Vaginal & genitourinary reconstruction

Vaginal & Genitourinary Vaginal & Genitourinary ReconstructionReconstruction

Sanjay Sharma, M.D.Sanjay Sharma, M.D.

Jeffrey Friedman, M.D.Jeffrey Friedman, M.D.

Rahul Nath, M.D.Rahul Nath, M.D.

Tue Dinh, M.D.Tue Dinh, M.D.

OutlineOutline

EmbryologyEmbryology Vaginal ReconstructionVaginal Reconstruction

– Congenital defectsCongenital defects– Acquired defectsAcquired defects

Penile/Scrotal ReconstructionPenile/Scrotal Reconstruction– Cavernous nerve reconstructionCavernous nerve reconstruction

Other entities of GU reconstructionOther entities of GU reconstruction

Anatomy/EmbryologyAnatomy/Embryology

Anatomy/EmbryologyAnatomy/Embryology

Genital and urinary tracts intimately Genital and urinary tracts intimately associated in developmentassociated in development

All 3 germ layers involvedAll 3 germ layers involved– MesodermMesoderm

» Nephrotic system, Wolffian Ducts, Mullerian Ducts, Nephrotic system, Wolffian Ducts, Mullerian Ducts, GonadsGonads

– EndodermEndoderm» Cloaca, Cloacal membraneCloaca, Cloacal membrane

– EctodermEctoderm» External GenitaliaExternal Genitalia

Anatomy/EmbryologyAnatomy/Embryology

MaleMale– Wolffian DuctsWolffian Ducts

» EpididymisEpididymis» Vas deferensVas deferens» Seminal vesiclesSeminal vesicles» Mullerian ducts regressMullerian ducts regress

Anatomy/EmbryologyAnatomy/Embryology

FemaleFemaleMullerian Ducts differentiate intoMullerian Ducts differentiate into– Fallopian tubesFallopian tubes– UterusUterus– Upper portion of vaginaUpper portion of vagina– Wolffian tubes degenerateWolffian tubes degenerate

•2 pairs genital 2 pairs genital ductsductsMalesMales- - mesonephric mesonephric (Wolffian)(Wolffian)FemalesFemales- - paramesonephric paramesonephric (Mullerian)(Mullerian)

External GenitaliaExternal Genitalia

•11th week

•Genital tubercle

•Labioscrotal swellings

•Urethral folds

•Male- fuse proximal-distal (central raphe)

Congenital DefectsCongenital Defects

Vaginal AgenesisVaginal Agenesis– Mayer-Rokitansky SyndromeMayer-Rokitansky Syndrome

Ambiguous GenitaliaAmbiguous Genitalia– Congenital Adrenal HyperplasiaCongenital Adrenal Hyperplasia– Mixed Gonadal DysgenesisMixed Gonadal Dysgenesis– Male pseudohermaphroditismMale pseudohermaphroditism

Ambiguous GenitaliaAmbiguous Genitalia

Bladder ExstrophyBladder Exstrophy

Absence of a portion of lower abdominal wall Absence of a portion of lower abdominal wall and anterior vesical walland anterior vesical wall

Thought to be cleft of lower trunk, pubic Thought to be cleft of lower trunk, pubic diastasisdiastasis

Failure of cloacal membrane to allow ingrowth Failure of cloacal membrane to allow ingrowth of mesoderm—leads to ruptureof mesoderm—leads to rupture

Incidence: 1:25,000 to 1:40,000 live birthsIncidence: 1:25,000 to 1:40,000 live births Severe genitourinary defectSevere genitourinary defect

Bladder ExstrophyBladder Exstrophy

Surgical CorrectionSurgical Correction– Diversion of urinary streamDiversion of urinary stream– Closure of exstrophied bladderClosure of exstrophied bladder– Reconstruction of external genitaliaReconstruction of external genitalia

» Epispadias, release of chordeeEpispadias, release of chordee» Cleft clitorisCleft clitoris» Diastasis of labia minoraDiastasis of labia minora» Mons pubisMons pubis

