Phalloplasty for male congenital anomalies

Since 1946, when Sir Harold Delf Gillies, an astute otolaryngologist based out London performed what was said to be the first gender reassignment surgical procedure documented within the medical literature, there continues to be tremendous interest and momentum within the field of male genital reconstruction. There are numerous causes of phallic deformation which result in patients seeking surgical intervention from those specialists trained in genital reconstruction.Among male children however, congenital anomalies are not only the most common cause for penile reconstruction but can also be the most devastating to the patient both physiologically and psychologically. Of those congenital malformations leading to the need for consideration of phalloplasty, the most common causes include aphallia, micropenis, severe penile inadequacy, ambiguous genitalia, epispadias, bladder exstrophy and gender reassignment. Historically, those male children who had suffered from severe genital defects were often provided with gender-conversion procedures early on in infancy so as to provide the child with a urological functional construct of female phenotypic identity.This chapter provides a brief history of those surgical techniques, namely local tissue rearrangement, pedicled flaps and free tissue transfer, commonly used for both partial and complete male genital reconstruction, with particular focus on tissue defects subsequent to male congenital anomalies. In addition to a review of reconstructive phalloplasty, we provide a brief outline of published procedural steps for those performing genital reconstruction as well as specific indications and risks associated with each form of soft tissue reconstruction alternative.Finally, like most general reconstructive options, some approaches have fallen out of favor, such as most local pedicled flaps, for more reliable free flap options. Among these free tissue transfer options, the "gold standard" radial forearm free flap, provides single stage reconstruction, intrinsic urethropalsty options, erotic sensation and a potential for prosthetic induced erectile function capable of penetration, intercourse and orgasm.Consideration of these reconstructive efforts for phalloplasty in male congenital anomalies not only requires cooperation between the reconstructive plastic surgeon and the urologist, but also an understanding of how timing of the procedure(s) impacts not only the neophallus but also the psyche of the patient. Among those actively participating in the field, many have agreed on five fundamental criteria when entertaining reconstructive options: (1) The procedure should be reproducible (2) The penile unit should result in a neourethra that is capable of passing urine while standing in those patients who are continent; (3) The neophallus should have both tactile and erogenous sensation; (4) The reconstruction should provide enough bulk to accept a prosthetic for erection and sexual penetration; (5) The penile unit should be aesthetically acceptable to the patient.