A Study Of Correction Of Penile Defect And Applied Anatomy Of Penile Suspensory Ligament

Backgrounds Penis is important organ of male with urological and generative function. Penile defects, which be caused by iatrogenic penile injury or other reasons, are an uncommon, challenging condition that causes severe physiological and psychological problems. Loss of the glans, penile shaft and/or urethra, although rare, can occur as a complication of iatrogenic penile injury, burn or animal bite. The ultimate goal of reconstructive surgery is to have a penis with normal function and appearance. So far there is not a reconstructive surgery of penis which can make patient with normal erect function and sexual excitement.Objective We investigated a reconstructive method with better sensory and erectile function for partial penile defects and report our long-term results of surgical correction using scrotal skin flaps. We will carry out regional anatomy study of the penile suspensory ligament and the mechanism of penile elongation to provide better date for penile reconstructive surgery. To patient with total penile defect we designed a new penile reconstructive method by use free flap of dorsum of foot.Methods Part I Anatomic dissection of penis and perineum was performed on 20 adult male cadavers. The body height, cause of death and exactage of these cadavers were unknown. Observation and measurement were focused on the penile length of different parts, the morphological relationship of infundibular ligament and suspensory ligament with penile radix, and the feature of cruspenis with relation to the deep penile artery.Part II We retrospectively analyzed the records of 18 patients with penile defects referred to us between 2000 and 2009. All cases were treated with a scrotal skin flap initially to repair the secondary defect after penile elongation.Part III Two patients with total penile defect were carried out a new penile reconstructive method by use free flap of dorsum of foot with a year follow-up.Results Part I The average length of the penile shaft was 8.04 cm, the penile radix was 7.71 cm. The deep penile artery penetrated into the cruspenis at its middle 1. The infundibular ligament attached to superficial fascia of the penis and extended downward to the scrotal septum to constitute the suspensory structure for both of them. The suspensory ligament attached to the dorsal deep fascia of the penis. Becoming thicker, the rear part of the suspensory ligament connected firmly to the pubic arcuate ligament to constitute a part of suspensory mechanism for the urethra. There was a part of cavernous body, which was free from either ligament or bony attachment, between the penile radix and the cruspenis, where the dorsal artery and nerve of penis turned around from the ventral to the dorsal aspect of the penis and the penile dorsal vain penetrated the urogenital septum, draining into intrapelvic venous plexus. The deep component is closely adhering to lower pubic branch.Part II Of the 18 cases treated during the 9-year period the mechanism of primary injury was circumcision in 3, animal bite in 9 and penile tumor dissection in 6. Penile elongation, division of the suspensory ligament and scrotal skin flaps achieved penile augmentation and enhancement. Six cases were treated with a bilateral scrotal skin flap supplied by the anterior scrotal artery and 12 were repaired with a total anterior scrotal skin flap supplied by the anterior and posterior scrotal arteries. Penile length in the flaccid and erectile states was obviously increased postoperatively （p₀.05）. All patients were followed 1 to 9 years （mean 2.3） postoperatively. Deep and superficial sensation recovered and erectile function was retained. Of the 18 patients 15 reported satisfied sexual intercourse during the 0.5 to 5-year follow-up.Part III Two patients with total penile defect were caused by iatrogenic trauma. They were carried out long time microwave treatment after circumcision and their penis was necrosis one week later. Two operation s were dong:the necrosis penis is cutting off in the first-stage operation and the reconstructive penis in ht second-stage with free dorsum pedis flap supplying by dorsum pedis artery. The donor artery is superficial iliac circumflex artery. They got good results in terms of cosmetic outcome, function, low rate of complications.Conclusion Part I The divisional measurement of the penis length, the recognition of the suspensory ligaments and the anatomic feature of the cruspenis with relation to the deep penile artery are all of significant importance to improve the operation of penis reconstruction, but The extra length gain from this surgery may be limited by the nonstretchable neurovascular pedicle lying in the penile hilium.Part II The method of correcting partial penile defect using scrotal skinflaps is effective and simple according to our long-term experience. This method achieves reasonable cosmesis and penile length in most cases with better sensory and erectile function.Part III Phalloplasty with free dorsum pedis flap has the ability of the free radial forearm free flap and reduce the limits such as donor-sitemorbidity, and, in terms of function, bulkiness. We concluded by affirming that the free dorsum pedis flap should be considered as the standard in penile reconstruction.