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CC BY 4.0 · Surg J (N Y) 2021; 07(03): e237-e240
DOI: 10.1055/s-0041-1735649
Case Report

Salvage of a Near-Total Penile Amputation following Urinary Fistulization and Carbapenemase-Producing Klebsiella pneumoniae Infection with a Composite ALT Flap and Vascularized Fascia Lata

Ricardo Horta 
1   Department of Plastic and Reconstructive Surgery and Burn Unity, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
,
Margarida Mendes
1   Department of Plastic and Reconstructive Surgery and Burn Unity, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
,
Diogo Barreiro
1   Department of Plastic and Reconstructive Surgery and Burn Unity, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
,
Alexandre Almeida
1   Department of Plastic and Reconstructive Surgery and Burn Unity, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
,
Mariana Jarnalo
1   Department of Plastic and Reconstructive Surgery and Burn Unity, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
,
Sérgio Teixeira
1   Department of Plastic and Reconstructive Surgery and Burn Unity, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
,
Rui Pinto
2   Department of Urology, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
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Abstract

Reconstruction of complex penile defects is always challenging, as some defects are not possible to reconstruct with skin or mucosa grafts, and even local flaps may be precluded in complex wounds. We present a case of a 63-year-old otherwise healthy man, who underwent transurethral resection of the prostate for benign prostatic hyperplasia. After the procedure, he developed panurethral necrosis with consequent stricture. Three urethroplasties for reconstruction of the bulbar and distal urethra using buccal mucosa grafts, a preputial flap, and penile skin were performed by urology team in different institutions, but serious urinary fistulization and carbapenemase-producing Klebsiella pneumoniae (KPC) infection translated in a chronic wound, urethra necrosis, and near-total penile amputation. A composite anterolateral thigh flap and vascularized fascia lata were used with success together with a perineal urethroplasty in different stages, improving the ischemic wound condition. The extended segment of fascia lata was used for Buck's fascia replacement and circumferential reinforcement to cover the erectile bodies of the penis. The postoperative period was uneventful and after 12 months, there were no signs of recurrence or wound dehiscence. He was able and easily adapted to void in a seated position through the perineal urethrostomy that was made. To the best of our knowledge, this procedure has not been reported previously as a salvage procedure in a fistulizated and KPC infected penis, but it may be considered to avoid penile amputation in chronic infected and intractable wounds.

Keywords

penile amputation - salvage - KPC infection - ALT flap - vascularized fascia lata