Rokitansky SyndromeRokitansky Syndrome

Congenital absence of Congenital absence of the Vaginathe Vagina

1:40001:4000 Defect mullerian duct Defect mullerian duct

developmentdevelopment Partial or complete Partial or complete

vaginal agenesis with vaginal agenesis with renal abnormalitiesrenal abnormalities

Usually normal external Usually normal external genitaliagenitalia

Rokitansky SyndromeRokitansky Syndrome

46 XY karyotype46 XY karyotype Usually present 14-16Usually present 14-16 11° amenorrhea° amenorrhea Rudimentary uterus, normal ovariesRudimentary uterus, normal ovaries Baseline IVP for preop evaluationBaseline IVP for preop evaluation

ReconstructionReconstruction

Frank MethodFrank Method Bowel FlapsBowel Flaps McIndoe ProcedureMcIndoe Procedure VulvovaginoplastyVulvovaginoplasty Musculocutaneous flapsMusculocutaneous flaps

Preoperative EvaluationPreoperative Evaluation

Mature individual, post pubertyMature individual, post puberty Compliance of patient/family—stentsCompliance of patient/family—stents History & PhysicalHistory & Physical

– Rectal examinationRectal examination– C-spineC-spine– Buccal smearBuccal smear

Baseline U/S, IVPBaseline U/S, IVP

Frank MethodFrank Method Serial progressive Serial progressive

dilatation & pressuredilatation & pressure Rigid dilator slowly Rigid dilator slowly

expanded into expanded into rudimentary vaginarudimentary vagina

Placed between rectum Placed between rectum and urethraand urethra

painfulpainful 12-24 months12-24 months High failure due to non-High failure due to non-

compliancecompliance

Bowel FlapsBowel Flaps

Small bowel or colonSmall bowel or colon Laparotomy and Laparotomy and

associated associated complicationscomplications

Large amount of Large amount of mucousmucous

Malodorous dischargeMalodorous discharge Fissures, bleeding, Fissures, bleeding,

stenosis frequentstenosis frequent 1-2% mortality rate1-2% mortality rate

Local FlapsLocal Flaps

VulvovaginoplasyVulvovaginoplasy– Williams: labia majora infoldedWilliams: labia majora infolded– Hwang: labia minora flapsHwang: labia minora flaps

Tissue expansionTissue expansion Musculocutanous flapsMusculocutanous flaps

– GracilisGracilis– RectusRectus– Posterior thigh fasciacutaeousPosterior thigh fasciacutaeous– TFLTFL

McIndoe TechniqueMcIndoe Technique

Neovagina lined with skin graftNeovagina lined with skin graft Surgically created space between Surgically created space between

bladder and rectumbladder and rectum Relatively easy procedureRelatively easy procedure Obviates need for laparotomyObviates need for laparotomy Gynecology assistanceGynecology assistance

McIndoe ProcedureMcIndoe Procedure

McIndoe TechniqueMcIndoe Technique

Patient SelectionPatient Selection– Mature, 16-18 years oldMature, 16-18 years old– Approaching sexual activityApproaching sexual activity– Mature and compliantMature and compliant

Pre-operative considerationsPre-operative considerations– Full bowel prepFull bowel prep– EmemasEmemas– Foley catheterFoley catheter– DVT prohylaxisDVT prohylaxis

ProcedureProcedure

STSG harvestSTSG harvest Suprapubic regionSuprapubic region TumescenceTumescence Alternative sites: lateral thigh, buttockAlternative sites: lateral thigh, buttock Single sheet, depth 0.015Single sheet, depth 0.015" -0.018"" -0.018"

