GU Reconstruction Flashcards
A 34-year-old man with schizophrenia is examined 1 hour after amputating his penis at the base of the shaft with a cleaver. The penis has been retrieved and a decision is made to attempt microvascular replantation. Repair of which of the following arteries is paramount to a successful outcome?
A) Bulbourethral
B) Deep cavernosal
C) Dorsal penile
D) Helicine
E) Internal pudendal
The correct response is Option C.
The blood supply to the penis arises from the internal pudendal arteries, which continue into the penis as the bulbourethral artery (supplying the bulb of the penis and penile urethra), the deep corporal/cavernosal artery (responsible for erection and supply to the penile shaft), and the dorsal penile artery (supplying the penile skin). A meta-analysis has shown that repair of the dorsal penile artery predicted the best combined sexual function, urinary function, and sensation outcomes. Repair of the deep corporal/cavernosal artery did not correlate with improved outcomes. The helicine artery is one of the terminal branches of the dorsal penile artery, and is distal to the site of amputation. The internal pudendal artery supplies the penis, but more proximal than the site of amputation.
2018
A 32-year-old patient, who was born as a female, identifies as male and requests breast reduction surgery for a masculine appearance. The patient has C-cup breasts with grade 2 ptosis. Which of the following is the most appropriate surgical option?
A) Liposuction
B) Periareolar breast reduction
C) Circumvertical breast reduction
D) Wise pattern breast reduction
E) Mastectomy with free nipple graft
The correct response is Option E.
The most appropriate treatment for this patient is a free nipple graft and mastectomy due to breast size and nipple ptosis. Gender dysphoria is a commonly acknowledged disorder, affecting up to 0.3% of the population. Hundreds of patients have undergone subcutaneous mastectomy surgery with a high reported patient satisfaction rate. Smaller-sized patients can achieve excellent results with periareolar mastectomy or donut excision to reduce large areola size. Large patients with ptosis, similar to gynecomastia surgery, require longer scars for skin removal and have good results, but longer scars. One study of outcomes found that patients and surgeons preferred the outcome appearance with free nipple graft and a single inframammary crease scar versus an extended areola incision with scars across the mid chest.
Neither liposuction nor periareolar reduction would adequately reduce the skin envelope and breast tissue. Circumvertical and Wise pattern breast reduction would create a more feminized shape.
2017
A 35-year-old man is brought to the emergency department for penile amputation at the base of the shaft. The amputated part has been appropriately transported with the patient. Revascularization of which of the following vessels will result in the highest probability of successful replantation?
A) Bulbar artery and vein
B) Cavernosal artery and vein
C) Deep dorsal arteries and vein
D) Internal pudendal artery and vein
The correct response is Option C.
The most important vessels to anastomose in this clinical scenario are the deep dorsal arteries and vein. There are two deep arteries and one deep vein. There is a superficial dorsal vein as well, but no superficial dorsal artery runs with it. The vascular supply of the penis is from the internal iliac system, not the external iliac system. The internal pudendal artery comes off the anterior division of the internal iliac artery and is the main blood supply to the penis. It branches into the bulbar, cavernosal, and dorsal penile arterial branches. The other vessels listed are all involved in the blood supply to the penile structure, but are too small, less accessible, or too proximal for replantation purposes. The deep dorsal vessels alone can adequately revascularize the whole penile structure. The steps in replantation include: formation of a suprapubic urinary diversion, urethral anastomosis over a Foley catheter, corporal body coaptation by approximating the tunica albuginea, microsurgical anastomosis of the dorsal vessels and coaptation of the dorsal nerves, and skin closure.
2017
A 58-year-old woman is evaluated for squamous cell carcinoma of the posterior vagina. Wide local excision of the vagina with flap reconstruction is planned. Which of the following flap options is most likely to provide a reconstruction that is sensate immediately after surgery?
A) Gracilis myocutaneous
B) Oblique rectus abdominis myocutaneous
C) Pedicled anterolateral thigh perforator
D) Pudendal thigh (Singapore)
E) Vertical rectus abdominis myocutaneous
The correct response is Option D.
The pudendal thigh flap is an axial patterned flap based on terminal branches of the superficial perineal artery. The superficial perineal nerve follows the course of this artery and becomes the posterior labial nerve to provide sensation to the proximal skin paddle. The superficial perineal nerve arises from the pudendal nerve. In a series of 19 patients who underwent pudendal thigh flap reconstruction, all reported sensation. The gracilis myocutaneous flap may provide some pressure sensation from cutaneous branches of the obturator nerve, although this is inconsistent. The anterolateral thigh perforator flap and vertical or oblique rectus abdominis myocutaneous flap may be neurotized to provide sensation; however, this would not result in immediate sensation.
