Postoperative Imaging of Phalloplasties and Their Complications

Transcription

1 Genitourinary Imaging Review laschke et al. Postoperative Imaging of Phalloplasty Genitourinary Imaging Review Eric laschke 1 Gregory T. ales 2 Stephen Thomas 1 laschke E, ales GT, Thomas S Keywords: female-to-male gender reassignment surgery, fistula, neourethra, phalloplasty, radial forearm flap phalloplasty DOI: /JR Received October 30, 2013; accepted after revision January 14, Presented at 2013 RRS annual meeting, Washington, D. 1 Department of Radiology, University of hicago, 5841 S Maryland ve, M 2026, hicago, IL ddress correspondence to E. laschke (emblaschke@gmail.com). 2 Department of Surgery, Section of Urology, University of hicago, hicago, IL. This article is available for credit. JR 2014; 203: X/14/ merican Roentgen Ray Society Postoperative Imaging of Phalloplasties and Their omplications OJETIVE. In this article, we summarize the common phalloplasty indications, surgical techniques, and relevant anatomy. We review the appropriate imaging techniques used in postoperative evaluation of the neophallus and illustrate the postoperative appearance and complications associated with phalloplasty. ONLUSION. Phalloplasty is an infrequently encountered yet complex procedure requiring careful postoperative imaging assessment. Modern microsurgical techniques have made free flaps the reference standard in phalloplasty, and the radiologist must be aware of the expected postoperative appearance and complications to appropriately manage these patients. T he first penile reconstruction capable of micturition and coitus was performed by argoras [1] in 1936 using rib cartilage and a bipedicled tubed abdominal flap in a patient after penile amputation. Numerous surgical techniques have since been described with varying rates of success. No procedure has yet achieved the ideal of a single-stage operation with minimal complications allowing tactile and erogenous sensibility, a watertight neourethra permitting voiding in the standing position, sufficient bulk and stiffness for intercourse, and an aesthetically acceptable appearance. However, modern microsurgical techniques have made considerable progress, with free-flap procedures representing the current reference standard of care [2, 3]. multistage procedure with high rates of complications, the free-flap phalloplasty is most likely to be encountered by the practicing radiologist. In this article, we will review the indications, relevant anatomy, postoperative appearance, and complications associated with phalloplasty. Indications lthough an uncommon procedure, contemporary indications for phalloplasty include gender reassignment surgery, penile enhancement, and reconstruction after penectomy for penile cancer, penile necrosis, congenital abnormality, or traumatic amputation. In the context of female-to-male gender reassignment surgery, the radiologist should be aware that phalloplasty represents just one of a series of operations and treatments, often including psychotherapy, hormone therapy, mastectomy, vaginectomy, hysterectomy, salpingo-oophorectomy, scrotal construction, and phallic and scrotal prosthesis implantation. Female-to-male gender reassignment surgery is performed as a treatment of gender dysphoria, which has an incidence of one in 60,000 worldwide [4]. It is important to note that not all patients with gender dysphoria undergo or even desire treatment or surgery, and those selected for surgery according to formalized guidelines published by the World Professional ssociation for Transgender Health have undergone extensive evaluation and counseling and have referrals from at least two gender psychiatrists [5]. Surgical Techniques Multiple techniques have been used to surgically fashion the neophallus [6, 7] (Table 1). The metoidioplasty is a single-stage procedure wherein the hypertrophied clitoris is mobilized and a flap of vaginal epithelium is used to extend the existing urethra to the tip, creating a phallus resembling a micropenis. The benefits of metoidioplasty include ease of technique, lower complication risk, and quick recovery time, but the resulting short phallus is often not capable of sexual penetration or voiding while standing. The suprapubic flap procedure involves an anterior abdominal wall flap rolled into a tube, with vaginal epithelium and skin used JR:203, ugust

