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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: