Southern Medical Journal, Volume 52, Pages 288-290. March 1959.
Fort Smith, Ark.
Southern Medical Journal, Volume 52, Pages 288-290. March 1959.
Fort Smith, Ark.
PRIOR TO THE ERA of sulfonamide and antibiotic therapy, most cases of necrosis and sloughing of genital skin resulted from infection. In this mechanical age the most common loss of penile skin is avulsion by moving parts of machinery. Technical faults in circumcision, of course, can produce a similar result. Years ago a common method of circumcision was removal of excess skin by electrocautery. The redundant skin was pulled forward, a clamp applied, and the distal portion removed with the electrosurgical blade. This procedure is quick and simple. It controls bleeding, but it may occasionally result in interesting complications. Excessive traction on the foreskin may lead to removal of too much skin, varying amounts of glans may be included in the clamp or excessive current may energize the clamp, charring the skin proximal to it and producing gangrene with slough. We have recently treated such a case.
Repair of genital injuries must strive for cosmetic restoration as well as functional result, since the psychologic injury may be quite as severe and the physical destruction.
Surgery must usually be limited to skin grafting, since replacement of glandular or cavernosal substance cannot be accomplished. The ideal result should supply integument extensive enough to cover the denuded area and elastic enough to accommodate to erection, making allowance for growth in the infant and prepubertal boy. If possible, it is desirable to employ skin free of hair and of good tactile quality. The simplest, but least satisfactory, method is to utilize split thickness grafts from a relatively hairless donor sites such as the arm, thigh, or upper abdomen. Although employed successfully by Thorek,1, Brown2 and others, this procedure supplies relatively inelastic skin, and it is technically difficult to graft skin over a roundedsurface.
Full thickness pedicle grafts from the thigh or adjacent portions involve complicated multistage plastic procedures, and the skin so obtained is often too thick, lacking the necessary elasticity. Profuse sweating of the grafted skin may also be disturbing to the patient.
The ideal solution is to employ a full thickness graft of scrotal skin which is particularly suitable due to its elasticity, redundancy, and abundant drug supply. Like penile skin, scrotal integument is sparsely covered with hair and rich in sebaceous glands.
Repair can be accomplished either by the sandwich
method (Byars3) of dissecting up flaps of scrotal skin which are approximated over the penis, or by undermining a cuff of scrotal skin and burying the naked penis in this subcutaneous tunnel (Veseen4). The covered penis is freed from this bed at a second stage. In those injuries to the penis which are accompanied by loss of scrotal skin, the same technic may be applied to utilize the adjacent skin in the thigh or abdomen.
Sexually active patients who undergo partial amputation of the penis for carcinoma of the glans usually are able to maintain satisfactory sexual relationships. Thus, attempts to reconstuct a penis using rib cartilege or an acrylic prothesis should be reserved for virtually complete amputations.
We saw this patient 3 weeks after birth. The child had bene circumcised one day after delivery. The guillotine method of circumcision had been used and the electrocautery employed. Mother and child left the hospital on the 6th postpartum day. One week later another physician examined the child and found the entire penis to be black and gangrenous. Two days later it had apparently sloughed off completely and there remained only a small scarred area at the base.
On physical examination at 3 weeks the penis appeared to have been amputated at its base. All that remained was an area of scarring the size of a five cent piece (Fig.1, a) The patient could void a stream about the caliber of a #23 hypodermic needle through a hairlike orifice in this scar. Cavernosal tissue could be palpated under the scar.
At the age of 3 weeks a first stage procedure was performed under whiskey anesthesia. Scar tissue was excised and after removing dense adhesions, a completely denuded penis was exposed. There was complete loss of the glans, but about two-thirds of the penile shaft was intact. Two horizontal incisions were made an inch apart in the scrotum and the intervening skin undermined to create a subcutaneous tunnel (Fig. 2, b). The penis was inserted under this bridge of full thickness skin and the distal end sutured around the end of the penis leaving the amputated end exposed. (Fig. 1, c). The proximal, horizontal incision was closed vertically, utilizing the Heineke-Mikulitz principle to created increased skin length. (Fig. 1, d). A Furacin dressing was applied. Recovery was uneventful, healing complete and the patient discharged 12 days later.
The second stage was performed six weeks later under open-drop ether. By this time scrotal skin was adherent over the entire penis and the cut distal end completely epithelialized (Fig 1, e). The penis was freed from its subcutaneous bed along with adequate flaps of scrotal skin adherent to the sides and distal end (Fig. 1, f). These three flaps were approximated without tension, over the naked ventral surface and the scrotal incision closed vertically (Fig. 1, e) The penis was freed from its subcutaneous bed along with adequate flaps of scrotal skin adherent to the sides and distal end (Fig. 1, f). These three flaps were approximated, without tension, over the naked ventral surface and the scrotal incision closed vertically (Fig. 1, g). A meatotomy was performed to insure an adequate urethral orifice. Recovery for this second procedure was also uneventful.
The child is now four and one-half years after the operation, with a good functional and cosmetic result (Fig 2 a and b). He is voiding with a large stream (Fig 2, c).
* Read before the Section on Urology, Southern Medical Association, Fifty-Second Annual Meeting, New Orleans, La., November 3-6, 1958.
† From the Holt-Krock Clinic, Fort Smith, Ark.
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