2017
A 25-year-old woman who is considering female-to-male gender reassignment surgery inquires about penile reconstruction. The patient is interested in a technique that would involve the fewest number of total procedures. Which of the following techniques would be most appropriate?
A) Free fibula flap
B) Free radial forearm flap
C) Metoidioplasty
D) Pedicled groin flap
E) Tissue expansion
The correct response is Option C.
Currently, there are several techniques available for penile reconstruction in patients undergoing female-to-male sex reassignment. Multiple goals are sought, including good appearance, standing micturition, sexual sensation, coital ability, and sufficient bulk to accommodate a stiffener.
In metoidioplasty, the clitoris is partially released and stretched, and the urethra is lengthened to reach the tip of the phallus using an anterior musculomucosal vaginal flap, which is done as a single-stage procedure. The advantages of this technique are a shorter procedure and lower risk of complications. Its disadvantages are a shorter phallus with decreased possibility of standing micturition.
Phalloplasty, in which a phallus is created de novo, can be performed using a variety of possible flaps, including anterolateral thigh, fibula, groin, latissimus dorsi, and radial forearm. Phalloplasty can seldom be performed in one stage because of the need to create a competent neourethra and is associated with a 20 to 40% rate of urinary complications (fistulas, stenoses). Soft-tissue-only flaps typically involve placement of a stiffener, which can be prosthetic or autologous, while the fibula flap results in a permanent erection. Free flaps (radial forearm, latissimus, fibula) involve lengthier microsurgical procedures, while some pedicled flaps (groin) necessitate a minimum of two stages.
Tissue expansion is not a method used for penile reconstruction in female-to-male sex reassignment surgery.
2016
A 56-year-old man comes to the office because of recurrent and locally advanced rectal cancer 2 years after undergoing low anterior resection and adjuvant chemotherapy and radiation therapy. Surgical extirpation involving the external perianal skin, anus, rectum, and musculature of the pelvic floor is performed. Which of the following is the most appropriate method of perineal reconstruction in this patient?
A) Gracilis flap
B) Local propeller flap
C) Omental flap
D) Rectus abdominis musculocutaneous flap
E) Rectus femoris flap
The correct response is Option D.
In the clinical setting of the patient described, the method for perineal reconstruction that has the most evidence to support it is the vertical rectus abdominis myocutaneous (VRAM) flap. Omental flaps are effective for smaller defects that primarily involve internal structures. Primary skin closure, local advancement flaps, and propeller flaps are not ideal in the setting of prior radiation because of the high risk of wound-healing complications. Gracilis flaps are low in volume and may be useful for smaller defects, although bilateral flaps can be adequate for moderate-sized defects. This patient has a large composite defect that will benefit from the large volume and cutaneous component of a VRAM flap.
2016
A 42-year-old woman is scheduled to undergo penile reconstruction with a fibula flap as part of gender reassignment. She has been evaluated by all appropriate specialists in the context of a multidisciplinary transgender clinic. Which of the following is the most significant advantage of the fibula flap over the forearm flap in this patient?
A) Ability to create an innervated skin island
B) Avoidance of prosthesis to provide sexual function
C) Decreased incidence of urethral stricture
D) Improved sensory recovery
E) More reliable and constant anatomy
The correct response is Option B.
The most significant advantage of the fibula flap over the forearm flap in penile reconstruction is the avoidance of a prosthesis to provide erectile and sexual function. Another advantage is the less conspicuous donor site. Both flaps allow for the creation of an innervated skin island. The fibula skin island can be innervated via the superficial peroneal nerve, and the forearm skin island can be innervated via the medial and lateral antebrachial cutaneous nerves. The forearm flap utilizes vascularized forearm skin for the neourethra, whereas the fibula flap employs a full-thickness skin graft. Thus, the incidence of urethral stricture is greater with the fibula flap. Both flaps are based on reliable and relatively constant anatomy, although the septocutaneous branch of the peroneal artery to the skin of the fibula flap can be variable or even absent. One disadvantage of the fibula flap is that sensation is not as good as with the forearm flap.
2016
A 56-year-old woman undergoes abdominoperineal resection secondary to aggressive rectal cancer. Neoadjuvant chemotherapy and radiation therapy have been performed. Surgical examination shows defect of the anus, rectum, and posterior vaginal wall. An intraoperative photograph is shown. Which of the following is the most appropriate reconstructive option in this patient?
A) Bilateral Singapore (pudendal thigh) flaps
B) Gracilis muscle flap
C) Omental flap
D) Rectus femoris flap
E) Vertical rectus abdominis musculocutaneous flap
The correct response is Option E.
