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Vaginal & genitourinary reconstruction

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S Patel

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Vaginal & genitourinary reconstruction

  1. 1. Vaginal & Genitourinary Reconstruction Sanjay Sharma, M.D. Jeffrey Friedman, M.D. Rahul Nath, M.D. Tue Dinh, M.D.
  2. 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. 3. Anatomy/Embryology
  4. 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. 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. 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. 7. <ul><li>2 pairs genital ducts Males - mesonephric (Wolffian) Females - paramesonephric (Mullerian) </li></ul>
  8. 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. 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. 10. Ambiguous Genitalia
  11. 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. 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. 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. 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. 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. 16. Preoperative Evaluation <ul><li>Mature individual, post puberty </li></ul><ul><li>Compliance of patient/family—stents </li></ul><ul><li>History & 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. 17. Frank Method <ul><li>Serial progressive dilatation & 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. 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. 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. 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. 21. McIndoe Procedure
  22. 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. 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 &quot; -0.018&quot; </li></ul>
  24. 24. STSG Donor Sites Tumescence for uniform Surface skin graft
  25. 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. 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. 29. Graft Fixation , dermal side out
  28. 30. <ul><li>Spiral Suture Line </li></ul>
  29. 32. Avoid straight line incisions at introitus
  30. 34. Rectovesical Space Peritoneal reflection (15 cm)
  31. 35. Meticulous hemostasis is essential
  32. 38. Suture labia together, prevents extrusion
  33. 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>
  34. 41. Check graft at POD #7 Regraft if >2 cm necrosis
  35. 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>
  36. 43. Acquired Defects of GU System
  37. 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>
  38. 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>
  39. 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>
  40. 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>
  41. 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>
  42. 52. Vulvoperineal Surface <ul><li>Local Flaps </li></ul><ul><ul><li>Irradiated tissue </li></ul></ul>
  43. 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>
  44. 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>
  45. 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>
  46. 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>
  47. 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>
  48. 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>
  49. 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
  50. 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>
  51. 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>
  52. 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>
  53. 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>
  54. 76. Vaginal Vault Posterior Thigh Flap
  55. 77. Vaginal Vault Reconstuction
  56. 78. Vaginal Vault Reconstuction
  57. 79. Vaginal Vault Reconstuction
  58. 80. Vaginal Vault Reconstuction
  59. 81. Vaginal Vault Reconstuction
  60. 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>
  61. 83. Penis and Scrotum
  62. 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>
  63. 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>
  64. 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>
  65. 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>
  66. 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>
  67. 89. Scrotal Defects
  68. 90. Scrotal Defects
  69. 91. Scrotal Defect Gracilis myocutaneous flap
  70. 92. Scrotal Defect
  71. 93. Coverage with Gracilis
  72. 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>
  73. 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>
  74. 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>
  75. 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>
  76. 98. Penis Replantation
  77. 99. Penis Replantation
  78. 100. Penis Replantation
  79. 103. Penis Replantation
  80. 104. Penis Reconstruction
  81. 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>
  82. 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>
  83. 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>
  84. 108. Radial Forearm Flap
  85. 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>
  86. 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>
  87. 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>
  88. 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>
  89. 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>
  90. 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>
  91. 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>
  92. 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>
  93. 118. Unilateral Cavernous Nerve resection with Sural Nerve graft
  94. 119. Nerve graft Silastic tubing Metal clip microsuture Melted end of suture Cavernous nerve repair with Sural nerve grafts Nerve graft
  95. 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
  96. 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>
  97. 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>
  98. 123. Vascular Graft Coverage
  99. 124. Gracilis Rotation Coverage
  100. 125. Gracilis Rotation Flap
  101. 126. Sartorius Flap
  102. 127. Exposed Vascular Graft
  103. 128. Sartorius Rotation Coverage
  104. 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>
  105. 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>
  106. 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>
  107. 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>
  108. 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>
  109. 134. Pelvic/Perineum Defect
  110. 135. VRAM Reconstruction
  111. 136. VRAM to Pelvic Defect
  112. 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>
  113. 138. Pelvic/Perineal Defects
  114. 140. Pelvic/Perineal Defects
  115. 141. Final Result
  116. 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>
  117. 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>
  118. 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>
  119. 145. THANKS TO: Jeff Friedman, M.D. Rahul Nath, M.D Tue Dinh, M.D.

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