Quality of life after penile reconstruction using the radial forearm flap in adult bladder exstrophy patients – technique and outcomes

Abstract

Background:  Patients who have undergone reconstruction of bladder extrophy can have an extremely short penis, which can be functionally and psychologically debilitating. Penile reconstruction with the radial forearm free flap has the potential to provide these patients with improved genital appearance and sexual function. Quality of life after penile reconstruction is an important outcome measure in evaluation of the procedure.

Methods:  We describe five patients who underwent total penile reconstruction with radial forearm free flaps and interview them with a quality of life questionnaire.

Results:  Responses were overwhelmingly positive with regard to improved self-image as well as sexual function.

Conclusions:  This series supports the overwhelmingly positive change in quality of life to be gained with radial forearm free flap penile reconstruction for patients with an extremely short native penis in the adult exstrophy patient.

Abbreviations

QoL

quality of life

Introduction

The exstrophy–epispadias complex encompasses a spectrum of congenital abnormalities attributed embryologically to failure of ingrowth of mesoderm, prevented by the cloacal membrane. The spectrum includes classic bladder exstrophy, epispadias and cloacal exstrophy.

There is malformation of the bladder and external genitalia, specifically exstrophy and, commonly, a deficient penis in the male. The two halves of the pelvis are split and rotated downward. Characteristically, the penis is short, partly because so much of the corporeal length is taken up in reaching the midline before uniting to emerge from the perineum, but also because of shorter than normal corpora. There may also be asymmetry of shape and size of the corporeal bodies. The resultant defects may cause major problems both functionally and psychologically.

Not surprisingly, previous survey-based studies have suggested that patients with bladder exstrophy feel dissatisfied with their physical appearance. This included their genital appearance as well as concerns about abdominal scars.¹

Sexuality is a common focus, and one of the primary concerns found by authors is the association between dissatisfaction with genital appearance and anxiety over sexual function.^2,3 Anxieties relating to initiation of sexual experiences and fear of rejection cause these patients to avoid such contacts.

DeFontaine et al.⁴ first described the use of a free radial forearm flap in the reconstruction of the short penis associated with bladder exstrophy, and advances in phalloplasty have paralleled developments in microsurgical technique.⁵ Phalloplasty in female-to-male transsexuals as well as post-traumatic reconstruction are now routinely a microsurgical reconstruction.⁶

Achieving an ideal phallic reconstruction is described as requiring simultaneously meeting the following goals⁶:

• • 
  Requiring only one stage
• • 
  Having normal appearance and adequate size for intercourse
• • 
  Possessing both tactile and erogenous sensation
• • 
  Containing a urethra that extends to the distal tip to allow voiding while standing
• • 
  Being large enough to accommodate a permanent erectile prosthesis.

Measurement of improvement in body image and, consequently, quality of life (QoL) after phalloplasty is an important outcome measure of the procedure.

The World Health Organization has defined QoL as an integrative measure of physical and emotional well-being, level of independence, social relationships and their relationship to salient features of the subject's environment.⁷ In this study, we look at five cases who underwent phalloplasty and the improvement this has had on their QoL.

Patients and methods

Five patients underwent phalloplasty using a modified free vascularized forearm flap tube in tube as described by Hage et al .⁵ between December 2004 and February 2007. Information was obtained from records relating to the number of previous operations, type of urinary diversion in use, the phalloplasty procedure and fitting of an erectile device.

The radial forearm free flap design was created on the left forearm according to the pattern generally used in female-to-male transsexuals (Fig. 1). Urinary diversion in both patients was by way of their Mitrofanoff, which they were happy to maintain; therefore, no urethral reconstruction was necessary in the neopenis. Ejaculation would still occur through the scrotal or current penile meatus.

Figure 1. Free flap design on volar aspect of left forearm. The design modifications include skin paddle for reconstruction of the navicular fossa.

The flap was raised in routine retrograde fashion; the radial nerve was neurolysed from the flap and left in situ. A small distal extension of the paddle was taken to create an apparent glandular urethral meatus. The lateral cutaneous nerve of the forearm was isolated and taken with the flap. Prior to division of the vessels, the penis was fashioned on the forearm with the small extension to create a blind ending meatal opening. The coronal sulcus was created by undercutting at the base of the neo-glans in a caudal direction and then being folded upon itself, with a split thickness skin graft being placed on the secondary defect.

