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Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
Vaginal & genitourinary reconstruction
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Vaginal & genitourinary reconstruction

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S Patel

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  • SCC vulva
  • F. l. flap
  • Transcript

    • 1. Vaginal & Genitourinary Reconstruction Sanjay Sharma, M.D. Jeffrey Friedman, M.D. Rahul Nath, M.D. Tue Dinh, M.D.
    • 2. Outline <ul><li>Embryology </li></ul><ul><li>Vaginal Reconstruction </li></ul><ul><ul><li>Congenital defects </li></ul></ul><ul><ul><li>Acquired defects </li></ul></ul><ul><li>Penile/Scrotal Reconstruction </li></ul><ul><ul><li>Cavernous nerve reconstruction </li></ul></ul><ul><li>Other entities of GU reconstruction </li></ul>
    • 3. Anatomy/Embryology
    • 4. Anatomy/Embryology <ul><li>Genital and urinary tracts intimately associated in development </li></ul><ul><li>All 3 germ layers involved </li></ul><ul><ul><li>Mesoderm </li></ul></ul><ul><ul><ul><li>Nephrotic system, Wolffian Ducts, Mullerian Ducts, Gonads </li></ul></ul></ul><ul><ul><li>Endoderm </li></ul></ul><ul><ul><ul><li>Cloaca, Cloacal membrane </li></ul></ul></ul><ul><ul><li>Ectoderm </li></ul></ul><ul><ul><ul><li>External Genitalia </li></ul></ul></ul>
    • 5. Anatomy/Embryology <ul><li>Male </li></ul><ul><ul><li>Wolffian Ducts </li></ul></ul><ul><ul><ul><li>Epididymis </li></ul></ul></ul><ul><ul><ul><li>Vas deferens </li></ul></ul></ul><ul><ul><ul><li>Seminal vesicles </li></ul></ul></ul><ul><ul><ul><li>Mullerian ducts regress </li></ul></ul></ul>
    • 6. Anatomy/Embryology <ul><li>Female </li></ul><ul><ul><li>Mullerian Ducts differentiate into </li></ul></ul><ul><ul><li>Fallopian tubes </li></ul></ul><ul><ul><li>Uterus </li></ul></ul><ul><ul><li>Upper portion of vagina </li></ul></ul><ul><ul><li>Wolffian tubes degenerate </li></ul></ul>
    • 7. <ul><li>2 pairs genital ducts Males - mesonephric (Wolffian) Females - paramesonephric (Mullerian) </li></ul>
    • 8. External Genitalia <ul><li>11 th week </li></ul><ul><li>Genital tubercle </li></ul><ul><li>Labioscrotal swellings </li></ul><ul><li>Urethral folds </li></ul><ul><li>Male- fuse proximal-distal (central raphe) </li></ul>
    • 9. Congenital Defects <ul><li>Vaginal Agenesis </li></ul><ul><ul><li>Mayer-Rokitansky Syndrome </li></ul></ul><ul><li>Ambiguous Genitalia </li></ul><ul><ul><li>Congenital Adrenal Hyperplasia </li></ul></ul><ul><ul><li>Mixed Gonadal Dysgenesis </li></ul></ul><ul><ul><li>Male pseudohermaphroditism </li></ul></ul>
    • 10. Ambiguous Genitalia
    • 11. Bladder Exstrophy <ul><li>Absence of a portion of lower abdominal wall and anterior vesical wall </li></ul><ul><li>Thought to be cleft of lower trunk, pubic diastasis </li></ul><ul><li>Failure of cloacal membrane to allow ingrowth of mesoderm—leads to rupture </li></ul><ul><li>Incidence: 1:25,000 to 1:40,000 live births </li></ul><ul><li>Severe genitourinary defect </li></ul>
    • 12. Bladder Exstrophy <ul><li>Surgical Correction </li></ul><ul><ul><li>Diversion of urinary stream </li></ul></ul><ul><ul><li>Closure of exstrophied bladder </li></ul></ul><ul><ul><li>Reconstruction of external genitalia </li></ul></ul><ul><ul><ul><li>Epispadias, release of chordee </li></ul></ul></ul><ul><ul><ul><li>Cleft clitoris </li></ul></ul></ul><ul><ul><ul><li>Diastasis of labia minora </li></ul></ul></ul><ul><ul><ul><li>Mons pubis </li></ul></ul></ul>