2 laschke et al. to create a neourethra. Ease of technique favors this procedure, but limitations include poor aesthetics, donor site morbidity, urinary tract complications, partial sensation, and the requirement of a prosthesis for erection. The desire for superior aesthetic and functional results has led to both these procedures largely but not entirely being replaced by microsurgical free-flap techniques [2 4, 8]. The radial forearm flap currently represents the most commonly used free-flap phalloplasty technique [2, 4, 9]. The forearm flap is divided, with the narrow inner part rolled to form a skin tube neourethra (pars pendulans) and the remainder rolled outward to form a phallus (Fig. 1). The proximal urethra is formed from a tube of labia minora and vaginal epithelium formed around a catheter and connected to the neourethra of the neophallus. The graft is supplied from the femoral artery via the harvested saphenous vein. uccal mucosa may be used to lengthen or repair the neourethra. The clitoris is often left at the base of the neophallus. To improve the aesthetics of the neophallus, the coronal sulcus (glans penis) can be created after, or even during, the phalloplasty. y use of the Norfolk technique for glans sculpturing, a skin flap is raised from the glans penis, with split skin grafts used to fill the resulting defect and tattooing of the glans for cosmesis [7, 10] (Fig. 2). The limitations of this procedure include multiple stages, urinary tract problems, and requirement for an erectile prosthesis (or permanent erection if bone is used) as well as donor-site morbidity. The procedure allows sexual intercourse and possibly the best cosmetic result. dditional procedures that may be encountered include the anterolateral thigh flap, fibular flap, and latissimus dorsi flap, each with unique benefits and limitations [6, 7] (Table 1). Postoperative natomy The modern free-flap phalloplasty provides a gross cosmetic appearance vastly superior to older techniques, with normal bulk, appearance, and even function of the neophallus. There are specific anatomic landmarks the radiologist should be familiar with on postoperative imaging. The native urethra forms the proximal portion of the urethra near the bladder. The pars fixa is the urethra tubed forward from the perineum using tissue from the labia minora. It can be identified by the abrupt transition from the thin native urethra to the bulbous proximal neourethra. The anastomosis forms the mucocutaneous junction between the pars fixa and the phallic urethra (pars pendulans) formed from a rolled skin flap (Fig. 3). TLE 1: enefits and Limitations of Phalloplasty Surgical Techniques Surgical Technique enefits Limitations Postoperative Imaging and omplications The majority of patients will undergo postoperative imaging after phalloplasty, primarily for evaluation of suspected complications. Urethrocutaneous fistula represents the most common complication after free-flap phalloplasty, with rates ranging widely from 15% to 70% [3, 11]. Fistulas and sinus tracts may occur at any point along the urethra, although they most commonly occur at the anastomosis of the native urethra and neourethra or along the fashioned neourethra [4, 11, 12] (Fig. 3). areful attention to the location and extent of urinary leaks is required because large extravasations may require surgical repair rather than simple urinary diversion (Fig. 4). dditional urethral findings include strictures, sinus tracts, stones, pseudodiveriticula, or fistulas involving the native urethra (Figs. 5 and 6). Urethral strictures most commonly occur at the anastomosis (mucocutaneous junction) between the pars fixa and phallic urethra. Strictures in the pars fixa or the phallic urethra are uncommon and strictures of the native urethra are extremely rare [11 13]. Our experience suggests evaluation should include antegrade voiding cystourethrography when feasible that covers the entire course of the urethra to the base of the bladder to avoid missing pathology (Fig. 7). Examinations may be facilitated by the presence of suprapubic catheters, which are often in place to avoid damage to the partially innervated neophallus by mechanical shearing from long-standing Foley catheters. Retrograde cystourethrography can be performed by placing a vascular 20- or 22-gauge catheter beside the existing Foley catheter. This technique is effective to evaluate for fistulas and is limited for evaluating for strictures because the indwelling Foley catheter can obscure strictures (Fig. 8). Evaluation of the abdomen and pelvis with contrast-enhanced T or MRI may be considered in evaluating for additional complications, such as abscess; soft-tissue infection; bladder outlet obstruction; or complications related to additional pelvic surgery such as hysterectomy, salpingo-oophorectomy, or vaginectomy in patients after gender reassignment surgery (Fig. 9). The risk of periprosthetic infections with erectile implants ranges from 8% to 20%, and careful assessment should be made for evidence of longterm component failure [14]. In addition to causing disfigurement, graft or saphenous vein donor sites may develop complications, such as hematoma, seroma, or infection (Fig. 10). Other considerations in cases of osteocutaneous flaps include the risk of fracture, extrusion, and bone graft resorption [14 16]. Free flap Radial forearm flap Possibly best cosmetic and functional result Urinary tract complications, multiple stages, donor site morbidity, prosthesis Thigh flap Easy to hide donor site Similar to radial forearm, no long-term data Fibula flap No need for erection device Urinary tract not reconstructed, muscle and erection function and sexual and tactile sensitivity questionable, no long-term data Latissimus dorsi flap No need for erection device Urinary tract not reconstructed, muscle and erection function and sexual and tactile sensitivity questionable, no long-term data Suprapubic flap Ease of technique Poor cosmetic result, donor site morbidity, urinary tract problems, poor sensation, multiple stages Other Metoidioplasty Easy technique, reduced complications, quick recovery time Short phallus, not capable of sexual penetration, cannot void while standing 324 JR:203, ugust 2014

3 Postoperative Imaging of Phalloplasty onclusion Modern free-flap phalloplasty techniques provide patients with improved cosmetic and functional outcomes but carry a high risk of complications. ppreciation of the appropriate imaging techniques and expected postoperative imaging findings after free-flap phalloplasty is necessary for the radiologist to appropriately manage patients. Flap to form urethra Neophallus atheter Flap to form phallus References 1. argoras N. Plastic construction of penis capable of accomplishing coitus. Zentralbl hir 1936; 63: Hage JJ, De Graaf FH. ddressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery 1993; 14: Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg 2009; 124: Monstrey SJ, eulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg 2011; 25: oleman E, ockting W, otzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism 2012; 13: Selvaggi G, Elander. Penile reconstruction/formation. urr Opin Urol 2008; 18: Selvaggi G, ellringer J. Gender reassignment surgery: an overview. Nat Rev Urol 2011; 8: Terrier JE, ourtois F, Ruffion, Morel Journel N. Surgical outcomes and patients satisfaction with suprapubic phalloplasty. J Sex Med 2014; 11: Kim SK, Kim TH, Yang JI, Kim MH, Kim MS, Lee K. The etiology and treatment of the softened phallus after the radial forearm osteocutaneous free flap phalloplasty. rch Plast Surg 2012; 39: Doornaert M, Hoebeke P, eulemans P. T Sjoen G, Heylens G, Monstrey S. Penile reconstruction with the radial forearm flap: an update. Handchir Mikrochir Plast hir 2011; 43: Hoebeke P, Selvaggi G, eulemans P, et al. Im- Flap to form urethra atheter Neophallus Saphenous vein Flap to form phallus Femoral artery D pact of sex reassignment surgery on lower urinary tract function. Eur Urol 2005; 47: Kim SK, Moon J, Heo J, Kwon YS, Lee K. new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. nn Plast Surg 2010; 64: Kim SK, Lee K, Kwon YS, ha H. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast Reconstr esthet Surg 2009; 62: Hoebeke P, Decaestecker K, eysens M, Opdenakker Y, Lumen N, Monstrey SM. Erectile implants in female-to-male transsexuals: our experience in 129 patients. Eur Urol 2010; 57: Fang RH, Kao YS, Ma S, Lin JT. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. r J Plast Surg 1999; 52: Sengezer M, Ozturk S, Deveci M, Odabasi Z. Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients. Plast Reconstr Surg 2004; 114: ; discussion, Fig. 1 Radial free-flap phalloplasty. D, Drawings show full-thickness flaps raised on radial artery with cutaneous nerves intact with flap to form phallus and neourethra (). Forearm flap is divided with narrow inner part rolled to form skin tube neourethra (pars pendulans) (), and remainder is rolled outward to form phallus (). Formed neophallus is transferred from donor site (D). Neophallus is attached to saphenous vein graft and branch of femoral artery. utaneous nerves are anastomosed to dorsal nerve of clitoris and ilioinguinal nerve. JR:203, ugust

4 laschke et al. Fig. 2 Drawing shows Norfolk technique used for creating coronal sulcus (glans penis). Skin flap is raised for glans penis, with split skin grafts used to fill resulting defect, and glans is tattooed for cosmesis. Markings for incision Fig. 3 Gender reassignment free-flap phalloplasty., 39-year-old man 1 month after gender reassignment free-flap phalloplasty. Voiding cystourethrogram shows normal native urethra (black arrow) and proximal neourethra or pars fixa (white arrow), which is irregular but not narrowed., 42-year-old man 1 month after gender reassignment free-flap phalloplasty. Voiding cystourethrogram shows normal pars fixa (white arrow) and normal pars pendulans (black arrow). Fig year-old man after free-flap phalloplasty. Voiding cystourethrogram shows four urethrocutaneous fistulas (arrowheads) from penile urethra. oronal sulcus created from rolled up skin Skin defect repaired with split skin graft Fig. 5 Voiding cystourethrogram in 28-year-old man 1 month after radial forearm flap phalloplasty shows two proximal extravasation sites (arrows) around neourethra anastomosis. Fig year-old man after free-flap phalloplasty., Voiding cystourethrogram shows fistula from urethra to vaginectomy bed (arrow) around anastomosis. (Fig. 6 continues on next page) 326 JR:203, ugust 2014

5 Postoperative Imaging of Phalloplasty Fig. 6 (continued) 47-year-old man after free-flap phalloplasty., oned-down image shows midurethral pseudodiverticulum (arrow)., Patient was treated with suprapubic urinary diversion, and subsequent voiding cystourethrogram shows resolution of fistula and pseudodiverticulum. Fig year-old man with native-neourethral junction stricture after free-flap phalloplasty., Retrograde cystourethrogram fails to fully show extent of stricture due to catheter (arrow)., ntegrade cystourethrogram shows 15-mm segment of severe narrowing (arrow) at nativeneourethral anastomosis. Fig. 8 Fluoroscopic spot image from retrograde urethrogram in 26-year-old man with mid urethral fistula (arrow) and lack of proximal flow after accidental early removal of Foley catheter. JR:203, ugust

6 laschke et al. FOR YOUR INFORMTION Fig year-old man with periimplant abscess and associated bladder outlet obstruction., xial contrast-enhanced T image shows implant reservoir (asterisk) with adjacent fluid collection (arrow)., oronal T image shows extent of abscess (arrow) extending from implant to neophallus., Spot fluoroscopic image from antegrade cystourethrogram. Patient was unable to void despite maximal bladder distention. Fig year-old man with large proximal neourethral extravasation and several fluid collections after free-flap phalloplasty., ntegrade cystourethrogram shows large proximal extravasation (arrow) requiring repair with buccal mucosal graft., xial contrast-enhanced T image shows small perianal surgical bed abscess (arrow)., oronal contrast-enhanced T image shows saphenous vein donor site seroma (arrow). This article is available for ME and Self-ssessment (S-ME) credit that satisfies Part II requirements for maintenance of certification (MO). To access the examination for this article, follow the prompts associated with the online version of the article. 328 JR:203, ugust 2014