The flap was divided from the forearm and transferred to the groin with microvascular repairs performed usually between the radial artery and saphenous vein graft extension and the femoral artery, and also the antebrachial vein and the transposed saphenous vein. The lateral cutaneous nerve of the forearm was coapted to the dorsal nerve of the penis. The wounds at the base of the new penis were closed by advancing the escutcheon flaps. The head of the native short penis was transposed caudally to the ventral base of the neophallus.

There have been several modifications to the design of the radial forearm flap, predominantly in an attempt to minimize the complication of urethral stenosis and fistula formation.^8,9 Our flap has a number of modifications of standard design to help prevent scar contracture and also to maximize the aesthetic appearance of the reconstructed phallus. Two interdigitating inset skin flaps are used along the ventral suture line to prevent future contraction of this scar (Fig. 2); the coronal sulcus is constructed in an oblique fashion to more accurately recreate a natural appearance of the glans (Fig. 3) and the use of a distal extension to the flap to create the appearance of the meatal opening. Further modification included neurorrhaphy of the sensory nerves of the flap with sensory nerves of the penis (usually dorsal nerve of the penis). This provided erogenous sensibility in the neophallus as well as a level of protective sensation, allowing safe prosthesis placement.¹⁰

Figure 2. Neophallus showing modifications of standard design; interdigitating inset skin flaps along the ventral suture line to minimize contraction, and oblique fashioning of the coronal sulcus.

Figure 3. Post-operative view at 4 weeks with native phallus preserved and transposed caudally to maintain erogenous sensibility.

Each patient provided responses via telephone interview relating to QoL after their phalloplasty with emphasis on cosmesis and sexual function (Appendix S1). The QoL questionnaire was developed in accordance with the World Health Organization QoL group guidelines and was based on a survey used to look at similar outcomes in the transsexual population.¹¹

Results

Five patients underwent successful phalloplasty typically around the age of 20 years as described above. Most had undergone multiple (between 4 and 80) previous operative procedures relating to their exstrophy, and all had Mitrofanoff urinary diversions that were maintained.

One patient required micro-anastomotic revision for a thrombosed artery. The flap was successfully salvaged. Another patient had cellulitis of the groin, which settled on intravenous antibiotics.

Three of the five patients have proceeded to have a three-piece inflatable penile prosthesis fitted to their phalloplasty (AMS 700CX, American Medical Systems, MN, USA).¹² See Table 1.

Table 1.  Patients undergoing phalloplasty for bladder exstrophy

	Case 1	Case 2	Case 3	Case 4	Case 5
Ceph, cephalic vein; DNP, dorsal nerve of penis; GFN, genitofemoral nerve; LCNF, lateral cutaneous nerve of forearm; LSV, long saphenous vein; PFA, profunda femoris artery; RA, radial artery; RA vc, radial artery vena comitans; RFFF, radial artery free flap; SFA, superficial femoral artery; SIEA, superficial inferior epigastric artery.
Age at phalloplasty (years)	35	20	20	20	19
Urinary diversion	Mitrofanoff	Mitrofanoff	Mitrofanoff	Mitrofanoff	Mitrofanoff
Flap	(R)RFFF	(L) RFFF	(L) RFFF	(L) RFFF	(R) RFFF
Vessels	RA-SFA	RA-SFA	RA-SIEA	RA-PFA	RA-SIEA
	RA vc-LSV	Ceph-LSV	Ceph-LSV	Antebrachial v-LSV	Antebrachial v-LSV
Nerve	LCNF-ilioinguinal nerve	LCNF-DNP	LCNF-genital br GFN	LCNF-genital branch GFN	LCNF-DNP
Complications	Nil	Nil	Anastomotic thrombosis ×3 (day 10, 24, 25) Phalloplasty removed (at 3 years)	R groin cellulitis	Nil
Erection device (when)	AMS 700CX (13 m)	AMS 700CX (17 m)	No	AMS 700CX (10 m)	No
Follow-up post-phalloplasty	3 years 5 months	4 years 11 months	2 years 10 months	2 years 11 months	2 years 3 months

The QoL questionnaire covered both cosmesis and sexual function. Responses relating to cosmesis were almost exclusively positive, with patients being more satisfied with body image, appearance in clothes and bathing attire. This translated to greater likelihood of using public change rooms and swimming publically.