STSG Donor SitesSTSG Donor Sites

Tumescence for uniform Surface skin graft

ProcedureProcedure

Perineal PhasePerineal Phase Rectovesicular space between bladder Rectovesicular space between bladder

and rectumand rectum Avoid straight line incisions at introitusAvoid straight line incisions at introitus Vaginal stent used to guide depth of Vaginal stent used to guide depth of

spacespace ABSOLUTE HEMOSTASISABSOLUTE HEMOSTASIS

ProcedureProcedure

Graft Fixation:Graft Fixation: Dermal side outDermal side out Affix to mold, non linear suture lineAffix to mold, non linear suture line Use of Tisseel or similar fibrin glueUse of Tisseel or similar fibrin glue Suture labia togetherSuture labia together Keep in hospital 1 weekKeep in hospital 1 week

Graft Fixation , dermal side out

•Spiral Suture LineSpiral Suture Line

Avoid straight line incisions at introitus

Rectovesical SpaceRectovesical Space

Peritoneal reflection (15 cm)Peritoneal reflection (15 cm)

Meticulous hemostasis is essentialMeticulous hemostasis is essential

Suture labia together, prevents extrusion

ProcedureProcedure

Post-operative carePost-operative care Strict bedrestStrict bedrest Foley catheterFoley catheter Anti-motility agent—Anti-motility agent—

lomotillomotil Return to OR 1 week Return to OR 1 week

for stent removalfor stent removal Assessment of graft Assessment of graft

take, re-graft if take, re-graft if necessarynecessary

Replace stentReplace stent

Check graft at POD #7Regraft if >2 cm necrosis

Post-operative carePost-operative care

Continue mold 3-6 monthsContinue mold 3-6 months Sexual activity resume in 6 weeksSexual activity resume in 6 weeks Mucosalization/sensitivityMucosalization/sensitivity Yearly followupYearly followup Functional success ~90%Functional success ~90% Complications: fistula, stenosis, Complications: fistula, stenosis,

dyspareunia, graft failure, SCC (15 years)dyspareunia, graft failure, SCC (15 years)

Acquired Defects of GU SystemAcquired Defects of GU System

Acquired Defects of GU SystemAcquired Defects of GU System

ExtensivenessExtensiveness– Defects of vulvoperineal surfaceDefects of vulvoperineal surface– Defects of scrotal skinDefects of scrotal skin– Defects of vaginal vaultDefects of vaginal vault– Defects of penisDefects of penis– Combined perineum and pelvic support Combined perineum and pelvic support

structuresstructures– Other—pelvic brim, urethra, sphinter mechOther—pelvic brim, urethra, sphinter mech

Preoperative EvaluationPreoperative Evaluation

Define goals of reconstructionDefine goals of reconstruction– Wound healingWound healing– Functional restorationFunctional restoration– Individualize for each patient—70 yo vs 20 yoIndividualize for each patient—70 yo vs 20 yo

Condition of surrounding tissueCondition of surrounding tissue– Need for adjuvent radiotherapyNeed for adjuvent radiotherapy– Previous pelvic surgeryPrevious pelvic surgery

Physical examinationPhysical examination– Groin pulsesGroin pulses– Other incisions around planned flapsOther incisions around planned flaps

Assessment of DefectAssessment of Defect

Post oncologicPost oncologic– Evaluation of size, missing tissue, donor vesselsEvaluation of size, missing tissue, donor vessels– Planning of routes of flap transferPlanning of routes of flap transfer– Intrapelvic—width of pelvis, heightIntrapelvic—width of pelvis, height– Body habitus—thick, bulky flapsBody habitus—thick, bulky flaps

TraumaTrauma– Zone of injuryZone of injury– Local-regional tissuesLocal-regional tissues

Vulvoperineal SurfaceVulvoperineal Surface

Cancer resectionsCancer resections– Skinning vulvectomySkinning vulvectomy– Wide local excisionWide local excision– Loss of skin, subcutaneous tissueLoss of skin, subcutaneous tissue

Vulvoperineal SurfaceVulvoperineal Surface

Skin graftsSkin grafts– Appropriate for unsure margins, high Appropriate for unsure margins, high

recurrence recurrence – Best in non-irradiated bedsBest in non-irradiated beds– Non-meshed sheet STSG vs FTSGNon-meshed sheet STSG vs FTSG