As the treatment of anorectal cancers has shifted to more sphincter-preserving surgeries and radiochemotherapy, the need for abdominoperineal resection (APR) has decreased. However, in cases of locally persistent disease, involvement of nearby structures (vagina), or recurrent disease, there is an increased rate of survival and improved quality of life with pelvic extirpation. These cases typically result in problematic wounds secondary to previous radiation therapy, with complication rates as increased as 60%. Complications include delayed wound healing, infection, internal hernia, chronic sinus formation, and the psychological and physical concerns associated with vaginal resection in the female patient. In an effort to minimize these complications and restore sexual function in the female patient, musculocutaneous flap reconstruction is recommended.
In the patient described, the most appropriate option for reconstruction is the vertical rectus abdominis musculocutaneous (VRAM) flap.
The advantages of the rectus flap include an excellent and safe pedicle (Mathes/Nahai Type III flap), rapid technique, abundant well-vascularized tissue, wide arc of rotation, acceptable donor-site morbidity, and ease of access in relation to the APR procedure. The well-vascularized bulky tissue is effective in obliterating the pelvic dead space, minimizes the risk of internal herniation of the abdominal contents, and provides healthy tissue in the event of suture line dehiscence allowing more rapid healing by secondary intention if necessary. The disadvantages of the VRAM include lack of sensation in the vagina/perineum, loss of secretory function that may result in dyspareunia, abdominal weakness/hernia, and unsightly bulk in the perineum that may require a secondary debulking procedure for aesthetic improvement. In the patient described, the decision was made to close the perineal skin over the de-epithelialized flap. Another patient is shown below with a perineal skin paddle.
Primary closure is inappropriate secondary to the increased rate of complications and poor sexual function without reconstruction as noted above. Bilateral pudendal thigh (Singapore) flaps are a great option for vaginal or labial reconstruction in the congenital or ablative setting when there is not a need for a large volume of tissue. In this case, the flaps are not an option because of the need for bulky tissue, previous radiation therapy administered to the base of the flaps, and transection of the flap’s blood supply (posterior labial artery). The extended groin flap is inappropriate for the same reason.
A skin graft is not likely to be successful, given the patient’s radiation history and violation of the rectum.
2016
A 51-year-old patient presents for male-to-female gender confirmation surgery. World Professional Association for Transgender Health (WPATH) guidelines have been met, and the patient is deemed a good candidate for penile inversion vaginoplasty. Which of the following is the most likely long-term complication of this procedure?
A) Neovaginal stenosis
B) Partial prolapse
C) Rectovaginal fistula
D) Urethrovaginal fistula
E) Urologic dysfunction
The correct response is Option A.
In contrast to female-to-male gender confirmation surgery, where complications of urological reconstruction and anastomosis are most common, in male-to-female gender confirmation surgery the most common complication is neovaginal stenosis. A recent literature review suggests that this is true for both penile inversion and bowel vaginoplasty.
2019
A 21-year-old patient comes to the office seeking genital surgery for female-to-male gender confirmation. The patient is an appropriate candidate for phalloplasty with a radial forearm free flap. Which of the following is the most common complication of this technique?
A) Dissatisfaction with the aesthetic result
B) Formation of urethral strictures and fistulas
C) Inability to void while standing
D) Lack of sensation in the neophallus
E) Partial or total flap loss
The correct response is Option B.
The radial forearm free flap is the most commonly used technique for phalloplasty. A neophallus with a length of 7.5 to 14 cm can be reconstructed. The tube-within-a-tube design is commonly employed, in which the flap is tubed to create a neourethra over which the remainder of the flap is tubed to create the bulk of the flap. The clitoris is de-epithelialized and placed under the neophallus. Vascular anastomosis of the radial artery is performed to the inferior epigastric or femoral vessels. The medial and lateral antebrachial cutaneous nerves are coapted to the ilioinguinal nerve and the dorsal nerve of the clitoris or deep pudendal nerve to provide tactile and erogenous sensation.
The goals of phalloplasty are: creation of an aesthetically pleasing neophallus, with tactile and erogenous sensation, the ability to micturate while standing, and the ability to perform penetrative sexual intercourse.
