Scrotal and perineal reconstruction

Abstract

The scrotal and perineal area serves a special function. It is the pelvic outlet for the gastrointestinal tract, urinary system, and sexual function. In the male, the scrotum allows testicular mobility to reduce trauma and allow optimal thermal regulation for spermatogenesis. Trauma, infection, and cancer resection create defects that require reconstruction. The reconstructive goal here is to obtain durable coverage, function, and lastly aesthetic outcome. Pedicled local and regional flaps are the mainstay for this area. Due to the special function and appearance of the scrotum, reconstructive options for total scrotal defect always fall far short of the native scrotum. On the other hand, perineal reconstruction is overall satisfactory.

Keywords: Scrotal wound; flap coverage; perineal wound.

Figure 1

Scrotal infection (A,B) and trauma (C,D) created significant defects. A healthy wound bed after debridement allowed split thickness skin graft to obtain healing. Note the lack of color match and dynamic function of a normal scrotum. (Courtesy of Dr. P.G. Arnold.)

Figure 2

Primary closure provides the best color match and potential function in partial scrotal defect. This patient with a locally advanced penile cancer underwent total penectomy and partial scrotal resection. Remaining scrotal tissue was used to cover the defect.

Figure 3

Local flaps provides good color match. After a free margin was obtained for this perineal recurrent squamous cell carcinoma, the terminal branches of the internal pudendal vessels were still present per a handheld Doppler exam. The bilateral V-Y perineal flaps could provide tissue with excellent color match. Prior irradiation of local tissue, a disadvantage in local option, caused a midline wound dehiscence (middle panel), which subsequently healed by secondary intention (bottom panel).

Figure 4

Vertical rectus abdominis myocutaneous flap (VRAM) is an excellent option for perineal region in case of through and through perineal-pelvic defect from pelvic exenteration. A supraumbilical skin island over the rectus muscle provides excellent reach to pelvic and perineum while the deep inferior epigastric vascular bundle is the blood supply. This patient with hidradenitis suppurativa and recurrent squamous cell carcinoma of the anus after prior resection and irradiation underwent an abdominoperineal resection. Surrounding perineal scars from hidradenitis suppurativa and irradiation made local flaps such as V-Y perineal flap or bilateral gluteal flaps not possible (last image, bottom panel). A VRAM served well in this scenario.

Figure 5

When radical anterior and posterior pelvic exenteration combined with perineal, scrotal, perineal, and perianal skin resection leaves a large defect, the VRAM is an excellent choice. Ostomies or prior scars destroy the rectus abdominis blood supply; therefore, other options are necessary. This case of recurrent prostatic cancer post irradiation (external beam and seeds) required such radical resection including the pubic symphysis. Unfortunately, both rectus abdominis muscles were consumed by ureterostomy and colostomy. A pedicle omentum from the right gastroepiploic vessel allowed excellent reach to fill the pelvis. Meanwhile, an extended gracilis myocutaneous flap provide additional coverage and support for the reconstructed pelvic floor. Finally, remnant of surrounding skin allowed good color match to the close a very difficult problem. In standing position, patient had no pelvic hernia.