    • 13. Rokitansky Syndrome <ul><li>Congenital absence of the Vagina </li></ul><ul><li>1:4000 </li></ul><ul><li>Defect mullerian duct development </li></ul><ul><li>Partial or complete vaginal agenesis with renal abnormalities </li></ul><ul><li>Usually normal external genitalia </li></ul>
    • 14. Rokitansky Syndrome <ul><li>46 XY karyotype </li></ul><ul><li>Usually present 14-16 </li></ul><ul><li>1 ° amenorrhea </li></ul><ul><li>Rudimentary uterus, normal ovaries </li></ul><ul><li>Baseline IVP for preop evaluation </li></ul>
    • 15. Reconstruction <ul><li>Frank Method </li></ul><ul><li>Bowel Flaps </li></ul><ul><li>McIndoe Procedure </li></ul><ul><li>Vulvovaginoplasty </li></ul><ul><li>Musculocutaneous flaps </li></ul>
    • 16. Preoperative Evaluation <ul><li>Mature individual, post puberty </li></ul><ul><li>Compliance of patient/family—stents </li></ul><ul><li>History &amp; Physical </li></ul><ul><ul><li>Rectal examination </li></ul></ul><ul><ul><li>C-spine </li></ul></ul><ul><ul><li>Buccal smear </li></ul></ul><ul><li>Baseline U/S, IVP </li></ul>
    • 17. Frank Method <ul><li>Serial progressive dilatation &amp; pressure </li></ul><ul><li>Rigid dilator slowly expanded into rudimentary vagina </li></ul><ul><li>Placed between rectum and urethra </li></ul><ul><li>painful </li></ul><ul><li>12-24 months </li></ul><ul><li>High failure due to non-compliance </li></ul>
    • 18. Bowel Flaps <ul><li>Small bowel or colon </li></ul><ul><li>Laparotomy and associated complications </li></ul><ul><li>Large amount of mucous </li></ul><ul><li>Malodorous discharge </li></ul><ul><li>Fissures, bleeding, stenosis frequent </li></ul><ul><li>1-2% mortality rate </li></ul>
    • 19. Local Flaps <ul><li>Vulvovaginoplasy </li></ul><ul><ul><li>Williams: labia majora infolded </li></ul></ul><ul><ul><li>Hwang: labia minora flaps </li></ul></ul><ul><li>Tissue expansion </li></ul><ul><li>Musculocutanous flaps </li></ul><ul><ul><li>Gracilis </li></ul></ul><ul><ul><li>Rectus </li></ul></ul><ul><ul><li>Posterior thigh fasciacutaeous </li></ul></ul><ul><ul><li>TFL </li></ul></ul>
    • 20. McIndoe Technique <ul><li>Neovagina lined with skin graft </li></ul><ul><li>Surgically created space between bladder and rectum </li></ul><ul><li>Relatively easy procedure </li></ul><ul><li>Obviates need for laparotomy </li></ul><ul><li>Gynecology assistance </li></ul>
    • 21. McIndoe Procedure
    • 22. McIndoe Technique <ul><li>Patient Selection </li></ul><ul><ul><li>Mature, 16-18 years old </li></ul></ul><ul><ul><li>Approaching sexual activity </li></ul></ul><ul><ul><li>Mature and compliant </li></ul></ul><ul><li>Pre-operative considerations </li></ul><ul><ul><li>Full bowel prep </li></ul></ul><ul><ul><li>Ememas </li></ul></ul><ul><ul><li>Foley catheter </li></ul></ul><ul><ul><li>DVT prohylaxis </li></ul></ul>
    • 23. Procedure <ul><li>STSG harvest </li></ul><ul><li>Suprapubic region </li></ul><ul><li>Tumescence </li></ul><ul><li>Alternative sites: lateral thigh, buttock </li></ul><ul><li>Single sheet, depth 0.015 &amp;quot; -0.018&amp;quot; </li></ul>
    • 24. STSG Donor Sites Tumescence for uniform Surface skin graft