The most common complications of phalloplasty are urologic, with an incidence of approximately 40%. A recent review of radial forearm free flap phalloplasty showed an average rate of fistula formation of 26.58% and strictures of 12.27%. The most common location for fistulas and strictures is at the anastomosis of the fixed urethra and the phallic urethra. Approximately half of these can be managed nonoperatively, with suprapubic catheter placement and endoscopic fistula dilation. Another recent systematic review of radial forearm free flap phalloplasty showed that 69% of patients reported erogenous sensation and 77% reported tactile sensation in their neophallus. Another review showed that standing micturition was achieved in 97.5% of patients and successful penetrative sexual intercourse was reported by 21.1%. The overall rate of partial flap loss was 5.43% and total flap loss was 1.69%. Overall 70% of patients reported satisfaction with the aesthetic result.
2019
A 16-year-old transmasculine (female-to-male) patient is evaluated for bilateral mastectomy for gender confirmation. According to the World Professional Association for Transgender Health (WPATH) Standard of Care Guidelines, this procedure is considered to be medically necessary, appropriate, and indicated when which of the following conditions is met?
A) The patient has the capacity to make a fully informed decision
B) The patient has had 6 months of continuous hormone therapy
C) The patient has one physician who can document gender dysphoria
D) The patient has recently started pharmacologic therapy for depression
E) The patient must be at least 21 years of age
The correct response is Option A.
The criteria among most insurance plans for coverage of procedures for treatment of gender dysphoria are quite stringent and rely on the concept of medical necessity for the patient. According to the World Professional Association for Transgender Health (WPATH), which is considered the authority on transgender health, standard-of-care guidelines to verify medically necessary procedures include:
- -the capacity of the patient to make a fully informed decision and provide consent (patients who are younger than 18 may provide assent, along with parental consent, for mastectomy)
- -at least 12 months of hormone therapy, consistent with the individual’s gender goals
- -living life fully in the role of the desired sex for at least 12 months
- -psychiatric illnesses must be stable and well-controlled
- -documentation of gender dysphoria and the potential benefit from surgery by at least two health-care providers
2019
A 20-year-old otherwise healthy individual who has a diagnosis of gender dysphoria would like to undergo masculinization of the chest for female-to-male transition. According to the World Professional Association for Transgender Health (WPATH) Standards of Care, which of the following criteria should be fulfilled before the patient can be cleared for such a procedure?
A) The patient should be at least 21 years of age
B) The patient should have completed 12 months of hormone therapy
C) The patient should have health insurance coverage
D) The patient should have lived 12 months in a male gender role
E) The patient should have one letter of support from a mental health professional
The correct response is Option E.
The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) lists having one letter of support from a qualified mental health professional as a prerequisite for female-to-male (FTM) chest surgery. As for all of the SOC, the criteria for initiation of surgical treatments for gender dysphoria were developed to promote optimal patient care. While the SOC allow for an individualized approach to best meet a patient’s health care needs, a criterion for all breast/chest and genital surgeries is documentation of persistent gender dysphoria by a qualified mental health professional. For some surgeries, additional criteria include preparation and treatment consisting of feminizing/masculinizing hormone therapy and one year of continuous living in a gender role that is congruent with one’s gender identity. Based on the available evidence and expert clinical consensus, different recommendations are made for different surgeries. For FTM chest surgery, the criteria are as follows:
Persistent, well-documented gender dysphoria
Capacity to make a fully informed decision and to consent for treatment
Age of majority in a given country (if younger, follow the SOC for children and adolescents)
If significant medical or mental health concerns are present, they must be reasonably well controlled
Hormone therapy is not a prerequisite
One referral
For male-to-female breast surgery, it is recommended to have completed 1 year of hormonal therapy, although it is not a specific criterion according to WPATH SOC. For genital surgery, it is recommended to have two referrals, be on 1 year of hormonal therapy, and to have lived in the gender role congruent with their gender identity for at least 1 year. Insurance coverage is not part of any WPATH SOC
2020
A 76-year-old woman presents with a diagnosis of recurrent adenocarcinoma of the rectum after chemotherapy and radiation. The planned oncologic surgical treatment will be an abdominoperineal resection to include the rectum, anus and posterior wall of the vagina, and left end colostomy. She has had a prior laparoscopic bowel resection, but no open abdominal surgeries. Which of the following is the most appropriate surgical management for her planned perineal wound?
A) Bilateral pudendal flaps
B) Omental flap and skin graft
C) Primary perineal closure
D) Right gracilis myocutaneous flap
E) Right vertical rectus abdominis myocutaneous flap
The correct response is Option E.
Abdominoperineal resection and pelvic exenteration in previously irradiated patients create a large-volume non-collapsible dead space in the pelvis that can lead to large persistent perineal wounds. Meta-analysis reviews of existing patient series report that primary perineal closure is associated with twice the rate of perineal wound formation as flap closure. When compared with thigh-based flaps, such as the gracilis flap and gluteal-based flaps, the vertical rectus abdominis myocutaneous flap is associated with lower perineal wound and flap complication rates.
