RECONSTRUCTIVE UROLOGY

New Technique of Total Phalloplasty with Reinnervated Latissimus Dorsi Myocutaneous Free Flap in Female-to-Male Transsexuals
Vesely J, Hyza P, Ranno R, Cigna E, Monni N, Stupka I, Justan I, Dvorak Z, Novak P, Ranno S
Clinic of Plastic and Aesthetic Surgery, St. Anna University Hospital, Masaryk University in Brno, Brno, Czech Republic
Ann Plast Surg. 2007; 58: 544-50

• From December 2001 to September 2005, the technique of total penile reconstruction with a reinnervated free latissimus dorsi myocutaneous flap was used in 22 patients (24-38 years old) with gender dysphoria. These patients were followed up for at least 11 months (range, 11-44 months). All flaps survived. Complications include hematoma (7 cases), vascular thrombosis (2 cases), partial necrosis (1 case), excessive swelling of the neophallus (3 cases), and skin graft loss at the donor site (1 case). Of the 19 patients included in the final evaluation, the transplanted muscle was able to obtain contraction in 18 (95%) cases and 8 patients (42%) had sexual intercourse by contracting the muscle to stiffen and move the neopenis. The described technique of neophalloplasty proved to be a reliable technique and the muscle movement in the neophallus can be expected in almost all cases. The muscle contraction in the neophallus leads to “paradox” erection-stiffening, widening, and shortening of the neopenis, which allows for sexual intercourse in some patients. Subsequent reconstruction of the urethra is possible.
  
  
• Editorial Comment
  Functioning free muscle flaps have recently been shown to successfully restore volitional voiding in patients with acontractile bladders (1). Apart from the anastomosis of the flap, vasculature to suitable vessels at the recipient site function is achieved by microsurgical coaptation of the motor nerve supplying the flap muscle to a recipient motor nerve supplying an abdominal muscle. The transferred muscle starts acting as a “piggyback” muscle to the same muscle with which it shares its new innervation.
  The authors of this paper have applied the same principle for phalloplasty in female-to-male transsexuals. In addition to obtaining a neophallus, the majority of patients were able to contract the muscle after a mean of 4 months. Almost half of the patients used the muscle contraction to stiffen the penis and were thus able to have intercourse.
  Contrary to the sole use of latissimus dorsi muscle in detrusor, myoplasty phalloplasty needs a large portion of the overlying skin similar to musculocutaneous flaps used for breast reconstruction. Therefore, the rate of donor site morbidity was larger than previously reported (2), but according to the authors, 83 % considered donor site morbidity as acceptable.
  The fact that no urethral reconstruction was done in these patients may be seen as a downfall. However, the possibility of actively stiffening the neophallus may be appealing for some patients. The mean follow-up of almost two years with some patients just followed for a year is too short. Some patients apparently had considerable shrinkage of the graft and this number might get larger with a longer follow-up. However, the concept of using a functioning muscle transfer for phalloplasty is worth to be considered and shows furthermore the possible versatility of this technique applicable in various fields of urology.

References

1. Stenzl A, Ninkovic M, Kölle D, Knapp R, Anderl H, Bartsch G: Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle. Lancet. 1998; 351: 1483-5.
2. Ninkovic M, Stenzl A, Schwabegger A, Bartsch G, Prosser R, Ninkovic M: Free neurovascular transfer of latisstmus dorsi muscle for the treatment of bladder acontractility: II. Clinical results. J Urol. 2003; 169: 1379-83.

Dr. Arnulf Stenzl &
Dr. Karl-Dietrich Sievert
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: Arnulf.Stenzl@med.uni-tuebingen.de