Publication History

Received: 22 February 2021

Accepted: 20 July 2021

Article published online:
14 September 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Yazar Ş, Eroğlu M, Gökkaya A, Semerciöz A. The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap. Ulus Travma Acil Cerrahi Derg 2015; 21 (03) 223-227
    PubMedGoogle Scholar
  • 2 Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Phalloplasty: a review of techniques and outcomes . Plast Reconstr Surg 2016; 138 (03) 594-615
    CrossrefPubMedGoogle Scholar
  • 3 Salgado CJ, Chim H, Tang JC, Monstrey SJ, Mardini S. Penile reconstruction. Semin Plast Surg 2011; 25 (03) 221-228
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 van der Sluis WB, Smit JM, Pigot GLS. et al. Double flap phalloplasty in transgender men: surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction. Microsurgery 2017; 37 (08) 917-923
    CrossrefPubMedGoogle Scholar
  • 5 Wierckx K, Van Caenegem E, Elaut E. et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med 2011; 8 (12) 3379-3388
    CrossrefPubMedGoogle Scholar
  • 6 Monstrey S, Hoebeke P, Selvaggi G. et al. Penile reconstruction: is the radial forearm flap really the standard technique?. Plast Reconstr Surg 2009; 124 (02) 510-518
    CrossrefPubMedGoogle Scholar
  • 7 D'Arpa S, Claes K, Lumen N, Oieni S, Hoebeke P, Monstrey S. Urethral reconstruction in anterolateral thigh flap phalloplasty: a 93-case experience. Plast Reconstr Surg 2019; 143 (02) 382e-392e
    CrossrefPubMedGoogle Scholar
  • 8 Xu KY, Watt AJ. The pedicled anterolateral thigh phalloplasty. Clin Plast Surg 2018; 45 (03) 399-406
    CrossrefPubMedGoogle Scholar
  • 9 Hu ZQ, Hyakusoku H, Gao JH, Aoki R, Ogawa R, Yan X. Penis reconstruction using three different operative methods. Br J Plast Surg 2005; 58 (04) 487-492
    CrossrefPubMedGoogle Scholar
  • 10 Ceulemans P. The pedicled antero-lateral thigh (ALT) perforator flap: A new technique for phallic reconstruction. Paper presented at: XIX Biennial Symposium of the Harry Benjamin International Gender Dysphoria (HBIGDA) Association; April 6–9, 2005; Bologna, Italy
    PubMedGoogle Scholar
  • 11 Felici N, Felici A. A new phalloplasty technique: the free anterolateral thigh flap phalloplasty. J Plast Reconstr Aesthet Surg 2006; 59 (02) 153-157
    CrossrefPubMedGoogle Scholar
  • 12 Valdatta L, Tuinder S, Buoro M, Thione A, Faga A, Putz R. Lateral circumflex femoral arterial system and perforators of the anterolateral thigh flap: an anatomic study. Ann Plast Surg 2002; 49 (02) 145-150
    CrossrefPubMedGoogle Scholar
  • 13 Hage JJ, Bouman FG, de Graaf FH, Bloem JJ. Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience. J Urol 1993; 149 (06) 1463-1468
    CrossrefPubMedGoogle Scholar
  • 14 Schaff J, Papadopulos NA. A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: experience in 37 patients. Microsurgery 2009; 29 (05) 413-419
    CrossrefPubMedGoogle Scholar
  • 15 Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol 2003; 44 (05) 611-614
    CrossrefPubMedGoogle Scholar
  • 16 Chen KL, Eberli D, Yoo JJ, Atala A. Bioengineered corporal tissue for structural and functional restoration of the penis. Proc Natl Acad Sci U S A 2010; 107 (08) 3346-3350
    CrossrefPubMedGoogle Scholar
  • 17 Yoo JJ, Park HJ, Lee I, Atala A. Autologous engineered cartilage rods for penile reconstruction. J Urol 1999; 162 (3 Pt 2): 1119-1121
    CrossrefPubMedGoogle Scholar
  • 18 Kim BS, Yoo JJ, Atala A. Engineering of human cartilage rods: potential application for penile prostheses. J Urol 2002; 168 (4 Pt 2): 1794-1797
    CrossrefPubMedGoogle Scholar
  • 19 Nolazco G, Kovanecz I, Vernet D. et al. Effect of muscle-derived stem cells on the restoration of corpora cavernosa smooth muscle and erectile function in the aged rat. BJU Int 2008; 101 (09) 1156-1164
    CrossrefPubMedGoogle Scholar
  • 20 Song YS, Lee HJ, Park IH, Kim WK, Ku JH, Kim SU. Potential differentiation of human mesenchymal stem cell transplanted in rat corpus cavernosum toward endothelial or smooth muscle cells. Int J Impot Res 2007; 19 (04) 378-385
    CrossrefPubMedGoogle Scholar
  • 21 Barreiro D, Jarnalo M, Rocha-Pereira N, Oliveira O, Silva A. Carbapenemase-producing Enterobacterales in plastic and reconstructive surgery departments in Portugal: should we be worried?. J Plast Reconstr Aesthet Surg 2019; 72 (08) 1436-1447
    CrossrefPubMedGoogle Scholar
  • 22 Spyriounis PK, Karmiris NI. Partial penile reconstruction following fat augmentation with anterolateral thigh perforator flap. J Plast Reconstr Aesthet Surg 2012; 65 (01) e15-e17
    CrossrefPubMedGoogle Scholar
  • 23 Gayam V, Mandal A, Garlapati P, Khalid M, Shrestha B, Gill A. Rectourethral fistula secondary to transurethral resection of the prostate. Cureus 2018; 10 (10) e3476
    PubMedGoogle Scholar
  • 24 Garg G, Deliso M, Li S, Sharma P, Abdelbaki A, Gupta N. Prostatosymphyseal fistula after transurethral resection of the prostate (TURP), a rare and difficult to recognize complication. Urol Case Rep 2018; 21: 70-72
    CrossrefPubMedGoogle Scholar