A tie‐over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique

Abstract

• The subsequent 29 operations used the same protocol where a proflavine-soaked gauze dressing was left undisturbed for 10 days. RESULTS• In the original 11 patients, two required re-grafting. After this initial development period, we amended the technique to use stronger sutures and left the dressing undisturbed for 10 days.• In addition, we standardized the use of proflavin-soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3-year period.• The cosmetic results were excellent with only one patient requiring re-grafting. The mean and median postoperative length of stay was 2 days.• One patient with a urethral squamous cell carcinoma associated with urethral and glans LS required a urethral dilatation to allow a check cystoscopy, and a further asymptomatic patient had a meatal dilatation in the clinic but meatal stenosis was otherwise not seen, with no patients requiring regular meatal dilatation. CONCLUSION• The TODGA technique of SSG application and fixation allows immediate mobilization and reduces hospital stay whilst providing excellent cosmetic results with a high percentage of graft uptake. KEYWORDSneo-glans, penile cancer, glansectomy, glans resurfacing, split-skin graft, tie-over dressing What's known on the subject? and What does the study add? The treatment of penile cancer has been revolutionised by modern penile preserving surgery, particularly glansectomy and glans reconstruction using split skin graft. These techniques can produce a cosmetically good result but also preserve the sexual and urinary function of the penis.Applying a split skin graft to the penis is technically difficult and most authors recommend a period of up to 5 days bed rest after surgery to maximize graft take. This is expensive in health economic terms and may increase the risk to the patient of thromboembolic complications. The paper describes a new technique of tie-over dressing which allows early mobilization and discharge without compromising graft viability.Study Type -Therapy (case series) Level of Evidence 4 OBJECTIVES• To describe a novel method of split-skin graft (SSG) fixation for neo-glans formation after distal penectomy for penile cancer and glans resurfacing for carcinoma in situ or lichen sclerosus (LS); the TODGA technique.• Rather than 'quilting' the graft onto the neo-glans, which requires up to 5 days bed rest, the tie-over method fixes the graft adequately enough to allow immediate patient mobilization. PATIENTS AND METHODS• In all, 41 consecutive operations, with a follow-up of ≥ 12 months, were performed on 40 patients (mean age 62 years, range

Penile lichen sclerosus (balanitis xerotica obliterans)

“…Severe lichen sclerosus may require extensive surgery (Fig. 3) involving either glans resurfacing with grafting or complete degloving with or without split skin grafting depending on any previous circumcision [25,26]. What must always be kept in mind is that disease control, function (voiding and intercourse) and cosmesis all need to be carefully balanced.…”

Glans Resurfacing with Skin Graft for Penile Cancer: A Step-by-Step Video Presentation of the Technique and Review of the Literature

“…It is important to stress that for the TGR technique the positive surgical margins (PSM) have been reported to be up to 20%, while when taking into consideration both the PGR and the TGR, the PSMs can reach 45% [3, 4]. Even though the overall recurrence rate was only 4%, the rate of secondary operation after performing TGR was 10% [3, 10]. Glansectomy was the preferred technique as a second procedure in most of the cases [3, 8, 9].…”

“…Moreover, it is important to harvest a partial thickness graft ranging from 0,02 to 0.04 cm, carefully trimmed to fit and quilted with interrupted sutures in order to promote graft survival. Some authors have proposed immobilization of the skin graft without quilting but instead covering the neoglans with proflavine soaked gauge dressing anchored with tie-over sutures (TODGA-technique) [10]. Furthermore some surgeons suggest performing multiple small incisions (fenestration) on the graft to allow mild exudate to drain in order to prevent any underlying hematoma or seroma formation (Step 4) [6].…”

An observational study to evaluate improved graft acceptance and viability after single dressing on 15th postoperative day in cases of split thickness skin graft (STSG)

“…Various dressing techniques (tieover/mould) are suitable for this purpose. 11 The dressing may need to be changed if it is soiled by discharge from the wound or external soakage. This is observed in patients such as post-burn wounds wherein early dressing is necessary to prevent maceration and skin graft rejection.…”