New Techniques and Technologies
Total phallic reconstruction using radial forearm free flap after iatrogenic penile amputation
Reconstrucción fálica total con colgajo libre antebraquial radial tras amputación peneana iatrogénica
J.C. Anguloa,
, I. Arancea, C. Gómez-Llorensb, C. Esquinasa, C. Gómez-Martínc, J.L. Fernández-Cañamaquec
Corresponding author
a Departamento Clínico, Facultad de Ciencias Biomédicas, Servicio de Urología, Hospital Universitario de Getafe, Universidad Europea de Madrid, Laureate Universities, Madrid, Spain
b Zephyr Surgical Implants, Ginebra, Switzerland
c Servicio de Cirugía Plástica, Hospital Universitario de Getafe, Madrid, Spain
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Angulo, I. Arance, C. Gómez-Llorens, C. Esquinas, C. Gómez-Martín, J.L. Fernández-Cañamaque" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Angulo" "email" => array:1 [ 0 => "jangulo@futurnet.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Arance" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Gómez-Llorens" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." 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"apellidos" => "Fernández-Cañamaque" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento Clínico, Facultad de Ciencias Biomédicas, Servicio de Urología, Hospital Universitario de Getafe, Universidad Europea de Madrid, Laureate Universities, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Zephyr Surgical Implants, Ginebra, Switzerland" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Plástica, Hospital Universitario de Getafe, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reconstrucción fálica total con colgajo libre antebraquial radial tras amputación peneana iatrogénica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1003 "Ancho" => 1543 "Tamanyo" => 279729 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">In situ</span> flap constructed according to the technique of ‘tube in tube’, with bladder catheter in neouretra.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Loss of penile tissue is a serious complication for urinary, copulatory, and ejaculatory function. Different techniques of phalloplasty have been described, useful for individuals with congenital aphalia, traumatic loss of the phallus, or gender dysphoria.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> The simplest technique of phalloplasty is the rotation pedicled tubular flap with skin of the abdomen or groin, lacking sensitivity.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> Microsurgical advances have allowed plastic surgeons to develop phalloplasty techniques with free grafting. Thus, since Chang and Hwang<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> described phalloplasty with radial forearm free flap (RFFF), this technique has become the standard for the construction of a neophallus.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> For this reason, female to male transsexualism is used.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4,5</span></a> Also in genetic males, it is the first choice to perform total genital reconstruction, thanks to the fact that it makes it possible to recover sensitivity and can accommodate a penile prosthesis.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of penile loss due to abscess after oral mucosal graft cavernoplasty to treat Peyronie's disease.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> In this patient, the performance of RFFF and penile prosthesis implantation has made it possible to partially recover his psychological, cosmetic, urinary, orgasmic, and copulatory sequelae.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 57-year-old male was referred to our center for having been operated on in another institution due to Peyronie's disease, where cavernoplasty was performed with an oral mucosa graft, which presented postoperative complications leading to penile necrosis, requiring serial debridement resulting in subtotal penile amputation. The patient had severe anxiety syndrome. The CT scan performed at our institution showed a necrotic collection in the cavernous body with air inside (Appendix A, supplementary material). Therefore, abscess drainage, new debridement to the root of the cavernous bodies, and placement of hypogastric carcass were performed. The cultures obtained showed amoxicillin-clavulanate-resistant <span class="elsevierStyleItalic">Escherichia coli</span>, piperacillin, tazobactam and trimethoprim-sulfamethoxazole, and <span class="elsevierStyleItalic">Streptococcus viridans</span> sensitive to all antibiotics evaluated. Treatment with iv vancomycin was performed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Seven weeks later, after confirmation of repeated negative cultures, a complete reconstruction of the penis is carried out, and a year and a half later, placement of a 3-component inflatable penile prosthesis, personalized with a single body implanted in the root of its own corpus cavernosum.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">Penile reconstruction was performed by left-sided RFFF and neourethral formation using the ‘tube-in-tube’ technique, keeping the radial artery and the concomitant veins as pedicles (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The cephalic vein and the lateral antebrachial cutaneous nerve were included. De-epidermization and folding of the area corresponding to neourethra around the 16 Ch bladder probe and tubular closure of the flap was conducted (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the remnant of the root of the penis, another bladder catheter was inserted to expose the border of the bulbar urethra and the residual corpus spongiosum, and penile skin and urethral Friedrich was performed. With great difficulty, the dorsal nerve of the penis was located, which was dissected to a healthy level and prepared for nervous anastomosis. At the level of the right thigh, the femoral artery and the saphenous vein and their branches were dissected and prepared as receptive vessels of the flap. After the section of the pedicle, the neophallus was transferred to the receiving area. First, the urethra was anastomosed to neourethra with Vicryl 4/0 suture in 2 planes and sealing of the stump of the spongiosum body. Anastomosis of the dorsal nerve of the penis was then performed on the antebrachial cutaneous nerve of the flap with Nylon 8/0 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). An end-to-end anastomosis of the cephalic vein to the right saphenous vein was then performed, and later on the end-to-side anastomosis of the radial artery to the femoral artery (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). End-to-end anastomosis of the concomitant radial vein was then performed on the saphenous branch and the good vascularization of the flap was confirmed (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Finally, the skin of the flap was sutured to the remaining skin of the penile root with Nylon 4/0, requiring a meshed graft free from skin of partial thickness 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>cm to facilitate the closure of the neophallus, and a carved of the glans was made according to Norfolk principles to create the cosmetic appearance of a pseudogland. The left forearm was covered with donor skin from the lateral side of the right thigh. The total duration of the surgical procedure was 10<span class="elsevierStyleHsp" style=""></span>h. At 12 days, the bladder catheter was removed and spontaneous urination was detected through the neourethra. The patient was discharged on postoperative day 16 (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">There was no intraoperative or postoperative complication, but despite preoperative depilation of the forearm, there was growth of hair in the urethra that required dilation and mechanical endoscopic depilation on 3 occasions, one under anesthesia and dilation with Beniqués up to a 22 Ch gauge. This intervention was used to perform an echo-Doppler modeling that served to accurately refer the arterial branch of the graft before the placement of penile prosthesis. The patient progressively regained penile sensitivity from the 6th month.</p><p id="par0035" class="elsevierStylePara elsevierViewall">18 months after phalloplasty, a 3-element inflatable Zephyr ZSI 475 (Geneva, Switzerland) prosthesis was implanted, but using a single body using the albuginea itself of the proximal cavernous body on the right cavernous body, with a length of 19<span class="elsevierStyleHsp" style=""></span>cm and proximal extender of 5<span class="elsevierStyleHsp" style=""></span>cm, and reservoir with 70<span class="elsevierStyleHsp" style=""></span>cc of saline solution. This intervention lasted 150<span class="elsevierStyleHsp" style=""></span>min and did not present any complications (Appendix B, supplementary material). The patient was discharged after admission of 24<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patient is relatively satisfied from a cosmetic, voiding, and sensitive point of view. He has a normal sensitivity in the skin of the neophallus, with a certain grade of hyperesthesia. He is able to reach orgasm and ejaculate. He does not present any micturition disorder, although possibly in the future he needs depilation of the urethral light. Four months after the placement of the penile prosthesis, he is able to activate and deactivate it, although with some difficulty, and he is gaining confidence to approach penetration. The rigidity of his neophallus with the activated prosthesis is smaller than that obtained when a prosthesis is placed with double corpus cavernosum, and much smaller than a natural erection. The psychological effect and anxiety persist and the patient is not free from presenting future complications or dysfunction of the prosthesis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Penile mutilation due to iatrogenic penile necrosis after cavernoplasty is such an uncommon complication that it is not even described in large series and reviews of the surgical treatment of Peyronie's disease.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> It is an absolutely disproportionate and severely disabling sequel. Other traumatic circumstances that may lead to complete loss of the penis (for example biting, firing, electric burn, or amputation by a knife) are also very uncommon. Surgical reimplantation may be successful in those cases with clean avulsion injuries (usually self-amputation in a psychotic outbreak or accidental amputation) in which the amputated stump has been adequately preserved, under aseptic conditions and wrapped in ice.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> When these conditions are not met, as it is the case that we present, the best attitude is the deferred repair.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Several reconstructive techniques have been used, especially in patients with gender dysphoria, but sometimes also with traumatic amputation or aphasia of diverse etiology.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,4,5</span></a> The first phalloplasty was a tubularized abdominis flap described in 1936.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> Rotation flaps from the thigh<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> or flap free from <span class="elsevierStyleItalic">latissimus dorsi</span> were also used.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> However, the description by Chang and Wang in 1984 led to RFFF being established as the standard for this type of reconstructions with the development of microsurgical techniques.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Among its advantages, we can point out that it is a graft with relatively less hair, which maintains sensitivity and allows for excellent venous perfusion and drainage. Its main disadvantage is the morbidity of the donor site, since the forearm scar is an added stigma.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> Other possible options are the fibular osteocutaneous free flap or the anterolateral free flap of the thigh<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,13</span></a>; although these techniques make it possible to recover sensitivity, but they do not usually obtain, in this sense, the excellent results that a RFFF gives performed in optimal conditions.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore, the indication of this type of vascularized grafts has also been extended to patients with exstrophy–epispadias complex with very encouraging results.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">14,15</span></a> Even a variant of the technique preserving the original glans has been described by microvascular transfer of the glans to the distal portion of the radial forearm graft, which may be useful in severe hypospadias, micropenis, and in patients with loss of penile tissue and preserved glans.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The most important complications of RFFF are those that can occur on the flap, ranging from anastomotic revision to partial necrosis or total loss of the flap, and they may occur in one out of 5 cases.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> The application of a successful second forearm flap has been described after partial necrosis of a first RFFF.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> The most feared complication is acute venous thrombosis of the microsurgical anastomosis, which occurs 2–3 days after surgery and can occur in approximately 3% of patients. When it is recognized late, it usually entails the loss of the neophallus. Acute thrombosis of the radial artery occurs immediately and is easily identified. In most cases, the neophallus can be preserved with immediate reexamination. Urinary complications are the most frequent in RFFF (neourethral stenosis and/or fistula) and occur in 30% of cases, although their delayed surgical correction is usually successful.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> Other minor urinary complications are also common in phalloplasty, including pseudodiverticula, bladder lithiasis, and formation of hair in the urethra that may lead to urinary retention.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The placement of the penile prosthesis in this type of patients is a topic to be debated. There is greater agreement to consider inflatable devices.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> Unless the neophallus has large dimensions, it is a usual measure to place prostheses of a single cavernous body. Even a model of a 3-component prosthesis has recently been developed but a single penile body with a glans form built-in, which rests on the periosteum of the pubis. However, this device makes more sense in transsexualism surgery. In the case that we described, it was preferred to use the healthy root of the cavernous body, as other authors recommend,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12,15</span></a> when possible, to avoid hyperpressure with risk of bedsore in the neophallus. Therefore, it seems more advisable to place a prosthesis not rigid and not excessively tense. Either way, the placement of a prosthesis in a patient with neophallus has a much higher risk of complications than in a native penis,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> and it can lead to explant or revision in almost half of the implanted patients, due to erosion (8%), infection (12%), or mechanical failure (22%).<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">5,6,12,14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, the loss of the penis of iatrogenic origin is a severe urologic complication that may be partially palliated by a microsurgical plastic reconstruction with radial flap and prosthetic support, which is not free from complications. It is possible to achieve a partial cosmetic and functional recovery of the organ, but it is much more difficult to avoid the psychological sequelae in these patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">C. Gómez-Llorens is General Manager in ZSI.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The rest of authors have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres886526" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec872684" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres886525" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec872683" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack296392" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-23" "fechaAceptado" => "2016-09-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec872684" "palabras" => array:4 [ 0 => "Penile amputation" 1 => "Phalloplasty" 2 => "Radial forearm free flap" 3 => "Penile prosthesis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec872683" "palabras" => array:4 [ 0 => "Amputación peneana" 1 => "Faloplastia" 2 => "Colgajo libre de antebrazo radial" 3 => "Prótesis peneana" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The iatrogenic loss of the penis is a rare situation. We present a challenging case of deferred total penile reconstruction in a genetic male.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 57-year-old man with the loss of the penis due to a penile abscess and necrosis secondary to penile curvature surgery. The reconstruction was performed over several operations using a radial forearm free flap (RFFF) and placement of a customized inflatable prosthesis a year later.