PEDICLE PHALLOPLASTY. By A. J. EVANS, F.R.C.S. Plastic Surgery and Burns Centre, Queen Mary's Hospital, Roehampton

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1 BURIED SKIN-STRIP URETHRA IN A TUBE PEDICLE PHALLOPLASTY By A. J. EVANS, F.R.C.S. Plastic Surgery and Burns Centre, Queen Mary's Hospital, Roehampton IN 1949 Denis Browne described his operation for the repair of hypospadias, in which he introduced the principle of the buried skin strip (Browne, I949 a, b). Johanson's follow-up of Browne's cases underlined the success of the operation (Johanson, I953), and it is now a routine method of hypospadias repair at most plastic surgery centres in this country, Browne (I953), in a comparison of his technique with the Duplay procedure, stated that prior to his own operation every :surgeon constructed some kind of tube, complete or incomplete, to form the new urethra. This new and original concept of leaving an intact strip of epithelium to form a tube is now accepted as a most valuable contribution to surgery. Although Browne had stated that the success of his technique was, to some extent, dependent.on the special qualities of penile skin, he suggested further applications of the principle, including the construction of a new lacrimal duct and forming the labiogingival groove in cases of double harelip with displaced premaxilla (Browne, 1953). Johanson (I953) adapted the principle for the treatment of urethral strictures. In his procedure the urethra is opened along the strictured area and the penoscrotal skin sutured to the edges of the divided urethral mucosa. At a second stage the.,strip of intact epithelium is covered, as in the Denis Browne operation. At the Second International Congress of Plastic Surgery, held in London in 1959, Arneri showed a film of a phalloplasty procedure in which the urethra was formed by a buried strip of abdominal skin as part of a tube pedicle reconstruction. The skin strip was outlined on the abdominal wall and buried by bringing together the widely undermined adjoining skin. At a later stage the preformed urethra was incorporated in a tube pedicle. He has since carried out this procedure in two further cases with very satisfactory results (Ameri, 1962). In the case to be described the technique differs in that the buried strip urethra was constructed of necessity on an existing tube pedicle. The patient had been under the care of Sir Harold Gillies, who had performed a previous phalloplasty operation for traumatic avulsion of the penis, which had occurred in 1946 when the patient was 22 years old. Details of the case and of the original phalloplasty will be found in the first issue of this journal (Gillies and Harrison, 1948). The original condition is shown in Fig. I and the result of the repair in Fig. 2. The urethra had been formed by the Gillies procedure of inturned local flaps later incorporated within a tube pedicle. In I955 the patient sustained a hot-water bottle burn of the reconstructed penis with loss of half the length of the organ and with distortion of the meatus and terminal urethra (Fig. 3), so that he could no longer pass urine without soiling his clothes. Sir Harold Gillies decided to construct a new abdominal tube pedicle with preformed urethra as before, and to join this to the stump of the previous penis. At operation on 2nd December I955 a first-stage phalloplasty was performed, the urethra being constructed by inturned longitudinal flaps and 280

2 BURIED SKIN-STRIP URETHRA IN A TUBE PEDICLE PHALLOPLASTY 281 Fie. x Fro. 2 Fig. I.--Traumatic avulsion of penis and scrotum. Fig. 2.--Result following original phalloplasty. Fig. 3---Result of hot-water bottle burn to reconstructed penis seven years after completion of repair. FIG. 3

3 282 BRITISH JOURNAL OF PLASTIC SURGERY buried beneath a rectangular flap 889 by 3 in. The second stage was performed only two weeks later, on I6th December 1955, when the previously raised flap was wrapped around the urethra to form a tube pedicle containing a Skin-lined tube. A few days later the suture line showed signs of inflammation, and one week after operation had separated along its entire length. It soon became apparent that the contained urethral flap was devitalised and a large part of this gradually sloughed away, leaving only the urethral floor. Healing was complete by the twenty-fourth day and the urethra was then represented by a strip of skin between two parallel scars, one of which was the original seam of the tube pedicle.(fig. 4). Infection had been minimal and it was obvious that the reconstructed urethra had had an insufficient blood supply. This was due partly to tension within the Undermined area FIG. 4 FIG. 5 Fig. 4.--Loss of intumed urethra leaving strip of skin between two parallel scars. Fig. 5---Incisions each side of skin strip and undermining of pedicle skin. pedicle, which had contained rather a large amount of fat, but mainly to the short interval of two weeks between the first and second stages. Unfortunately it had been necessary to bring the second stage forward as Sir Harold Gillies was due to leave on a lengthy visit to New Zealand. As might be imagined, the patient was deeply depressed at this time. The psychological impact of the original injury had been extremely severe, the patient was naturally upset by the accident with the hot-water bottle and the prospect of further prolonged surgery, and now he was faced with this serious setback. Sir Harold Gillies, who had left for New Zealand, was not due to return for some three months, but it was thought undesirable for the patient to undergo a long period of waiting before active surgery was recommenced. The appearance of the pedicle with the skin strip outlined by parallel scars at least suggested one form of approach to the problem, although it was considered very doubtful whether a Denis Browne urethroplasty would succeed on an abdominal tube pedicle. However, there was little to be lost, and at operation on 27th January I956 the scars were outlined by incision and the adjoining pedicle skin widely undermined (Fig. 5). A considerable amount of pedicle fat had to be removed to allow wide apposition of the skin edges, as obviously a dorsal relaxation incision would not be practicable. A surprising amount of apposition was nltimately achieved and tension sutures were inserted through lengths of Polythene