Donor siteDonor site– Suprapubic area, injectable salineSuprapubic area, injectable saline– Lateral thigh, gluteal areaLateral thigh, gluteal area

Vulvoperineal SurfaceVulvoperineal Surface

Local FlapsLocal Flaps– Irradiated tissueIrradiated tissue

Vulvoperineal SurfaceVulvoperineal Surface

Laxity posterior, lateral regionsLaxity posterior, lateral regions– Small to medium defects: local rotation Small to medium defects: local rotation

flaps, rhomboidflaps, rhomboid– Larger defects: fasciocutaneous flaps, Larger defects: fasciocutaneous flaps,

posterior thighposterior thigh Limit pressure in areaLimit pressure in area

– DVT prophylaxisDVT prophylaxis– Sexual activity 6 weeksSexual activity 6 weeks

Vaginal VaultVaginal Vault

Advantages of immediate Advantages of immediate reconstructionreconstruction– Primary healing of perineal defectPrimary healing of perineal defect– Decreased fluid lossDecreased fluid loss– Reduced infection rateReduced infection rate– Emotional/psychological well-beingEmotional/psychological well-being– Early rehabilitationEarly rehabilitation– Future radiotherapyFuture radiotherapy

Vaginal VaultVaginal Vault

ConsiderationsConsiderations– Patient SelectionPatient Selection

» Wound coverage vs functional reconstructionWound coverage vs functional reconstruction

– Defect AnalysisDefect Analysis» OncologicOncologic» TraumaTrauma» Entire vagina vs anterior or posterior wallEntire vagina vs anterior or posterior wall

Vaginal VaultVaginal Vault

Goals of ReconstructionGoals of Reconstruction

Neovagina of sufficient depthNeovagina of sufficient depth Durability, pliabilityDurability, pliability Provide closure of peritoneal cavity, Provide closure of peritoneal cavity,

separate bowel from pelvisseparate bowel from pelvis Minimal morbidityMinimal morbidity

Vaginal VaultVaginal VaultGracilisGracilis Small dead Small dead

spacespace Relatively thin Relatively thin

patientpatient No associated No associated

laparotomylaparotomy Previous Previous

workhorse flapworkhorse flap

Vaginal VaultVaginal Vault

GracilisGracilis Originates pubic symphysis, inserts on medial Originates pubic symphysis, inserts on medial

tibial condyletibial condyle Raised distal to proximal off adductor groupRaised distal to proximal off adductor group Medial circumflex femoral artery (Type II)Medial circumflex femoral artery (Type II)

– 8-10 cm below origin8-10 cm below origin

Lithotomy positionLithotomy position

Vaginal VaultVaginal Vault

Gracilis LimitationsGracilis Limitations– Distal skin island less Distal skin island less

reliablereliable– Rotation of flap Rotation of flap

dependent on pedicledependent on pedicle– Thus, limits depth of Thus, limits depth of

vaultvault

Bilateral gracilis for Bilateral gracilis for complete vault reconcomplete vault recon

Donor site issuesDonor site issues– Bulge, unsightly scarsBulge, unsightly scars

8X15 cm skin island

Vaginal VaultVaginal Vault

Rectus AbdominusRectus Abdominus Total or partial defectsTotal or partial defects Ease of elevation, obliterates dead Ease of elevation, obliterates dead

spacespace Robust blood supply, resists radiationRobust blood supply, resists radiation ContraindicationsContraindications

– Previous abdominoplasty, stoma through Previous abdominoplasty, stoma through muscle, incisions across DIEAmuscle, incisions across DIEA

Vaginal VaultVaginal Vault

Rectus AbdominusRectus Abdominus Originates on pubis, inserts on ribs 5-7Originates on pubis, inserts on ribs 5-7 Superior and inferior epigastric arteries Superior and inferior epigastric arteries

