Historical Considerations

Phallic reconstruction poses a difficult challenge for the penile cancer surgeon. The main goals of surgery are the creation of a cosmetically acceptable sensate neophal-lus with the incorporation of a neourethra to allow voiding standing up and with enough bulk to allow the insertion of a penile prosthesis in order to allow sexual intercourse.1

The classic method of penis reconstruction involved the use of abdominal flaps. The first total phallic reconstruction was attempted in 1936 by Bogoras who used a random pedicled oblique abdominal singular tube without incorporating a neourethra. Phallic rigidity was obtained by the insertion of a rib cartilage inside the flap.2

Matz and Gillies subsequently improved Bogoras's technique by creating a phallus which incorporated a urethra using the "tube within a tube" concept. These procedures were multistaged, resulted in extensive scarring and disfigurement of the donor area, and produced a phallus with no sensation.3,4 These types of phalloplasty are currently used for salvage cases only. Further advances involved the use of infraumbilical skin and groin flaps.5-10 However, the main limitation of these techniques were the formation of a nonsensate and wedge-shaped phallus.

Musculocutaneous thigh flaps, used when there is extensive abdominal scarring from previous surgery or radiotherapy, also have been abandoned due to poor results.11"16

With the advent of microsurgical techniques, a new era has started for total phallic reconstruction. Originally described by Song in 1982,17 the use of the radial artery-free flap phalloplasty was first published in 1984 by Chang who successfully used this technique for total penile reconstruction in seven patients who had previously undergone a penile amputation.16 The reconstructive procedure involved the creation of 'a tube within a tube' using forearm skin with the urethra fashioned from the nonhair-bearing area and the whole flap based on the radial artery.

Following the success of this series many teams have adopted this technique and applied some modifications in flap design in order to improve the cosmesis of the neophallus and to minimize the overall complication rate and donor site morbidity that may occur in 45% of cases.18 In particular the shape of the forearm flap has been modified in order to improve the blood supply to the flap and to reduce the risk of meatal stenosis.19-24 Ulnar artery-based flaps which reduce the amount of hair-bearing skin incorporated have also been used.25

Partial or subtotal penectomy for carcinoma of the penis or urethra results in a significant loss in sexual function. Patient satisfaction with their overall sexual life is less than 34% and therefore they represent the ideal candidates for total phallic reconstruction.26-28

The current types of phalloplasty that are used are:

1. The forearm free flap based on the radial artery (RAP)

2. The pedicled abdominal phalloplasty

3. The anterolateral thigh flap (ALT)

All have their advantages and disadvantages and will be discussed in turn below.

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