All reported improved self-esteem and felt ‘more complete’; other positive responses included improved body image, and less fear or apprehension relating to sexual experiences.

Of those who had attempted sexual intercourse prior to their phalloplasty procedure, fewer problems with intercourse were encountered after phalloplasty, and they were more able to achieve sexual penetration.

Three patients would be happy to undergo the surgery again, and all would recommend the surgery to others.

Of the questions that were gradable, each response was given a score in terms of cosmesis or sexual function. A score of 1 indicated a positive, 0 indicated a neutral and –1 indicated a negative response. The highest possible score is 6 for cosmesis and 5 for sexual function. Four patients scored 6 and one patient scored 4 out of a possible 6 for cosmesis. Of the patients that had erection devices fitted, two scored 5 and one scored 4 out of a possible 5 for sexual function.

One patient had significant improvement in the length of his native penis following phalloplasty that he was able to achieve sexual penetration without the use of his neophallus. This was because of release of adherent scar and the introduction of new tissue from the neophallus flap above his native phallus. Consequently, he requested that the neophallus be removed and underwent this procedure 3 years post-phalloplasty.

Discussion

Reconstruction of exstrophy–epispadias complex is challenging and multistaged. The goal of both a cosmetic and functionally satisfactory result has seen an extensive evolution of reconstructive methods. There have been several procedures described for penile lengthening.¹³ Such methods usually involve partial mobilization of the corpora cavernosa as well as skin coverage to the dorsal penile surface. This often presents a risk to the neurovascular bundle, and the methods generally give a very modest improvement in penile length, usually still insufficient for vaginal penetration.

In relation to this point and of particular interest is one patient who requested, and has subsequently had, his neophallus removed. During the phalloplasty, the native penile length was improved because of the release of scar tissue in the mons pubis region with subsequent importation of well-vascularized tissue from his phalloplasty. As one of the modifications to this design is to preserve the native penis, the patient found that after his phalloplasty, he was able to achieve penetration and ejaculation with the native penis (9 cm when erect). This finding was unexpected and raises the possibility that future well-selected patients may simply benefit from release of the dense scar tissue in the suprapubic area, importation of well-vascularized tissue and release of the native penis.

In reconstructing exstrophy patients, it is our view that the positioning of the glans of the native short penis needs to be carefully considered to maintain erogenous sensation and stimulation for ejaculation, and also to maximize the aesthetics of the reconstructed phallus. In our cases, these men had both erectile function, and erogenous sensation and the ability to ejaculate. The glans of the native penis was placed ventrally near the base of the neophallus so that erogenous sensation would be maintained.

Outcomes in terms of QoL are important measures in order to determine the relative worth of the procedure. Subjecting a patient to a complex procedure after enduring multiple other surgeries needs careful consideration to ensure that definitive phalloplasty is a procedure that is effective and will enhance the QoL of the patient.

There is evidence in the literature that there is overall satisfaction with long-term outcomes in exstrophy patients after phalloplasty.¹⁴ One of the limitations of this study is the lack of a well-validated QoL instrument to use in this rare subgroup of patients. Most literature relates to the transsexual population, who have a different psychological profile to the population studied. Phalloplasty in the transsexual group clearly improves a patient's QoL,¹¹ allowing them to live in a ‘normal’ relationship fitting with their sexual orientation.¹⁵ The positive responses of our exstrophy group to penile reconstruction are encouraging, where psychological barriers are overcome through an improvement in self-image translating to self-confidence both publically and sexually.

Conclusion

Reconstruction of the extremely short penis associated with bladder exstrophy is not a new concept. Its primary goal is to alleviate some of the anxieties that these patients have of self-image, particularly in relation to sexual function.

This series supports the overwhelmingly positive change in QoL to be gained with radial forearm free flap penile reconstruction in the adult exstrophy patient.

The importance of this finding cannot be understated as counselling of patients and families at the outset regarding long-term penile reconstruction will allay many of the fears and uncertainty relating to QoL issues.