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During the first operation, the penile abscess was drained, the necrotic residues were debrided and placement of hypogastric drainage. Seven weeks later, phalloplasty was performed with RFFF and a tube-in-tube neourethra was constructed. Multiple microsurgical anastomosis was performed, and the donor site was coated with a skin graft from the thigh of partial thickness. The surgery lasted 10<span class="elsevierStyleHsp" style=""></span>h and had the complication of hair growth in the neourethra, which required mechanical endoscopic depilation on repeated occasions. The patient regained penile sensitivity. Eighteen months after the phalloplasty, a Zephyr single-body inflatable prosthesis (Geneva, Switzerland) was implanted, using the tunica albuginea of the proximal corpus cavernosum. The patient was satisfied with the esthetics and urinary and sensory function. Four months later, the patient is gaining confidence to consider penetration.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the risk of postoperative complications and the need for multiple operations, phallic reconstruction with RFFF and the placement of a customized prosthetic implant can improve urinary and sexual function secondary to the loss of the penis.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La pérdida del pene de causa iatrogénica es una circunstancia muy infrecuente. Se presenta un caso desafiante de reconstrucción peneana total diferida en varón genético.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Varón de 57 años con pérdida del falo por absceso peneano y necrosis secundaria a cirugía de incurvadura peneana. La reconstrucción se realizó en varios tiempos empleando colgajo libre de antebrazo radial (CLAR) y colocación de prótesis inflable personalizada un año después.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En un primer tiempo quirúrgico se llevó a cabo drenaje de absceso peneano, desbridamiento de restos necróticos y colocación de talla hipogástrica. Siete semanas después se llevó a cabo faloplastia con CLAR y construcción de neouretra tubo-en-tubo, anastomosis microquirúrgica múltiple y recubrimiento del sitio donante con injerto de piel del muslo de espesor parcial. La duración de esta cirugía fue 10 horas y tuvo como complicación crecimiento de vello en la neouretra, que obligó a depilación mecánica endoscópica en repetidas ocasiones. El paciente recuperó sensibilidad peneana, y 18 meses tras la faloplastia se le implantó prótesis Zephyr (Ginebra, Suiza) inflable de un solo cuerpo, utilizando la propia albugínea del cuerpo cavernoso proximal. El paciente se encuentra satisfecho desde el punto de vista cosmético, miccional y sensitivo. Cuatro meses después se encuentra ganando confianza para abordar la penetración.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A pesar del riesgo de complicaciones postoperatorias y de la necesidad de operaciones múltiples, la reconstrucción fálica con CLAR y colocación de implante protésico personalizado puede mejorar el impacto en la función urinaria y sexual secundario a la pérdida del pene.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Angulo JC, Arance I, Gómez-Llorens C, Esquinas C, Gómez-Martín C, Fernández-Cañamaque JL. Reconstrucción fálica total con colgajo libre antebraquial radial tras amputación peneana iatrogénica. Actas Urol Esp. 2017;41:471–476.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0095" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:</p> <p id="par0100" class="elsevierStylePara elsevierViewall">CT with subtotal penile amputation and persistent bilateral cavernous abscess with gas inside are presented.<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1517 "Ancho" => 2333 "Tamanyo" => 569847 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Preparation of the radial forearm flap and detail of the vascular pedicle of it.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1003 "Ancho" => 1543 "Tamanyo" => 279729 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">In situ</span> flap constructed according to the technique of ‘tube in tube’, with bladder catheter in neouretra.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1516 "Ancho" => 2333 "Tamanyo" => 614274 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Left: anastomosis of urethra to neourethra; right: dorsal nerve anastomosis of the penis to the antebrachial cutaneous nerve.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1517 "Ancho" => 2333 "Tamanyo" => 872016 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Left: anastomosis of cephalic vein to right saphenous vein; right: radial to right femoral artery anastomosis.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1003 "Ancho" => 1543 "Tamanyo" => 334334 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Surgical field with exposure of the right femoral field, where the multiple complete vascular anastomoses and the neophallus are observed before completion of the ventral portion closure.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1408 "Ancho" => 2167 "Tamanyo" => 450106 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Neophallus in flaccidity before placement of the penile prosthesis and in erection with activated prosthesis.</p>" ] ] 6 => array:6 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 153284868 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">We present a video that shows the fundamental steps of the placement of the ZSI 475 penile implant with adaptation to a floor implanted in the root of the right cavernous body of the patient with phalloplasty.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phalloplasty: the dream and the reality" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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| 2018 July | 1 | 0 | 1 |
| 2017 December | 1 | 0 | 1 |
| 2017 September | 2 | 0 | 2 |
| 2017 August | 1 | 0 | 1 |
| 2017 July | 0 | 1 | 1 |