    • 25. Procedure <ul><li>Perineal Phase </li></ul><ul><li>Rectovesicular space between bladder and rectum </li></ul><ul><li>Avoid straight line incisions at introitus </li></ul><ul><li>Vaginal stent used to guide depth of space </li></ul><ul><li>ABSOLUTE HEMOSTASIS </li></ul>
    • 26. Procedure <ul><li>Graft Fixation: </li></ul><ul><li>Dermal side out </li></ul><ul><li>Affix to mold, non linear suture line </li></ul><ul><li>Use of Tisseel or similar fibrin glue </li></ul><ul><li>Suture labia together </li></ul><ul><li>Keep in hospital 1 week </li></ul>
    • 27. &nbsp;
    • 28. &nbsp;
    • 29. Graft Fixation , dermal side out
    • 30. <ul><li>Spiral Suture Line </li></ul>
    • 31. &nbsp;
    • 32. Avoid straight line incisions at introitus
    • 33. &nbsp;
    • 34. Rectovesical Space Peritoneal reflection (15 cm)
    • 35. Meticulous hemostasis is essential
    • 36. &nbsp;
    • 37. &nbsp;
    • 38. Suture labia together, prevents extrusion
    • 39. &nbsp;
    • 40. Procedure <ul><li>Post-operative care </li></ul><ul><li>Strict bedrest </li></ul><ul><li>Foley catheter </li></ul><ul><li>Anti-motility agent—lomotil </li></ul><ul><li>Return to OR 1 week for stent removal </li></ul><ul><li>Assessment of graft take, re-graft if necessary </li></ul><ul><li>Replace stent </li></ul>
    • 41. Check graft at POD #7 Regraft if &gt;2 cm necrosis
    • 42. Post-operative care <ul><li>Continue mold 3-6 months </li></ul><ul><li>Sexual activity resume in 6 weeks </li></ul><ul><li>Mucosalization/sensitivity </li></ul><ul><li>Yearly followup </li></ul><ul><li>Functional success ~90% </li></ul><ul><li>Complications: fistula, stenosis, dyspareunia, graft failure, SCC (15 years) </li></ul>
    • 43. Acquired Defects of GU System
    • 44. Acquired Defects of GU System <ul><li>Extensiveness </li></ul><ul><ul><li>Defects of vulvoperineal surface </li></ul></ul><ul><ul><li>Defects of scrotal skin </li></ul></ul><ul><ul><li>Defects of vaginal vault </li></ul></ul><ul><ul><li>Defects of penis </li></ul></ul><ul><ul><li>Combined perineum and pelvic support structures </li></ul></ul><ul><ul><li>Other—pelvic brim, urethra, sphinter mech </li></ul></ul>
    • 45. Preoperative Evaluation <ul><li>Define goals of reconstruction </li></ul><ul><ul><li>Wound healing </li></ul></ul><ul><ul><li>Functional restoration </li></ul></ul><ul><ul><li>Individualize for each patient—70 yo vs 20 yo </li></ul></ul><ul><li>Condition of surrounding tissue </li></ul><ul><ul><li>Need for adjuvent radiotherapy </li></ul></ul><ul><ul><li>Previous pelvic surgery </li></ul></ul><ul><li>Physical examination </li></ul><ul><ul><li>Groin pulses </li></ul></ul><ul><ul><li>Other incisions around planned flaps </li></ul></ul>
    • 46. Assessment of Defect <ul><li>Post oncologic </li></ul><ul><ul><li>Evaluation of size, missing tissue, donor vessels </li></ul></ul><ul><ul><li>Planning of routes of flap transfer </li></ul></ul><ul><ul><li>Intrapelvic—width of pelvis, height </li></ul></ul><ul><ul><li>Body habitus—thick, bulky flaps </li></ul></ul><ul><li>Trauma </li></ul><ul><ul><li>Zone of injury </li></ul></ul><ul><ul><li>Local-regional tissues </li></ul></ul>
    • 47. Vulvoperineal Surface <ul><li>Cancer resections </li></ul><ul><ul><li>Skinning vulvectomy </li></ul></ul><ul><ul><li>Wide local excision </li></ul></ul><ul><ul><li>Loss of skin, subcutaneous tissue </li></ul></ul>