(type III)(type III) Harvested as inferiorly based musculo-Harvested as inferiorly based musculo-

cutaneous flap (TRAM or VRAM)cutaneous flap (TRAM or VRAM)

Vaginal VaultVaginal Vault

ReconstructionReconstruction– Skin paddle designed Skin paddle designed

high over line of Douglas high over line of Douglas to decrease herniationto decrease herniation

– Can curve superior Can curve superior aspect of skin paddle aspect of skin paddle onto ribs for increased onto ribs for increased length in total length in total reconstructionreconstruction

– Fold cutaneous paddle Fold cutaneous paddle on itself or suture to on itself or suture to vaginal wall remnantvaginal wall remnant

– Extend flap to edge of Extend flap to edge of introitus to limit strictureintroitus to limit stricture

Vaginal VaultVaginal Vault

Posterior Thigh FlapPosterior Thigh Flap– Fasciocutaneous flapFasciocutaneous flap– Descending branch of inferior gluteal vesselDescending branch of inferior gluteal vessel– Great for large skin loss, total vaginal Great for large skin loss, total vaginal

reconstructionsreconstructions– Lack of rectus abdominusLack of rectus abdominus– Sensory innervation by posterior femoral Sensory innervation by posterior femoral

cutaneous n.cutaneous n.– Bilateral harvest in lithotomy positionBilateral harvest in lithotomy position

Vaginal VaultVaginal VaultPosterior Thigh FlapPosterior Thigh Flap

Vaginal Vault ReconstuctionVaginal Vault Reconstuction

Vaginal Vault ReconstuctionVaginal Vault Reconstuction

Vaginal Vault ReconstuctionVaginal Vault Reconstuction

Vaginal Vault ReconstuctionVaginal Vault Reconstuction

Vaginal Vault ReconstuctionVaginal Vault Reconstuction

Vaginal VaultVaginal Vault

Other flapsOther flapsOmentum with skin graftOmentum with skin graft– Obese patients, small pelvisObese patients, small pelvis– Left gastroepiploic artery, pedicle flapLeft gastroepiploic artery, pedicle flap– STSG with stent as in McIndoeSTSG with stent as in McIndoeTFLTFL– Hemivaginal or perineal defectsHemivaginal or perineal defects– Shorter reach, donor site morbidityShorter reach, donor site morbidity

Penis and ScrotumPenis and Scrotum

Penile-Scrotal ReconstructionPenile-Scrotal Reconstruction

CongenitalCongenital– HypospadiasHypospadias– EpispadiasEpispadias

AcquiredAcquired– AvulsionsAvulsions– AmputationsAmputations– BurnsBurns– InfectionsInfections

Penile-Scrotal DefectsPenile-Scrotal Defects

GoalsGoalsacceptable appearanceacceptable appearancenormal micturitionnormal micturitionnormal sexual activitynormal sexual activity

Translates to a penis with adequate Translates to a penis with adequate length, tactile sensation, sufficient length, tactile sensation, sufficient rigidityrigidity

AvulsionsAvulsions

PenisPenis– Caused by deceleration injuryCaused by deceleration injury– Gently clean any pedicled soft tissue and Gently clean any pedicled soft tissue and

replacereplace– STSG—0.020 inchSTSG—0.020 inch– Lymphedematous changes arise in skin Lymphedematous changes arise in skin

proximal to corona, therefore, removeproximal to corona, therefore, remove

Scrotal avulsionsScrotal avulsions

Small defectsSmall defects– Debridement and direct approxDebridement and direct approx– Highly elastic and compliantHighly elastic and compliant

Complete scrotal avulsionsComplete scrotal avulsions– Moist dressings over exposed testiclesMoist dressings over exposed testicles– Testes and cords buried in subcutaneous thigh Testes and cords buried in subcutaneous thigh

pocketspockets– Reconstruct scrotum by 4 weeks due to increased Reconstruct scrotum by 4 weeks due to increased

temp and injury to spermatogenesistemp and injury to spermatogenesis

Scrotal avulsionsScrotal avulsions

ReconstructionReconstruction– STSG 0.014-0.018 inSTSG 0.014-0.018 in– FlapsFlaps

» Superolateral thighSuperolateral thigh» TFLTFL» Rectus abdominusRectus abdominus» GracilisGracilis» posterior thigh posterior thigh