With prior abdominal surgery, the omentum may not be available or of sufficient volume for reconstruction. A skin graft is often applied to the omentum for sternal wound reconstruction, but would not be appropriate for resurfacing of the posterior wall of the vagina in concert with an omental flap.
Bilateral pudendal flaps would be in the previously irradiated field, increasing the potential for wound healing trouble with this flap selection. Additionally, pudendal flaps would not bring the bulk necessary to address an abdominoperineal resection defect.
2020
A 35-year-old affirmed male (birth-assigned female) presents to the office requesting top surgery for a more masculine chest appearance. On examination, the patient has a large C-cup breast, grade 2 ptosis, and a nipple-to-inframammary fold distance of 11 cm. Which of the following surgical options is the most appropriate?
A) Circumvertical reduction mammaplasty
B) Liposuction alone
C) Mastectomy with free nipple graft
D) Periareolar reduction mammaplasty
E) Wise pattern reduction mammaplasty
The correct response is Option C.
The most appropriate surgical procedure in this patient is a subcutaneous mastectomy with free nipple graft due to breast size and ptosis. Top surgery, or excision of the female breast tissue and shaping of the male chest, is often the first surgical procedure for female-to-male transgender patients. This marks the beginning of their surgical transition into a masculine phenotype and is associated with profound and impactful psychological and aesthetic benefits for the individual. The goal of top surgery is to produce a normal-appearing male chest. This is achieved by removing the breast parenchyma, obliterating the inframammary fold, reducing the areolar size, and positioning the nipple-areola complex into the appropriate position.
There are numerous studies demonstrating excellent results and high patient satisfaction with subcutaneous mastectomy and free nipple grafts in patients with large and ptotic breasts. Additionally, patients with a BMI over 27 kg/m2 and a nipple-to-inframammary fold distance greater than 7 cm demonstrate better outcomes with fewer complications. Periareolar breast reduction also demonstrates excellent results when limited to patients with smaller breasts, minimal ptosis, and a smaller skin envelope.
Liposuction alone will not achieve the goals above and will result in residual breast tissue and excess skin. Additionally, liposuction will not address areolar size or position. Liposuction is useful when combined with other techniques to help feather tissue thickness and contour the edges of the chest. Both Wise pattern and circumvertical reduction mammaplasty will leave behind too much breast tissue and will not create the desired masculine chest appearance.
2020
A 40-year-old transgender woman (assigned male at birth) undergoes penile inversion vaginoplasty for treatment of gender dysphoria. She hopes to gain the ability for penetrative intercourse following surgery. She was counseled on the risks of surgery to include urethral injury, rectal injury, and fistula formation. Which of the following is the most appropriate plane in which to dissect the neovaginal cavity so that those risks may be minimized while obtaining adequate depth for penetrative intercourse?
A) Anterior rectal fascia
B) Prostatic capsule
C) Rectoprostatic fascia (Denonvilliers’ fascia)
D) Rectosacral fascia (Waldeyer’s fascia)
E) Superficial perineal fascia (Colles’ fascia)
The correct response is Option C.
The most appropriate plane in which to dissect the neovaginal cavity in gender affirming vaginoplasty is within Denonvilliers’ fascia, also known as the rectoprostatic fascia. This is a relatively avascular plane that separates the rectum and prostate until reaching the peritoneal fold, when performing the dissection perineally. Once the peritoneal fold is reached, a neovaginal cavity with depth compatible with penetrative intercourse is created.
Dissecting along the prostatic capsule may inadvertently lead toward the prostatic urethra. Injury to the urethra at this level may result in a urethrovaginal fistula and urinary incontinence.
Colles’ fascia is a superficial perineal plane that is continuous with Scarpa’s fascia of the inferior abdomen. Dissection along this plane is necessary initially until the central tendon and perineal body is opened to enter Denonvilliers’ fascia. Dissecting through Colles’ fascia alone and not through Denonvilliers’ fascia will avoid urethral and rectal injury, but will not permit penetrative intercourse in such a short neovaginal cavity.
Dissection along the rectal fascia will expose the longitudinal muscle fibers of the rectum. Not only does this increase the risk of sharp rectal injury during dissection, it will also increase the risk of pressure injury to the rectum when stenting the neovaginal cavity lining and in case of a hematoma. This is not the recommended plane for neovaginal cavity dissection.
Waldeyer’s fascia, also known as the rectosacral fascia, is a presacral fascia along the posterior aspect of the rectum. This is not an anatomic position to create a neovaginal cavity, and therefore is not the recommended plane for dissection.
2021