    • 48. Vulvoperineal Surface <ul><li>Skin grafts </li></ul><ul><ul><li>Appropriate for unsure margins, high recurrence </li></ul></ul><ul><ul><li>Best in non-irradiated beds </li></ul></ul><ul><ul><li>Non-meshed sheet STSG vs FTSG </li></ul></ul><ul><li>Donor site </li></ul><ul><ul><li>Suprapubic area, injectable saline </li></ul></ul><ul><ul><li>Lateral thigh, gluteal area </li></ul></ul>
    • 49. &nbsp;
    • 50. &nbsp;
    • 51. &nbsp;
    • 52. Vulvoperineal Surface <ul><li>Local Flaps </li></ul><ul><ul><li>Irradiated tissue </li></ul></ul>
    • 53. Vulvoperineal Surface <ul><li>Laxity posterior, lateral regions </li></ul><ul><ul><li>Small to medium defects: local rotation flaps, rhomboid </li></ul></ul><ul><ul><li>Larger defects: fasciocutaneous flaps, posterior thigh </li></ul></ul><ul><li>Limit pressure in area </li></ul><ul><ul><li>DVT prophylaxis </li></ul></ul><ul><ul><li>Sexual activity 6 weeks </li></ul></ul>
    • 54. &nbsp;
    • 55. &nbsp;
    • 56. &nbsp;
    • 57. &nbsp;
    • 58. &nbsp;
    • 59. Vaginal Vault <ul><li>Advantages of immediate reconstruction </li></ul><ul><ul><li>Primary healing of perineal defect </li></ul></ul><ul><ul><li>Decreased fluid loss </li></ul></ul><ul><ul><li>Reduced infection rate </li></ul></ul><ul><ul><li>Emotional/psychological well-being </li></ul></ul><ul><ul><li>Early rehabilitation </li></ul></ul><ul><ul><li>Future radiotherapy </li></ul></ul>
    • 60. Vaginal Vault <ul><li>Considerations </li></ul><ul><ul><li>Patient Selection </li></ul></ul><ul><ul><ul><li>Wound coverage vs functional reconstruction </li></ul></ul></ul><ul><ul><li>Defect Analysis </li></ul></ul><ul><ul><ul><li>Oncologic </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Entire vagina vs anterior or posterior wall </li></ul></ul></ul>
    • 61. Vaginal Vault <ul><li>Goals of Reconstruction </li></ul><ul><li>Neovagina of sufficient depth </li></ul><ul><li>Durability, pliability </li></ul><ul><li>Provide closure of peritoneal cavity, separate bowel from pelvis </li></ul><ul><li>Minimal morbidity </li></ul>
    • 62. Vaginal Vault <ul><li>Gracilis </li></ul><ul><li>Small dead space </li></ul><ul><li>Relatively thin patient </li></ul><ul><li>No associated laparotomy </li></ul><ul><li>Previous workhorse flap </li></ul>
    • 63. Vaginal Vault <ul><li>Gracilis </li></ul><ul><li>Originates pubic symphysis, inserts on medial tibial condyle </li></ul><ul><li>Raised distal to proximal off adductor group </li></ul><ul><li>Medial circumflex femoral artery (Type II) </li></ul><ul><ul><li>8-10 cm below origin </li></ul></ul><ul><li>Lithotomy position </li></ul>
    • 64. Vaginal Vault <ul><li>Gracilis Limitations </li></ul><ul><ul><li>Distal skin island less reliable </li></ul></ul><ul><ul><li>Rotation of flap dependent on pedicle </li></ul></ul><ul><ul><li>Thus, limits depth of vault </li></ul></ul><ul><li>Bilateral gracilis for complete vault recon </li></ul><ul><li>Donor site issues </li></ul><ul><ul><li>Bulge, unsightly scars </li></ul></ul>8X15 cm skin island
    • 65. Vaginal Vault <ul><li>Rectus Abdominus </li></ul><ul><li>Total or partial defects </li></ul><ul><li>Ease of elevation, obliterates dead space </li></ul><ul><li>Robust blood supply, resists radiation </li></ul><ul><li>Contraindications </li></ul><ul><ul><li>Previous abdominoplasty, stoma through muscle, incisions across DIEA </li></ul></ul>
    • 66. Vaginal Vault <ul><li>Rectus Abdominus </li></ul><ul><li>Originates on pubis, inserts on ribs 5-7 </li></ul><ul><li>Superior and inferior epigastric arteries (type III) </li></ul><ul><li>Harvested as inferiorly based musculo-cutaneous flap (TRAM or VRAM) </li></ul>
    • 67. Vaginal Vault <ul><li>Reconstruction </li></ul><ul><ul><li>Skin paddle designed high over line of Douglas to decrease herniation </li></ul></ul><ul><ul><li>Can curve superior aspect of skin paddle onto ribs for increased length in total reconstruction </li></ul></ul><ul><ul><li>Fold cutaneous paddle on itself or suture to vaginal wall remnant </li></ul></ul><ul><ul><li>Extend flap to edge of introitus to limit stricture </li></ul></ul>
    • 68. &nbsp;
    • 69. &nbsp;
    • 70. &nbsp;
    • 71. &nbsp;
    • 72. &nbsp;
    • 73. &nbsp;
    • 74. &nbsp;
    • 75. Vaginal Vault <ul><li>Posterior Thigh Flap </li></ul><ul><ul><li>Fasciocutaneous flap </li></ul></ul><ul><ul><li>Descending branch of inferior gluteal vessel </li></ul></ul><ul><ul><li>Great for large skin loss, total vaginal reconstructions </li></ul></ul><ul><ul><li>Lack of rectus abdominus </li></ul></ul><ul><ul><li>Sensory innervation by posterior femoral cutaneous n. </li></ul></ul><ul><ul><li>Bilateral harvest in lithotomy position </li></ul></ul>
    • 76. Vaginal Vault Posterior Thigh Flap
    • 77. Vaginal Vault Reconstuction
    • 78. Vaginal Vault Reconstuction
    • 79. Vaginal Vault Reconstuction
    • 80. Vaginal Vault Reconstuction
    • 81. Vaginal Vault Reconstuction
    • 82. Vaginal Vault <ul><li>Other flaps </li></ul><ul><ul><li>Omentum with skin graft </li></ul></ul><ul><ul><li>Obese patients, small pelvis </li></ul></ul><ul><ul><li>Left gastroepiploic artery, pedicle flap </li></ul></ul><ul><ul><li>STSG with stent as in McIndoe </li></ul></ul><ul><ul><li>TFL </li></ul></ul><ul><ul><li>Hemivaginal or perineal defects </li></ul></ul><ul><ul><li>Shorter reach, donor site morbidity </li></ul></ul>
    • 83. Penis and Scrotum
    • 84. Penile-Scrotal Reconstruction <ul><li>Congenital </li></ul><ul><ul><li>Hypospadias </li></ul></ul><ul><ul><li>Epispadias </li></ul></ul><ul><li>Acquired </li></ul><ul><ul><li>Avulsions </li></ul></ul><ul><ul><li>Amputations </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Infections </li></ul></ul>
    • 85. Penile-Scrotal Defects <ul><li>Goals </li></ul><ul><li>acceptable appearance </li></ul><ul><li>normal micturition </li></ul><ul><li>normal sexual activity </li></ul><ul><li>Translates to a penis with adequate length, tactile sensation, sufficient rigidity </li></ul>
    • 86. Avulsions <ul><li>Penis </li></ul><ul><ul><li>Caused by deceleration injury </li></ul></ul><ul><ul><li>Gently clean any pedicled soft tissue and replace </li></ul></ul><ul><ul><li>STSG—0.020 inch </li></ul></ul><ul><ul><li>Lymphedematous changes arise in skin proximal to corona, therefore, remove </li></ul></ul>
    • 87. Scrotal avulsions <ul><li>Small defects </li></ul><ul><ul><li>Debridement and direct approx </li></ul></ul><ul><ul><li>Highly elastic and compliant </li></ul></ul><ul><li>Complete scrotal avulsions </li></ul><ul><ul><li>Moist dressings over exposed testicles </li></ul></ul><ul><ul><li>Testes and cords buried in subcutaneous thigh pockets </li></ul></ul><ul><ul><li>Reconstruct scrotum by 4 weeks due to increased temp and injury to spermatogenesis </li></ul></ul>
