • Perovic S.
        Phalloplasty in children and adolescents using the extended pedicle island groin flap.
        J Urol. 1995; 154: 848-853
        • Mutaf M.
        • Işik D.
        • Bulut Ö.
        • Büyükgüral B.
        A true one-stage nonmicrosurgical technique for total phallic reconstruction.
        Ann Plast Surg. 2006; 57: 100-106
        • Goyal A.
        • Bianchi A.
        The parascrotal flap phallo-urethroplasty for aphallia reconstruction in childhood: report of a new technique.
        J Pediatr Urol. 2014; 10: 769-772
        • Bajpai M.
        Scrotal phalloplasty: a novel surgical technique for aphallia during infancy and childhood by pre-anal anterior coronal approach.
        J Indian Assoc Pediatr Surg. 2012; 17: 162
        • Oliveira D.E.G.
        • Da Cruz M.L.
        • Liguori R.
        • Garrone G.
        • Leslie B.
        • Ottoni S.L.
        • et al.
        Neophalloplasty in boys with aphallia: a systematic review.
        J Pediatr Urol. 2016; 12: 19-24
        • Gouvea JJ. oaqui.
        • Garrone G.
        • da Cruz M.L.
        • Martins G.M.C.
        • Parizi J.L.G.
        • Oliveira D.E.
        • et al.
        Penile prosthesis implantation in a patient with congenital aphallia treated using the De Castro technique 10 years previously. Is it feasible?.
        J Pediatr Urol. 2015; 11: 287-288
        • Goetz J.
        • White J.
        • Garcia de Mitchell C.A.
        • Leslie J.
        • Prieto J.
        V3-07 Scrotal flap phalloplasty (SFP) as temporary neophallus in pre-pubertal children with penile agenesis.
        J Urol [Internet, 2014 ([cited 2021 Apr 12];191(4S))
        • Venkatesh S.K.
        • Babu P.
        • Joseph T.
        • Varma K.
        Male gender assignment of a child with aphallia and associated complex urological anomaly.
        J Indian Assoc Pediatr Surg. 2016; 22: 38
        • Chaudhry R.
        • Theisen K.M.
        • Dangle P.P.
        • Schneck F.X.
        Congenital aphallia: novel use of acellular dermal matrix during scrotal flap phalloplasty.
        Urology. 2017; 105: 167-170
        • Lackgren G.
        • Cooper C.
        • Neveus T.
        • Kirsch A.
        Management of vesicoureteral reflux: what have we learned over the last 20 years.
        Frontiers in Pediatrics. 2021; 9: 650326
        • Mouriquand P.D.E.
        • Gorduza D.B.
        • Gay C.L.
        • Meyer-Bahlburg H.F.L.
        • Baker L.
        • Baskin L.S.
        • Lee P.
        Surgery in disorders of sex development (DSD) with a gender issue: if (why), when, and How?.
        J Pediatr Urol. 2016; 12: 139-149