Scrotal DefectsScrotal Defects

Scrotal DefectsScrotal Defects

Scrotal DefectScrotal Defect

Gracilis myocutaneous flap

Scrotal DefectScrotal Defect

Coverage with GracilisCoverage with Gracilis

AlgorithmAlgorithm

PenisPenis

PartialPartial TotalTotal

11° closure STSG° closure STSG MeshedMeshed ThickThick (thick)(thick) STSG STSG

STSGSTSG

or FTSGor FTSG

AlgorithmAlgorithm

ScrotumScrotum

PartialPartial TotalTotal

11° closure° closure Testes in pouchesTestes in pouches

Meshed STSGMeshed STSG Thigh FlapsThigh Flaps

Penis AmputationsPenis Amputations

Primary reattachmentPrimary reattachment– Bux and coworkersBux and coworkers– 14 cases, no vascular anastomosis14 cases, no vascular anastomosis– Corpus spongiosum approximatedCorpus spongiosum approximated– Corpus cavernosa sutured through tunica Corpus cavernosa sutured through tunica

albugineaalbuginea– Aspiration of corpora cavernosa 2X dayAspiration of corpora cavernosa 2X day– Survival, but shaft skin sloughSurvival, but shaft skin sloughSTSGSTSG

AmputationsAmputations

Microvascular repairMicrovascular repair– Artery x2, vein, nervesArtery x2, vein, nerves– Urethra repair with urology svcUrethra repair with urology svc– Approximate corpora spongiosaApproximate corpora spongiosa– Better outcomeBetter outcome

Penis ReplantationPenis Replantation

Penis ReplantationPenis Replantation

Penis ReplantationPenis Replantation

Penis ReplantationPenis Replantation

Penis ReconstructionPenis Reconstruction

Penile ReconstructionPenile Reconstruction

Previous attempts multistagePrevious attempts multistage– Tubed abdominal flapsTubed abdominal flaps– Scrotal skin flapsScrotal skin flaps– Muscle pedicle flapsMuscle pedicle flaps

All generally overly bulky or lack of lengthAll generally overly bulky or lack of length Best reconstructions one stage Best reconstructions one stage

microvascular transfermicrovascular transfer

Phallus ReconstructionPhallus Reconstruction

Goals:Goals:– Urinary conduitUrinary conduit– RigidityRigidity– Errogenous and protective sensationErrogenous and protective sensation– AppearanceAppearance

Penile ReconstructionPenile Reconstruction

Radial Forearm Free FlapRadial Forearm Free Flap– Tube-within-tubeTube-within-tube– Innervation via antebrachial cutaneous Innervation via antebrachial cutaneous

nerves to pudendal nervenerves to pudendal nerve– Limited hairLimited hair– Vascularized urethraVascularized urethra– Return of tactile, errogenous sensationReturn of tactile, errogenous sensation– Rigidity via rib bone graft or prosthesisRigidity via rib bone graft or prosthesis

Radial Forearm FlapRadial Forearm Flap

Radial ForearmRadial Forearm

Nondominant armNondominant arm Allen’s test/duplex Allen’s test/duplex

dopplerdoppler Do not shave armDo not shave arm

– Urethral stonesUrethral stones 15 x 17 cm15 x 17 cm Suprapubic Suprapubic

cathetercatheter

Radial ForearmRadial Forearm

Saphenous vein Saphenous vein loop- temp A-V loop- temp A-V fistulafistula

LAC to dorsal penile LAC to dorsal penile branches (Pudendal branches (Pudendal Nerve)Nerve)