    • 88. Scrotal avulsions <ul><li>Reconstruction </li></ul><ul><ul><li>STSG 0.014-0.018 in </li></ul></ul><ul><ul><li>Flaps </li></ul></ul><ul><ul><ul><li>Superolateral thigh </li></ul></ul></ul><ul><ul><ul><li>TFL </li></ul></ul></ul><ul><ul><ul><li>Rectus abdominus </li></ul></ul></ul><ul><ul><ul><li>Gracilis </li></ul></ul></ul><ul><ul><ul><li>posterior thigh </li></ul></ul></ul>
    • 89. Scrotal Defects
    • 90. Scrotal Defects
    • 91. Scrotal Defect Gracilis myocutaneous flap
    • 92. Scrotal Defect
    • 93. Coverage with Gracilis
    • 94. Algorithm <ul><li>Penis </li></ul><ul><li>Partial Total </li></ul><ul><li>1 ° closure STSG Meshed Thick </li></ul><ul><ul><ul><ul><ul><li>(thick) STSG STSG </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>or FTSG </li></ul></ul></ul></ul></ul>
    • 95. Algorithm <ul><li>Scrotum </li></ul><ul><li> Partial Total </li></ul><ul><li>1 ° closure Testes in pouches </li></ul><ul><li>Meshed STSG Thigh Flaps </li></ul>
    • 96. Penis Amputations <ul><li>Primary reattachment </li></ul><ul><ul><li>Bux and coworkers </li></ul></ul><ul><ul><li>14 cases, no vascular anastomosis </li></ul></ul><ul><ul><li>Corpus spongiosum approximated </li></ul></ul><ul><ul><li>Corpus cavernosa sutured through tunica albuginea </li></ul></ul><ul><ul><li>Aspiration of corpora cavernosa 2X day </li></ul></ul><ul><ul><li>Survival, but shaft skin slough  STSG </li></ul></ul>
    • 97. Amputations <ul><li>Microvascular repair </li></ul><ul><ul><li>Artery x2, vein, nerves </li></ul></ul><ul><ul><li>Urethra repair with urology svc </li></ul></ul><ul><ul><li>Approximate corpora spongiosa </li></ul></ul><ul><ul><li>Better outcome </li></ul></ul>
    • 98. Penis Replantation
    • 99. Penis Replantation
    • 100. Penis Replantation
    • 101. &nbsp;
    • 102. &nbsp;
    • 103. Penis Replantation
    • 104. Penis Reconstruction
    • 105. Penile Reconstruction <ul><li>Previous attempts multistage </li></ul><ul><ul><li>Tubed abdominal flaps </li></ul></ul><ul><ul><li>Scrotal skin flaps </li></ul></ul><ul><ul><li>Muscle pedicle flaps </li></ul></ul><ul><li>All generally overly bulky or lack of length </li></ul><ul><li>Best reconstructions one stage microvascular transfer </li></ul>
    • 106. Phallus Reconstruction <ul><li>Goals: </li></ul><ul><ul><li>Urinary conduit </li></ul></ul><ul><ul><li>Rigidity </li></ul></ul><ul><ul><li>Errogenous and protective sensation </li></ul></ul><ul><ul><li>Appearance </li></ul></ul>
    • 107. Penile Reconstruction <ul><li>Radial Forearm Free Flap </li></ul><ul><ul><li>Tube-within-tube </li></ul></ul><ul><ul><li>Innervation via antebrachial cutaneous nerves to pudendal nerve </li></ul></ul><ul><ul><li>Limited hair </li></ul></ul><ul><ul><li>Vascularized urethra </li></ul></ul><ul><ul><li>Return of tactile, errogenous sensation </li></ul></ul><ul><ul><li>Rigidity via rib bone graft or prosthesis </li></ul></ul>
    • 108. Radial Forearm Flap
    • 109. Radial Forearm <ul><li>Nondominant arm </li></ul><ul><li>Allen’s test/duplex doppler </li></ul><ul><li>Do not shave arm </li></ul><ul><ul><li>Urethral stones </li></ul></ul><ul><li>15 x 17 cm </li></ul><ul><li>Suprapubic catheter </li></ul>
    • 110. &nbsp;
    • 111. Radial Forearm <ul><li>Saphenous vein loop- temp A-V fistula </li></ul><ul><li>LAC to dorsal penile branches (Pudendal Nerve) </li></ul>
