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Background: Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex., Objective: This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty., Materials and Methods: A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical., Results: A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement., Conclusion: Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective To determine the prevalence of patients who require vaginal cavity remnant excision and obliteration during neourethral stricture repair and to characterize the histological composition of the excised tissue. Methods A retrospective review was performed of all transgender men who underwent neourethral stricture repair. Preoperative imaging and operative reports were reviewed to determine the presence of a vaginal cavity remnant that was excised and obliterated during neourethral reconstruction. Pathology slides were reviewed by 2 pathologists to determine if there was presence of stratified squamous epithelium consistent with vaginal tissue within the vaginal cavity remnant. Results A total of 47 consecutive transgender men underwent neourethral stricture repair between January 2014 and December 2020. Of these, 18 patients (38%) with a mean age of 37 years (23-59) underwent excision and obliteration of a vaginal cavity remnant. Seventy eight percent (14/18) had a prior phalloplasty and 22% (4/18) had a prior metoidioplasty. Primary vaginectomy type was not associated with whether or not a patient had a vaginal cavity remnant (P = .12). Histological evaluation demonstrated the presence of vaginal epithelium in all vaginal cavity remnant specimens. Conclusion A high percentage of transgender men with neourethral strictures present with vaginal cavity remnants despite prior vaginectomy. Pathological evaluation confirms that all vaginal cavity remnant specimens contain vaginal epithelium that was either incompletely excised or regenerated. While the implications of this residual vaginal epithelium require further investigation, total removal of vaginal tissue primarily or during reconstruction is important given the risk of associated symptoms.

Objective To describe the outcomes of single-stage and staged repairs in properly selected patients with phalloplasty anastomotic strictures. Methods A bi-institutional retrospective review was performed of all patients who underwent anastomotic stricture repairs between 7/2014-8/2020. Those who had prior augmented urethroplasties or poorly vascularized tissue underwent two-stage repairs (Group-2), all others underwent single-stage repair with a double-face (dorsal inlay and ventral onlay) buccal mucosal graft urethroplasty (Group-1). Postoperatively, urethral patency and patient reported outcome measures (PROMs) were assessed. Results Twenty-three patients with anastomotic strictures were identified. Fourteen patients met inclusion criteria and had 1-year follow-up (9 in Group-1; 5 in Group-2). Nine patients (64%) had prior failed interventions (56% Group-1; 80% Group-2). At a mean follow-up of 33.9 (Group-1) and 35.2 months (Group-2) there were two stricture recurrences in Group-1 (22%) and none in Group-2. PROMs were completed by 12 patients. All patients reported the ability to void standing. Post-void dribbling was present in the majority of patients (7/7 Group-1; 2/4 in Group-2). Mean IPSS was 3.9 (0-14) for Group-1 and 1 (0-3) for Group-2. All reported at least a moderate improvement in their condition on GRA (Group-1 +3 71%, +2 29%; Group-2 +3 100%). Conclusion Single-stage repairs are feasible for patients with anastomotic strictures who have well vascularized tissue and no prior single-stage buccal mucosa augmented urethroplasty failures. Staged repairs are feasible for patients with poor tissue quality. Proper patient selection is important for successful reconstruction.

Objective To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty. Materials and Methods After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications. Results In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks. Conclusion Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

Background Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate. Objective To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes. Methods We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique. Results For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2). Conclusion We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications.

Objective: To describe an easy-to-perform surgical refinement to create a meatal appearance in phalloplasty without urethral lengthening by using a triangular flap extension., Methods: Transgender men undergoing phalloplasty without urethral lengthening are candidate for this flap extension. A triangular flap is drawn at the distal part of the flap. When the flap is raised, this triangle is raised with the flap and subsequently folded in the tip of the neophallus, thus creating a neomeatal appearance., Results: We present this easy-to-perform technique, our experience and postoperative results. Two pitfalls of this technique are: (1) when it is insufficiently trimmed and thinned, it adds too much bulk to the phallic top and (2) when it is insufficiently vascularized, wound healing problems will occur; especially since the neophallus will swell in the immediate postoperative phase., Conclusion: Using a triangular flap extension is an easy method to create a neomeatal appearance., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

OBJECTIVE Gender-affirming vaginectomy treats gender dysphoria associated with the presence of a vagina in transgender males. 1 , 2 Prior reported approaches include transperineal vaginectomy, mucosal fulguration, and robotic-assisted. We present key steps in transperineal gender-affirming vaginectomy in a 39-year-old transgender male. METHODS Informed consent for video recording was obtained. The patient underwent a first-stage phalloplasty 6 months prior. He was placed in high lithotomy Tredelenberg position. After Foley placement, an incision was made along the mucocutaneous junction laterally and posteriorly. The anterior sulci were incised and a transverse incision made anteriorly at the bladder neck. The vaginal mucosa was excised, except for the distal anterior vaginal wall mucosa which would be mobilized as a flap for urethral lengthening later. The paravaginal space was closed with a series of purse-string sutures starting at the apex. The anterior vaginal wall flap is mobilized with the base of the flap at the urethral meatus. Cystoscopy confirms ureteral patency and no lower urinary tract involvement. A suprapubic tube was placed. The procedure then proceeded with a second-stage phalloplasty that included urethral lengthening and scrotoplasty. RESULTS The demonstrated procedure took 110 minutes and estimated blood loss was 75 mL. In our published series of 40 vaginectomies for 27 phalloplasties and 13 metoidioplasties, median operative time was 135 minutes and median estimated blood loss was 250cc. 3 No complications related to the vaginectomy, including mucocele, fistulae to the vaginal space, or visceral injuries occurred. Peritoneal entry occurred in 44% of the cases and was closed primarily without further sequelae. Two patients required blood transfusion and 1 patient had C. difficile colitis. The anterior vaginal wall mucosa flap was incorporated in 83% of the time. CONCLUSION Transperineal vaginectomy results in low periprocedural complications, takes approximately 2 hours after a learning curve. Detailed results from our series of these procedures have been previously reported. 3

Objective To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere. Methods We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using the Fisher's exact test to determine differences in presenting symptoms by GRS. Results Fifty-five patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n = 47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n = 31, 56%) and vaginal remnant (n = 26, 47%). The majority of patients presented with 2 or more simultaneous complications (n = 40, 73%). Conclusion There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

Objective To report our novel technique and mid-term follow-up for robotic-assisted laparoscopic vaginectomy (RALV), a component procedure of staged gender-affirming penile reconstructive surgery. Materials and Methods The records of patients seeking gender-affirming penile reconstructive surgery who underwent RALV, performed by a single surgeon at our institution, between May 2016 and January 2020 were reviewed retrospectively for demographic and perioperative data. Patients were included irrespective of history of previous phalloplasty. A subset of these patients elected to have urethral lengthening during second stage phalloplasty for which an anterior vaginal mucosa flap urethroplasty was performed. Postoperative complications and outcomes and most recent follow-up were obtained. Results A total of 42 patients were reviewed, of whom 19 (45%) patients ultimately had radial forearm free flap, 15 (41%) had anterolateral thigh flap, 5 (12%) had metoidioplasty, and 1 (2.4%) had abdominal phalloplasty. A vaginal mucosa and gracilis flap was used in all of 36 (86%) patients in whom a pars fixa was created. Average operative time was 299 minutes (range 153-506). Median estimated blood loss was 200 mL (range 100-400). Median length of stay was 3 days (range 1-7). Complications within 30 days from surgery occurred in 15 patients (36%), of whom 12/15 were Clavien-Dindo grade 1 or 2, and 11/15 had complications unrelated to vaginectomy. Of the 4 patients who had vaginectomy-related complications, all resolved with conservative management. Median overall follow-up was 15.8 months. Conclusion RALV offers a safe and efficient approach during staged gender-affirming penile reconstruction and may mitigate the subsequent risk of urethral complications.

Objective To determine the effect of the postpenile surgery illustrated healing atlas on caregivers' anxiety levels pre- and postoperatively, the frequency of family's postoperative communication with the urology care team, and the number of unplanned emergency room (ER) return for wound checks. Methods A prospective cohort enrolled children who underwent penile surgeries (distal hypospadias repair and phalloplasty) with no concomitant procedures from December 2016 to June 2017. A 6-item short-form Spielberger State-Trait Anxiety Inventory (STAI) was used to determine baseline and postoperative anxiety levels of the caregivers. Two groups were created: caregivers who did not view the illustrated atlas vs caregivers who were shown the atlas. Baseline characteristics and demographics were compared, along with caregiver's pre- to postoperative anxiety level difference, frequency of postoperative communication, and number of unplanned ER return for wound checks. Results Fifty-four patients were enrolled with 27 families in each group. Baseline characteristics and demographics were comparable with no significant differences. The assessment of the pre- to postoperative anxiety levels in both groups showed no significant differences (median difference −5 [interquartile range −8 to −5] vs −5 [interquartile range −8 to −4], P = .94). Although no differences were noted for ER-return rates between the groups (18% vs 11.1%, P = .704), significantly less postoperative calls and e-mails were noted among families who received or viewed the postpenile surgery illustrated healing atlas (51.9% vs 11.1%, P = .003). Conclusion The utilization of a postpenile surgery illustrated healing atlas as part of the postoperative support provided to families was able to decrease postoperative calls and e-mails.

Phallic reconstruction is an important part of management for congenital aphallia. Scrotal flap phalloplasty has been described in pediatric patients to create the appearance of a nonfunctioning phallus. We describe a modified scrotal flap technique with the addition of an acellular dermal matrix patch (AlloDerm) to provide additional girth and support to the phallus. The postoperative cosmetic outcome has been satisfactory and there is no documented complication over a 12-month follow-up. AlloDerm dermal matrix can be a safe addition to phallic reconstruction and its overall application needs to be further studied.

Objective To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report postoperative outcomes. Materials and Methods Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26-50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20-39) post-op following their primary vaginectomy and radial forearm free flap (n = 3) or anterolateral thigh (n = 1) phalloplasty. All had multiple urologic complications after primary phalloplasty, most commonly urinary retention (n = 4), urethral stricture (n = 3), fistula (n = 3), dribbling (n = 2), and obstruction (n = 2). Indication for revision was obstruction and retention (n =3 ) and/or dribbling (n = 2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal, or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum. Results At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up. Conclusion Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.

As gender-affirming genital surgery for transgender men becomes more common, general urologists may be confronted with unfamiliar anatomy and complications. We describe the use of voiding cystourethrogram and retrograde urethrogram in a transgender man in demonstrating the anatomy of the urethra, urethrocutaneous fistula, and a vaginal remnant after phalloplasty.

Objective To evaluate the feasibility and outcomes of full thickness penile skin grafting (FTSG) for phalloplasty during acquired buried penis repair. Materials and methods A retrospective cohort study of patients undergoing complex genital reconstruction for buried penis between January 2013 and April 2018 was performed. Patients undergoing FTSG were identified. All patients underwent escutcheonectomy, scrotoplasty, and penile skin grafting by a single Urologist (MM) and Plastic surgeon (JS). Escutcheon tissue was used for the FTSG. The primary outcome was graft take and the secondary outcome was recurrence requiring surgical revision. Results Thirteen patients were identified for inclusion in the study with average age of 43.4 and average BMI of 42. Median (range) follow-up for the cohort was 8 (3-44) months. Surgical indication was lymphedema in 6 (46.2%), morbid obesity in 6 (46.2%), and hidradenitis suppurativa in one (7.7%). Seven required concurrent urethromeatoplasty for meatal stenosis and fossa navicularis strictures. All grafts were successful. Two patients developed postoperative wound infections requiring antibiotics. One patient redeveloped lymphedema of the scrotum and required complete revision surgery although the FTSG remained intact. No patients had reburying of the penis. Minor outpatient surgical revision was performed for 2 patients for scarring and edema of the glans. Conclusion Full thickness skin grafts provide a useful option for penile reconstruction during surgical management of buried penis. Patients had excellent graft acceptance and minimal wound complications. Further research and comparative cohorts are warranted to fully determine the role of FTSG in genital reconstruction.

OBJECTIVE After gender-affirming phalloplasty the anastomosis between the perineal urethra (pars fixa) and the penile urethra is the most common site of stricture. 1 Excisional urethroplasty after phalloplasty is known to have high failure rates due to poor vascularization of neourethra. 2 Our objective is to demonstrate the feasibility of a single-stage repair of neophallus anastomotic strictures using a “double-face” urethroplasty technique. METHODS All patients who presented with anastomotic neophallus strictures and underwent a “double-face” buccal mucosal graft (BMG) urethroplasty were identified. Preoperatively, all patients had retrograde urethrogram and voiding cystourethrogram. Intraoperatively, pars fixa was exposed through a perineal dissection. A ventral sagittal urethrotomy followed by a dorsal urethrotomy was carried 1-2 cm beyond the stenotic area. An Asopa-type BMG inlay was performed by securing an appropriately sized BMG dorsally. 3 A separate ventral graft was placed in a “double-face” technique described by Palminteri. 4 Surrounding tissue analogous to Martius flap was rotated medially to support the ventral graft. Retrograde urethrogram and voiding cystourethrogram and voiding trials were performed three weeks postoperatively. Patients were followed for stricture recurrence and patient-reported outcome measures. RESULTS Thirty-one patients presented for neophallus stricture repair between December 2014 and December 2019. Of these, 9 underwent a single-stage repair of an anastomotic stricture after radial forearm flap phalloplasty, 8 were available for follow-up. At a mean follow-up of 31 months (10-56), there were 2 (25%) stricture recurrences treated with perineal urethrostomy in 1 patient and staged urethroplasty in another. Ultimately, 7 of 8 patients reported the ability to void in upright position and all reported an improvement in their condition following surgery. Mean International Prostate Symptom Score postoperatively was 3.1 (0-11), International Prostate Symptom Score -QOL 0.9 (0-3). CONCLUSION A single-stage double-face BMG urethroplasty is a feasible option for select patients with post-phalloplasty anastomotic strictures, 5 demonstrating promising early surgical success rates and high patient satisfaction on patient-reported outcome measures.

To present our technique of musculocutaneous latissimus dorsi (MLD) free-flap total phalloplasty. This technically demanding female-to-male gender reassignment surgery consists of creating a neophallus from extragenital tissue.The presented technique included: removal of internal and/or external female genitalia, creation of neophallus using latissimus dorsi free flap, clitoral incorporation into the neophallus, urethral lengthening, and insertion of testicular implants into the newly created scrotum. The MLD flap with proper dimension is harvested from nondominant side and tubularized. Microvascular anastomosis is done between thoracodorsal vessels and femoral artery and saphenous vein. Neophallus is positioned in adequate place. Urethroplasty is performed by combining different genital flaps that are harvested from anterior vaginal wall, urethral plate, and both labia minora and clitoral skin. Scrotoplasty is done by joining both labia majora with implantation of testicular implants.Operative time was 427 minutes with minimal blood loss. Both donor site and graft healed well, and the patient reports voiding well while standing. Penile prosthesis implantation as well as neophallic urethroplasty are planned for the second stage.Total MLD flap phalloplasty with urethral lengthening is a challenging and complex surgical procedure. This technique presents good variant for female transgenders with acceptable cosmetic outcome and enables good volume of neophallus, sexual arousal, and voiding while standing.

Objective To provide sexual function and quality of life outcomes in patients with severe penile deficiency who underwent radial forearm flap phalloplasty with and without penile prosthesis implantation. Patients and Methods Patients with history of severe penile deficiency who underwent microsurgical radial forearm flap phalloplasty with and without penile prosthesis implantation between 2007 and 2014 were identified. They completed a set of web-based validated questionnaires including the International Index of Erectile Function, the Pediatric Penile Perception Score, the Sexual Quality of Life for Men, and several items addressing general quality of life. Outcomes were compared between groups. Results Nine of the 12 identified patients who had prosthesis after phalloplasty and 4 out of the 7 phalloplasty-only patients completed the survey, resulting in an overall response rate of 68%. Among the phalloplasty-prosthesis patients, 66% reported current sexual activity and 78% reported regular masturbation, whereas 1 of the 4 phalloplasty-only patients reported both. Prosthesis patients scored notably higher in all domains of the International Index of Erectile Function except for sexual desire. In contrast, they demonstrated similar scores of penile perception, as well as general and sexual quality of life. Conclusion Among patients who have undergone flap phalloplasty, the subsequent placement of penile prosthesis appears to effectively allow for both intercourse and masturbation, resulting in measurable improvements in orgasmic function, intercourse satisfaction, and overall sexual satisfaction. Despite these important benefits, prosthesis placement does not appear to result in improvements in penile perception scores, or general or sexual quality of life.

Objective To improve the donor-site morbidity of the radial forearm flap through coverage with a free vascularized groin flap and comparing this flap coverage to the current standard, a full-thickness skin graft (FTSG). Materials and Methods A retrospective analysis of all free radial forearm flap phalloplasties for transgender surgery at our institution was performed. We examined patient characteristics, donor site defects, surgical procedure, and clinical courses. Results Between October 2013 and February 2016, 27 consecutive patients underwent phalloplasty for female-to-male reassignment surgery with free radial forearm flaps. A total of 7 free groin flaps (group A) and 20 full-thickness skin graft from the groin region (group B) for donor-site defect coverage of the forearm were performed. The mean age in group A was 28.4 years with a mean body mass index of 21.6 kg/m2 and a mean follow-up time of 10.6 months. The mean surgery time was 724 minutes. The mean patients' functional rating was 3.6 accompanied by the mean patients' aesthetical rating of 3.7. The mean age in group B was 30.5 years with a mean body mass index of 23.7 kg/m2 and a mean follow-up time of 13.4 months. The mean surgery time was 563 minutes. The mean patients' functional rating was 3.1 accompanied by the mean patients' aesthetical rating of 2.9. Conclusion We suggest that the free microvascular groin flap should be considered for immediate defect closure after phalloplasty with a radial forearm flap due to its beneficial functional and aesthetic results and the low rate of complications.

Objectives To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency. Methods Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction. Results There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed. Conclusions This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

We report on a rare case of aphallia in an X, Y-born male treated at our institution. The child underwent phalloplasty at 5 years of age using the De Castro phalloplasty technique and an abdominal skin flap. Although moderate distal necrosis was seen, the overall immediate and 12-month postoperative results were highly encouraging for our patient. Thus, this technique should be seen as a temporizing reconstructive option for patients with aphallia. Long-term follow-up is necessary to determine whether the neophallic size augments with axial growth and the need for additional intervention to facilitate onset of sexual activity.

OBJECTIVES To introduce a novel questionnaire by which we attempted to identify the most suitable candidates for augmentation phalloplasty surgery for penile dysmorphophobia and to objectively estimate the outcome. METHODS A total of 45 physically normal young adult men who presented with complaints of a "small penis" and were seeking surgical correction were included in the study. In addition to the ordinary evaluation, all completed the questionnaire devised by our department, the Augmentation Phalloplasty Patient Selection and Satisfaction Inventory (APPSSI). The APPSSI aims to quantitatively assess the severity of the condition and the degree of the patient's willingness to undergo penile augmentation and to numerically measure the postoperative result. The APPSSI consists of four questions, with each having five possible answers (scale 0 to 4). Questions 1 through 3 were asked preoperatively (suitability assessment) and questions 1, 2, and 4 postoperatively (outcome evaluation). The eligibility threshold for surgery was a preoperative score of 6 or less. The preoperative scores ranged from 0 (surgery justified) to 12 (surgery not justified), and the postoperative scores ranged from 0 (disappointed) to 12 (excited). The Student t test was used for statistical analysis, and P

Hidradenitis suppurativa is a chronic, recurrent inflammatory disease affecting the cutaneous apocrine glands and resulting in their obstruction. This enigmatic disease causes recurrent episodes of infection, edema, scarring, and fibrosis of surrounding tissues. We present the case of a 55-year-old man with two decades of inguinal hidradenitis suppurativa that resulted in extensive penile subcutaneous lymphedema and enlargement secondary to scarring and obstructive lymphadenopathy. Reconstructive phalloplasty to restore normal penile function was required. Minimal recurrent induration, normal cutaneous sensation, and normal voiding and erectile function were noted at 3 years of follow-up.