4 BURIED SKIN-STRIP URETHRA IN A TUBE PEDICLE PHALLOPLASTY 283 tubing rather than the usual beads, which might be more likely to cause localised necrosis of the undermined pedicle skin (Fig. 6). Healing was surprisingly trouble-free and was complete eleven days post-operatively (Fig. 7). On the eighteenth day the upper end of the pedicle was delayed by partial division under local aneesthesia, and on the twenty-eighth day division was completed and the upper end of the pedicle swung down for attachment to the penile stump. No ~ ~-"----- FIG. 6 ~ Fig. 6.--Skin strip buried and tension sutures tied through lengths of Polythene tubing. Fig. 7.--Reconstructed urethra. FiG. 7 FIG. 8 FIG. 9 Fig. 8.--Pedicle has been attached to penile stump but urethra left open at site of join. Incisions are now made at edges of urethral defect. Fig. 9.--Adjoining skin undermined. attempt at full urethral iunction was made at this stage, the urethral ends simply being butted against each other to form a continuous floor. A catheter was inserted via the existing meatus and left for a few days until healing was reasonably secure. The position now was similar to that reached after the first stage of a Johanson stricture repair and the final urethral closure was on these lines (Fig. 8). At operation on I3th March I956 urine was diverted by posterior urethrostomy and then the edges of the urethral defect were incised and the adjoining skin widely undermined (Fig. 9). Tension sutures were again tied through lengths of Polythene tubing (Fig. Io, A and B). By 3rd April I956 sound healing had been achieved and the catheter was removed. One week later he was passing a good stream of urine through the new meatus and a pin-point leak which had appeared to one side of the join had subsided spontaneously (Fig. ii). The remaining abdominal attachment was divided on I3th April I956, after a preliminary partial division.

5 284 BRITISH JOURNAL OF PLASTIC SURGERY Before the patient left hospital urethral sounds were passed up to I6/Zo without any difficulty. Six months later he was readmitted for a final trimming A FIG. I0 B Fig. Io.--A and B, Urethral defect dosed on Denis Browne principle, Tension sutures tied through lengths of Polythene tubing. Fig. I I. -- Urethral repair completed. At this stage he was passing urine through the new meatus on the still-attached pedicle. Fig. i2.--urethrogram six months later. FIG. II FIG. I2 operation to the end of the penis, and on the same occasion a urethrogram showed a very satisfactory urinary passage (Fig. i2). He was finally discharged on ISth November I956 (Fig. I3, A and B), and was capable of passing a very good stream of urine. He remains liable to occasional attacks of burning or smarting sensations in the perineum and says he sometimes has difficulty in passing an adequate stream. This was noted in the original description of the case (Gillies and Harrison, I948) and repeated examination

6 BURIED SKIN-STRIP URETHRA IN A TUBE PEDICLE PHALLOPLASTY 285 has shown no real cause in the reconstructed urethra. It is attributed to the severe psychological disturbance and also to probable damage in the region of the posterior urethra from the original tearing injury. A FIG. I3 Completion of repair. B DISCUSSION This " one and only" case is presented first of all as an example of the use of the Denis Browne buried skin strip principle in unusual and unpromising circumstances. It is not recommended as a method of phalloplasty, and the writer prefers the original Gillies operation in which the urethra is constructed from inturned flaps. If the buried-strip technique is to be employed, Arneri's method of forming the urethra on the abdominal wall and then incorporating it within a tube pedicle is obviously preferable. The case is also presented as a description of a plastic disaster. Those who knew or worked with the late Sir Harold Gillies will remember how much he relished the challenge of finding a way out when things had gone seriously wrong. He frequently stated that far more could be learned from a single disaster than from a hundred cases which had gone smoothly. The susceptibility of the original tube pedicle to a hot-water bottle burn some seven years after completion could hardly have been avoided and the patient had been warned of the risk. In the second reconstruction the short interval between stages obviously led to trouble, and here perhaps it came under the

7 286 BRITISH JOURNAL OF PLASTIC SURGERY heading of a calculated risk. Sir Harold often recalled from his long experience that troubles usually arose when stages were hurried, either at the patient's insistence or under the pressure of the surgeon's own commitments. It was particularly fortunate that the buried skin urethra succeeded in this case. The alternative procedures were :-- I. A skin graft within the pedicle. The chance of success was very small and in any case a free-graft urethra is not to be recommended. 2. To transfer the pedicle to another site where it could be opened out to pick up a new urethra formed by inturned flaps. This would have required several stages and the incorporation of the urethra would have presented difficulties in a " second-hand" pedicle. 3- To abandon the tube pedicle and start afresh. SUMMARY I. A patient who had undergone a tube pedicle phalloplasty lost a large part of the reconstructed organ as the result of a hot-water bottle burn seven years later. 2. During a second reconstruction the inturned urethra was lost owing to too short an interval between stages. 3- A new urethra was constructed on the tube pedicle by the buried skin strip principle. Junction of the new urethra with that of the penile stump was also effected by using the same principle. I would like to thank Mr E. B. Ferrill, Department of Photography, Queen Mary's Hospital, Roehampton, for the photographs, and Miss Archer, Clinical Artist, Queen Mary's Hospital, Roehampton, for the diagrams. REFERENCES ARNERI, V. (1962). Personal communication. BROWNE, D. (1949 a). Proc. R. Soc. Med., 42, (1949 b). Postgrad. reed. J., 25, (1953). Surgery, 34, GILLIES, H. ]D., and HARRISON, R. J. (1948). Brit. J. plast. Surg., I, 8. JOHANSON, B. (1953). Acta chit. seand., x76, 17. Submitted for publication, November 1962.