    • 112. Radial Forearm <ul><li>Tactile sensation 4-6 mo </li></ul><ul><li>Prosthesis 6-9 mo </li></ul><ul><li>Achieve orgasm </li></ul><ul><li>Complications </li></ul><ul><ul><li>Urethral stones </li></ul></ul><ul><ul><li>Sinuses, fistulae </li></ul></ul><ul><ul><li>Strictures </li></ul></ul><ul><ul><li>Hypopigmentation </li></ul></ul><ul><ul><li>Implant exposure </li></ul></ul>
    • 113. Penile Reconstruction <ul><li>Fibula sensate free flap </li></ul><ul><ul><li>Lateral sural nerve </li></ul></ul><ul><ul><li>Osteocutaneous free flap </li></ul></ul><ul><ul><li>Concealed donor site </li></ul></ul><ul><ul><li>Fistula prone </li></ul></ul><ul><ul><li>hirsute </li></ul></ul>
    • 114. Phallus Reconstruction <ul><li>Other descriptions: </li></ul><ul><ul><li>Ulnar forearm free flap </li></ul></ul><ul><ul><li>Lateral Arm flap </li></ul></ul><ul><ul><ul><li>Pre-fabricated </li></ul></ul></ul><ul><ul><li>“ Cricket-bat” Flap </li></ul></ul>
    • 115. Gender Reassignment <ul><li>Psychological issues </li></ul><ul><li>Physical issues </li></ul><ul><li>Multispecialty approach </li></ul><ul><li>Male to female </li></ul><ul><ul><li>Breast aug </li></ul></ul><ul><ul><li>Genitalia </li></ul></ul><ul><li>Female to male </li></ul><ul><ul><li>Mastectomy </li></ul></ul><ul><ul><li>Genitalia, partial transformation </li></ul></ul><ul><ul><li>More difficult </li></ul></ul>
    • 116. Male Potency <ul><li>Radical prostatectomy </li></ul><ul><li>Cavernous nerves mediate erectile function </li></ul><ul><li>Sacrifice unilateral or bilateral depending on extent of tumor </li></ul><ul><li>Erectile function diminished to degree of nerve sacrifice </li></ul>
    • 117. Cavernous Nerve Grafting <ul><li>Cavernous nerve grafting </li></ul><ul><ul><li>Sural nerve harvest </li></ul></ul><ul><ul><li>Loupe magnification </li></ul></ul><ul><ul><li>Large instruments operating in a hole </li></ul></ul><ul><ul><li>Clips and microsuture to hold grafts </li></ul></ul><ul><ul><li>Epineural repair </li></ul></ul><ul><ul><li>Results can be enhanced with Viagra </li></ul></ul>
    • 118. Unilateral Cavernous Nerve resection with Sural Nerve graft
    • 119. Nerve graft Silastic tubing Metal clip microsuture Melted end of suture Cavernous nerve repair with Sural nerve grafts Nerve graft
    • 120. Results 0% 60% Bilateral nerve grafts 21% 75% Unilateral nerve grafts Percentage of successful inter-course WITHOUT nerve grafting Percentage of successful inter-course WITH nerve grafting 200 cases to date
    • 121. Inguinal Region <ul><li>Infected Vascular Grafts </li></ul><ul><li>Presentation </li></ul><ul><ul><li>Local signs </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Pseudoaneurysm </li></ul></ul><ul><ul><li>Thrombosis </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul>
    • 122. Inguinal Region <ul><li>Vascular grafts </li></ul><ul><li>Common Flaps </li></ul><ul><li>Sartorius </li></ul><ul><li>Gracilis </li></ul><ul><li>Rectus Abdominus </li></ul><ul><li>Rectus Femoris </li></ul><ul><li>TFL </li></ul><ul><li>Vastus Lateralis </li></ul>
    • 123. Vascular Graft Coverage
    • 124. Gracilis Rotation Coverage
    • 125. Gracilis Rotation Flap
    • 126. Sartorius Flap
    • 127. Exposed Vascular Graft
    • 128. Sartorius Rotation Coverage