Radial ForearmRadial Forearm

Tactile sensation 4-6 Tactile sensation 4-6 momo

Prosthesis 6-9 moProsthesis 6-9 mo Achieve orgasmAchieve orgasm ComplicationsComplications

– Urethral stonesUrethral stones– Sinuses, fistulaeSinuses, fistulae– StricturesStrictures– HypopigmentationHypopigmentation– Implant exposureImplant exposure

Penile Penile ReconstructionReconstruction

Fibula sensate free Fibula sensate free flapflap– Lateral sural nerveLateral sural nerve– Osteocutaneous free Osteocutaneous free

flapflap– Concealed donor siteConcealed donor site– Fistula proneFistula prone– hirsutehirsute

Phallus Phallus ReconstructionReconstruction

Other Other descriptions:descriptions:– Ulnar forearm Ulnar forearm

free flapfree flap– Lateral Arm flapLateral Arm flap

» Pre-fabricatedPre-fabricated

– ““Cricket-bat” Cricket-bat” FlapFlap

Gender ReassignmentGender Reassignment

Psychological issuesPsychological issues Physical issuesPhysical issues Multispecialty approachMultispecialty approach Male to femaleMale to female

– Breast augBreast aug– Genitalia Genitalia

Female to maleFemale to male– MastectomyMastectomy– Genitalia, partial Genitalia, partial

transformationtransformation– More difficultMore difficult

Male PotencyMale Potency

Radical prostatectomyRadical prostatectomy Cavernous nerves mediate erectile Cavernous nerves mediate erectile

functionfunction Sacrifice unilateral or bilateral Sacrifice unilateral or bilateral

depending on extent of tumordepending on extent of tumor Erectile function diminished to degree of Erectile function diminished to degree of

nerve sacrificenerve sacrifice

Cavernous Nerve GraftingCavernous Nerve Grafting

Cavernous nerve grafting Cavernous nerve grafting – Sural nerve harvestSural nerve harvest– Loupe magnificationLoupe magnification– Large instruments operating in a holeLarge instruments operating in a hole– Clips and microsuture to hold graftsClips and microsuture to hold grafts– Epineural repairEpineural repair– Results can be enhanced with ViagraResults can be enhanced with Viagra

Unilateral Cavernous Nerve resection with Sural Nerve graft

Nerve graft

Silastic tubingMetal clip

microsuture

Melted end of suture

Cavernous nerve repair with Sural nerve grafts

Nerve graft

ResultsResults

200 cases 200 cases to dateto date

Percentage of Percentage of successful inter-successful inter-course course WITHWITH nerve graftingnerve grafting

Percentage of Percentage of successful inter-successful inter-course course WITHOUT WITHOUT nerve graftingnerve grafting

Unilateral Unilateral nerve nerve graftsgrafts

75%75% 21%21%

Bilateral Bilateral nerve nerve graftsgrafts

60%60% 0%0%

Inguinal RegionInguinal Region

Infected Vascular Infected Vascular GraftsGrafts

PresentationPresentation– Local signsLocal signs– FeverFever– SepsisSepsis– PseudoaneurysmPseudoaneurysm– ThrombosisThrombosis– BleedingBleeding

Inguinal RegionInguinal Region

Vascular graftsVascular grafts

Common FlapsCommon Flaps

SartoriusSartorius

GracilisGracilis

Rectus AbdominusRectus Abdominus

Rectus FemorisRectus Femoris

TFLTFL

Vastus LateralisVastus Lateralis

Vascular Graft CoverageVascular Graft Coverage

Gracilis Rotation CoverageGracilis Rotation Coverage

Gracilis Rotation FlapGracilis Rotation Flap

Sartorius FlapSartorius Flap

Exposed Vascular GraftExposed Vascular Graft

Sartorius Rotation CoverageSartorius Rotation Coverage

InfectionsInfections

Necrotizing infectionsNecrotizing infections Fournier’s Gangrene—Fournier’s Gangrene—

