V09-01: Bladder exstrophy radial artery phalloplasty: exstrophy related issues and saphenous vein interposition graft
Bladder exstrophy is a congenital abnormality that occurs along a spectrum of the exstrophy-epispadias complex. Cases of penile reconstruction are often difficult in men with bladder exstrophy due to prior and potential future surgeries and abnormal anatomy. Interposition grafts may be used in cases where vessels cannot be anastomosed directly.
This video shows the surgical steps of complex penile reconstruction and discusses specific exstrophy related issues. A 37 year old man with micropenis secondary to bladder exstrophy previously underwent numerous reconstructive procedures including failed mitrofanoff channel. He had multiple abdominal scars and a stretched penile length of 5cm. His condition was impairing his psychological heath and sexual relationships. Full thickness buttock skin grafts are harvested. The radial artery forearm flap is dissected and cephalic vein, radial artery and cutaneous sensory nerves are isolated. The micropenis is disassembled, the glans divided and the corpora cavernosa amputated. For arterial supply usual end-to-side radial artery to common femoral anastomosis is not possible, due to pelvic distraction and vessels being further away from the phallus. Multiple prior and potential surgeries (for example Mitrofanoff revision) could risk the inferior epigastric artery injury with potential abdominal skin or neophallus devascularisation. Thus interposition graft is required – at the groin, the long saphenous vein has issues with tortuosity, valves and higher risk of thrombosis and bleeding. The ankle segment is better suited as it is straight, smaller and will appropriately limit inflow thus reducing bleeding. With an operative microscope, the radial artery is anastomosed to the distal end of the saphenous vein graft, the cephalic vein to the great saphenous vein and an end-to-side anastomosis is next performed between the interposition graft and the common femoral artery. The ilio-inguinal nerve is then sutured to the sensory phallus nerves. The previously harvested skin grafts are applied to the forearm. A Doppler ultrasound is used to confirm the arterial flow.
The post operative time has been uneventful and a saphenous vein interposition graft was successfully used.
Typically, a tension free anastomosis is created from the inferior epigastric artery to the radial artery phalloplasty. We demonstrate the use of a saphenous vein interposition graft between the radial artery and the common femoral artery for the creation of a tension free anastomosis.