    • 129. Infections <ul><li>Necrotizing infections </li></ul><ul><li>Fournier’s Gangrene—1882 </li></ul><ul><li>Penetrates Colles fascia </li></ul><ul><li>Spreads in subDartos space, involves superficial tissues </li></ul><ul><li>Sx: pain, fever, crepitus </li></ul><ul><li>Pathophys: thrombosis of small vessels </li></ul>
    • 130. Fournier’ Gangrene <ul><li>Treatment </li></ul><ul><ul><li>Radical debridement, repeat usually necessary </li></ul></ul><ul><ul><li>Cultures, broad spectrum antibiotics </li></ul></ul><ul><ul><ul><li>Mixed aerobic/anaerobic organisms </li></ul></ul></ul><ul><ul><li>Hydrotherapy </li></ul></ul><ul><ul><li>Skin grafting of defect, testes coverage </li></ul></ul>
    • 131. Genital Burns <ul><li>Children more often than adults </li></ul><ul><li>Involve CPS for suspicious burns </li></ul><ul><li>Usually 1 st and 2 nd degree burns </li></ul><ul><li>Local wound care </li></ul><ul><ul><li>Serial debridement, dressing care with Bacitracin </li></ul></ul><ul><ul><li>Hydrotherapy </li></ul></ul><ul><li>3 rd degree—excision and grafting </li></ul>
    • 132. Pelvic Exenteration <ul><li>Through-and-through defects </li></ul><ul><li>Skin defect </li></ul><ul><li>Space filler to prevent bowel descent </li></ul><ul><li>Flap choice—bulky, robust blood supply </li></ul><ul><ul><li>Posterior thigh </li></ul></ul><ul><ul><li>Rectus abdominus </li></ul></ul><ul><ul><li>Omentum—filler only, clear infection </li></ul></ul><ul><ul><li>Gracilis—small lower pelvis/perineum </li></ul></ul>
    • 133. Pelvic Exenteration <ul><li>Importance of vascularized flaps </li></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Clear infection—pelvic abscess </li></ul></ul><ul><ul><li>Durable tissue for sitting </li></ul></ul><ul><ul><li>Prevents herniation of bowel </li></ul></ul>
    • 134. Pelvic/Perineum Defect
    • 135. VRAM Reconstruction
    • 136. VRAM to Pelvic Defect
    • 137. Pelvic Defects <ul><li>Pelvic Bone defects </li></ul><ul><li>Ensure continuity of pelvic ring </li></ul><ul><ul><li>Heavy, large non-absorbable mesh </li></ul></ul><ul><li>Support herniation of bowel </li></ul><ul><ul><li>Local flaps </li></ul></ul><ul><ul><li>TFL </li></ul></ul><ul><ul><li>Rectus </li></ul></ul><ul><ul><li>omentum </li></ul></ul>
    • 138. Pelvic/Perineal Defects
    • 139. &nbsp;
    • 140. Pelvic/Perineal Defects
    • 141. Final Result
    • 142. Anal Sphincter Reconstruction <ul><li>Restoration of fecal continence </li></ul><ul><li>Rotational gracilis </li></ul><ul><li>Free gracilis with implantable stimulator </li></ul><ul><li>Inferior gluteus maximus </li></ul>
    • 143. Gracilis Sphincter Reconstruction <ul><li>Pickrell 1956 </li></ul><ul><ul><li>Rt gracilis, clockwise 1 wrap </li></ul></ul><ul><ul><li>N=6 all continent </li></ul></ul><ul><li>Song 1982 </li></ul><ul><ul><li>2 wraps counterclockwise </li></ul></ul><ul><li>Inferior Gluteus- procedure of choice </li></ul>
    • 144. Summary <ul><li>Form follows function </li></ul><ul><li>Analyze the defect </li></ul><ul><ul><li>Vaginial—partial or total </li></ul></ul><ul><ul><li>Penis/Scrotum—skin grafting, free tissue transfer </li></ul></ul><ul><ul><li>Pelvis/inguinal defects </li></ul></ul><ul><li>Primary flaps </li></ul><ul><ul><li>Rectus, gracilis, posterior thigh </li></ul></ul>
    • 145. THANKS TO: Jeff Friedman, M.D. Rahul Nath, M.D Tue Dinh, M.D.

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