18821882 Penetrates Colles Penetrates Colles

fasciafascia Spreads in subDartos Spreads in subDartos

space, involves space, involves superficial tissuessuperficial tissues

Sx: pain, fever, crepitusSx: pain, fever, crepitus Pathophys: thrombosis Pathophys: thrombosis

of small vesselsof small vessels

Fournier’ GangreneFournier’ Gangrene

TreatmentTreatment– Radical debridement, Radical debridement,

repeat usually repeat usually necessarynecessary

– Cultures, broad Cultures, broad spectrum antibioticsspectrum antibiotics

» Mixed Mixed aerobic/anaerobic aerobic/anaerobic organismsorganisms

– HydrotherapyHydrotherapy– Skin grafting of defect, Skin grafting of defect,

testes coveragetestes coverage

Genital BurnsGenital Burns

Children more often than adultsChildren more often than adults Involve CPS for suspicious burnsInvolve CPS for suspicious burns Usually 1Usually 1stst and 2 and 2ndnd degree burns degree burns Local wound careLocal wound care

– Serial debridement, dressing care with Serial debridement, dressing care with BacitracinBacitracin

– HydrotherapyHydrotherapy 33rdrd degree—excision and grafting degree—excision and grafting

Pelvic ExenterationPelvic Exenteration

Through-and-through defectsThrough-and-through defects Skin defectSkin defect Space filler to prevent bowel descentSpace filler to prevent bowel descent Flap choice—bulky, robust blood supplyFlap choice—bulky, robust blood supply

– Posterior thighPosterior thigh– Rectus abdominusRectus abdominus– Omentum—filler only, clear infectionOmentum—filler only, clear infection– Gracilis—small lower pelvis/perineumGracilis—small lower pelvis/perineum

Pelvic ExenterationPelvic Exenteration

Importance of vascularized flapsImportance of vascularized flaps– RadiationRadiation– Clear infection—pelvic abscessClear infection—pelvic abscess– Durable tissue for sittingDurable tissue for sitting– Prevents herniation of bowelPrevents herniation of bowel

Pelvic/Perineum DefectPelvic/Perineum Defect

VRAM ReconstructionVRAM Reconstruction

VRAM to Pelvic DefectVRAM to Pelvic Defect

Pelvic DefectsPelvic Defects

Pelvic Bone defectsPelvic Bone defects Ensure continuity of pelvic ringEnsure continuity of pelvic ring

– Heavy, large non-absorbable meshHeavy, large non-absorbable mesh Support herniation of bowelSupport herniation of bowel

– Local flapsLocal flaps– TFLTFL– RectusRectus– omentumomentum

Pelvic/Perineal DefectsPelvic/Perineal Defects

Pelvic/Perineal DefectsPelvic/Perineal Defects

Final ResultFinal Result

Anal Sphincter ReconstructionAnal Sphincter Reconstruction

Restoration of fecal continenceRestoration of fecal continence Rotational gracilisRotational gracilis Free gracilis with implantable stimulatorFree gracilis with implantable stimulator Inferior gluteus maximusInferior gluteus maximus

Gracilis Sphincter ReconstructionGracilis Sphincter Reconstruction

Pickrell 1956Pickrell 1956– Rt gracilis, clockwise 1 wrapRt gracilis, clockwise 1 wrap– N=6 all continent N=6 all continent

Song 1982Song 1982– 2 wraps counterclockwise2 wraps counterclockwise

Inferior Gluteus- procedure Inferior Gluteus- procedure of choiceof choice

SummarySummary

Form follows functionForm follows function Analyze the defectAnalyze the defect

– Vaginial—partial or totalVaginial—partial or total– Penis/Scrotum—skin grafting, free tissue Penis/Scrotum—skin grafting, free tissue

transfer transfer – Pelvis/inguinal defectsPelvis/inguinal defects

Primary flaps Primary flaps – Rectus, gracilis, posterior thighRectus, gracilis, posterior thigh

THANKS TO:THANKS TO: