One-Stage Penile and Urethral Reconstruction - A New Extension of Inferiorly Based Rectus Abdominis Myocutaneous Flap

Abstract

The loss of a penis, either through trauma or other causes, is psychologically and physiologically intolerable for the victim. The ideal reconstruction should be a reliable single-stage procedure that requires minimum hospitalization and yields acceptable cosmetic and functional results. The traditional techniques, which use tube flaps, are three-to five-stage procedures that are time consuming and physically and economically difficult for the patients. 1The rectus abdominis myocutaneous flap has gained popularity for various reconstructive procedures, including coverage of the groin, 2 thigh, 2 and above-knee amputation stumps. 3 Recently it has been used for vaginal and pelvic reconstruction. 4 We have used an interiorly based rectus abdominis myocutaneous flap to reconstruct an amputated penis and urethra as a single-stage procedure. Surgical ReportA six-year-old boy was referred to our unit for possible reconstruction for his knife-amputated penis, inflicted two years earlier by his psychologically disturbed mother. He was operated on twice at his local hospital, but no details of these attempted procedures were available.Examination revealed absence of the penis, with the urethral opening flush with the scrotum, which was normal (Figure 1). There were irregular scars over the upper medial aspects of both thighs and the groin, suggesting that a gracilis myocutaneous flap had been attempted previously. A micturating cystourethrogram showed a truncated urethra (3 cm), with a short stricture posteriorly.The patient was subsequently operated on using an inferiorly based rectus abdominis myocutaneous flap. At operation a suprapubic puncture cystostomy catheter was first introduced. The right rectus muscle was used as the source of the flap. A vertical skin strip (3 x 12 cm) extending from 3 cm below the xiphoid process to 3 cm below the umbilicus was marked and an incision made down to the anterior rectus sheath, which was incised vertically at the medial and lateral borders of the rectus (Figure 2). This area was then divided at the upper border of the flap and the superior epigastric artery ligated. The whole muscle was freed from the posterior rectus sheath and dissected downward, with the attached skin, care being taken not to injure the inferior epigastric artery.At the level of the inferior border of skin, fascia was separated from the muscle pedicle and the muscle further dissected down. Subcutaneous dissection in the suprapubic area was done and a tunnel was created, through which the flap was rotated and passed underneath to the recipient area (Figure 3). The skin was folded and sutured with interrupted 4-0 chromic catgut to reconstruct the urethra. The proximal end was anastomosed to the urethral opening after appropriate fashioning and a No. 10 Foley catheter was introduced down to the bladder as a stent.The distal end of the skin was folded back dorsally to shape the glans penis (Figure 3). The borders of the rectus were approximated ventrally over the attached skin urethral tube using 3-0 chromic. Th...